namespace csharp_gen837x223a2 { public partial class Form1 : Form { public Form1() { InitializeComponent(); }

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1 using System; using System.Collections.Generic; using System.ComponentModel; using System.Data; using System.Drawing; using System.Text; using System.Windows.Forms; using Edidev.FrameworkEDI; 1 namespace csharp_gen837x223a2 public partial class Form1 : Form public Form1() InitializeComponent(); private void btngenerate_click(object sender, EventArgs e) edidocument oedidoc; edischemas oschemas; ediinterchange ointerchange; edigroup ogroup; editransactionset otransactionset; edidatasegment osegment; int nbillprovider; int nsubscribers; int ndependents; int nhlcounter; int nhlsubscriberparent; int nhldependentparent; string spath = AppDomain.CurrentDomain.BaseDirectory; string sedifile = "837_5010X223A2.X12"; string sseffile = "837_005010X223A2.SemRef.EVAL0.SEF"; //CREATES OEDIDOC OBJECT oedidoc = new edidocument(); //THIS MAKES CERTAIN THAT FREDI ONLY USES THE SEF FILE PROVIDED, AND THAT IT DOES //NOT USE ITS BUILT IN STANDARD REFERENCE TABLE TO GENERATE THE EDI FILE. oschemas = (edischemas)oedidoc.getschemas(); oschemas.enablestandardreference = false; //ENABLES FORWARD WRITE, AND INCREASES BUFFER I/O TO IMPROVE PERFORMANCE oedidoc.cursortype = DocumentCursorTypeConstants.Cursor_ForwardWrite; oedidoc.set_property(documentpropertyidconstants.property_documentbufferio, 200); //SET TERMINATORS oedidoc.segmentterminator = "~"; oedidoc.elementterminator = "*"; oedidoc.compositeterminator = ":"; //LOADS THE SEF FILE oedidoc.loadschema(spath + sseffile, 0); //CREATES THE ISA SEGMENT ointerchange = (ediinterchange)oedidoc.createinterchange("x", "005010"); osegment = (edidatasegment)ointerchange.getdatasegmentheader(); osegment.set_dataelementvalue(1, 0, "00"); //Authorization Information Qualifier

2 osegment.set_dataelementvalue(2, 0, ""); //Authorization Information osegment.set_dataelementvalue(3, 0, "00"); //Security Information Qualifier osegment.set_dataelementvalue(4, 0, ""); //Security Information osegment.set_dataelementvalue(5, 0, "ZZ"); //Interchange ID Qualifier osegment.set_dataelementvalue(6, 0, "SENDER_ID"); //Interchange Sender ID osegment.set_dataelementvalue(7, 0, "ZZ"); //Interchange ID Qualifier osegment.set_dataelementvalue(8, 0, "REVEIVER_ID"); //Interchange Receiver ID osegment.set_dataelementvalue(9, 0, "020617"); //Interchange Date osegment.set_dataelementvalue(10, 0, "1816"); //Interchange Time osegment.set_dataelementvalue(11, 0, "^"); //Repetition Separator osegment.set_dataelementvalue(12, 0, "00501"); //Interchange Control Version Number osegment.set_dataelementvalue(13, 0, " "); //Interchange Control Number osegment.set_dataelementvalue(14, 0, "0"); //Acknowledgment Requested osegment.set_dataelementvalue(15, 0, "T"); //Usage Indicator osegment.set_dataelementvalue(16, 0, ":"); //Component Element Separator 2 //CREATES THE GS SEGMENT ogroup = (edigroup)ointerchange.creategroup("005010x223a2"); edidatasegment.set(ref osegment, ogroup.getdatasegmentheader()); osegment.set_dataelementvalue(1, 0, "HC"); //Functional Identifier Code osegment.set_dataelementvalue(2, 0, "SENDER_ID"); //Application Sender//s Code osegment.set_dataelementvalue(3, 0, "RECEIVER_ID"); //Application Receiver//s Code osegment.set_dataelementvalue(4, 0, " "); //Date osegment.set_dataelementvalue(5, 0, "1816"); //Time osegment.set_dataelementvalue(6, 0, "206"); //Group Control Number osegment.set_dataelementvalue(7, 0, "X"); //Responsible Agency Code osegment.set_dataelementvalue(8, 0, "005010X223A2"); //Version / Release / Industry Identifier Code //CREATES THE ST SEGMENT otransactionset = (editransactionset)ogroup.createtransactionset("837"); edidatasegment.set(ref osegment, otransactionset.getdatasegmentheader()); osegment.set_dataelementvalue(1, 0, "837"); //Transaction Set Identifier Code osegment.set_dataelementvalue(2, 0, "987654"); //Transaction Set Control Number osegment.set_dataelementvalue(3, 0, "005010X223A2"); //Implementation Convention Reference //BHT BEGINNING OF HIERARCHICAL TRANSACTION edidatasegment.set(ref osegment, otransactionset.createdatasegment("bht")); osegment.set_dataelementvalue(1, 0, "0019"); //Hierarchical Structure Code osegment.set_dataelementvalue(2, 0, "00"); //Transaction Set Purpose Code osegment.set_dataelementvalue(3, 0, "0123"); //Reference Identification osegment.set_dataelementvalue(4, 0, " "); //Date osegment.set_dataelementvalue(5, 0, "1023"); //Time osegment.set_dataelementvalue(6, 0, "CH"); //Transaction Type Code //1000A SUBMITTER //NM1 SUBMITTER NAME edidatasegment.set(ref osegment, otransactionset.createdatasegment("nm1\\nm1")); osegment.set_dataelementvalue(1, 0, "41"); //Entity Identifier Code osegment.set_dataelementvalue(2, 0, "2"); //Entity Type Qualifier osegment.set_dataelementvalue(3, 0, "JONES HOSPITAL"); //Name Last or Organization Name osegment.set_dataelementvalue(8, 0, "46"); //Identification Code Qualifier osegment.set_dataelementvalue(9, 0, "12345"); //Identification Code //PER SUBMITTER EDI CONTACT INFO edidatasegment.set(ref osegment, otransactionset.createdatasegment("nm1\\per")); osegment.set_dataelementvalue(1, 0, "IC"); //Contact Function Code osegment.set_dataelementvalue(2, 0, "JANE DOE"); //Name osegment.set_dataelementvalue(3, 0, "TE"); //Communication Number Qualifier osegment.set_dataelementvalue(4, 0, " "); //Communication Number //osegment.set_dataelementvalue(5, 0, "EX"); //Communication Number Qualifier //osegment.set_dataelementvalue(6, 0, "231"); //Communication Number //1000B RECEIVER //NM1 RECEIVER edidatasegment.set(ref osegment, otransactionset.createdatasegment("nm1\\nm1"));

3 osegment.set_dataelementvalue(1, 0, "40"); //Entity Identifier Code osegment.set_dataelementvalue(2, 0, "2"); //Entity Type Qualifier osegment.set_dataelementvalue(3, 0, "MEDICARE"); //Name Last or Organization Name osegment.set_dataelementvalue(8, 0, "46"); //Identification Code Qualifier osegment.set_dataelementvalue(9, 0, "00120"); //Identification Code 3 nbillprovider = 1; nsubscribers = 1; ndependents = 1; nhlcounter = 0; //This example has one billing provider... //...one subscriber //...and one dependent //2000A BILLING PROVIDER HL LOOP for (int nbillprovidercounter = 1; nbillprovidercounter <= nbillprovider; nbillprovidercounter+ +) nhlcounter = nhlcounter + 1; //increment HL loop nhlsubscriberparent = nhlcounter; //The value of this HL counter is the HL parent for the HL subscriber loop //HL BILLING PROVIDER edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\hl")); osegment.set_dataelementvalue(1, 0, nhlcounter.tostring()); //Hierarchical ID Number osegment.set_dataelementvalue(3, 0, "20"); //Hierarchical Level Code osegment.set_dataelementvalue(4, 0, "1"); //Hierarchical Child Code //PRV BILLING PROVIDER SPECIALTY INFORMATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\prv")); osegment.set_dataelementvalue(1, 0, "BI"); //Provider Code osegment.set_dataelementvalue(2, 0, "PXC"); //Reference Identification Qualifier osegment.set_dataelementvalue(3, 0, "203BA0200N"); //Reference Identification //2010AA BILLING PROVIDER //NM1 BILLING PROVIDER NAME edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\nm1")); osegment.set_dataelementvalue(1, 0, "85"); //Entity Identifier Code osegment.set_dataelementvalue(2, 0, "2"); //Entity Type Qualifier osegment.set_dataelementvalue(3, 0, "JONES HOSPITAL"); //Name Last or Organization Name osegment.set_dataelementvalue(8, 0, "XX"); //Identification Code Qualifier osegment.set_dataelementvalue(9, 0, " "); //Identification Code //N3 BILLING PROVIDER ADDRESS INFORMATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\n3")); osegment.set_dataelementvalue(1, 0, "225 MAIN STREET BARKLEY BUILDING"); //Address Information //N4 BILLING PROVIDER LOCATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\n4")); osegment.set_dataelementvalue(1, 0, "CENTERVILLE"); //City Name osegment.set_dataelementvalue(2, 0, "PA"); //State or Province Code osegment.set_dataelementvalue(3, 0, "17111"); //Postal Code //REF BILLING PROVIDER TAX IDENTIFICATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\ref")); osegment.set_dataelementvalue(1, 0, "EI"); //Reference Identification Qualifier osegment.set_dataelementvalue(2, 0, " "); //Reference Identification ////2010AB PAY TO PROVIDER ////NM1 PAY TO PROVIDER NAME //edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\nm1")); //osegment.set_dataelementvalue(1, 0, "87"); //Entity Identifier Code //osegment.set_dataelementvalue(2, 0, "2"); //Entity Type Qualifier ////N3 PAY TO PROVIDER ADDRESS INFORMATION //edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\n3")); //osegment.set_dataelementvalue(1, 0, "2345 OCEAN BLVD"); //Address Information

4 ////N4 PAY TO PROVIDER LOCATION //edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\n4")); //osegment.set_dataelementvalue(1, 0, "MAIMI"); //City Name //osegment.set_dataelementvalue(2, 0, "FL"); //State or Province Code //osegment.set_dataelementvalue(3, 0, "33111"); //Postal Code 4 //2000B SUBSCRIBER HL LOOP for (int nsubscribercounter = 1; nsubscribercounter <= nsubscribers; nsubscribercounter++) nhlcounter = nhlcounter + 1; nhldependentparent = nhlcounter; //HL SUBSCRIBER LEVEL edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\hl")); osegment.set_dataelementvalue(1, 0, nhlcounter.tostring()); //Hierarchical ID Number osegment.set_dataelementvalue(2, 0, nhlsubscriberparent.tostring()); //Hierarchical Parent ID Number osegment.set_dataelementvalue(3, 0, "22"); //Hierarchical Level Code if (ndependents > 0) osegment.set_dataelementvalue(4, 0, "1"); //Hierarchical Child Code else osegment.set_dataelementvalue(4, 0, "0"); //Hierarchical Child Code Code //SBR SUBSCRIBER INFORMATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\sbr")); osegment.set_dataelementvalue(1, 0, "P"); //Payer Responsibility Sequence Number osegment.set_dataelementvalue(2, 0, ""); // Individual Relationship Code (1069) //osegment.set_dataelementvalue(3, 0, ""); //Reference Identification osegment.set_dataelementvalue(9, 0, "MB"); //Claim Filing Indicator Code //2010BA SUBSCRIBER //NM1 SUBSCRIBER NAME edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\nm1")); osegment.set_dataelementvalue(1, 0, "IL"); //Entity Identifier Code osegment.set_dataelementvalue(2, 0, "1"); //Entity Type Qualifier osegment.set_dataelementvalue(3, 0, "DOE"); //Name Last or Organization Name osegment.set_dataelementvalue(4, 0, "JOHN"); //Name First osegment.set_dataelementvalue(5, 0, "T"); // Name Middle (1037) osegment.set_dataelementvalue(8, 0, "MI"); //Identification Code Qualifier osegment.set_dataelementvalue(9, 0, " A"); //Identification Code (166) // Subscriber Address (N3) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\n3")); osegment.set_dataelementvalue(1, 0, "125 CITY AVENUE"); // Address Information // Subscriber City, State, ZIP Code (N4) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\n4")); osegment.set_dataelementvalue(1, 0, "CENTERVILLE"); // City Name (19) osegment.set_dataelementvalue(2, 0, "PA"); // State or Province Code (156) osegment.set_dataelementvalue(3, 0, "17111"); // Postal Code (116) //osegment.set_dataelementvalue(4, 0, "IDI"); // Country Code (26) //osegment.set_dataelementvalue(7, 0, "IDI"); // Country Subdivision Code (1715) //DMG SUBSCRIBER DEMOGRAPHIC INFORMATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\dmg")); osegment.set_dataelementvalue(1, 0, "D8"); //Date Time Period Format Qualifier osegment.set_dataelementvalue(2, 0, " "); //Date Time Period osegment.set_dataelementvalue(3, 0, "M"); //Gender Code

5 //2010BB PAYER //NM1 PAYER NAME edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\nm1")); osegment.set_dataelementvalue(1, 0, "PR"); //Entity Identifier Code osegment.set_dataelementvalue(2, 0, "2"); //Entity Type Qualifier osegment.set_dataelementvalue(3, 0, "MEDICARE B"); //Name Last or Organization Name osegment.set_dataelementvalue(8, 0, "PI"); //Identification Code Qualifier osegment.set_dataelementvalue(9, 0, "00435"); //Identification Code //REF BILLING PROVIDER SECONDARY IDENTIFICATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\ref")); osegment.set_dataelementvalue(1, 0, "G2"); //Reference Identification Qualifier osegment.set_dataelementvalue(2, 0, "330127"); //Reference Identification 5 loop ++) //The claims loop can occur in both the HL subscriber loop and HL patient (dependent) if (ndependents == 0) //Subscriber//s claims Proc_2300_Claim(oTransactionset); else //2000C PATIENT HL LOOP for (int ndependentcounter = 1; ndependentcounter <= ndependents; ndependentcounter nhlcounter = nhlcounter + 1; //HL PATIENT LEVEL edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\hl")); osegment.set_dataelementvalue(1, 0, nhlcounter.tostring()); //Hierarchical ID Number osegment.set_dataelementvalue(2, 0, nhldependentparent.tostring()); // Hierarchical Parent ID Number osegment.set_dataelementvalue(3, 0, "23"); //Hierarchical Level Code osegment.set_dataelementvalue(4, 0, "0"); //Hierarchical Child Code //PAT PATIENT INFORMATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\pat")); osegment.set_dataelementvalue(1, 0, "19"); //Individual Relationship Code NM1")); Name ")); ")); //2010CA PATIENT //NM1 PATIENT NAME edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\ osegment.set_dataelementvalue(1, 0, "QC"); osegment.set_dataelementvalue(2, 0, "1"); osegment.set_dataelementvalue(3, 0, "SMITH"); osegment.set_dataelementvalue(4, 0, "TED"); //Entity Identifier Code //Entity Type Qualifier //Name Last or Organization //Name First //N3 PATIENT ADDRESS INFORMATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\n3 osegment.set_dataelementvalue(1, 0, "236 N MAIN ST"); //Address Information //N4 PATIENT LOCATION edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\n4 osegment.set_dataelementvalue(1, 0, "MIAMI"); osegment.set_dataelementvalue(2, 0, "FL"); osegment.set_dataelementvalue(3, 0, "33413"); //City Name //State or Province Code //Postal Code //DMG PATIENT DEMOGRAPHIC INFORMATION

6 edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\nm1\\ DMG")); osegment.set_dataelementvalue(1, 0, "D8"); //Date Time Period Format Qualifier osegment.set_dataelementvalue(2, 0, " "); //Date Time Period osegment.set_dataelementvalue(3, 0, "M"); //Gender Code 6 //Patient//s claims Proc_2300_Claim(oTransactionset); ; // for 2000C patient ; // if dependent ; //for 2000B subscriber ; //for 2000A billing //TRAILING SEGMENTS ARE AUTOMATICALLY CREATED WHEN FREDI COMMITS (SAVES) //THE EDIDOC OBJECT INTO AN EDI FILE. oedidoc.save(spath + sedifile); //DISPLAY EDI ON SCREEN MessageBox.Show(oEdiDoc.GetEdiString(),"Health Care Claim: Institutional X223A2" ); //DESTROYS OBJECTS osegment.dispose(); otransactionset.dispose(); ogroup.dispose(); ointerchange.dispose(); oschemas.dispose(); oedidoc.dispose(); // btngenerate private void Proc_2300_Claim(ediTransactionSet otransactionset) edidatasegment osegment=null; int nclaims ; int nservices ; nclaims = 1; //This example has one Claim... //2300 CLAIM for (int nclaimcounter=1; nclaimcounter <= nclaims; nclaimcounter++) //CLM HEALTH CLAIM edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\clm")); osegment.set_dataelementvalue(1, 0, "756048Q"); //Claim Submitter//s Identifier osegment.set_dataelementvalue(2, 0, "89.93"); //Monetary Amount osegment.set_dataelementvalue(5, 1, 0, "14"); //Facility Code Value osegment.set_dataelementvalue(5, 2, 0, "A"); //Facility Code Qualifier osegment.set_dataelementvalue(5, 3, 0, "1"); //Claim Frequency Type Code osegment.set_dataelementvalue(7, 0, "A"); //Provider Accept Assignment Code osegment.set_dataelementvalue(8, 0, "Y"); //Yes/No Condition or Response Code osegment.set_dataelementvalue(9, 0, "Y"); //Release of Information Code (1250) // Statement Date (DTP) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\dtp")); osegment.set_dataelementvalue(1, 0, "434"); // Date/Time Qualifier (374) osegment.set_dataelementvalue(2, 0, "RD8"); // Date Time Period Format Qualifier osegment.set_dataelementvalue(3, 0, " "); // Date Time Period (1251) //// Received Date (DTP)

7 (1250) //edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\dtp(2)")); //osegment.set_dataelementvalue(1, 0, "050"); // Date/Time Qualifier (374) //osegment.set_dataelementvalue(2, 0, "D8"); // Date Time Period Format Qualifier //osegment.set_dataelementvalue(3, 0, " "); // Date Time Period (1251) 7 // Claim Codes (CL1) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\cl1")); osegment.set_dataelementvalue(1, 0, "3"); // Admission Type Code (1315) osegment.set_dataelementvalue(2, 0, ""); // Admission Source Code (1314) osegment.set_dataelementvalue(3, 0, "01"); // Patient Status Code (1352) //HI HEALTH CARE INFORMATION DIAGNOSIS CODES Principal Diagnosis edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\hi")); osegment.set_dataelementvalue(1, 1, 0, "BK"); //Code List Qualifier Code osegment.set_dataelementvalue(1, 2, 0, "3669"); //Industry Code //HI HEALTH CARE INFORMATION DIAGNOSIS CODES Other Diagnosis Information edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\hi(2)")); osegment.set_dataelementvalue(1, 1, 0, "BF"); //Code List Qualifier Code osegment.set_dataelementvalue(1, 2, 0, "4019"); //Industry Code osegment.set_dataelementvalue(2, 1, 0, "BF"); //Code List Qualifier Code osegment.set_dataelementvalue(2, 2, 0, "79431"); //Industry Code //HI HEALTH CARE INFORMATION DIAGNOSIS CODES Occurrence Information edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\hi(3)")); osegment.set_dataelementvalue(1, 1, "BH"); // Code List Qualifier Code (1270) osegment.set_dataelementvalue(1, 2, "A1"); // Industry Code (1271) osegment.set_dataelementvalue(1, 3, "D8"); // Date Time Period Format Qualifier (1250) osegment.set_dataelementvalue(1, 4, " "); // Date Time Period (1251) osegment.set_dataelementvalue(2, 1, "BH"); // Code List Qualifier Code (1270) osegment.set_dataelementvalue(2, 2, "A2"); // Industry Code (1271) osegment.set_dataelementvalue(2, 3, "D8"); // Date Time Period Format Qualifier (1250) osegment.set_dataelementvalue(2, 4, " "); // Date Time Period (1251) osegment.set_dataelementvalue(3, 1, "BH"); // Code List Qualifier Code (1270) osegment.set_dataelementvalue(3, 2, "B1"); // Industry Code (1271) osegment.set_dataelementvalue(3, 3, "D8"); // Date Time Period Format Qualifier (1250) osegment.set_dataelementvalue(3, 4, " "); // Date Time Period (1251) osegment.set_dataelementvalue(4, 1, "BH"); // Code List Qualifier Code (1270) osegment.set_dataelementvalue(4, 2, "B2"); // Industry Code (1271) osegment.set_dataelementvalue(4, 3, "D8"); // Date Time Period Format Qualifier (1250) osegment.set_dataelementvalue(4, 4, " "); // Date Time Period (1251) //HI HEALTH CARE INFORMATION DIAGNOSIS CODES Value Information edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\hi(4)")); osegment.set_dataelementvalue(1, 1, "BE"); // Code List Qualifier Code (1270) osegment.set_dataelementvalue(1, 2, "A2"); // Industry Code (1271) osegment.set_dataelementvalue(1, 3, ""); // Date Time Period Format Qualifier (1250) osegment.set_dataelementvalue(1, 4, ""); // Date Time Period (1251) osegment.set_dataelementvalue(1, 5, "15.31"); // Monetary Amount (782) //HI HEALTH CARE INFORMATION DIAGNOSIS CODES Condition Information edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\hi(5)")); osegment.set_dataelementvalue(1, 1, "BG"); // Code List Qualifier Code (1270) osegment.set_dataelementvalue(1, 2, "09"); // Industry Code (1271) // 2310A ATTENDING PROVIDER NAME // Attending Provider Name (NM1) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\nm1\\nm1")); osegment.set_dataelementvalue(1, 0, "71"); // Entity Identifier Code (98) osegment.set_dataelementvalue(2, 0, "1"); // Entity Type Qualifier (1065)

8 (1035) osegment.set_dataelementvalue(3, 0, "JONES"); // Name Last or Organization Name osegment.set_dataelementvalue(4, 0, "JOHN"); // Name First (1036) osegment.set_dataelementvalue(5, 0, "J"); // Name Middle (1037) 8 Code (1138) // Attending Provider Secondary Identification (REF) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\nm1\\ref")); osegment.set_dataelementvalue(1, 0, "1G"); // Reference Identification Qualifier (128) osegment.set_dataelementvalue(2, 0, "B99937"); // Reference Identification (127) // 2320 OTHER SUBSCRIBER INFORMATION // Subscriber Information (SBR) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\sbr\\sbr")); osegment.set_dataelementvalue(1, 0, "S"); // Payer Responsibility Sequence Number osegment.set_dataelementvalue(2, 0, "01"); // Individual Relationship Code (1069) osegment.set_dataelementvalue(3, 0, "351630"); // Reference Identification (127) osegment.set_dataelementvalue(4, 0, "STATE TEACHERS"); // Name (93) osegment.set_dataelementvalue(9, 0, "CI"); // Claim Filing Indicator Code (1032) // Other Health Insurance Information (OI) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\sbr\\oi")); osegment.set_dataelementvalue(3, 0, "Y"); // Yes/No Condition or Response Code (1073) osegment.set_dataelementvalue(6, 0, "Y"); // Release of Information Code (1363) (1035) )); (166) )); // 2330A OTHER SUBSCRIBER NAME // Other Subscriber Name (NM1) osegment = otransactionset.createdatasegment("hl\\clm\\sbr\\nm1\\nm1"); osegment.set_dataelementvalue(1, 0, "IL"); // Entity Identifier Code (98) osegment.set_dataelementvalue(2, 0, "1"); // Entity Type Qualifier (1065) osegment.set_dataelementvalue(3, 0, "DOE"); // Name Last or Organization Name osegment.set_dataelementvalue(4, 0, "JANE"); // Name First (1036) osegment.set_dataelementvalue(5, 0, "S"); // Name Middle (1037) //osegment.set_dataelementvalue(7, 0, ""); // Name Suffix (1039) osegment.set_dataelementvalue(8, 0, "MI"); // Identification Code Qualifier (66) osegment.set_dataelementvalue(9, 0, " "); // Identification Code (67) // Other Subscriber Address (N3) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\sbr\\nm1\\n3" osegment.set_dataelementvalue(1, 0, "125 CITY AVENUE"); // Address Information // Other Subscriber City, State, ZIP Code (N4) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\sbr\\nm1\\n4" osegment.set_dataelementvalue(1, 0, "CENTERVILLE"); // City Name (19) osegment.set_dataelementvalue(2, 0, "PA"); // State or Province Code (156) osegment.set_dataelementvalue(3, 0, "17111"); // Postal Code (116) //osegment.set_dataelementvalue(4, 0, ""); // Country Code (26) //osegment.set_dataelementvalue(7, 0, ""); // Country Subdivision Code (1715) Name (1035) // 2330B OTHER PAYER NAME // Other Payer Name (NM1) osegment = otransactionset.createdatasegment("hl\\clm\\sbr\\nm1\\nm1"); osegment.set_dataelementvalue(1, 0, "PR"); // Entity Identifier Code (98) osegment.set_dataelementvalue(2, 0, "2"); // Entity Type Qualifier (1065) osegment.set_dataelementvalue(3, 0, "STATE TEACHERS"); // Name Last or Organization osegment.set_dataelementvalue(8, 0, "PI"); // Identification Code Qualifier (66) osegment.set_dataelementvalue(9, 0, "1135"); // Identification Code (67)

9 nservices = 4 ; //This example has 4 services under this claim 9 //2400 SERVICE LINE for(int nservicecounter=1 ; nservicecounter <= nservices; nservicecounter++) //LX SERVICE LINE COUNTER edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\lx\\lx")); osegment.set_dataelementvalue(1, 0, nservicecounter.tostring()); //Assigned Number ; (355) ; // Institutional Service (SV2) edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\lx\\sv2")) osegment.set_dataelementvalue(1, 0, "0305"); // Product/Service ID (234) osegment.set_dataelementvalue(2, 1, "HC"); // Product/Service ID Qualifier (235) osegment.set_dataelementvalue(2, 2, "85025"); // Product/Service ID (234) //osegment.set_dataelementvalue(2, 3, ""); // Procedure Modifier (1339) //osegment.set_dataelementvalue(2, 4, ""); // Procedure Modifier (1339) //osegment.set_dataelementvalue(2, 5, ""); // Procedure Modifier (1339) //osegment.set_dataelementvalue(2, 6, ""); // Procedure Modifier (1339) //osegment.set_dataelementvalue(2, 7, ""); // Description (352) osegment.set_dataelementvalue(3, 0, "13.39"); // Monetary Amount (782) osegment.set_dataelementvalue(4, 0, "UN"); // Unit or Basis for Measurement Code osegment.set_dataelementvalue(5, 0, "1"); // Quantity (380) //osegment.set_dataelementvalue(7, 0, ""); // Monetary Amount (782) //DTP SERVICE DATE OR TIME OR PERIOD edidatasegment.set(ref osegment, otransactionset.createdatasegment("hl\\clm\\lx\\dtp")) osegment.set_dataelementvalue(1, 0, "472"); //Date/Time Qualifier osegment.set_dataelementvalue(2, 0, "D8"); //Date Time Period Format Qualifier osegment.set_dataelementvalue(3, 0, " "); //Date Time Period //for 2400 service line //for 2300 claim //private void Proc_2300_Claim

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