Health Care Claim: Institutional (X223A3)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231103*0222*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*022254*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*19960918*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*9005555555~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
PRV*BI*PXC*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*9876540809~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*EI*567891234~
PER*IC*CONNIE*TE*3055551234~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*35202~
REF*G2*330127~
CLM*756048Q*89.93***14>A>1**A*Y*Y~
DTP*434*RD8*19960911~
CL1*3**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
HI*BH>A1>D8>19261111*BH>A2>D8>19911101*BH>B1>D8>19261111*BH>B2>D8>19870101~
HI*BE>A2>>>15.31~
HI*BG>09~
NM1*71*1*JONES*JOHN*J~
REF*1G*B99937~
SBR*S*01*351630*STATE TEACHERS*****CI~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*0730*HC>93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*43*987654~
GE*1*000000001~
IEA*1*000000001~

Example 1a: Institutional Claim

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231103*0222*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*022254*000000001*X*005010X223A3~
ST*837*987654*005010X223A3~
BHT*0019*00*0123*20050630*0932*CH~
NM1*41*2*JONES HOSPITAL*****46*12345~
PER*IC*JANE DOE*TE*1112223333~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
PRV*BI*PXC*282N00000X~
NM1*85*2*JONES HOSPITAL*****XX*1234567890~
N3*225 MAIN STREET~
N4*ANYWHERE*PA*17111~
REF*EI*123456789~
HL*2*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*DOE*JOHN*T***MI*030005074~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19681111*M~
NM1*PR*2*TRICARE*****PI*35202~
CLM*756048Q*89.95***13>A>1**C*Y*Y~
DTP*434*RD8*20050315-20050315~
CL1*1**01~
HI*BK>3669~
HI*BF>4019*BF>79431~
NM1*71*1*JONES*JOHN*J***XX*1122334455~
REF*1G*U12345~
LX*1~
SV2*0305*HC>85025*13.39*UN*1~
DTP*472*D8*20050315~
LX*2~
SV2*0730*HC>93010*76.56*UN*3~
DTP*472*D8*20050315~
HL*3*1*22*0~
SBR*P*18*******CH~
NM1*IL*1*SMITH*JOE****MI*123405074~
N3*5 MAIN STREET~
N4*ANYWHERE*PA*17111~
DMG*D8*19621210*M~
NM1*PR*2*TRICARE*****PI*35202~
CLM*756049Q*50***13>A>1**C*Y*Y~
DTP*434*RD8*20050401-20050401~
CL1*1**01~
HI*BK>30000~
NM1*71*1*JONES*JUDY*J***XX*9999999999~
PRV*AT*PXC*363LP0200N~
LX*1~
SV2*0300*HC>85087*50*UN*1~
DTP*472*D8*20050401~
SE*48*987654~
GE*1*000000001~
IEA*1*000000001~

Example 1b: Two Claims for the Same Provider

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231103*0222*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*022254*000000001*X*005010X223A3~
ST*837*1002*005010X223A3~
BHT*0019*00*1002*20050721*09460000*CH~
NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~
PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~
NM1*40*2*Security Health Plan*****46*39045~
HL*1**20*1~
NM1*85*2*GOOD HEALTH HOSPITAL*****XX*1257234346~
N3*592 NORTH ELM STREET~
N4*EDGEWOOD*AZ*860015590~
REF*EI*344232321~
HL*2*1*22*1~
SBR*P**46522567AW******CI~
NM1*IL*1*JONES*JENNY****MI*345U8423H~
N3*4512 WEST AVENUE~
N4*EVANSVILLE*AZ*863030000~
DMG*D8*19690731*F~
NM1*PR*2*LOCAL INSURANCE COMPANY*****PI*35202~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*JONES*JOY~
N3*4512 WEST AVENUE~
N4*EVANSVILLE*AZ*863030000~
DMG*D8*19980820*F~
CLM*456DFH43*237.5***13>A>1**A*Y*Y~
DTP*434*RD8*20050706-20050706~
DTP*435*DT*200507060800~
CL1*1*2*01~
AMT*F3*237.5~
REF*9A*09459034092~
REF*D9*04566877634343456~
HI*BK>38181~
HI*BF>38900~
HI*BH>11>D8>20050706~
HCP*03*182.88*54.62*123456789~
NM1*71*1*JOHNSON*SIMON****XX*5544332211~
SBR*S*19**T&T PLUMBING COMPANY*****CI~
OI***Y***Y~
NM1*IL*1*JONES*GEORGE****MI*56454566~
NM1*PR*2*OTHER COVERAGE COMPANY*****PI*534524~
LX*1~
SV2*0471*HC>92557*178*UN*1~
DTP*472*D8*20050706~
HCP*03*137.06*40.94~
LX*2~
SV2*0471*HC>92567*59.5*UN*1~
DTP*472*D8*20050706~
HCP*03*45.82*13.68~
SE*48*1002~
GE*1*000000001~
IEA*1*000000001~

Example 1c: PPO Repriced Claim

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *231103*0230*^*00501*000000001*0*T*>~
GS*HC*SENDERGS*RECEIVERGS*20231103*023056*000000001*X*005010X223A3~
ST*837*1024*005010X223A3~
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*Security Health Plan*****46*39045~
HL*1**20*1~
NM1*85*2*LOCAL HOSPITAL*****XX*1122334455~
N3*3423 SMALL STREET~
N4*COLUMBUS*OH*432150000~
REF*EI*111002222~
HL*2*1*22*0~
SBR*P*18*34561W******CI~
NM1*IL*1*SMITH*JAMES*A***MI*34902390F~
N3*934 NORTH STREET~
N4*COLUMBUS*OH*432150000~
DMG*D8*19621015*M~
NM1*PR*2*CONSERVATIVE INSURANCE*****PI*35202~
CLM*W392-49141*14.84***13>A>1**A*Y*Y~
DTP*434*RD8*20050617-20050617~
DTP*435*DT*200506170800~
CL1*1*1*01~
AMT*F3*14.84~
REF*9A*459804390823~
REF*D9*32423466233~
HI*BK>53081~
HCP*00*0**333001234*********T1~
NM1*71*1*RIVERS*DAWN****XX*2244224455~
LX*1~
SV2*0301*HC>82270*14.84*UN*1~
DTP*472*D8*20050617~
SE*31*1024~
GE*1*000000001~
IEA*1*000000001~

X12 837 Health Care Claim: Institutional (X223A3)