public static void Save837P(TS837P tran)
{
using (var db = new HIPAA_5010_837P_Context())
{
tran.ClearCache();
db.TS837P.Add(tran);
db.SaveChanges();
}
}
public static void Save837P(TS837P tran)
{
using (var db = new HIPAA_5010_837P_Context())
{
tran.ClearCache();
db.Configuration.AutoDetectChangesEnabled = false;
db.Configuration.ValidateOnSaveEnabled = false;
db.TS837P.Add(tran);
db.SaveChanges();
}
}
/// <summary>
/// Build claim.
/// Original from http://www.x12.org/examples/005010X222/commercial-health-insurance/
/// </summary>
public static TS837P BuildClaim(string controlNumber)
{
var result = new TS837P();
// Indicates the start of a claim transaction set and assigns a control number.
result.ST = new ST();
result.ST.TransactionSetIdentifierCode_01 = "837";
result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
result.ST.ImplementationConventionPreference_03 = "005010X222A1";
// Indicates the claim was created on October 15, 2006 and submitter is identified with 244579.
result.BHT_BeginningofHierarchicalTransaction = new BHT_BeginningofHierarchicalTransaction_7();
result.BHT_BeginningofHierarchicalTransaction.HierarchicalStructureCode_01 = "0019";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetPurposeCode_02 = "00";
result.BHT_BeginningofHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "244579";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationDate_04 = "20061015";
result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationTime_05 = "1023";
result.BHT_BeginningofHierarchicalTransaction.TransactionTypeCode_06 = "CH";
// Occurrence of NM1 Loops in any order
result.AllNM1 = new All_NM1_837P_6();
// Begin 1000A Loop SUBMITTER
result.AllNM1.Loop1000A = new Loop_1000A_837P();
// Premier Billing Service with EDI# TGJ23
result.AllNM1.Loop1000A.NM1_SubmitterName = new NM1_InformationReceiverName_4();
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityIdentifierCode_01 = "41";
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactLastorOrganizationName_03 = "PREMIER BILLING SERVICE";
result.AllNM1.Loop1000A.NM1_SubmitterName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactIdentifier_09 = "TGJ23";
// Repeating PER
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation = new List <PER_BillingProviderContactInformation>();
// CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231
var perLoop1000A = new PER_BillingProviderContactInformation();
perLoop1000A.ContactFunctionCode_01 = "IC";
perLoop1000A.ResponseContactName_02 = "JERRY";
perLoop1000A.CommunicationNumberQualifier_03 = "TE";
perLoop1000A.ResponseContactCommunicationNumber_04 = "3055552222";
perLoop1000A.CommunicationNumberQualifier_05 = "EX";
perLoop1000A.ResponseContactCommunicationNumber_06 = "231";
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation.Add(perLoop1000A);
// End 1000A Loop SUBMITTER
// Begin 1000B Loop RECEIVER
result.AllNM1.Loop1000B = new Loop_1000B_837P();
// Key Insurance Company with EDI #:66783JJT
result.AllNM1.Loop1000B.NM1_ReceiverName = new NM1_ReceiverName();
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityIdentifierCode_01 = "40";
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactLastorOrganizationName_03 = "KEY INSURANCE COMPANY";
result.AllNM1.Loop1000B.NM1_ReceiverName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactIdentifier_09 = "66783JJT";
// End 1000B Loop RECEIVER
// Repeating 2000A Loops
result.Loop2000A = new List <Loop_2000A_837P>();
// Begin 2000A Loop BILLING PROVIDER Hierarchy
var loop2000A = new Loop_2000A_837P();
// Hierarchical Number 1
loop2000A.HL_BillingProviderHierarchicalLevel = new HL_BillingProviderHierarchicalLevel();
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalIDNumber_01 = "1";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalLevelCode_03 = "20";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalChildCode_04 = "1";
// Taxonomy Code: 203BF0100Y
loop2000A.PRV_BillingProviderSpecialtyInformation = new PRV_BillingProviderSpecialtyInformation();
loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderCode_01 = "BI";
loop2000A.PRV_BillingProviderSpecialtyInformation.ReferenceIdentificationQualifier_02 = "PXC";
loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderTaxonomyCode_03 = "203BF0100Y";
// Occurrence of NM1 Loops in any order
loop2000A.AllNM1 = new All_NM1_837P();
// Begin 2010AA Loop BILLING PROVIDER
loop2000A.AllNM1.Loop2010AA = new Loop_2010AA_837P();
// Name is BEN KILDARE SERVICE with NPI: 9876543210
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName = new NM1_BillingProviderName_2();
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityIdentifierCode_01 = "85";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityTypeQualifier_02 = "2";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactLastorOrganizationName_03 = "BEN KILDARE SERVICE";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.IdentificationCodeQualifier_08 = "XX";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactIdentifier_09 = "9876543210";
// ADDRESS: 234 Seaway St
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress.ResponseContactAddressLine_01 = "234 SEAWAY ST";
// LOCATION: Miami, FL, 33111
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33111";
// Occurrence of REF Loops in any order
loop2000A.AllNM1.Loop2010AA.AllREF = new All_REF_837P_8();
// TIN: 587654321
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification = new REF_BillingProviderTaxIdentification();
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification.ReferenceIdentificationQualifier_01 = "EI";
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification.MemberGrouporPolicyNumber_02 = "587654321";
// End 2010AA Loop BILLING PROVIDER
// Begin 2010AB Loop PAY-TO PROVIDER
loop2000A.AllNM1.Loop2010AB = new Loop_2010AB_837P();
// PAY-TO PROVIDER Name is Kildare Associates
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName = new NM1_Pay();
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.EntityIdentifierCode_01 = "87";
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.EntityTypeQualifier_02 = "2";
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.ResponseContactLastorOrganizationName_03 = "Kildare Associates";
// PROVIDER ADDRESS: 2345 Ocean Blvd
loop2000A.AllNM1.Loop2010AB.N3_Pay_ToAddress_ADDRESS = new N3_AdditionalPatientInformationContactAddress();
loop2000A.AllNM1.Loop2010AB.N3_Pay_ToAddress_ADDRESS.ResponseContactAddressLine_01 = "2345 OCEAN BLVD";
// PROVIDER LOCATION: Miami, Fl 33111
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33111";
// End 2010AB Loop PAY-TO PROVIDER
// Repeating 2000B Loops
loop2000A.Loop2000B = new List <Loop_2000B_837P>();
// Begin 2000B Loop SUBSCRIBER Hierarchy
var loop2000B = new Loop_2000B_837P();
// Hierarchical Number 2
loop2000B.HL_SubscriberHierarchicalLevel = new HL_SubscriberHierarchicalLevel();
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalIDNumber_01 = "2";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalParentIDNumber_02 = "1";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalLevelCode_03 = "22";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalChildCode_04 = "1";
// SUBSCRIBER GROUP #: 2222-SJ
loop2000B.SBR_SubscriberInformation = new SBR_SubscriberInformation();
loop2000B.SBR_SubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "P";
loop2000B.SBR_SubscriberInformation.InsuredGrouporPolicyNumber_03 = "2222-SJ";
loop2000B.SBR_SubscriberInformation.ClaimFilingIndicatorCode_09 = "CI";
// Occurrence of NM1 Loops in any order
loop2000B.AllNM1 = new All_NM1_837P_2();
// Begin 2010BA Loop SUBSCRIBER
loop2000B.AllNM1.Loop2010BA = new Loop_2010BA_837P();
// SUBSCRIBER name is Jane Smith
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName = new NM1_SubscriberName_5();
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "SMITH";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactFirstName_04 = "JANE";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactIdentifier_09 = "JS00111223333";
// SUBSCRIBER SEX: F and DOB: 05 / 01 / 43
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation = new DMG_PatientDemographicInformation();
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentBirthDate_02 = "19430501";
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentGenderCode_03 = "F";
// End 2010BA Loop SUBSCRIBER
// Begin 2010BB Loop PAYER
loop2000B.AllNM1.Loop2010BB = new Loop_2010BB_837P();
// Payer name is Key Insurance Company with PAYER ID: 999996666
loop2000B.AllNM1.Loop2010BB.NM1_PayerName = new NM1_OtherPayerName();
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityIdentifierCode_01 = "PR";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityTypeQualifier_02 = "2";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactLastorOrganizationName_03 = "KEY INSURANCE COMPANY";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.IdentificationCodeQualifier_08 = "PI";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactIdentifier_09 = "999996666";
// Occurrence of REF in any order
loop2000B.AllNM1.Loop2010BB.AllREF = new All_REF_837P_5();
// Repeating REF
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification = new List <REF_BillingProviderSecondaryIdentification>();
// KEY INSURANCE COMPANY PROVIDER ID #: KA6663
var refLoop2000B = new REF_BillingProviderSecondaryIdentification();
refLoop2000B.ReferenceIdentificationQualifier_01 = "G2";
refLoop2000B.MemberGrouporPolicyNumber_02 = "KA6663";
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.Add(refLoop2000B);
// End 2010BB Loop PAYER
// Repeating 2000C Loops
loop2000B.Loop2000C = new List <Loop_2000C_837P>();
// Begin 2000C Loop PATIENT Hierarchy
var loop2000C = new Loop_2000C_837P();
// Hierarchical Number 3
loop2000C.HL_PatientHierarchicalLevel = new HL_DependentLevel();
loop2000C.HL_PatientHierarchicalLevel.HierarchicalIDNumber_01 = "3";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalParentIDNumber_02 = "2";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalLevelCode_03 = "23";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalChildCode_04 = "0";
loop2000C.PAT_PatientInformation = new PAT_PatientInformation();
loop2000C.PAT_PatientInformation.IndividualRelationshipCode_01 = "19";
// Begin 2010CA Loop PATIENT
loop2000C.Loop2010CA = new Loop_2010CA_837P();
// PATIENT name is Ted Smith
loop2000C.Loop2010CA.NM1_PatientName = new NM1_PatientName_3();
loop2000C.Loop2010CA.NM1_PatientName.EntityIdentifierCode_01 = "QC";
loop2000C.Loop2010CA.NM1_PatientName.EntityTypeQualifier_02 = "1";
loop2000C.Loop2010CA.NM1_PatientName.ResponseContactLastorOrganizationName_03 = "SMITH";
loop2000C.Loop2010CA.NM1_PatientName.ResponseContactFirstName_04 = "TED";
// PATIENT ADDRESS: 236 N. Main St.
loop2000C.Loop2010CA.N3_PatientAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000C.Loop2010CA.N3_PatientAddress.ResponseContactAddressLine_01 = "236 N MAIN ST";
// PATIENT LOCATION: Miami, Fl, 33413
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33413";
// PATIENT SEX: M and DOB: 05 / 01 / 73
loop2000C.Loop2010CA.DMG_PatientDemographicInformation = new DMG_PatientDemographicInformation();
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DependentBirthDate_02 = "19730501";
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DependentGenderCode_03 = "M";
// End 2010CA Loop PATIENT
// Repeating 2300 Loops
loop2000C.Loop2300 = new List <Loop_2300_837P>();
// Begin 2300 Loop CLAIM
var loop2300 = new Loop_2300_837P();
// PATIENT ACCOUNT NUMBER: 2-646-3774
loop2300.CLM_ClaimInformation = new CLM_ClaimInformation_2();
loop2300.CLM_ClaimInformation.PatientControlNumber_01 = "26463774";
loop2300.CLM_ClaimInformation.TotalClaimChargeAmount_02 = "100";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05 = new C023_HealthCareServiceLocationInformation_2();
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityTypeCode_01 = "11";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityCodeQualifier_02 = "B";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.ClaimFrequencyTypeCode_03 = "1";
loop2300.CLM_ClaimInformation.ProviderorSupplierSignatureIndicator_06 = "Y";
loop2300.CLM_ClaimInformation.AssignmentorPlanParticipationCode_07 = "A";
loop2300.CLM_ClaimInformation.BenefitsAssignmentCertificationIndicator_08 = "Y";
loop2300.CLM_ClaimInformation.ReleaseofInformationCode_09 = "I";
// Occurrence of REF in any order
loop2300.AllREF = new All_REF_837P_6();
// ELECTRONIC ROUTE: Billing provider (sender), to VAN to Key Insurance Company (receiver). VAN claim identification number = 17312345600006351.
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries = new REF_ClaimIdentificationNumberForClearinghousesandOtherTransmissionIntermediaries();
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries.ReferenceIdentificationQualifier_01 = "D9";
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries.MemberGrouporPolicyNumber_02 = "17312345600006351";
// Occurrence of HI in any order
loop2300.AllHI = new All_HI_837P();
// CASE: Patient has sore throat.
loop2300.AllHI.HI_HealthCareDiagnosisCode = new HI_DependentHealthCareDiagnosisCode();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation_8();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BK";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01.IndustryCode_02 = "0340";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation_4();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BF";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02.IndustryCode_02 = "V7389";
// Repeating 2400 Loops
loop2300.Loop2400 = new List <Loop_2400_837P>();
// Begin 2400 Loop SERVICE LINE 1
var loop24001 = new Loop_2400_837P();
loop24001.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24001.LX_ServiceLineNumber.AssignedNumber_01 = "1";
// SERVICES: Office visit, intermediate service, established patient, throat culture.
// CHARGES: Office first visit = $40.00
loop24001.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier_12();
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "99213";
loop24001.SV1_ProfessionalService.LineItemChargeAmount_02 = "40";
loop24001.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24001.SV1_ProfessionalService.ServiceUnitCount_04 = "1";
loop24001.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24001.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "1";
// Occurrence of DTP in any order
loop24001.AllDTP = new All_DTP_837P();
// INITIAL VISIT: DOS=10/03/06. POS=Office
loop24001.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24001.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24001.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24001.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061003";
// End 2400 Loop SERVICE LINE 1
loop2300.Loop2400.Add(loop24001);
// Begin 2400 Loop SERVICE LINE 2
var loop24002 = new Loop_2400_837P();
loop24002.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24002.LX_ServiceLineNumber.AssignedNumber_01 = "2";
// SERVICES: Office visit, intermediate service, established patient, throat culture.
// CHARGES: Lab test for strep = $15.00
loop24002.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24002.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier_12();
loop24002.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24002.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "87070";
loop24002.SV1_ProfessionalService.LineItemChargeAmount_02 = "15";
loop24002.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24002.SV1_ProfessionalService.ServiceUnitCount_04 = "1";
loop24002.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24002.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "1";
// Occurrence of DTP in any order
loop24002.AllDTP = new All_DTP_837P();
// INITIAL VISIT: DOS=10/03/06. POS=Office
loop24002.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24002.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24002.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24002.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061003";
// End 2400 Loop SERVICE LINE 2
loop2300.Loop2400.Add(loop24002);
// Begin 2400 Loop SERVICE LINE 3
var loop24003 = new Loop_2400_837P();
loop24003.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24003.LX_ServiceLineNumber.AssignedNumber_01 = "3";
// SERVICES: Office visit, intermediate service, established patient, mono screening.
// CHARGES: Follow-up visit = $35.00
loop24003.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24003.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier_12();
loop24003.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24003.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "99214";
loop24003.SV1_ProfessionalService.LineItemChargeAmount_02 = "35";
loop24003.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24003.SV1_ProfessionalService.ServiceUnitCount_04 = "1";
loop24003.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24003.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "2";
// Occurrence of DTP in any order
loop24003.AllDTP = new All_DTP_837P();
// FOLLOW-UP VISIT: DOS=10/10/06 POS=Office
loop24003.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24003.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24003.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24003.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061010";
// End 2400 Loop SERVICE LINE 3
loop2300.Loop2400.Add(loop24003);
// Begin 2400 Loop SERVICE LINE 4
var loop24004 = new Loop_2400_837P();
loop24004.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24004.LX_ServiceLineNumber.AssignedNumber_01 = "4";
// SERVICES: Office visit, intermediate service, established patient, mono screening.
// CHARGES: Lab test for mono = $10.00
loop24004.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24004.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier_12();
loop24004.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24004.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "86663";
loop24004.SV1_ProfessionalService.LineItemChargeAmount_02 = "10";
loop24004.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24004.SV1_ProfessionalService.ServiceUnitCount_04 = "1";
loop24004.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24004.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "2";
// Occurrence of DTP in any order
loop24004.AllDTP = new All_DTP_837P();
// FOLLOW-UP VISIT: DOS=10/10/06 POS=Office
loop24004.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24004.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24004.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8";
loop24004.AllDTP.DTP_Date_ServiceDate.AccidentDate_03 = "20061010";
// End 2400 Loop SERVICE LINE 4
loop2300.Loop2400.Add(loop24004);
// End 2300 Loop CLAIM
loop2000C.Loop2300.Add(loop2300);
// End 2000C Loop PATIENT Hierarchy
loop2000B.Loop2000C.Add(loop2000C);
// End 2000B Loop SUBSCRIBER Hierarchy
loop2000A.Loop2000B.Add(loop2000B);
// End 2000A Loop BILLING PROVIDER Hierarchy
result.Loop2000A.Add(loop2000A);
return(result);
}
/// <summary>
/// Build claim with EVV.
/// Original from https://www.dmas.virginia.gov/files/links/685/AD%20Services%20837P%20with%20EVV%20Information%20Example%20(01.29.2019).pdf
/// </summary>
public static TS837P BuildClaim(string controlNumber)
{
var result = new TS837P();
// Indicates the start of a claim transaction set and assigns a control number.
result.ST = new ST();
result.ST.TransactionSetIdentifierCode_01 = "837";
result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0');
result.ST.ImplementationConventionPreference_03 = "005010X222A1";
// Indicates the claim was created on October 15, 2006 and submitter is identified with 244579.
result.BHT_BeginningOfHierarchicalTransaction = new BHT_BeginningOfHierarchicalTransaction_8();
result.BHT_BeginningOfHierarchicalTransaction.HierarchicalStructureCode_01 = "0019";
result.BHT_BeginningOfHierarchicalTransaction.TransactionSetPurposeCode_02 = "00";
result.BHT_BeginningOfHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "244579";
result.BHT_BeginningOfHierarchicalTransaction.TransactionSetCreationDate_04 = "20061015";
result.BHT_BeginningOfHierarchicalTransaction.TransactionSetCreationTime_05 = "1023";
result.BHT_BeginningOfHierarchicalTransaction.TransactionTypeCode_06 = "CH";
// Occurrence of NM1 Loops in any order
result.AllNM1 = new All_NM1_837P_6();
// Begin 1000A Loop SUBMITTER
result.AllNM1.Loop1000A = new Loop_1000A_837P();
// Premier Billing Service with EDI# TGJ23
result.AllNM1.Loop1000A.NM1_SubmitterName = new NM1_InformationReceiverName_4();
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityIdentifierCode_01 = "41";
result.AllNM1.Loop1000A.NM1_SubmitterName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactLastorOrganizationName_03 = "PREMIER BILLING SERVICE";
result.AllNM1.Loop1000A.NM1_SubmitterName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactIdentifier_09 = "TGJ23";
// Repeating PER
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation = new List <PER_BillingProviderContactInformation>();
// CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231
var perLoop1000A = new PER_BillingProviderContactInformation();
perLoop1000A.ContactFunctionCode_01 = "IC";
perLoop1000A.ResponseContactName_02 = "JERRY";
perLoop1000A.CommunicationNumberQualifier_03 = "TE";
perLoop1000A.ResponseContactCommunicationNumber_04 = "3055552222";
perLoop1000A.CommunicationNumberQualifier_05 = "EX";
perLoop1000A.ResponseContactCommunicationNumber_06 = "231";
result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation.Add(perLoop1000A);
// End 1000A Loop SUBMITTER
// Begin 1000B Loop RECEIVER
result.AllNM1.Loop1000B = new Loop_1000B_837P();
// Key Insurance Company with EDI #:66783JJT
result.AllNM1.Loop1000B.NM1_ReceiverName = new NM1_ReceiverName();
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityIdentifierCode_01 = "40";
result.AllNM1.Loop1000B.NM1_ReceiverName.EntityTypeQualifier_02 = "2";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactLastorOrganizationName_03 = "KEY INSURANCE COMPANY";
result.AllNM1.Loop1000B.NM1_ReceiverName.IdentificationCodeQualifier_08 = "46";
result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactIdentifier_09 = "66783JJT";
// End 1000B Loop RECEIVER
// Repeating 2000A Loops
result.Loop2000A = new List <Loop_2000A_837P>();
// Begin 2000A Loop BILLING PROVIDER Hierarchy
var loop2000A = new Loop_2000A_837P();
// Hierarchical Number 1
loop2000A.HL_BillingProviderHierarchicalLevel = new HL_BillingProviderHierarchicalLevel();
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalIDNumber_01 = "1";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalLevelCode_03 = "20";
loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalChildCode_04 = "1";
// Taxonomy Code: 203BF0100Y
loop2000A.PRV_BillingProviderSpecialtyInformation = new PRV_BillingProviderSpecialtyInformation();
loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderCode_01 = "BI";
loop2000A.PRV_BillingProviderSpecialtyInformation.ReferenceIdentificationQualifier_02 = "PXC";
loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderTaxonomyCode_03 = "203BF0100Y";
// Occurrence of NM1 Loops in any order
loop2000A.AllNM1 = new All_NM1_837P();
// Begin 2010AA Loop BILLING PROVIDER
loop2000A.AllNM1.Loop2010AA = new Loop_2010AA_837P();
// Name is BEN KILDARE SERVICE with NPI: 9876543210
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName = new NM1_BillingProviderName_2();
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityIdentifierCode_01 = "85";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.EntityTypeQualifier_02 = "2";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactLastorOrganizationName_03 = "BEN KILDARE SERVICE";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.IdentificationCodeQualifier_08 = "XX";
loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactIdentifier_09 = "9876543210";
// ADDRESS: 234 Seaway St
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress.ResponseContactAddressLine_01 = "234 SEAWAY ST";
// LOCATION: Miami, FL, 33111
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33111";
// Occurrence of REF Loops in any order
loop2000A.AllNM1.Loop2010AA.AllREF = new All_REF_837P_8();
// TIN: 587654321
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification = new REF_BillingProviderTaxIdentification();
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification.ReferenceIdentificationQualifier_01 = "EI";
loop2000A.AllNM1.Loop2010AA.AllREF.REF_BillingProviderTaxIdentification.MemberGrouporPolicyNumber_02 = "587654321";
// End 2010AA Loop BILLING PROVIDER
// Begin 2010AB Loop PAY-TO PROVIDER
loop2000A.AllNM1.Loop2010AB = new Loop_2010AB_837P();
// PAY-TO PROVIDER Name is Kildare Associates
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName = new NM1_Pay();
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.EntityIdentifierCode_01 = "87";
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.EntityTypeQualifier_02 = "2";
loop2000A.AllNM1.Loop2010AB.NM1_Pay_AddressName.ResponseContactLastorOrganizationName_03 = "Kildare Associates";
// PROVIDER ADDRESS: 2345 Ocean Blvd
loop2000A.AllNM1.Loop2010AB.N3_Pay_ToAddress_ADDRESS = new N3_AdditionalPatientInformationContactAddress();
loop2000A.AllNM1.Loop2010AB.N3_Pay_ToAddress_ADDRESS.ResponseContactAddressLine_01 = "2345 OCEAN BLVD";
// PROVIDER LOCATION: Miami, Fl 33111
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000A.AllNM1.Loop2010AB.N4_Pay_AddressCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33111";
// End 2010AB Loop PAY-TO PROVIDER
// Repeating 2000B Loops
loop2000A.Loop2000B = new List <Loop_2000B_837P>();
// Begin 2000B Loop SUBSCRIBER Hierarchy
var loop2000B = new Loop_2000B_837P();
// Hierarchical Number 2
loop2000B.HL_SubscriberHierarchicalLevel = new HL_SubscriberHierarchicalLevel();
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalIDNumber_01 = "2";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalParentIDNumber_02 = "1";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalLevelCode_03 = "22";
loop2000B.HL_SubscriberHierarchicalLevel.HierarchicalChildCode_04 = "1";
// SUBSCRIBER GROUP #: 2222-SJ
loop2000B.SBR_SubscriberInformation = new SBR_SubscriberInformation();
loop2000B.SBR_SubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "P";
loop2000B.SBR_SubscriberInformation.InsuredGrouporPolicyNumber_03 = "2222-SJ";
loop2000B.SBR_SubscriberInformation.ClaimFilingIndicatorCode_09 = "CI";
// Occurrence of NM1 Loops in any order
loop2000B.AllNM1 = new All_NM1_837P_2();
// Begin 2010BA Loop SUBSCRIBER
loop2000B.AllNM1.Loop2010BA = new Loop_2010BA_837P();
// 1)EVV- The Individual Receiving the Service(s), Medicaid ID
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName = new NM1_SubscriberName_5();
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityIdentifierCode_01 = "IL";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityTypeQualifier_02 = "1";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "SOLO";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactFirstName_04 = "HANS";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactMiddleName_05 = "RYAN";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI";
loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactIdentifier_09 = "123456789012";
// SUBSCRIBER SEX: F and DOB: 05 / 01 / 43
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation = new DMG_PatientDemographicInformation();
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentBirthDate_02 = "19430501";
loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentGenderCode_03 = "F";
// End 2010BA Loop SUBSCRIBER
// Begin 2010BB Loop PAYER
loop2000B.AllNM1.Loop2010BB = new Loop_2010BB_837P();
// Payer name is Key Insurance Company with PAYER ID: 999996666
loop2000B.AllNM1.Loop2010BB.NM1_PayerName = new NM1_OtherPayerName();
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityIdentifierCode_01 = "PR";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityTypeQualifier_02 = "2";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactLastorOrganizationName_03 = "KEY INSURANCE COMPANY";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.IdentificationCodeQualifier_08 = "PI";
loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactIdentifier_09 = "999996666";
// Occurrence of REF in any order
loop2000B.AllNM1.Loop2010BB.AllREF = new All_REF_837P_5();
// Repeating REF
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification = new List <REF_BillingProviderSecondaryIdentification>();
// KEY INSURANCE COMPANY PROVIDER ID #: KA6663
var refLoop2000B = new REF_BillingProviderSecondaryIdentification();
refLoop2000B.ReferenceIdentificationQualifier_01 = "G2";
refLoop2000B.MemberGrouporPolicyNumber_02 = "KA6663";
loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.Add(refLoop2000B);
// End 2010BB Loop PAYER
// Repeating 2000C Loops
loop2000B.Loop2000C = new List <Loop_2000C_837P>();
// Begin 2000C Loop PATIENT Hierarchy
var loop2000C = new Loop_2000C_837P();
// Hierarchical Number 3
loop2000C.HL_PatientHierarchicalLevel = new HL_DependentLevel();
loop2000C.HL_PatientHierarchicalLevel.HierarchicalIDNumber_01 = "3";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalParentIDNumber_02 = "2";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalLevelCode_03 = "23";
loop2000C.HL_PatientHierarchicalLevel.HierarchicalChildCode_04 = "0";
loop2000C.PAT_PatientInformation = new PAT_PatientInformation();
loop2000C.PAT_PatientInformation.IndividualRelationshipCode_01 = "19";
// Begin 2010CA Loop PATIENT
loop2000C.Loop2010CA = new Loop_2010CA_837P();
// PATIENT name is Ted Smith
loop2000C.Loop2010CA.NM1_PatientName = new NM1_PatientName_3();
loop2000C.Loop2010CA.NM1_PatientName.EntityIdentifierCode_01 = "QC";
loop2000C.Loop2010CA.NM1_PatientName.EntityTypeQualifier_02 = "1";
loop2000C.Loop2010CA.NM1_PatientName.ResponseContactLastorOrganizationName_03 = "SMITH";
loop2000C.Loop2010CA.NM1_PatientName.ResponseContactFirstName_04 = "TED";
// PATIENT ADDRESS: 236 N. Main St.
loop2000C.Loop2010CA.N3_PatientAddress = new N3_AdditionalPatientInformationContactAddress();
loop2000C.Loop2010CA.N3_PatientAddress.ResponseContactAddressLine_01 = "236 N MAIN ST";
// PATIENT LOCATION: Miami, Fl, 33413
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity();
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "MIAMI";
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "FL";
loop2000C.Loop2010CA.N4_PatientCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "33413";
// PATIENT SEX: M and DOB: 05 / 01 / 73
loop2000C.Loop2010CA.DMG_PatientDemographicInformation = new DMG_PatientDemographicInformation();
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8";
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DependentBirthDate_02 = "19730501";
loop2000C.Loop2010CA.DMG_PatientDemographicInformation.DependentGenderCode_03 = "M";
// End 2010CA Loop PATIENT
// Repeating 2300 Loops
loop2000C.Loop2300 = new List <Loop_2300_837P>();
// Begin 2300 Loop CLAIM
var loop2300 = new Loop_2300_837P();
// PATIENT ACCOUNT NUMBER: 2-646-3774
loop2300.CLM_ClaimInformation = new CLM_ClaimInformation_3();
loop2300.CLM_ClaimInformation.PatientControlNumber_01 = "26463774";
loop2300.CLM_ClaimInformation.TotalClaimChargeAmount_02 = "100";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05 = new C023_HealthCareServiceLocationInformation_2();
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityTypeCode_01 = "11";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.FacilityCodeQualifier_02 = "B";
loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05.ClaimFrequencyTypeCode_03 = "1";
loop2300.CLM_ClaimInformation.ProviderorSupplierSignatureIndicator_06 = "Y";
loop2300.CLM_ClaimInformation.AssignmentorPlanParticipationCode_07 = "A";
loop2300.CLM_ClaimInformation.BenefitsAssignmentCertificationIndicator_08 = "Y";
loop2300.CLM_ClaimInformation.ReleaseofInformationCode_09 = "I";
// Occurrence of REF in any order
loop2300.AllREF = new All_REF_837P_6();
// ELECTRONIC ROUTE: Billing provider (sender), to VAN to Key Insurance Company (receiver). VAN claim identification number = 17312345600006351.
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries = new REF_ClaimIdentificationNumberForClearinghousesAndOtherTransmissionIntermediaries();
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries.ReferenceIdentificationQualifier_01 = "D9";
loop2300.AllREF.REF_ClaimIdentifierForTransmissionIntermediaries.MemberGrouporPolicyNumber_02 = "17312345600006351";
// Occurrence of HI in any order
loop2300.AllHI = new All_HI_837P();
// CASE: Patient has sore throat.
loop2300.AllHI.HI_HealthCareDiagnosisCode = new HI_DependentHealthCareDiagnosisCode_2();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation_8();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BK";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_01.IndustryCode_02 = "0340";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation_4();
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BF";
loop2300.AllHI.HI_HealthCareDiagnosisCode.HealthCareCodeInformation_02.IndustryCode_02 = "V7389";
// Repeating 2400 Loops
loop2300.Loop2400 = new List <Loop_2400_837P>();
// Begin 2400 Loop SERVICE LINE 1
var loop24001 = new Loop_2400_837P();
loop24001.LX_ServiceLineNumber = new LX_HeaderNumber();
loop24001.LX_ServiceLineNumber.AssignedNumber_01 = "1";
// 2)EVV- The Type of Service Performed, Service Line Procedure Code SV101-1
// 3)EVV - The Time the Services Begins and Ends, Service Line Description SV101-7
loop24001.SV1_ProfessionalService = new SV1_ProfessionalService();
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01 = new C003_CompositeMedicalProcedureIdentifier_12();
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProductorServiceIDQualifier_01 = "HC";
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.ProcedureCode_02 = "S5135";
loop24001.SV1_ProfessionalService.CompositeMedicalProcedureIdentifier_01.Description_07 = "1230-1630";
loop24001.SV1_ProfessionalService.LineItemChargeAmount_02 = "50";
loop24001.SV1_ProfessionalService.UnitorBasisforMeasurementCode_03 = "UN";
loop24001.SV1_ProfessionalService.ServiceUnitCount_04 = "2";
loop24001.SV1_ProfessionalService.PlaceofServiceCode_05 = "11";
loop24001.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07 = new C004_CompositeDiagnosisCodePointer();
loop24001.SV1_ProfessionalService.CompositeDiagnosisCodePointer_07.DiagnosisCodePointer_01 = "1";
// Occurrence of DTP in any order
loop24001.AllDTP = new All_DTP_837P();
// 4)EVV- The Date(s) of Service Performed, Service Line Dates of Service
loop24001.AllDTP.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate();
loop24001.AllDTP.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472";
loop24001.AllDTP.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "RD8";
loop24001.AllDTP.DTP_Date_ServiceDate.DateTimePeriod_03 = "20160302-20160302";
// 5)EVV- The Individual Providing the Services (2 Segments)
loop24001.AllNM1 = new All_NM1_837P_5();
loop24001.AllNM1.Loop2420D = new Loop_2420D_837P();
// Attendant's Name
loop24001.AllNM1.Loop2420D.NM1_SupervisingProviderName = new NM1_SupervisingProviderName();
loop24001.AllNM1.Loop2420D.NM1_SupervisingProviderName.EntityIdentifierCode_01 = "DQ";
loop24001.AllNM1.Loop2420D.NM1_SupervisingProviderName.EntityTypeQualifier_02 = "1";
loop24001.AllNM1.Loop2420D.NM1_SupervisingProviderName.ResponseContactLastorOrganizationName_03 = "JONES";
loop24001.AllNM1.Loop2420D.NM1_SupervisingProviderName.ResponseContactFirstName_04 = "DEVIL";
loop24001.AllNM1.Loop2420D.REF_SupervisingProviderSecondaryIdentification = new List <REF_AssistantSurgeonSecondaryIdentification_2>();
// Attendant's ID
var refAssistantSurgeonSecondaryIdentification = new REF_AssistantSurgeonSecondaryIdentification_2();
refAssistantSurgeonSecondaryIdentification.ReferenceIdentificationQualifier_01 = "LU";
refAssistantSurgeonSecondaryIdentification.MemberGrouporPolicyNumber_02 = "1234567890";
loop24001.AllNM1.Loop2420D.REF_SupervisingProviderSecondaryIdentification.Add(refAssistantSurgeonSecondaryIdentification);
// 6)EVV- The Beginning/Ending Location of the Service Delivery (3 Address Segments each)
// Beginning Location of Service
loop24001.AllNM1.Loop2420G = new Loop_2420G_837P();
loop24001.AllNM1.Loop2420G.NM1_AmbulancePick_Location = new NM1_AmbulancePick();
loop24001.AllNM1.Loop2420G.NM1_AmbulancePick_Location.EntityIdentifierCode_01 = "PW";
loop24001.AllNM1.Loop2420G.NM1_AmbulancePick_Location.EntityTypeQualifier_02 = "2";
loop24001.AllNM1.Loop2420G.N3_AmbulancePick_LocationAddress = new N3_AdditionalPatientInformationContactAddress();
loop24001.AllNM1.Loop2420G.N3_AmbulancePick_LocationAddress.ResponseContactAddressLine_01 = "2777 HOOCH LANE";
loop24001.AllNM1.Loop2420G.N3_AmbulancePick_LocationAddress.ResponseContactAddressLine_02 = "APT 2005";
loop24001.AllNM1.Loop2420G.N4_AmbulancePick_LocationCity_State_ZipCode = new N4_AdditionalPatientInformationContactCity();
loop24001.AllNM1.Loop2420G.N4_AmbulancePick_LocationCity_State_ZipCode.AdditionalPatientInformationContactCityName_01 = "CLARICE";
loop24001.AllNM1.Loop2420G.N4_AmbulancePick_LocationCity_State_ZipCode.AdditionalPatientInformationContactStateCode_02 = "VA";
loop24001.AllNM1.Loop2420G.N4_AmbulancePick_LocationCity_State_ZipCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "22554";
// Ending Location of Service (may be same or different from Beginning Location of Service)
loop24001.AllNM1.Loop2420H = new Loop_2420H_837P();
loop24001.AllNM1.Loop2420H.NM1_AmbulanceDrop_Location = new NM1_AmbulanceDrop();
loop24001.AllNM1.Loop2420H.NM1_AmbulanceDrop_Location.EntityIdentifierCode_01 = "45";
loop24001.AllNM1.Loop2420H.NM1_AmbulanceDrop_Location.EntityTypeQualifier_02 = "2";
loop24001.AllNM1.Loop2420H.N3_AmbulanceDrop_LocationAddress = new N3_AdditionalPatientInformationContactAddress();
loop24001.AllNM1.Loop2420H.N3_AmbulanceDrop_LocationAddress.ResponseContactAddressLine_01 = "4545 RETURN ST";
loop24001.AllNM1.Loop2420H.N4_AmbulanceDrop_LocationCity_State_ZipCode = new N4_AdditionalPatientInformationContactCity();
loop24001.AllNM1.Loop2420H.N4_AmbulanceDrop_LocationCity_State_ZipCode.AdditionalPatientInformationContactCityName_01 = "NUCHOL";
loop24001.AllNM1.Loop2420H.N4_AmbulanceDrop_LocationCity_State_ZipCode.AdditionalPatientInformationContactStateCode_02 = "VA";
loop24001.AllNM1.Loop2420H.N4_AmbulanceDrop_LocationCity_State_ZipCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "22554";
// End 2400 Loop SERVICE LINE 1
loop2300.Loop2400.Add(loop24001);
// End 2300 Loop CLAIM
loop2000C.Loop2300.Add(loop2300);
// End 2000C Loop PATIENT Hierarchy
loop2000B.Loop2000C.Add(loop2000C);
// End 2000B Loop SUBSCRIBER Hierarchy
loop2000A.Loop2000B.Add(loop2000B);
// End 2000A Loop BILLING PROVIDER Hierarchy
result.Loop2000A.Add(loop2000A);
return(result);
}
