837 Health Care Claim: Professional (X222/A2/A1)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240117*2150*^*00501*000000001*0*T*>
GS*HC*SENDERGS*RECEIVERGS*20240117*215049*000000001*X*005010X222A2
ST*837*0001*005010X222A2
BHT*0019*00*123456*20101212*0945*CH
NM1*41*1*LASTNAME*FIRSTNAME****46*111111111
PER*IC**TE*1111111111
NM1*40*2*TMHP*****46*617591011CMSP
HL*1**20*1
PRV*BI*PXC*1223G0001X
NM1*85*2*ORGANIZATION NAME*****XX*1111111111
N3*100 MAIN STREET
N4*TOWN*TX*123456789
REF*EI*111111111
HL*2*1*22*0
SBR*P*18*******MC
NM1*IL*1*LASTNAME*FIRSTNAME*T***MI*111111111
N3*100 MAIN STREET
N4*TOWN*TX*12345
DMG*D8*19500211*F
REF*SY*111111111
NM1*PR*2*TDHS*****PI*617591011CMSP
N4*TOWN*TX*12345
CLM*XXXXXX*0000000000***XX>B>X*Y*B*W*I*P*AA>XX>*03********1
REF*G1*11111111111
NTE*ADD* 10 5
HI*ABK>XXXXX*ABF>X*ABF>XXX*BF>XXX*BF>XXXXXX*ABF>XXXXXX*BF>XXXXX*BF>X*BF>XX*BF>XXXXX*BF>XXXXXX*ABF>XXX~
NM1*82*1*LASTNAME*FIRSTNAME****XX*111111111
PRV*PE*PXC*1223G0001X
LX*1
SV1*HC>X>XX>XX>XX>XX>XXXXXX*00000*MJ*00000000000000*XX**00>00>00>0**Y**Y*Y***0
DTP*472*D8*20151015
SE*30*0001
GE*1*000000001
IEA*1*000000001


X12 837 837 Health Care Claim: Professional (X222/A2/A1)