C:\EDIdEv\Examples\HIPAA\5010\VbNet\vbNet_Gen837X222A1\Form1.vb Imports Edidev.FrameworkEDI

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Quentin Warner
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1 Imports Edidev.FrameworkEDI 1 Public Class Form1 Private Sub btngenerate_click(byval sender As System.Object, ByVal e As System.EventArgs) Handles btngenerate.click Dim oedidoc As edidocument Dim oschemas As edischemas Dim ointerchange As New ediinterchange Dim ogroup As New edigroup Dim otransactionset As New editransactionset Dim osegment As New edidatasegment Dim nbillprovider As Integer Dim nbillprovidercounter As Integer Dim nsubscribers As Integer Dim nsubscribercounter As Integer Dim ndependents As Integer Dim ndependentcounter As Integer Dim nhlcounter As Integer Dim nhlsubscriberparent As Integer Dim nhldependentparent As Integer Dim spath As String Dim sedifile As String = "837_5010X222A1.X12" Dim sseffile As String = "837_005010X222A1.SemRef.EVAL0.SEF" spath = AppDomain.CurrentDomain.BaseDirectory '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 = oedidoc.getschemas oschemas.enablestandardreference = False 'ENABLES FORWARD WRITE, AND INCREASES BUFFER I/O TO IMPROVE PERFORMANCE oedidoc.cursortype = DocumentCursorTypeConstants.Cursor_ForwardWrite oedidoc.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 ediinterchange.set(ointerchange, oedidoc.createinterchange("x", "005010")) edidatasegment.set(osegment, ointerchange.getdatasegmentheader) osegment.dataelementvalue(1) = "00" 'Authorization Information Qualifier osegment.dataelementvalue(2) = "" 'Authorization Information osegment.dataelementvalue(3) = "00" 'Security Information Qualifier osegment.dataelementvalue(4) = "" 'Security Information osegment.dataelementvalue(5) = "ZZ" 'Interchange ID Qualifier osegment.dataelementvalue(6) = "SENDER_ID" 'Interchange Sender ID osegment.dataelementvalue(7) = "ZZ" 'Interchange ID Qualifier osegment.dataelementvalue(8) = "REVEIVER_ID" 'Interchange Receiver ID osegment.dataelementvalue(9) = "020617" 'Interchange Date osegment.dataelementvalue(10) = "1816" 'Interchange Time osegment.dataelementvalue(11) = "^" 'Repetition Separator osegment.dataelementvalue(12) = "00501" 'Interchange Control Version Number osegment.dataelementvalue(13) = " " 'Interchange Control Number

2 osegment.dataelementvalue(14) = "0" 'Acknowledgment Requested osegment.dataelementvalue(15) = "T" 'Usage Indicator osegment.dataelementvalue(16) = ":" 'Component Element Separator 2 'CREATES THE GS SEGMENT edigroup.set(ogroup, ointerchange.creategroup("005010x222a1")) edidatasegment.set(osegment, ogroup.getdatasegmentheader) osegment.dataelementvalue(1) = "HC" 'Functional Identifier Code osegment.dataelementvalue(2) = "SENDER_ID" 'Application Sender's Code osegment.dataelementvalue(3) = "RECEIVER_ID" 'Application Receiver's Code osegment.dataelementvalue(4) = " " 'Date osegment.dataelementvalue(5) = "1816" 'Time osegment.dataelementvalue(6) = "206" 'Group Control Number osegment.dataelementvalue(7) = "X" 'Responsible Agency Code osegment.dataelementvalue(8) = "005010X222A1" 'Version / Release / Industry Identifier Code 'CREATES THE ST SEGMENT editransactionset.set(otransactionset, ogroup.createtransactionset("837")) edidatasegment.set(osegment, otransactionset.getdatasegmentheader) osegment.dataelementvalue(1) = "837" 'Transaction Set Identifier Code osegment.dataelementvalue(2) = "0021" 'Transaction Set Control Number osegment.dataelementvalue(3) = "005010X222A1" 'Implementation Convention Reference 'BHT BEGINNING OF HIERARCHICAL TRANSACTION edidatasegment.set(osegment, otransactionset.createdatasegment("bht")) osegment.dataelementvalue(1) = "0019" 'Hierarchical Structure Code osegment.dataelementvalue(2) = "00" 'Transaction Set Purpose Code osegment.dataelementvalue(3) = "244579" 'Reference Identification osegment.dataelementvalue(4) = " " 'Date osegment.dataelementvalue(5) = "1023" 'Time osegment.dataelementvalue(6) = "CH" 'Transaction Type Code '1000A SUBMITTER 'NM1 SUBMITTER NAME edidatasegment.set(osegment, otransactionset.createdatasegment("nm1\nm1")) osegment.dataelementvalue(1) = "41" 'Entity Identifier Code osegment.dataelementvalue(3) = "PREMIER BILLING SERVICE" 'Name Last or Organization Name osegment.dataelementvalue(8) = "46" 'Identification Code Qualifier osegment.dataelementvalue(9) = "TGJ23" 'Identification Code 'PER SUBMITTER EDI CONTACT INFO edidatasegment.set(osegment, otransactionset.createdatasegment("nm1\per")) osegment.dataelementvalue(1) = "IC" 'Contact Function Code osegment.dataelementvalue(2) = "JERRY" 'Name osegment.dataelementvalue(3) = "TE" 'Communication Number Qualifier osegment.dataelementvalue(4) = " " 'Communication Number osegment.dataelementvalue(5) = "EX" 'Communication Number Qualifier osegment.dataelementvalue(6) = "231" 'Communication Number '1000B RECEIVER 'NM1 RECEIVER edidatasegment.set(osegment, otransactionset.createdatasegment("nm1\nm1")) osegment.dataelementvalue(1) = "40" 'Entity Identifier Code osegment.dataelementvalue(3) = "KEY INSURANCE COMPANY" 'Name Last or Organization Name osegment.dataelementvalue(8) = "46" 'Identification Code Qualifier osegment.dataelementvalue(9) = "66783JJT" 'Identification Code nbillprovider = 1 'This example has one billing provider... nbillprovidercounter = 1 nsubscribers = 1 '...one subscriber nsubscribercounter = 1 ndependents = 1 '...and one dependent ndependentcounter = 1 nhlcounter = 0

3 3 '2000A BILLING PROVIDER HL LOOP Do While nbillprovidercounter <= nbillprovider 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(osegment, otransactionset.createdatasegment("hl\hl")) osegment.dataelementvalue(1) = nhlcounter 'Hierarchical ID Number osegment.dataelementvalue(3) = "20" 'Hierarchical Level Code osegment.dataelementvalue(4) = "1" 'Hierarchical Child Code 'PRV BILLING PROVIDER SPECIALTY INFORMATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\prv")) osegment.dataelementvalue(1) = "BI" 'Provider Code osegment.dataelementvalue(2) = "PXC" 'Reference Identification Qualifier osegment.dataelementvalue(3) = "203BF0100Y" 'Reference Identification '2010AA BILLING PROVIDER 'NM1 BILLING PROVIDER NAME osegment.dataelementvalue(1) = "85" 'Entity Identifier Code osegment.dataelementvalue(3) = "BEN KILDARE SERVICE" 'Name Last or Organization Name osegment.dataelementvalue(8) = "XX" 'Identification Code Qualifier osegment.dataelementvalue(9) = " " 'Identification Code 'N3 BILLING PROVIDER ADDRESS INFORMATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\n3")) osegment.dataelementvalue(1) = "234 SEAWAY ST" 'Address Information 'N4 BILLING PROVIDER LOCATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\n4")) osegment.dataelementvalue(1) = "MIAMI" 'City Name osegment.dataelementvalue(2) = "FL" 'State or Province Code osegment.dataelementvalue(3) = "33111" 'Postal Code 'REF BILLING PROVIDER TAX IDENTIFICATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\ref")) osegment.dataelementvalue(1) = "EI" 'Reference Identification Qualifier osegment.dataelementvalue(2) = " " 'Reference Identification '2010AB PAY TO PROVIDER 'NM1 PAY TO PROVIDER NAME osegment.dataelementvalue(1) = "87" 'Entity Identifier Code 'N3 PAY TO PROVIDER ADDRESS INFORMATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\n3")) osegment.dataelementvalue(1) = "2345 OCEAN BLVD" 'Address Information 'N4 PAY TO PROVIDER LOCATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\n4")) osegment.dataelementvalue(1) = "MAIMI" 'City Name osegment.dataelementvalue(2) = "FL" 'State or Province Code osegment.dataelementvalue(3) = "33111" 'Postal Code '2000B SUBSCRIBER HL LOOP Do While nsubscribercounter <= nsubscribers nhlcounter = nhlcounter + 1 nhldependentparent = nhlcounter 'HL SUBSCRIBER LEVEL edidatasegment.set(osegment, otransactionset.createdatasegment("hl\hl"))

4 osegment.dataelementvalue(1) = nhlcounter 'Hierarchical ID Number osegment.dataelementvalue(2) = nhlsubscriberparent 'Hierarchical Parent ID Number osegment.dataelementvalue(3) = "22" 'Hierarchical Level Code If ndependents > 0 Then osegment.dataelementvalue(4) = "1" 'Hierarchical Child Code Else osegment.dataelementvalue(4) = "0" 'Hierarchical Child Code End If 4 'SBR SUBSCRIBER INFORMATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\sbr")) osegment.dataelementvalue(1) = "P" 'Payer Responsibility Sequence Number Code osegment.dataelementvalue(3) = "2222 SJ" 'Reference Identification osegment.dataelementvalue(9) = "CI" 'Claim Filing Indicator Code '2010BA SUBSCRIBER 'NM1 SUBSCRIBER NAME osegment.dataelementvalue(1) = "IL" 'Entity Identifier Code osegment.dataelementvalue(2) = "1" 'Entity Type Qualifier osegment.dataelementvalue(3) = "SMITH" 'Name Last or Organization Name osegment.dataelementvalue(4) = "JANE" 'Name First osegment.dataelementvalue(8) = "MI" 'Identification Code Qualifier osegment.dataelementvalue(9) = "JS " 'Identification Code 'DMG SUBSCRIBER DEMOGRAPHIC INFORMATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\dmg")) osegment.dataelementvalue(1) = "D8" 'Date Time Period Format Qualifier osegment.dataelementvalue(2) = " " 'Date Time Period osegment.dataelementvalue(3) = "F" 'Gender Code '2010BB PAYER 'NM1 PAYER NAME osegment.dataelementvalue(1) = "PR" 'Entity Identifier Code osegment.dataelementvalue(3) = "KEY INSURANCE COMPANY" 'Name Last or Organization Name osegment.dataelementvalue(8) = "PI" 'Identification Code Qualifier osegment.dataelementvalue(9) = " " 'Identification Code 'REF BILLING PROVIDER SECONDARY IDENTIFICATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\ref")) osegment.dataelementvalue(1) = "G2" 'Reference Identification Qualifier osegment.dataelementvalue(2) = "KA6663" 'Reference Identification 'The claims loop can occur in both the HL subscriber loop and HL patient (dependent) loop If ndependents = 0 Then 'Subscriber's claims Call Proc_2300_Claim(oTransactionset) Else '2000C PATIENT HL LOOP Do While ndependentcounter <= ndependents nhlcounter = nhlcounter + 1 Number 'HL PATIENT LEVEL edidatasegment.set(osegment, otransactionset.createdatasegment("hl\hl")) osegment.dataelementvalue(1) = nhlcounter 'Hierarchical ID Number osegment.dataelementvalue(2) = nhldependentparent 'Hierarchical Parent ID osegment.dataelementvalue(3) = "23" 'Hierarchical Level Code osegment.dataelementvalue(4) = "0" 'Hierarchical Child Code 'PAT PATIENT INFORMATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\pat")) osegment.dataelementvalue(1) = "19" 'Individual Relationship Code

5 5 End Sub End If '2010CA PATIENT 'NM1 PATIENT NAME osegment.dataelementvalue(1) = "QC" 'Entity Identifier Code osegment.dataelementvalue(2) = "1" 'Entity Type Qualifier osegment.dataelementvalue(3) = "SMITH" 'Name Last or Organization Name osegment.dataelementvalue(4) = "TED" 'Name First 'N3 PATIENT ADDRESS INFORMATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\n3")) osegment.dataelementvalue(1) = "236 N MAIN ST" 'Address Information 'N4 PATIENT LOCATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\n4")) osegment.dataelementvalue(1) = "MIAMI" 'City Name osegment.dataelementvalue(2) = "FL" 'State or Province Code osegment.dataelementvalue(3) = "33413" 'Postal Code 'DMG PATIENT DEMOGRAPHIC INFORMATION edidatasegment.set(osegment, otransactionset.createdatasegment("hl\nm1\dmg")) osegment.dataelementvalue(1) = "D8" 'Date Time Period Format Qualifier osegment.dataelementvalue(2) = " " 'Date Time Period osegment.dataelementvalue(3) = "M" 'Gender Code 'Patient's claims Call Proc_2300_Claim(oTransactionset) ndependentcounter = ndependentcounter + 1 nsubscribercounter = nsubscribercounter + 1 nbillprovidercounter = nbillprovidercounter + 1 '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, sedifile) 'DESTROYS OBJECTS osegment.dispose() otransactionset.dispose() ogroup.dispose() ointerchange.dispose() oschemas.dispose() oedidoc.dispose() Private Sub Proc_2300_Claim(ByRef otransactionset As editransactionset) Dim osegment As edidatasegment Dim nclaims As Integer Dim nclaimcounter As Integer Dim nservices As Integer Dim nservicecounter As Integer nclaims = 1 'This example has one Claim... nclaimcounter = 1

6 '2300 CLAIM Do While nclaimcounter <= nclaims 'CLM HEALTH CLAIM edidatasegment.set(osegment, otransactionset.createdatasegment("hl\clm\clm")) osegment.dataelementvalue(1) = " " 'Claim Submitter's Identifier osegment.dataelementvalue(2) = "100" 'Monetary Amount osegment.dataelementvalue(5, 1) = "11" 'Facility Code Value osegment.dataelementvalue(5, 2) = "B" 'Facility Code Qualifier osegment.dataelementvalue(5, 3) = "1" 'Claim Frequency Type Code osegment.dataelementvalue(6) = "Y" 'Yes/No Condition or Response Code osegment.dataelementvalue(7) = "A" 'Provider Accept Assignment Code osegment.dataelementvalue(8) = "Y" 'Yes/No Condition or Response Code osegment.dataelementvalue(9) = "I" 'Release of Information Code 6 End Sub End Class 'REF CLAIM IDENTIFICATION NUMBER FOR CLEARING HOUSES edidatasegment.set(osegment, otransactionset.createdatasegment("hl\clm\ref")) osegment.dataelementvalue(1) = "D9" 'Reference Identification Qualifier osegment.dataelementvalue(2) = " " 'Reference Identification 'HI HEALTH CARE INFORMATION DIAGNOSIS CODES edidatasegment.set(osegment, otransactionset.createdatasegment("hl\clm\hi")) osegment.dataelementvalue(1, 1) = "BK" 'Code List Qualifier Code osegment.dataelementvalue(1, 2) = "0340" 'Industry Code osegment.dataelementvalue(2, 1) = "BF" 'Code List Qualifier Code osegment.dataelementvalue(2, 2) = "V7389" 'Industry Code nservices = 4 'This example has 4 services under this claim nservicecounter = 1 '2400 SERVICE LINE Do While nservicecounter <= nservices 'LX SERVICE LINE COUNTER edidatasegment.set(osegment, otransactionset.createdatasegment("hl\clm\lx\lx")) osegment.dataelementvalue(1) = nservicecounter 'Assigned Number 'SV1 PROFESSIONAL SERVICE edidatasegment.set(osegment, otransactionset.createdatasegment("hl\clm\lx\sv1")) osegment.dataelementvalue(1, 1) = "HC" 'Product/Service ID Qualifier osegment.dataelementvalue(1, 2) = "99213" 'Product/Service ID osegment.dataelementvalue(2) = "40" 'Monetary Amount osegment.dataelementvalue(3) = "UN" 'Unit or Basis for Measurement Code osegment.dataelementvalue(4) = "1" 'Quantity osegment.dataelementvalue(7, 1) = "1" 'Diagnosis Code Pointer 'DTP SERVICE DATE OR TIME OR PERIOD edidatasegment.set(osegment, otransactionset.createdatasegment("hl\clm\lx\dtp")) osegment.dataelementvalue(1) = "472" 'Date/Time Qualifier osegment.dataelementvalue(2) = "D8" 'Date Time Period Format Qualifier osegment.dataelementvalue(3) = " " 'Date Time Period nservicecounter = nservicecounter + 1 nclaimcounter = nclaimcounter + 1

namespace Gen837X222A1 { public partial class Form1 : Form { public Form1() { InitializeComponent(); }

namespace Gen837X222A1 { public partial class Form1 : Form { public Form1() { InitializeComponent(); } 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