 Health Care Claim Payment/Advice (X221A1)

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*012345678*X*005010X221A1~
ST*835*112233~
BPR*I*1100*C*ACH*CCP*01*888999777*DA*24681012*1935665544**01*111333555*DA*144444*20190316~
TRN*1*71700666555*1935665544~
DTM*405*20190314~
N1*PR*RUSHMORE LIFE~
N3*10 SOUTH AVENUET~
N4*RAPID CITY*SD*55111~
PER*BL*JOHN WAYNE*TE*8005551212*EX*123~
N1*PE*ACME MEDICAL CENTER*XX*5544667733~
REF*0B*777667755~
LX*1~
CLP*5554555444*1*800*500*300*12*94060555410000*11*1~
NM1*QC*1*BUDD*WILLIAM****MI*33344555510~
AMT*AU*800~
SVC*HC>99211*800*500~
DTM*472*20190301~
CAS*PR*1*300~
AMT*B6*800~
CLP*8765432112*1*1200*600*600*12*9407779923000*11*1~
NM1*QC*1*SETTLE*SUSAN****MI*44455666610~
AMT*AU*1200~
SVC*HC>93555*1200*600~
DTM*472*20190310~
CAS*PR*1*600~
AMT*B6*1200~
SE*26*112233~
GE*1*012345678~
IEA*1*191511902~

Example 1: Dollars and Data Sent Separately

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*35681~
BPR*I*810.8*C*CHK************20190331~
TRN*1*12345*1512345678~
REF*EV*XYZ CLEARINGHOUSE~
N1*PR*DENTAL OF ABC~
N3*225 MAIN STREET~
N4*CENTERVILLE*PA*17111~
PER*BL*JANE DOE*TE*9005555555~
N1*PE*BAN DDS LLC*XX*9999947036~
REF*0B*212121212~
LX*1~
CLP*7722337*1*226*132**12*119932404007801*11*1~
NM1*QC*1*DOE*SANDY****MI*SJD11112~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190324~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*119*74**12*119932404007801*11*1~
NM1*QC*1*DOE*SALLY****MI*SJD11111~
NM1*IL*1*DOE*JOHN****MI*SJD11111~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*74~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*226*108*24*12*119932404007801*11*1~
NM1*QC*1*SMITH*SALLY****MI*SJD11113~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*0~
DTM*472*20190324~
CAS*PR*3*14~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*0~
DTM*472*20190324~
CAS*PR*3*10~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*1145*14*902*12*119932404007801*11*1~
NM1*QC*1*SMITH*SAM****MI*SJD11116~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*14~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D2790*940*0~
DTM*472*20190324~
CAS*PR*3*756~
CAS*CO*45*184~
SVC*AD>D2950*180*0~
DTM*472*20190324~
CAS*PR*3*146~
CAS*CO*45*34~
CLP*7722337*1*348*16.8*44.2*12*119932404007801*11*1~
NM1*QC*1*JONES*SAM****MI*SJD11122~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*28~
SVC*AD>D4342*125*0~
DTM*472*20190313~
CAS*CO*45*125~
SVC*AD>D4381*43*0~
DTM*472*20190313~
CAS*PR*3*33~
CAS*CO*45*10~
SVC*AD>D2950*180*16.8~
DTM*472*20190313~
CAS*PR*3*11.2~
CAS*CO*45*152~
AMT*B6*28~
CLP*7722337*1*226*132**12*119932404007801*11*1~
NM1*QC*1*JONES*SALLY****MI*SJD11133~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190321~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190321~
CAS*CO*45*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190321~
CAS*CO*45*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190321~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190321~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*179*108**12*119932404007801*11*1~
NM1*QC*1*DOE*SAM****MI*SJD99999~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*108~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*45*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*45*24~
AMT*B6*49~
CLP*7722337*1*129*82**12*119932404007801*11*1~
NM1*QC*1*DOE*SUE****MI*SJD88888~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*82~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D1120*54*37~
DTM*472*20190324~
CAS*CO*45*17~
AMT*B6*37~
SVC*AD>D1208*29*20~
DTM*472*20190324~
CAS*CO*45*9~
AMT*B6*20~
CLP*7722337*1*221*144**12*119932404007801*11*1~
NM1*QC*1*DOE*DONNA****MI*SJD77777~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*144~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*45*21~
AMT*B6*25~
SVC*AD>D0330*92*62~
DTM*472*20190324~
CAS*CO*45*30~
AMT*B6*62~
SVC*AD>D1120*54*37~
DTM*472*20190324~
CAS*CO*45*17~
AMT*B6*37~
SVC*AD>D1208*29*20~
DTM*472*20190324~
CAS*CO*45*9~
AMT*B6*20~
SE*183*35681~
GE*1*12345678~
IEA*1*191511902~


Example 2: Multiple Claims Single Check

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*35681~
BPR*I*132*C*CHK************20190331~
TRN*1*12345*1512345678~
REF*EV*CLEARINGHOUSE~
N1*PR*DELTA DENTAL OF ABC~
N3*225 MAIN STREET~
N4*CENTERVILLE*PA*17111~
PER*BL*JANE DOE*TE*9005555555~
N1*PE*BAN DDS LLC*XV*999994703~
LX*1~
CLP*7722337*1*226*132**12*119932404007801~
NM1*QC*1*DOE*SALLY****MI*SJD11111~
NM1*82*1*BAN*ERIN****XX*1811901945~
AMT*AU*132~
SVC*AD>D0120*46*25~
DTM*472*20190324~
CAS*CO*131*21~
AMT*B6*25~
SVC*AD>D0220*25*14~
DTM*472*20190324~
CAS*CO*131*11~
AMT*B6*14~
SVC*AD>D0230*22*10~
DTM*472*20190324~
CAS*CO*131*12~
AMT*B6*10~
SVC*AD>D0274*60*34~
DTM*472*20190324~
CAS*CO*131*26~
AMT*B6*34~
SVC*AD>D1110*73*49~
DTM*472*20190324~
CAS*CO*131*24~
AMT*B6*49~
SE*35*35681~
GE*1*12345678~
IEA*1*191511902~


Example 3: Claim Specific Negotiated Discount

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*80.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*PATACCT*1*400*80**MC*CLAIMNUMBER*11*1~
NM1*QC*1*DOE*JOHN*N***MI*ABC123456789~
REF*1L*12345F~
DTM*050*20190209~
PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004074627~
AMT*AU*150~
SVC*HC>99213*150*80**1~
DTM*472*20190101~
CAS*CO*45*70~
AMT*B6*80~
SVC*HC>85003*100*0**1~
DTM*472*20190101~
CAS*CO*204*100~
SVC*HC>36415*150*0**1~
DTM*472*20190101~
CAS*CO*97*150~
SE*33*10060875~
GE*1*12345678~
IEA*1*191511902~


Example 4: Claim Adjustment Reason Code 45

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*11.06*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*PCN*1*36.20*11.06**12*CLAIMNUMB*11*1~
NM1*QC*1*LAST*FIRST*J***MI*123456789~
NM1*82*1******XX*1447481825~
MOA***N25~
REF*1L*102345~
REF*EA*065789~
DTM*050*20170113~
AMT*AU*36.20~
SVC*HC>99214*26.2*3.06~
DTM*472*20170109~
CAS*CO*45*23.2**137*-.06~
REF*6R*B1~
AMT*B6*3~
SVC*HC>36415*10*8~
DTM*472*20170109~
CAS*CO*45*2~
REF*6R*B2~
AMT*B6*8~
SE*35*10060875~
GE*1*12345678~
IEA*1*191511902~


Example 5a: Line Service Tax impacting payment only

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*12.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*PCN*1*25*12*10*12*CLAIMNUMB*11*1~
NM1*QC*1*LAST*FIRST*J***MI*123456789~
NM1*82*1******XX*1447481825~
MOA***N25~
REF*1L*102345~
REF*EA*065789~
DTM*050*20170113~
AMT*AU*25~
SVC*HC>99214*25*12~
DTM*472*20170109~
CAS*CO*45*5**161*-2~
CAS*PR*3*10~
REF*6R*123~
AMT*B6*20~
SE*31*10060875~
GE*1*12345678~
IEA*1*191511902~


Example 5b: Line Service Bonuses impacting payment only

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*8.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*PCN*1*25*8*10*12*CLAIMNUMB*11*1~
NM1*QC*1*LAST*FIRST*J***MI*123456789~
NM1*82*1******XX*1447481825~
MOA***N25~
REF*1L*102345~
REF*EA*065789~
DTM*050*20170113~
AMT*AU*25~
SVC*HC>99214*25*8~
DTM*472*20170109~
CAS*CO*45*5**B4*2~
CAS*PR*3*10~
REF*6R*123~
AMT*B6*20~
SE*31*10060875~
GE*1*12345678~
IEA*1*191511902~


Example 5c: Line Service Penalty impacting payment only

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*8000.00*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*PATACCT*1*40000*8000**MC*CLAIMNUMBER*11*1~
CAS*CO*197*2000*1*45*30000~
NM1*QC*1*DOE*JOHN*N***MI*ABC123456789~
REF*1L*12345F~
DTM*232*20190101~
DTM*233*20190105~
DTM*050*20190209~
PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004001212~
AMT*AU*38000~
QTY*CA*4~
SE*27*10060875~
GE*1*12345678~
IEA*1*191511902~


Example 6: Not Covered/Not Authorized Inpatient Facility claim days

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*|~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*120.03*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*04777796TLC777122*1*155*120.03**13*8838888212*11*1~
NM1*QC*1*MASTERS*MARVIN*L***MI*80444444403~
NM1*IL*1*CABLE*MABEL****MI*80444444403~
NM1*74*1*MASTERS*MARVIN****C*80444444401~
NM1*82*1*SHELTON MD*BLAKE****XX*1666666666~
REF*1L*28~
REF*CE*HSOAP-LAOA~
DTM*232*20191114~
DTM*233*20181114~
DTM*050*20181119~
AMT*AU*155~
SVC*HC|99393*155*120.03**1~
DTM*472*20181114~
CAS*CO*45*34.97~
REF*LU*11~
REF*6R*22261822~
AMT*B6*120.03~
SE*34*10060875~
GE*1*12345678~
IEA*1*191511902~


Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*|~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*35.06*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*02333TLC222222*1*115*35.06*35*13*8333333214*11*1~
NM1*QC*1*KEATON*ALEX*P***MI*80000006006~
NM1*IL*1*THOMAS*JASON****MI*80000006006~
NM1*74*1**JEROME****C*80000006001~
NM1*82*1*BLOOD MD*RED N****XX*1888888886~
REF*1L*28~
REF*CE*OAPOS-LAOA~
DTM*232*20191113~
DTM*233*20191113~
DTM*050*20191119~
AMT*AU*115~
SVC*HC|99213*115*35.06**1~
DTM*472*20191113~
CAS*CO*45*44.94~
CAS*PR*3*35~
REF*LU*11~
REF*6R*22261389~
AMT*B6*70.06~
SE*35*10060875~
GE*1*12345678~
IEA*1*191511902~


Example 8b: Claim submitted with incorrect subscriber name and ID

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*>~
GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~
ST*835*10060875~
BPR*I*2415.25*C*CHK************20190816~
TRN*1*CK NUMBER 1*1234567890~
REF*EV*FAC~
DTM*405*20190827~
N1*PR*ANY PLAN USA~
N3*1 WALK THIS WAY~
N4*ANYCITY*OH*45209~
PER*CX**TE*8661112222~
PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~
PER*IC**UR*WWW.ANYPAYER.COM~
N1*PE*PROVIDER*XX*1123454567~
N3*2255 ANY ROAD~
N4*ANY CITY*CA*12211~
REF*0B*123456789~
LX*1~
CLP*05444444TLC999999*1*3903*2415.25**13*8777777782*21*1~
NM1*QC*1*GONZALES*SAMMY****MI*80455555502~
NM1*IL*1*LAPLANTE*FERN****MI*80455555502~
NM1*74*1***R~
NM1*82*1*GOOD MD*ROBERT B****XX*19999999987~
REF*1L*28~
REF*CE*OAPOS-LAOA~
DTM*232*20191101~
DTM*233*20191101~
DTM*050*20191114~
AMT*AU*3903~
AMT*F5*150~
SVC*HC>59400*3903*2415.25**1~
DTM*472*20191101~
CAS*CO*45*1487.75~
REF*LU*21~
REF*6R*22215592~
AMT*B6*2415.25~
SE*35*10060875~
GE*1*12345678~
IEA*1*191511902~


X12 835 Health Care Claim Payment/Advice (X221A1)