Application Advice (X186A1)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1407*^*00501*000000001*0*T*>~
GS*AG*SENDERGS*RECEIVERGS*20240221*140702*000000001*X*005010X186A1~
ST*824*021390001*005010X186A1~
BGN*11*FFA.ABCDEF.123456*20020709*0932**123456789**WQ~
N1*41*ABC INSURANCE*46*111111111~
PER*IC*JOHN JOHNSON*TE*8005551212*EX*1439~
N1*40*SMITHCO*46*A1234~
OTI*TA*TN*NA***20020709*0902*2*0001*834*005010X220A1~
SE*7*021390001~
GE*1*000000001~
IEA*1*000000001~

Example 1: Positive Acknowledgment

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1407*^*00501*000000001*0*T*>~
GS*AG*SENDERGS*RECEIVERGS*20240221*140729*000000001*X*005010X186A1~
ST*824*021390002*005010X186A1~
BGN*11*FFA.ABCDEF.123456*20020709*0932**123456789**U~
N1*41*DEF INSURANCE*46*222222222~
PER*IC*TOM EVANS*TE*8005551212*EX*1439~
N1*40*JONESCO*46*B5678~
OTI*TR*TN*NA***20020709*0902*2*0001*124*005010~
TED*024**VEH*36*2~
RED*NA**94**IBP*E054~
SE*9*021390002~
GE*1*000000001~
IEA*1*000000001~

Example 2: Complete Transaction Set Reject Reporting

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240221*1409*^*00501*000000001*0*T*>~
GS*AG*SENDERGS*RECEIVERGS*20240221*140914*000000001*X*005010X186A1~
ST*824*0001*005010X186A1~
BGN*11*12345*20040831*150057**0123**RU~
N1*41*CONSOLIDATED INSURANCE CO*46*00000~
PER*IC*CUSTOMER SERVICE*TE*8005551212~
N1*40*PHIL GOOD, M.D.*46*TXX23~
OTI*TA*TN*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*F8*0123~
DTM*050*20040814~
AMT*GW*16970.33~
QTY*TO*5~
NM1*41*2*PHIL GOOD, M.D.*****46*TXX23~
TED*024~
RED*NA**94**IBP*W050~
OTI*BP*BT*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*1C*99983000~
AMT*2*16970.33~
QTY*46*5~
NM1*85*2*GOOD AND ASSOCIATES*****24*555667777~
OTI*IA*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*26462967~
AMT*GW*540~
NM1*QC*1*SMITH*TED****MI*000221111A~
OTI*IE*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*78945639837~
AMT*GW*1100.67~
NM1*QC*1*BROWN*ROBERT*W***MI*888553737~
TED*024**N4*32*3**10407~
RED*NA**94**IBP*E038~
OTI*IR*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*8437450584598~
AMT*GW*12642.16~
NM1*QC*1*JAMES*JIM*D***MI*011332211~
TED*024**N4*54*3**73076~
RED*NA**94**IBP*E038~
TED*024**REF*68~
CTX*2310A REFERRING PROVIDER*NM1*65*2310~
CTX*2010BB PAYER NAME*NM1*18*2010~
CTX*CLAIM FILING INDICATOR CODE - MB*SBR*13*2000*9~
RED*NA**94**IBP*E019~
OTI*IA*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*984576898~
AMT*GW*1900.5~
NM1*QC*1*MAE*SALLIE*M***MI*987654321~
OTI*IE*IX*NA***20040812*1253*1000001*0021*837*005010X222A1~
REF*EJ*8767657645765~
AMT*GW*787~
NM1*QC*1*DOE*JANE****MI*777553333~
TED*024**N4*113*3**27387~
RED*NA**94**IBP*E038~
TED*024**N4*124*3**27378~
RED*NA**94**IBP*E038~
SE*52*0001~
GE*1*000000001~
IEA*1*000000001~

X12 824 Application Advice (X186A1)