Health Care Claim: Professional (X222A1)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1408*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*140840*000000001*X*005010X222A1~
ST*837*0021*005010X222A1~
BHT*0019*00*244579*20061015*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222*EX*231~
NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~
HL*1**20*1~
PRV*BI*PXC*203BF0100Y~
NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
NM1*87*2~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*1~
SBR*P**2222-SJ******CI~
NM1*IL*1*SMITH*JANE****MI*JS00111223333~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
REF*G2*KA6663~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19730501*M~
CLM*26463774*100***11>B>1*Y*A*Y*I~
REF*D9*17312345600006351~
HI*BK>0340*BF>V7389~
LX*1~
SV1*HC>99213*40*UN*1***1~
DTP*472*D8*20061003~
LX*2~
SV1*HC>87070*15*UN*1***1~
DTP*472*D8*20061003~
LX*3~
SV1*HC>99214*35*UN*1***2~
DTP*472*D8*20061010~
LX*4~
SV1*HC>86663*10*UN*1***2~
DTP*472*D8*20061010~
SE*42*0021~
GE*1*000000001~
IEA*1*000000001~

Example 1: Commercial Health Insurance

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1411*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*141104*000000001*X*005010X222A1~
ST*837*0711*005010X222A1~
BHT*0019*00*0013*20040801*1200*CH~
NM1*41*2*Associates in Medicine*****46*587654321~
PER*IC*Bud Holly*TE*8017268899~
NM1*40*2*XYZ Receiver*****46*369852758~
HL*1**20*1~
NM1*85*2*Associates in Medicine*****XX*587654321~
N3*1313 Las Vegas Boulevard~
N4*Las Vegas*NV*89109~
REF*EI*587654321~
HL*2*1*22*0~
SBR*P*18*GRP01020102******CI~
NM1*IL*1*Vaughn*Steve*R***MI*MBRID12345~
N3*236 Diamond ST~
N4*Las Vegas*NV*89109~
DMG*D8*19430501*M~
NM1*PR*2*R&R Health Plan*****XV*PLANID12345~
CLM*CLMNO12345*103.37***11>B>1*Y*A*Y*Y~
HI*BK>03591~
NM1*82*1*Hendrix*Jim****XX*1122333341~
PRV*PE*PXC*208D00000X~
LX*1~
SV1*HC>90782*50*UN*1*11**1~
DTP*472*D8*20040711~
LX*2~
SV1*HC>J1550*53.37*UN*1*11**1~
DTP*472*D8*20040711~
AMT*T*3.37~
LIN**N4*00026063512~
CTP****10*ML~
SE*31*0711~
GE*1*000000001~
IEA*1*000000001~

Example 10a: Drug administered in the Physician Office

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1415*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*141535*000000001*X*005010X222A1~
ST*837*1002*005010X222A1~
BHT*0019*00*1002*20050620*09460000*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*EXTRA HEALTHY INSURANCE*****46*112244~
HL*1**20*1~
NM1*85*2*HAPPY DOCTORS GROUP PRACTICE*****XX*1234567890~
N3*P O BOX 123~
N4*FORT WAYNE*IN*462540000~
REF*EI*555512345~
PER*IC*SUE BILLINGSWORTH*TE*8881231234~
HL*2*1*22*0~
SBR*P*18*123XYZ******CI~
NM1*IL*1*RING*DIAMOND*D***MI*00124A089~
N3*123 EXAMPLE DRIVE~
N4*INDIANAPOLIS*IN*462290000~
DMG*D8*19401229*F~
NM1*PR*2*EXTRA HEALTHY INSURANCE*****PI*12345~
CLM*ABC123-RI*28.75***11>B>1*Y*A*Y*Y*P~
REF*9A*0902352342~
REF*D9*061505501749388~
HI*BK>496*BF>25000~
HCP*03*26.75*2*908231234~
NM1*DN*1*DOE*JOHN****XX*9988776655~
NM1*82*1*ANTHONY*SUSAN*B***XX*1122334455~
NM1*77*2*HAPPY DOCTORS GROUP~
N3*123 FEEL GOOD ROAD~
N4*WASHINGTON*IN*475010000~
LX*1~
SV1*HC>E0570>RR*25*UN*1***1>2~
DTP*472*D8*20050514~
HCP*03*23.75*1.25*908231234~
LX*2~
SV1*HC>A7003>NU*3.75*UN*1***1~
DTP*472*D8*20050514~
HCP*03*3*.75*908231234~
SE*37*1002~
GE*1*000000001~
IEA*1*000000001~

Example 11: PPO Repriced Claim

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1416*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*141631*000000001*X*005010X222A1~
ST*837*1024*005010X222A1~
BHT*0019*00*1024*20050711*1335*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002~
HL*1**20*1~
NM1*85*2*EMERGENCY PHYSICIANS GROUP*****XX*1122334455~
N3*7423 SUPER STREET~
N4*BILLINGS*MO*919910000~
REF*EI*111002222~
HL*2*1*22*1~
SBR*P**232AA******CI~
NM1*IL*1*SMITH*MATTHEW*R***MI*57976235C~
N3*5698 SOUTH STREET~
N4*BILLINGS*MO*919910000~
DMG*D8*19561015*M~
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*00123~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TOM*E~
N3*5698 SOUTH STREET~
N4*BILLINGS*MO*919910000~
DMG*D8*19960807*M~
CLM*TS234H3*252.71***23>B>1*Y*A*Y*Y*P~
REF*9A*0902345406~
REF*D9*687534234346~
HI*BK>9951~
HCP*00*0**333001234*********T1~
NM1*82*1*BLUE*JACKIE*D***XX*1112223336~
SBR*S*18*56567******CI~
OI***Y***Y~
NM1*IL*1*SMITH*TOM*E***MI*23424570~
N3*5698 SOUTH STREET~
N4*BILLINGS*MO*919910000~
NM1*PR*2*SECONDARY INSURANCE COMPANY*****PI*95645~
LX*1~
SV1*HC>99284*252.71*UN*1***1~
DTP*472*D8*20050506~
SE*39*1024~
GE*1*000000001~
IEA*1*000000001~

Example 2: Encounter

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1420*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*142058*000000001*X*005010X222A1~
ST*837*0021*005010X222A1~
BHT*0019*00*0123*20051015*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*3055552222~
NM1*40*2*XYZ REPRICER*****46*66783JJT~
HL*1**20*1~
NM1*85*1*KILDARE*BEN****XX*1999996666~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*123456789~
PER*IC*CONNIE*TE*3055551234~
NM1*87*2~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
DMG*D8*19430501*F~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
N3*3333 OCEAN ST~
N4*SOUTH MIAMI*FL*33000~
REF*G2*PBS3334~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19730501*M~
CLM*26407789*79.04***11>B>1*Y*A*Y*I*P~
HI*BK>4779*BF>2724*BF>2780*BF>53081~
NM1*82*1*KILDARE*BEN****XX*1999996666~
PRV*PE*PXC*204C00000X~
REF*G2*KA6663~
NM1*77*2*KILDARE ASSOCIATES*****XX*1581234567~
N3*2345 OCEAN BLVD~
N4*MIAMI*FL*33111~
SBR*S*01*******CI~
OI***Y*P**Y~
NM1*IL*1*SMITH*JACK****MI*T55TY666~
N3*236 N MAIN ST~
N4*MIAMI*FL*33111~
NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~
LX*1~
SV1*HC>99213*43*UN*1***1>2>3>4~
DTP*472*D8*20051003~
LX*2~
SV1*HC>90782*15*UN*1***1>2~
DTP*472*D8*20051003~
LX*3~
SV1*HC>J3301*21.04*UN*1***1>2~
DTP*472*D8*20051003~
SE*52*0021~
GE*1*000000001~
IEA*1*000000001~

Example 3a: Claim from Billing Provider to Payer A

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1421*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*142142*000000001*X*005010X222A1~
ST*837*0002*005010X222A1~
BHT*0019*00*000001142*20050214*115101*CH~
NM1*41*2*SPECIALISTS*****46*1111111~
PER*IC*SUE*TE*8005558888~
NM1*40*2*MEDICARE PENNSYLVANIA*****46*10234~
HL*1**20*1~
NM1*85*2*SPECIALISTS*****XX*0100000090~
N3*5 MAP COURT~
N4*MAYNE*PA*17111~
REF*EI*890123456~
REF*1G*110101~
HL*2*1*22*0~
SBR*S*18*MEDICARE*12*****MB~
NM1*IL*1*MEDYUM*WAYNE*M***MI*102200221B1~
N3*1010 THOUSAND OAK LANE~
N4*MAYN*PA*17089~
DMG*D8*19560110*M~
NM1*PR*2*MEDICARE PENNSYLVANIA*****PI*10234~
N3*5232 MAYNE AVENUE~
N4*LYGHT*PA*17009~
CLM*101KEN6055*120***11>B>1*Y*A*Y*Y*P~
HI*BK>71516*BF>71906~
NM1*DN*1*BRYHT*LEE*T~
REF*1G*B01010~
NM1*82*1*HENZES*JACK****XX*9090909090~
PRV*PE*PXC*207X00000X~
REF*G2*110102CCC~
SBR*P*01**COMMERCE*****CI~
AMT*D*80~
AMT*A8*15~
OI***Y*P**Y~
NM1*IL*1*MEDYUM*CAROL****MI*COM188-404777~
N3*PO BOX 45~
N4*MAYN*PA*17089~
NM1*PR*2*COMMERCE*****PI*59999~
LX*1~
SV1*HC>99203>25*120*UN*1***1>2~
DTP*472*D8*20050119~
SVD*59999*80*HC>99203>25**1~
CAS*CO*42*25~
CAS*PR*2*15~
DTP*573*D8*20050128~
SE*43*0002~
GE*1*000000001~
IEA*1*000000001~

Example 4: Medicare Secondary Payer (COB)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1422*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*142212*000000001*X*005010X222A1~
ST*837*000017712*005010X222A1~
BHT*0019*00*000017712*20050208*1112*CH~
NM1*41*2*AAA AMBULANCE SERVICE*****46*376985369~
PER*IC*LISA SMITH*TE*3037752536~
NM1*40*2*MEDICARE B*****46*123245~
HL*1**20*1~
PRV*BI*PXC*3416L0300X~
NM1*85*2*AAA AMBULANCE SERVICE*****XX*2366554859~
N3*12202 AIRPORT WAY~
N4*BROOMFIELD*CO*800210021~
REF*EI*376985369~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*JONES*SARAH*A***MI*012345678A~
N3*1129 REINDEER ROAD~
N4*CARR*CO*80612~
DMG*D8*19630729*F~
NM1*PR*2*MEDICARE PART B*****PI*123245~
N3*PO BOX 3543~
N4*BALTIMORE*MD*666013543~
CLM*051068*766.50***41>B>1*Y*A*Y*Y*P*OA~
DTP*439*D8*20050208~
CR1*LB*275**A*DH*21****PATIENT IMOBILIZED~
CRC*07*Y*04*06*09~
CRC*07*N*05*07*08~
HI*BK>8628*BF>E8888*BF>9592*BF>8540~
NM1*PW*2~
N3*1129 REINDEER ROAD~
N4*CARR*CO*80612~
NM1*45*2~
N3*10005 BANNOCK ST~
N4*CHEYENNE*WY*82009~
LX*1~
SV1*HC>A0427>RH*700*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
QTY*PT*2~
REF*6R*1001~
NTE*ADD*CARDIAC EMERGENCY~
LX*2~
SV1*HC>A0425>RH*8.20*UN*21***1>2>3>4**Y~
DTP*472*D8*20050208~
QTY*PT*2~
REF*6R*1002~
LX*3~
SV1*HC>A0422>RH*46*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
REF*6R*1003~
LX*4~
SV1*HC>A0382>RH*12.30*UN*1***1>2>3>4**Y~
DTP*472*D8*20050208~
REF*6R*1004~
SE*52*000017712~
GE*1*000000001~
IEA*1*000000001~

Example 5: Ambulance

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1422*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*142242*000000001*X*005010X222A1~
ST*837*3701*005010X222A1~
BHT*0019*00*007227*20050215*075420*CH~
NM1*41*2*DAVID GREEN*****46*S01057~
PER*IC*KATHY SMITH*TE*4105558888~
NM1*40*2*MEDICARE PART B MARYLAND*****46*12345~
HL*1**20*1~
NM1*85*1*GREENE*DAVID*M***XX*1234567890~
N3*1264 OAKWOOD AVE~
N4*BALTIMORE*MD*21236~
REF*EI*987654321~
PER*IC*DR*TE*4105551212~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*WILLIAMSON*MATTHEW*J***MI*123456789A~
N3*128 BROADCREEK~
N4*BALTIMORE*MD*21234~
DMG*D8*19250110*M~
NM1*PR*2*MEDICARE PART B MARYLAND*****PI*C12345~
CLM*125WILL*145.5***11>B>1*Y*A*Y*Y~
DTP*454*D8*20050115~
DTP*453*D8*20050110~
DTP*455*D8*20050113~
CR2********A**CHRONIC PAIN AND DISCOMFORT~
HI*BK>7215~
LX*1~
SV1*HC>98940*145.5*UN*1***1~
DTP*472*D8*20050215~
REF*6R*01~
SE*29*3701~
GE*1*000000001~
IEA*1*000000001~

Example 6: Chiropractic

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1423*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*142340*000000001*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*16*20050326*1036*CH~
NM1*41*2*OXYGEN SUPPLY COMPANY*****46*ABC11111~
PER*IC*BONNIE*TE*8125551111*EM*HELPDESK@OXYGEN.COM~
NM1*40*2*DMERC CARRIER*****46*99999~
HL*1**20*1~
NM1*85*2*OXYGEN SUPPLY COMPANY*****XX*9992233334~
N3*1800 EAST RIDGE DRIVE~
N4*RICHMOND*IN*46224~
REF*EI*389999999~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*SMITH*TERRY****MI*111222333A~
N3*121 SOUTH ST~
N4*RICHMOND*IN*46236~
DMG*D8*19380105*F~
NM1*PR*2*DMERC CARRIER*****PI*99999~
CLM*R03996273 #01*520.24***11>B>1*Y*A*Y*Y~
HI*BK>496*BF>51881*BF>2859~
LX*1~
SV1*HC>E1390>RR*461.1*UN*1***1>2~
PWK*CT*AD~
CR3*R*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*607*D8*20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
NM1*DK*1*WILSON*LARRY****XX*5555511111~
N3*1212 NORTH MERIDIAN~
N4*RICHMOND*IN*46223~
REF*1G*X99999~
PER*IC*LEE*TE*5554446666~
LQ*UT*04.03~
FRM*1A**056~
FRM*1C**20050228~
FRM*2**1~
FRM*3**1~
FRM*4*Y~
FRM*5**2~
FRM*7*Y~
FRM*8*N~
FRM*9*Y~
LX*2~
SV1*HC>E0431>RR*59.14*UN*1***1>2~
PWK*CT*AD~
CR3*R*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*607*D8*20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
NM1*DK*1*WILSON*LARRY****XX*5555511111~
N3*1212 NORTH MERIDIAN~
N4*RICHMOND*IN*46223~
REF*1G*X99999~
PER*IC*LEE*TE*5554446666~
LQ*UT*04.03~
FRM*1A**056~
FRM*1C**20050228~
FRM*2**1~
FRM*3**1~
FRM*4*Y~
FRM*5**2~
FRM*7*Y~
FRM*8*N~
FRM*9*Y~
SE*66*0001~
GE*1*000000001~
IEA*1*000000001~

Example 7: Oxygen

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1424*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*142406*000000001*X*005010X222A1~
ST*837*112233*005010X222A1~
BHT*0019*00*16*20050326*1036*CH~
NM1*41*2*XYZ WHEELCHAIRS INC*****46*ABC55~
PER*IC*JANE*TE*2225551111~
NM1*40*2*DMERC CARRIER*****46*99999~
HL*1**20*1~
NM1*85*2*XYZ WHEELCHAIR INC*****XX*7778889999~
N3*1440 NORTH STREET~
N4*LAFAYETTE*IN*47904~
REF*EI*123567989~
REF*1G*0426960001~
HL*2*1*22*0~
SBR*P*18*******MB~
PAT*******01*155~
NM1*IL*1*SMITH*JAMES****MI*987654321A~
N3*12 MAIN ST~
N4*FRANKFORT*IN*46209~
DMG*D8*19201023*M~
NM1*PR*2*DMERC CARRIER*****PI*99999~
CLM*SMI123*75***12>B>1*Y*A*Y*Y~
HI*BK>436*BF>3449~
LX*1~
SV1*HC>K0001>RR>KH>BR*75*UN*1***1>2~
PWK*CT*AD~
CR3*I*MO*99~
DTP*472*RD8*20050321-20050321~
DTP*463*D8*20040321~
DTP*461*D8*20050321~
MEA*TR*HT*70~
NM1*DK*1*WILSON*RANDALL****XX*1111155555~
N3*1226 WEST RAILROAD STREET~
N4*LAFAYETTE*IN*47905~
REF*1G*M12345~
PER*IC*LEE*TE*7659259999~
LQ*UT*02.03B~
FRM*1*Y~
FRM*2*N~
FRM*3*N~
FRM*4*N~
FRM*5**8~
FRM*8*N~
FRM*9*Y~
SE*43*112233~
GE*1*000000001~
IEA*1*000000001~

Example 8: Wheelchair

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231106*1424*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231106*142432*000000001*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*0123*20050117*1023*CH~
NM1*41*2*PROVIDER MEDICAL GROUP*****46*N305~
PER*IC*NINA*TE*6155551212*EX*911~
NM1*40*2*ABC PAYER*****46*05440~
HL*1**20*1~
NM1*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~
N3*1234 WEST END AVE~
N4*NASHVILLE*TN*37232~
REF*EI*756473826~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*JONES*MARGARET****MI*123456789A~
N3*123 RAINBOW ROAD~
N4*NASHVILLE*TN*37232~
DMG*D8*19740303*F~
NM1*PR*2*ABC PAYER*****PI*05440~
CLM*153829140*827***22>B>1*Y*A*Y*Y~
HI*BK>36616~
NM1*82*1*TOWNSEND*JACOB*E***XX*5678912345~
PRV*PE*PXC*207L00000X~
REF*G2*9741234~
NM1*77*2*PROVIDER OP HOSP*****XX*432198765~
N3*345 MAIN DRIVE~
N4*NASHVILLE*TN*37232~
LX*1~
SV1*HC>00142>QK>QS>P1*827*MJ*61***1~
DTP*472*D8*20050112~
SE*29*0001~
GE*1*000000001~
IEA*1*000000001~

X12 837 Health Care Claim: Professional (X222A1)