845 PRICE AUTHORIZATION ACKNOWLEDGEMENT/STATUS - VERSION 5010 This example represents a contract notification being sent by a Manufacturer to a Distributor eligible to service a contract to an end user or GPO. 845 Price Authorization Acknowledgement/Status Example 1 This is example is for a new contract containing both membership and products. TRANSACTION SET HEADER ST*845*100000103 Transaction Set Identifier Code ST01 845 X12 Price Authorization Acknowledgement/Status Transaction Set Control Number ST02 1000000103 BEGINNING SEGMENT FOR PRICE AUTHORIZATION ACKNOWLEDGEMENT/STATUS BPA*00*20070415 Transaction Set Purpose Code BPA01 00 Original Qualifier BPA02 20070415 of Transaction CONTRACT NUMBER DETAIL CON*CT*1000456456*OC Reference Identification Qualifier CON01 CT Contract Number Qualifier Reference Identifiction CON02 1000456456 Contract Number Contract Status Code CON03 OC Original Contract REFERENCE IDENTIFICATION REF*CT*GPO Name* Reference Identification Qualifier REF01 CT Contract Number Qualifier Reference Identification REF02 GPO Name Name of Contract DTM*091*20070501 /Time Qualifier DTM01 091 Contract Effective Qualifier DTM02 20070501 Contract Effective
DTM*092*20080430 /Time Qualifier DTM01 092 Contract Expiration Qualifier DTM02 20080430 Contract Expiration NAME N1*MF*MANUFACTURER NAME*21*75KGDC100 Entity Identifier Code N101 MF Manufacturer of Goods Qualifier Name N102 MANUFACTURER NAME Identification Code Qualifier N103 21 HIN Number Qualifier Identification Code N104 75KGDC100 HIN for Manufacturer ADDRESS INFORMATION N3*1234 Main Street Address Information N301 1234 Main Street GEOGRAPHIC LOCATION N4*FRANKLIN LAKES*NJ*07417 City Name N401 FRANKLIN LAKES City of Manufacturer State or Provice Code N402 NJ State of Manufacturer Postal Code N403 07417 Zip Code of Manufacturer. NAME N1*DB*M & D OF SHREVEPORT*21*BZ0521P00 Entity Identifier Code N101 DB Distributor Branch Qualifier Name N102 M & D OF SHREVEPORT Identification Code Qualifier N103 21 HIN Number Qualifier Identification Code N104 BZ0521P00 HIN Number ADDRESS INFORMATION N3*One First Street*Storage Location 1 Address Information
N301 One First Street Address 1 N302 Storage Location 1 Address 2 GEOGRAPHIC LOCATION N4*Shreveport*LA*60054 City N401 Shreveport City State N402 LA State Postal Code N403 60054 Postal Code NAME N1*EB*VALLEY HOSPITAL*21*221070C00 Entity Identifier Code N101 EB Eligible Party to the Contract Qualifier Name N102 VALLEY HOSPITAL Qualifier N103 21 HIN Number Qualifier DEA Number N104 221070C00 HIN Number ADDRESS INFORMATION N3*507 Maple Avenue Address Information N301 507 Maple Avenue Address 1 GEOGRAPHIC LOCATION N4*Ridgewood*NJ*07450 City N401 Ridgewood City State N402 NJ State Postal Code N403 07450 Postal Code REFERENCE IDENTIFICATION REF*TD*A Reference Identification Qualifier REF01 TD Reason for Change Qualifier Reference Identification REF02 A Customer Add DTM*129*20070501
/Time Qualifier DTM01 129 Customer Contract Effective Qualifier DTM02 20070501 Customer Contract Effective DTM*130*20080430 /Time Qualifier DTM01 130 Customer Contract Expiration Qualifier DTM02 20080430 Customer Contract Expiration PRODUCT ADJUSTMENT DETAIL PAD*0001**AI Assigned Identification PAD01 0001 Line Item Number Change or Response Type Code PAD03 AI Add Item(s) PRODUCT/ITEM DESCRIPTION PID*F****Surgical Blade - Size 11 Item Description Type PID01 F Free-form Description PID05 Surgical Blade - Size 11 ITEM IDENTIFICATION LIN*0001*MG*372234 Assigned Identification LIN01 0001 Line Number Product/Service ID Qualifier LIN02 MG Manufacturer's Part Number Qualifier Product/Service ID LIN03 372234 Manufacturer's Part Number PRICING INFORMATION CTP**CON*65.00*1*CA Price Identifier Code CTP02 CON Contract Price Qualifier Unit Price CTP03 65.00 Contract Unit Price Quantity CTP04 1 Quantity Composite Unit of Measure CTP05 CA Case
DTM*131*20070501 /Time Qualifier DTM01 131 Item Contract Effective Qualifier DTM02 20070501 Item Contract Effective DTM*132*20080430 /Time Qualifier DTM01 132 Item Contract Expiration Qualifier DTM02 20080430 Item Contract Expiration TRANSACTION TOTALS CTT*1 Number of Line Items CTT01 1 TRANSATION SET TRAILER SE*16*1000000103 Number of Included Segments SE01 16 Transaction Set Control Number SE02 1000000103 Transmission File: ST*845*1000000103 BPA*00*20070415 CON*CT*1000456456*OC REF*CT*GPO Name DTM*091*20070501 DTM*092*20080430 N1*MF*MANUFACTURER NAME*21*75KGDC100 N3*123 MAIN STREET N4*FRANKLIN LAKES*NJ*07417 N1*DB*M&D OF SHREVEPORT*21*BZ0521P00 N3*One First Street*Storage Location 1 N4*Shreveport*LA*60054 N1*EB*VALLEY HOSPITAL*21*221070C00 N3*507 MAPLE AVENUE N4*RIDGEWOOD*NJ*07450 REF*TD*A DTM*129*20070501 DTM*130*20080430 PAD*0001*AI PID*F****Surgical Blade- Size 11 LIN*0001*MG*372234 CPT**CON*65.00*1*CA
DTM*131*20070501 DTM*132*20080430 CTT*1