/// <summary> /// Build institutional claim. /// Original from http://www.x12.org/examples/005010X223/institutional/837-institutional-claim/ /// The patient is a different person than the subscriber. The payer is a commercial health insurance company. /// Scenario: /// PRIMARY PAYER SUBSCRIBER: John T Doe /// SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111 /// SEX: M /// DOB: 11/11/1926 /// MEDICARE INSURANCE ID#: 030005074A /// PAYER ID #: 00435 /// PATIENT: Same as Primary Subscriber /// DESTINATION PAYER: Medicare B /// SUBMITTER: Jones Hospital /// EDI#: 12345 /// RECEIVER: Medicare /// EDI#: 00120 /// BILLING PROVIDER: Jones Hospital /// NPI: 9876540809 /// TIN: 567891234 /// MEDICARE PROVIDER: #330127 /// ADDRESS: 225 Main Street Barkley Building, Centerville, PA 17111 /// ATTENDING PHYSICIAN: John J Jones /// UPIN #: B99937 /// PATIENT ACCOUNT NUMBER: 756048Q /// DATE OF ADMISSION: 09/11/96 /// STATEMENT PERIOD DATE: 09/11/96 - 09/11/96 /// PLACE OF SERVICE: Inpatient Hospital /// Occurrence Codes and Dates: /// A1 11/11/26 /// A2 11/01/91 /// B1 11/11/26 /// B2 01/01/87 /// Condition Codes: 09 /// Value Codes: A2 $15.31 /// PRINCIPAL DIAGNOSIS CODE: 366.9 /// SECONDARY DIAGNOSIS CODES: /// 401.9 /// 794.31 /// NUMBER OF COVERED DAYS: 1 /// SERVICES: /// INSTITUTIONAL SERVICES RENDERED: /// REVENUE CODE: 0305 HCPCS Procedure Code: 85025 Unit: 1 Price $13.39 /// REVENUE CODE: 0730 HCPCS Procedure Code: 93005 Unit: 1 Price: $76.54 /// TOTAL CHARGES: $89.93 /// SECONDARY PAYER SUBSCRIBER: Jane S Doe(wife) /// SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111 /// SEX: F /// DOB: 12/11/1927 /// STATE TEACHERS ID#: 222004433 /// PAYER ID #: 1135 /// </summary> static TS837I BuildInstitutionalClaim(string controlNumber) { var result = new TS837I(); // ST TRANSACTION SET HEADER result.ST = new ST(); result.ST.TransactionSetIdentifierCode_01 = "837"; result.ST.TransactionSetControlNumber_02 = controlNumber.PadLeft(9, '0'); result.ST.ImplementationConventionPreference_03 = "005010X223A2"; // BHT BEGINNING OF HIERARCHICAL TRANSACTION result.BHT_BeginningofHierarchicalTransaction = new BHT_BeginningofHierarchicalTransaction_7(); result.BHT_BeginningofHierarchicalTransaction.HierarchicalStructureCode_01 = "0019"; result.BHT_BeginningofHierarchicalTransaction.TransactionSetPurposeCode_02 = "00"; result.BHT_BeginningofHierarchicalTransaction.SubmitterTransactionIdentifier_03 = "0123"; result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationDate_04 = "19960918"; result.BHT_BeginningofHierarchicalTransaction.TransactionSetCreationTime_05 = "0932"; result.BHT_BeginningofHierarchicalTransaction.TransactionTypeCode_06 = "CH"; // Occurrence of NM1 Loops in any order result.AllNM1 = new All_NM1_837I_6(); // Begin 1000A Loop SUBMITTER NAME result.AllNM1.Loop1000A = new Loop_1000A_837I(); // NM1 SUBMITTER NAME result.AllNM1.Loop1000A.NM1_SubmitterName = new NM1_InformationReceiverName_2(); result.AllNM1.Loop1000A.NM1_SubmitterName.EntityIdentifierCode_01 = "41"; result.AllNM1.Loop1000A.NM1_SubmitterName.EntityTypeQualifier_02 = "2"; result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactLastorOrganizationName_03 = "JONES HOSPITAL"; result.AllNM1.Loop1000A.NM1_SubmitterName.IdentificationCodeQualifier_08 = "46"; result.AllNM1.Loop1000A.NM1_SubmitterName.ResponseContactIdentifier_09 = "12345"; // Repeating PER Patient information result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation = new List <PER_AdditionalPatientInformationContactInformation>(); // PER SUBMITTER EDI CONTACT INFORMATION var per1 = new PER_AdditionalPatientInformationContactInformation(); per1.ContactFunctionCode_01 = "IC"; per1.ResponseContactName_02 = "JANE DOE"; per1.CommunicationNumberQualifier_03 = "TE"; per1.ResponseContactCommunicationNumber_04 = "9005555555"; result.AllNM1.Loop1000A.PER_SubmitterEDIContactInformation.Add(per1); // End 1000A Loop // Begin 1000B Loop RECEIVER NAME result.AllNM1.Loop1000B = new Loop_1000B_837I(); // NM1 RECEIVER NAME 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 = "MEDICARE"; result.AllNM1.Loop1000B.NM1_ReceiverName.IdentificationCodeQualifier_08 = "46"; result.AllNM1.Loop1000B.NM1_ReceiverName.ResponseContactIdentifier_09 = "00120"; // End 1000B Loop // Repeating 2000A Loops result.Loop2000A = new List <Loop_2000A_837I>(); // Begin 2000A Loop BILLING PROVIDER var loop2000A = new Loop_2000A_837I(); // HL BILLING PROVIDER HIERARCHICAL LEVEL loop2000A.HL_BillingProviderHierarchicalLevel = new HL_BillingProviderHierarchicalLevel(); loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalIDNumber_01 = "1"; loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalLevelCode_03 = "20"; loop2000A.HL_BillingProviderHierarchicalLevel.HierarchicalChildCode_04 = "1"; // PRV BILLING PROVIDER SPECIALTY loop2000A.PRV_BillingProviderSpecialtyInformation = new PRV_BillingProviderSpecialtyInformation(); loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderCode_01 = "BI"; loop2000A.PRV_BillingProviderSpecialtyInformation.ReferenceIdentificationQualifier_02 = "PXC"; loop2000A.PRV_BillingProviderSpecialtyInformation.ProviderTaxonomyCode_03 = "203BA0200N"; // Occurrence of NM1 Loops in any order loop2000A.AllNM1 = new All_NM1_837I(); // Begin 2010AA Loop BILLING PROVIDER NAME loop2000A.AllNM1.Loop2010AA = new Loop_2010AA_837I(); // NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID 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 = "JONES HOSPITAL"; loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.IdentificationCodeQualifier_08 = "XX"; loop2000A.AllNM1.Loop2010AA.NM1_BillingProviderName.ResponseContactIdentifier_09 = "9876540809"; // N3 BILLING PROVIDER ADDRESS loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress = new N3_AdditionalPatientInformationContactAddress(); loop2000A.AllNM1.Loop2010AA.N3_BillingProviderAddress.ResponseContactAddressLine_01 = "225 MAIN STREET BARKLEY BUILDING"; // N4 BILLING PROVIDER LOCATION loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity(); loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE"; loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA"; loop2000A.AllNM1.Loop2010AA.N4_BillingProviderCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111"; // REF BILLING PROVIDER TAX IDENTIFICATION NUMBER loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification = new REF_BillingProviderTaxIdentification_2(); loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification.ReferenceIdentificationQualifier_01 = "EI"; loop2000A.AllNM1.Loop2010AA.REF_BillingProviderTaxIdentification.MemberGrouporPolicyNumber_02 = "567891234"; // Repeating PER billing provider contact information loop2000A.AllNM1.Loop2010AA.PER_BillingProviderContactInformation = new List <PER_AdditionalPatientInformationContactInformation>(); // PER BILLING PROVIDER CONTACT INFORMATION var per2 = new PER_AdditionalPatientInformationContactInformation(); per2.ContactFunctionCode_01 = "IC"; per2.ResponseContactName_02 = "CONNIE"; per2.CommunicationNumberQualifier_03 = "TE"; per2.ResponseContactCommunicationNumber_04 = "3055551234"; loop2000A.AllNM1.Loop2010AA.PER_BillingProviderContactInformation.Add(per2); // End 2010AA Loop // Repeating 2000B Loops loop2000A.Loop2000B = new List <Loop_2000B_837I>(); // Begin 2000B Loop SUBSCRIBER HL LOOP var loop2000B = new Loop_2000B_837I(); // HL SUBSCRIBER HIERARCHICAL LEVEL 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 = "0"; // SBR SUBSCRIBER INFORMATION loop2000B.SBR_SubscriberInformation = new SBR_SubscriberInformation(); loop2000B.SBR_SubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "P"; loop2000B.SBR_SubscriberInformation.IndividualRelationshipCode_02 = "18"; loop2000B.SBR_SubscriberInformation.ClaimFilingIndicatorCode_09 = "MB"; // Occurrence of NM1 Loops in any order loop2000B.AllNM1 = new All_NM1_837I_2(); // Begin 2010BA Loop SUBSCRIBER NAME LOOP loop2000B.AllNM1.Loop2010BA = new Loop_2010BA_837I(); // NM1 SUBSCRIBER NAME loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName = new NM1_InsuredName(); loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityIdentifierCode_01 = "IL"; loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.EntityTypeQualifier_02 = "1"; loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactLastorOrganizationName_03 = "DOE"; loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactFirstName_04 = "JOHN"; loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactMiddleName_05 = "T"; loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.IdentificationCodeQualifier_08 = "MI"; loop2000B.AllNM1.Loop2010BA.NM1_SubscriberName.ResponseContactIdentifier_09 = "030005074A"; // N3 SUBSCRIBER ADDRESS loop2000B.AllNM1.Loop2010BA.N3_SubscriberAddress = new N3_AdditionalPatientInformationContactAddress(); loop2000B.AllNM1.Loop2010BA.N3_SubscriberAddress.ResponseContactAddressLine_01 = "125 CITY AVENUE"; // N4 SUBSCRIBER LOCATION loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity(); loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE"; loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA"; loop2000B.AllNM1.Loop2010BA.N4_SubscriberCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111"; // DMG SUBSCRIBER DEMOGRAPHIC INFORMATION loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation = new DMG_DependentDemographicInformation(); loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DateTimePeriodFormatQualifier_01 = "D8"; loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentBirthDate_02 = "19261111"; loop2000B.AllNM1.Loop2010BA.DMG_SubscriberDemographicInformation.DependentGenderCode_03 = "M"; // End 2010BA Loop // Begin 2010BB Loop PAYER NAME LOOP loop2000B.AllNM1.Loop2010BB = new Loop_2010BB_837I(); // NM1 PAYER NAME loop2000B.AllNM1.Loop2010BB.NM1_PayerName = new NM1_CorrectedPriorityPayerName(); loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityIdentifierCode_01 = "PR"; loop2000B.AllNM1.Loop2010BB.NM1_PayerName.EntityTypeQualifier_02 = "2"; loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactLastorOrganizationName_03 = "MEDICARE B"; loop2000B.AllNM1.Loop2010BB.NM1_PayerName.IdentificationCodeQualifier_08 = "PI"; loop2000B.AllNM1.Loop2010BB.NM1_PayerName.ResponseContactIdentifier_09 = "00435"; // Occurrence of REF Segments in any order loop2000B.AllNM1.Loop2010BB.AllREF = new All_REF_837I_3(); // REF BILLING PROVIDER SECONDARY IDENTIFICATION loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification = new REF_BillingProviderSecondaryIdentification(); loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.ReferenceIdentificationQualifier_01 = "G2"; loop2000B.AllNM1.Loop2010BB.AllREF.REF_BillingProviderSecondaryIdentification.MemberGrouporPolicyNumber_02 = "330127"; // End 2010BB Loop // Repeating 2300 Loops loop2000B.Loop2300 = new List <Loop_2300_837I_2>(); // Begin 2300 Loop CLAIM INFORMATION var loop2300 = new Loop_2300_837I_2(); // CLM CLAIM LEVEL INFORMATION loop2300.CLM_Claiminformation = new CLM_ClaimInformation(); loop2300.CLM_Claiminformation.PatientControlNumber_01 = "756048Q"; loop2300.CLM_Claiminformation.TotalClaimChargeAmount_02 = "89.93"; loop2300.CLM_Claiminformation.NonInstitutionalClaimTypeCode_04 = "14:A:1"; loop2300.CLM_Claiminformation.HealthCareServiceLocationInformation_05 = new C023_HealthCareServiceLocationInformation(); loop2300.CLM_Claiminformation.HealthCareServiceLocationInformation_05.FacilityTypeCode_01 = "A"; loop2300.CLM_Claiminformation.ProviderorSupplierSignatureIndicator_06 = "Y"; loop2300.CLM_Claiminformation.AssignmentorPlanParticipationCode_07 = "Y"; // Occurrence of DTP Segments in any order loop2300.AllDTP = new All_DTP_837I(); // DTP STATEMENT DATES loop2300.AllDTP.DTP_StatementDates = new DTP_StatementDates(); loop2300.AllDTP.DTP_StatementDates.DateTimeQualifier_01 = "434"; loop2300.AllDTP.DTP_StatementDates.DateTimePeriodFormatQualifier_02 = "RD8"; loop2300.AllDTP.DTP_StatementDates.AccidentDate_03 = "19960911"; // CL1 INSTITUTIONAL CLAIM CODE loop2300.CL1_InstitutionalClaimCode = new CL1_InstitutionalClaimCode(); loop2300.CL1_InstitutionalClaimCode.AdmissionTypeCode_01 = "3"; loop2300.CL1_InstitutionalClaimCode.PatientStatusCode_03 = "01"; // Occurrence of HI Segments in any order loop2300.AllHI = new All_HI_837I(); // HI PRINCIPAL DIAGNOSIS CODES loop2300.AllHI.HI_PrincipalDiagnosis = new HI_PrincipalDiagnosis(); loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation(); loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BK"; loop2300.AllHI.HI_PrincipalDiagnosis.HealthCareCodeInformation_01.IndustryCode_02 = "3669"; // Repeatable HI Other Diagnostics loop2300.AllHI.HI_OtherDiagnosisInformation = new List <HI_OtherDiagnosisInformation>(); // HI OTHER DIAGNOSIS INFORMATION var hi1 = new HI_OtherDiagnosisInformation(); hi1.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation(); hi1.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BF"; hi1.HealthCareCodeInformation_01.IndustryCode_02 = "4019"; hi1.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation(); hi1.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BF"; hi1.HealthCareCodeInformation_02.IndustryCode_02 = "79431"; loop2300.AllHI.HI_OtherDiagnosisInformation.Add(hi1); // Repeatable HI Occurrence Information loop2300.AllHI.HI_OccurrenceInformation = new List <HI_OccurrenceInformation>(); // HI OCCURRENCE INFORMATION var hi3 = new HI_OccurrenceInformation(); hi3.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation(); hi3.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BH"; hi3.HealthCareCodeInformation_01.IndustryCode_02 = "A1"; hi3.HealthCareCodeInformation_01.DateTimePeriodFormatQualifier_03 = "D8"; hi3.HealthCareCodeInformation_01.DateTimePeriod_04 = "19261111"; hi3.HealthCareCodeInformation_02 = new C022_HealthCareCodeInformation(); hi3.HealthCareCodeInformation_02.CodeListQualifierCode_01 = "BH"; hi3.HealthCareCodeInformation_02.IndustryCode_02 = "A2"; hi3.HealthCareCodeInformation_02.DateTimePeriodFormatQualifier_03 = "D8"; hi3.HealthCareCodeInformation_02.DateTimePeriod_04 = "19911101"; hi3.HealthCareCodeInformation_03 = new C022_HealthCareCodeInformation(); hi3.HealthCareCodeInformation_03 = new C022_HealthCareCodeInformation(); hi3.HealthCareCodeInformation_03.CodeListQualifierCode_01 = "BH"; hi3.HealthCareCodeInformation_03.IndustryCode_02 = "B1"; hi3.HealthCareCodeInformation_03.DateTimePeriodFormatQualifier_03 = "D8"; hi3.HealthCareCodeInformation_03.DateTimePeriod_04 = "19261111"; hi3.HealthCareCodeInformation_04 = new C022_HealthCareCodeInformation(); hi3.HealthCareCodeInformation_04.CodeListQualifierCode_01 = "BH"; hi3.HealthCareCodeInformation_04.IndustryCode_02 = "B2"; hi3.HealthCareCodeInformation_04.DateTimePeriodFormatQualifier_03 = "D8"; hi3.HealthCareCodeInformation_04.DateTimePeriod_04 = "19870101"; loop2300.AllHI.HI_OccurrenceInformation.Add(hi3); // Repeatable HI Value Information loop2300.AllHI.HI_ValueInformation = new List <HI_ValueInformation>(); // HI VALUE INFORMATION var hi7 = new HI_ValueInformation(); hi7.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation(); hi7.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BE"; hi7.HealthCareCodeInformation_01.IndustryCode_02 = "A2"; hi7.HealthCareCodeInformation_01.MonetaryAmount_05 = "15.31"; loop2300.AllHI.HI_ValueInformation.Add(hi7); // Repeatable HI Condition Information loop2300.AllHI.HI_ConditionInformation = new List <HI_ConditionInformation>(); // HI CONDITION INFORMATION var hi8 = new HI_ConditionInformation(); hi8.HealthCareCodeInformation_01 = new C022_HealthCareCodeInformation(); hi8.HealthCareCodeInformation_01.CodeListQualifierCode_01 = "BG"; hi8.HealthCareCodeInformation_01.IndustryCode_02 = "09"; loop2300.AllHI.HI_ConditionInformation.Add(hi8); // Occurrence of NM1 Loops in any order loop2300.AllNM1 = new All_NM1_837I_3(); // Begin 2310A Loop ATTENDING PROVIDER NAME loop2300.AllNM1.Loop2310A = new Loop_2310A_837I(); // NM1 ATTENDING PROVIDER loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName = new NM1_AttendingProviderName(); loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.EntityIdentifierCode_01 = "71"; loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.EntityTypeQualifier_02 = "1"; loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactLastorOrganizationName_03 = "JONES"; loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactFirstName_04 = "JOHN"; loop2300.AllNM1.Loop2310A.NM1_AttendingProviderName.ResponseContactMiddleName_05 = "J"; // Repeating REF Secondary Identification loop2300.AllNM1.Loop2310A.REF_AttendingProviderSecondaryIdentification = new List <REF_AssistantSurgeonSecondaryIdentification>(); // REF ATTENDING PROVIDER SECONDARY IDENTIFICATION var ref1 = new REF_AssistantSurgeonSecondaryIdentification(); ref1.ReferenceIdentificationQualifier_01 = "1G"; ref1.MemberGrouporPolicyNumber_02 = "B99937"; loop2300.AllNM1.Loop2310A.REF_AttendingProviderSecondaryIdentification.Add(ref1); // End 2310A Loop // Repeating 2320 Loops loop2300.Loop2320 = new List <Loop_2320_837I>(); // Begin 2320 Loop OTHER SUBSCRIBER INFORMATION var loop2320 = new Loop_2320_837I(); // SBR OTHER SUBSCRIBER INFORMATION loop2320.SBR_OtherSubscriberInformation = new SBR_OtherSubscriberInformation(); loop2320.SBR_OtherSubscriberInformation.PayerResponsibilitySequenceNumberCode_01 = "S"; loop2320.SBR_OtherSubscriberInformation.IndividualRelationshipCode_02 = "01"; loop2320.SBR_OtherSubscriberInformation.InsuredGrouporPolicyNumber_03 = "351630"; loop2320.SBR_OtherSubscriberInformation.OtherInsuredGroupName_04 = "STATE TEACHERS"; loop2320.SBR_OtherSubscriberInformation.ClaimFilingIndicatorCode_09 = "CI"; // OI OTHER INSURANCE COVERAGE INFORMATION loop2320.OI_OtherInsuranceCoverageInformation = new OI_OtherInsuranceCoverageInformation(); loop2320.OI_OtherInsuranceCoverageInformation.BenefitsAssignmentCertificationIndicator_03 = "Y"; loop2320.OI_OtherInsuranceCoverageInformation.ReleaseofInformationCode_06 = "Y"; // Occurrence of NM1 Loops in any order loop2320.AllNM1 = new All_NM1_837I_4(); // Begin 2330A Loop OTHER SUBSCRIBER NAME loop2320.AllNM1.Loop2330A = new Loop_2330A_837I(); // NM1 OTHER SUBSCRIBER NAME loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName = new NM1_InsuredName(); loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.EntityIdentifierCode_01 = "IL"; loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.EntityTypeQualifier_02 = "1"; loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactLastorOrganizationName_03 = "DOE"; loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactFirstName_04 = "JANE"; loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactMiddleName_05 = "S"; loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.IdentificationCodeQualifier_08 = "MI"; loop2320.AllNM1.Loop2330A.NM1_OtherSubscriberName.ResponseContactIdentifier_09 = "222004433"; // N3 OTHER SUBSCRIBER ADDRESS loop2320.AllNM1.Loop2330A.N3_OtherSubscriberAddress = new N3_AdditionalPatientInformationContactAddress(); loop2320.AllNM1.Loop2330A.N3_OtherSubscriberAddress.ResponseContactAddressLine_01 = "125 CITY AVENUE"; // N4 OTHER SUBSCRIBER CITY, STATE, ZIP CODE loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode = new N4_AdditionalPatientInformationContactCity(); loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactCityName_01 = "CENTERVILLE"; loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactStateCode_02 = "PA"; loop2320.AllNM1.Loop2330A.N4_OtherSubscriberCity_State_ZIPCode.AdditionalPatientInformationContactPostalZoneorZIPCode_03 = "17111"; // End 2330A Loop // Begin 2330B Loop OTHER PAYER NAME loop2320.AllNM1.Loop2330B = new Loop_2330B_837I(); // NM1 OTHER PAYER NAME loop2320.AllNM1.Loop2330B.NM1_OtherPayerName = new NM1_CorrectedPriorityPayerName(); loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.EntityIdentifierCode_01 = "PR"; loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.EntityTypeQualifier_02 = "2"; loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.ResponseContactLastorOrganizationName_03 = "STATE TEACHERS"; loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.IdentificationCodeQualifier_08 = "PI"; loop2320.AllNM1.Loop2330B.NM1_OtherPayerName.ResponseContactIdentifier_09 = "1135"; // End 2330B Loop // End 2320 Loop loop2300.Loop2320.Add(loop2320); // Repeating 2400 Loops loop2300.Loop2400 = new List <Loop_2400_837I>(); // Begin 2400 Loop 1 SERVICE LINE var loop24001 = new Loop_2400_837I(); // LX SERVICE LINE COUNTER loop24001.LX_ServiceLineNumber = new LX_HeaderNumber(); loop24001.LX_ServiceLineNumber.AssignedNumber_01 = "1"; // SV2 INSTITUTIONAL SERVICE loop24001.SV2_InstitutionalServiceLine = new SV2_InstitutionalServiceLine(); loop24001.SV2_InstitutionalServiceLine.ServiceLineRevenueCode_01 = "0305"; loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02 = new C003_CompositeMedicalProcedureIdentifier(); loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProductorServiceIDQualifier_01 = "HC"; loop24001.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProcedureCode_02 = "85025"; loop24001.SV2_InstitutionalServiceLine.LineItemChargeAmount_03 = "13.39"; loop24001.SV2_InstitutionalServiceLine.UnitorBasisforMeasurementCode_04 = "UN"; loop24001.SV2_InstitutionalServiceLine.ServiceUnitCount_05 = "1"; // DTP DATE - SERVICE DATES loop24001.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate(); loop24001.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472"; loop24001.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8"; loop24001.DTP_Date_ServiceDate.AccidentDate_03 = "19960911"; // End 2400 Loop 1 loop2300.Loop2400.Add(loop24001); // Begin 2400 Loop 2 SERVICE LINE var loop24002 = new Loop_2400_837I(); // LX SERVICE LINE COUNTER loop24002.LX_ServiceLineNumber = new LX_HeaderNumber(); loop24002.LX_ServiceLineNumber.AssignedNumber_01 = "2"; // SV2 INSTITUTIONAL SERVICE loop24002.SV2_InstitutionalServiceLine = new SV2_InstitutionalServiceLine(); loop24002.SV2_InstitutionalServiceLine.ServiceLineRevenueCode_01 = "0730"; loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02 = new C003_CompositeMedicalProcedureIdentifier(); loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProductorServiceIDQualifier_01 = "HC"; loop24002.SV2_InstitutionalServiceLine.CompositeMedicalProcedureIdentifier_02.ProcedureCode_02 = "93005"; loop24002.SV2_InstitutionalServiceLine.LineItemChargeAmount_03 = "76.54"; loop24002.SV2_InstitutionalServiceLine.UnitorBasisforMeasurementCode_04 = "UN"; loop24002.SV2_InstitutionalServiceLine.ServiceUnitCount_05 = "3"; // DTP DATE - SERVICE DATES loop24002.DTP_Date_ServiceDate = new DTP_ClaimLevelServiceDate(); loop24002.DTP_Date_ServiceDate.DateTimeQualifier_01 = "472"; loop24002.DTP_Date_ServiceDate.DateTimePeriodFormatQualifier_02 = "D8"; loop24002.DTP_Date_ServiceDate.AccidentDate_03 = "19960911"; // End 2400 Loop 2 loop2300.Loop2400.Add(loop24002); // End 2300 Loop loop2000B.Loop2300.Add(loop2300); // End 2000B Loop loop2000A.Loop2000B.Add(loop2000B); // End 2000A Loop 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_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_2(); 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_AdditionalPatientInformationContactInformation>(); // CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231 var perLoop1000A = new PER_AdditionalPatientInformationContactInformation(); 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(); 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_InsuredName(); 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_DependentDemographicInformation(); 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_CorrectedPriorityPayerName(); 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_DependentName_2(); 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_DependentDemographicInformation(); 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(); loop2300.CLM_ClaimInformation.PatientControlNumber_01 = "26463774"; loop2300.CLM_ClaimInformation.TotalClaimChargeAmount_02 = "100"; loop2300.CLM_ClaimInformation.HealthCareServiceLocationInformation_05 = new C023_HealthCareServiceLocationInformation(); 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(); 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(); 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(); 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.AccidentDate_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_OtherPayerSupervisingProvider(); 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>(); // Attendant's ID var refAssistantSurgeonSecondaryIdentification = new REF_AssistantSurgeonSecondaryIdentification(); 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); }