X12

Example

ASC X12 Version: 005010 | Transaction Set: 999 | TR3 ID: 005010X231

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EDI Transmission

The following example describes a 999 transaction set that is responding to a functional group that was received containing three 837 transaction sets. The first transaction set conformed fully with the X12 standard, while the second and third contained errors.

The Interchange Control and Functional Group segments (ISA, GS, GE, and IEA) are required in the ASC X12 message. See Appendix C for additional details on these segments.

ISA*00*          *00*          *ZZ*123456789012345
*ZZ*123456789012346*080503*1705*>*00501*000010216*0*T*:~
GS*FA*1234567890*2345678901*20080503*1705*20213*X*005010X231A1~

The ST segment indicates the beginning of the 999 transaction set, control number 2870001.

ST*999*2870001*005010X231A1~

The AK1 segment describes the functional group to which this 999 is responding.

AK1*HC*17456*005010X222A2~

The first Transaction Response Loop indicates that the received transaction set, control number 0001, was accepted with no errors.

AK2*837*0001~
IK5*A~

The second Transaction Response Loop indicates that the received transaction set, control number 0002, was rejected due to a missing CLM02 data element. The CTX segment identifies the Business Unit (i.e. the claim) that was in error.

AK2*837*0002~
IK3*CLM*22**8~
CTX*CLM01:123456789~
IK4*2*782*1~
IK5*R*5~

The third Transaction Response Loop indicates that the received transaction set, control number 003, was rejected due to a missing REF (Original Reference Number ICN/DCN) segment. This segment is required by the implementation guide when CLM05-3 = 6, 7, or 8. The IK3 segment indicates the missing REF segment, and the first CTX segment indicates the CLM05-3 as the reason for the missing REF segment. The second CTX identifies the Business Unit (i.e. the claim) that was in error.

AK2*837*0003~
IK3*REF*57**3~
CTX*SITUATIONAL TRIGGER*CLM*43**5:3~
CTX*CLM01:987654321~
IK5*R*5~

The Trailer section provides a summary of the disposition of the received functional group, and ends the transaction set.

AK9*P*3*3*1~
SE*16*2870001~
GE*1*20213~
IEA*1*000010216~