ASC X12 Version: 008010 | Transaction Set: 278 | TR3 ID: 008010X342
Business Scenario - Dental request with multiple px codes
A Provider submits an initial Dental request with multiple procedure codes using the X342 8010 version.
Inbound Transmission Explanation
ST*278*1001*008010X342~
Submitter transaction Identifier
BHT*0007*13*16139462398*20200624*0734~
HL*1**20*1~
Payer Loop
NM1*X3*2*PAYOR A*****PI*1234567~
HL*2*1*21*1~
Requesting Entity Loop
NM1*1P*1*PCPLASTNAME*PCPFIRSTNAME****XX*1234567899~
Requesting Entity
PER*IC*CONTACT NAME*TE*5556368147*EX*551~
Contact Name and other information
HL*3*2*22*1~
Subscriber Loop
NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID~
Member Data
DMG*D8*19470701*M~
HL*4*3*EV*1~
Event Loop
UM*HS*I**11:B**E~
Health Services, Initial, Office, Elective
DTP*AAH*D8*20200702~
Event Date=7/2/20
HI*ABF:K032~
Diagnosis
MSG*PROVIDER COMMENTS CAN GO HERE~
Additional information
NM1*71*1*PROVIDER*ATTENDING****XX*1234567899~
Event Provider role identification
HL*5*4*SS*0~
Service Loop
UM*HS*I~
DTP*472*RD8*20200702-20201002~
Service Date to begin on 07/02/2020
SV3*AD:D2391*****1~
Dental Service Segment
TOO*JP*12*B~
Tooth Information Segment
DN2*11*M****JP~
Tooth Status Segment
HL*6*4*SS*0~
Service Loop
UM*HS*I~
DTP*472*RD8*20200702-20201002~
Service Date to begin on 07/02/2020
SV3*AD:D2391*****1~
Dental Service Segment
TOO*JP*28*B~
Tooth Information Segment
DN2*13*M****JP~
Tooth Status Segment
SE*29*1001~
Outbound Transmission Explanation
ST*278*1001*008010X342~
Submitter transaction Identifier
BHT*0007*11*16139462398*20200624*07344807*19~
HL*1**20*1~
Payer Loop
NM1*X3*2*PAYOR A*****PI*1234567~
HL*2*1*21*1~
Requesting Entity Loop
NM1*1P*1*PCPLASTNAME*PCPFIRSTNAME****XX*1234567899~
Requesting Entity
PER*IC*CONTACT NAME*TE*5556368147*EX*551~
Contact Name and other information
HL*3*2*22*1~
Subscriber Loop
NM1*IL*1*LASTNAME*FIRSTNAME****MI*MEMBERID~
Member Data
DMG*D8*19470701*M~
HL*4*3*EV*1~
Event Loop
HCR*A4**0V~
Certification Action Code
REF*NT*5554772110000000~
Administrative Reference number
UM*HS*I**11:B**E~
Health Services, Initial, Home, Elective
DTP*AAH*D8*20200702~
Event Date=7/2/20
HI*ABF:K032~
Diagnosis
MSG*PROVIDER COMMENTS GO HERE~
NM1*71*1*PROVIDER*ATTENDING****XX*1234567899~
Event Provider role identification
HL*5*4*SS*0~
Service Loop
HCR*A4**0V~
Certification Action Code
REF*NT*5554772110000000~
Administrative Reference number
UM*HS*I~
DTP*472*RD8*20200702-20201002~
Service Date to begin on 7/2/20
SV3*AD:D2391*****1~
Dental Service Segment
TOO*JP*12*B~
Tooth Information Segment
DN2*11*M****JP~
Tooth Status Segment
HL*6*4*SS*0~
Service Loop
HCR*A4**0V~
Certification Action Code
REF*NT*5554772110000000~
Administrative Reference number
UM*HS*I~
DTP*472*RD8*20200702-20201002~
Service Date to begin on 07/02/2020
SV3*AD:D2391*****1~
Dental Service Segment
TOO*JP*28*B~
Tooth Information Segment
DN2*13*M****JP~
Tooth Status Segment
SE*33*1001~