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Profession Claim example 837ProfessionalASC x12N (004010x098A1). Sita Kapoor Infotech Global Inc. 100 Franklin Square Dr. Somerset, NJ 08873 sk@igiusa.com. September 24, 2003. Claim Information, in English. SUBSCRIBER/PATIENT:Ted Smith ADDRESS:236 N. Main St., Miami, FL 33413 - PowerPoint PPT Presentation
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Sita KapoorSita KapoorInfotech Global Inc.Infotech Global Inc.100 Franklin Square Dr.100 Franklin Square Dr.Somerset, NJ 08873Somerset, NJ 08873sk@igiusa.comsk@igiusa.com
Profession Claim exampleProfession Claim example 837 Professional ASC x12N
(004010x098A1)
September 24, 2003
SUBSCRIBER/PATIENT: Ted Smith
ADDRESS: 236 N. Main St., Miami, FL 33413
TELEPHONE NUMBER: 305-555-1111
SEX: Male
DOB: 05/01/1948
GROUP#: 12312-A
SSN: 000-22-1111
DESTINATION PAYER: ACS BENEFITS SERVICES
PAYOR ADDRESS: P O Box 2181, Somerset, NJ 08853
PAYER ID NUMBER: 00520
Claim Information, in EnglishClaim Information, in EnglishClaim Information, in EnglishClaim Information, in English
Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500
BILLING PROVIDER/SENDER: Michael Brenett
ADDRESS: ASSAD, WASSAD NJ 12121212
TIN: 111753453
RENDERING PROVIDER: Michael Brenett
Payer Provider ID: 52054
UPIN ID C68426
PATIENT ACCOUNT NUMBER: SM-192619
CASE: Office Visit DOS=03/21/2003. POS=Office
SERVICES RENDERED:
Office first visit = $40.00
Next CPT Code = $15.00
Next CPT Code = $35.00
Claim Information, in EnglishClaim Information, in EnglishClaim Information, in EnglishClaim Information, in English
Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500
V1506
BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*Z9988~PER*IC*MNJY*TE*9089463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*1*BERNETT*MICHAEL****24*111753453~N3*ASSAD~N4*WSDSAD*NJ*12121212~REF*1C*52054~
Claim Information, in x12Claim Information, in x12Claim Information, in x12Claim Information, in x12
HL*2*1*22*0~SBR*P*18**ACS BENEFITS SERVICES*****16~NM1*IL*1*SMITH*TED****MI*000221111~N3*2316 N. MAIN STREET~N4*MIAMI*FL*33413~DMG*D8*19480501*M~REF*1G*12312-A~NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~N3*P O BOX 2181~N4*SOMERSET*NJ*08853~CLM*SM192619*55***22::1*Y*A*Y*A*C~DTP*431*D8*20030321~HI*BF:V1506~NM1*82*1*BERNETT*MICHAEL****ZZ*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~LX*1~SV1*HC:99213*40*UN*1*40**1**Y******0~DTP*472*RD8*20030321-20030321~LX*2~SV1*HC:99214*40*UN*1*15**1**Y******0~DTP*472*D8*20030321~LX*3~SV1*HC:99215*40*UN*1*30**1**Y******0~DTP*472*RD8*20030321-20030323~
Claim Information, in x12Claim Information, in x12Claim Information, in x12Claim Information, in x12
52054 C68426
HL*1**20*1~
NM1*85*1*BERNETT*MICHAEL****24*111753453~
N3*ASSAD~
N4*WSDSAD*NJ*12121212~
REF*1C*52054~
Provider InformationProvider InformationProvider InformationProvider Information
HL*2*1*22*0~
SBR*P*18**ACS BENEFITS SERVICES*****16~
NM1*IL*1*SMITH*TED****MI*000221111~
N3*2316 N. MAIN STREET~
N4*MIAMI*FL*33413~
DMG*D8*19480501*M~
NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~
N3*P O BOX 2181~
N4*SOMERSET*NJ*08853~
Subscriber InformationSubscriber InformationSubscriber InformationSubscriber Information
HL*2*1*22*0~
SBR*P*18**ACS BENEFITS SERVICES*****16~
NM1*IL*1*SMITH*TED****MI*000221111~
N3*2316 N. MAIN STREET~
N4*MIAMI*FL*33413~
DMG*D8*19480501*M~
REF*1G*12312-A~
NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~
N3*P O BOX 2181~
N4*SOMERSET*NJ*08853~
Subscriber InformationSubscriber InformationSubscriber InformationSubscriber Information
The Subscriber is the Patient
The Patient Loop will not be mapped
Patient InformationPatient InformationPatient InformationPatient Information
HL*2*1*22*0~
SBR*P*18**ACS BENEFITS SERVICES*****16~
NM1*IL*1*SMITH*TED****MI*000221111~
N3*2316 N. MAIN STREET~
N4*MIAMI*FL*33413~
DMG*D8*19480501*M~
REF*1G*12312-A~
NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~
N3*P O BOX 2181~
N4*SOMERSET*NJ*08853~
Subscriber Payer InformationSubscriber Payer InformationSubscriber Payer InformationSubscriber Payer Information
CLM*SM192619*85***11::1*Y*A*Y*A*C~
DTP*431*D8*20030321~
HI*BF:V1506~
NM1*82*1*BERNETT*MICHAEL****24*52054~
PRV*PE*ZZ*282N00000X~
REF*1G*C68426~
Original
Claim InformationClaim InformationClaim InformationClaim Information
CLM*SM192619*85***11::1*Y*A*Y*A*C~
DTP*431*D8*20030321~
HI*BF:V1506~
NM1*82*1*BERNETT*MICHAEL****24*52054~
PRV*PE*ZZ*282N00000X~
REF*1G*C68426~
Original
OfficeVisit
Original
Claim InformationClaim InformationClaim InformationClaim Information
V1506
LX*1~
SV1*HC:99213*40*UN*1*06**1**Y******0~
DTP*472*RD8*20030321-20030321~
LX*2~
SV1*HC:99214*40*UN*1*06**1**Y******0~
DTP*472*D8*20030321~
LX*3~
SV1*HC:99215*40*UN*2*06**1**Y******0~
DTP*472*RD8*20030321-20030323~
Service Line InformationService Line InformationService Line InformationService Line Information
BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*Z9988~PER*IC*MNJY*TE*9089463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*1*BERNETT*MICHAEL****24*111753453~N3*ASSAD~N4*WSDSAD*NJ*12121212~REF*1C*52054~HL*2*1*22*0~SBR*P*18*000221111*ACS BENEFITS SERVICES*****MB~NM1*IL*1*SMITH*TEX*S***MI*000221111~N3*2316 N. MAIN STREET~N4*MIAMI*FL*33413~REF*87*3053331111~DMG*D8*19480501*M~NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~N3*P O BOX 1181~N4*SOMERSET*NJ*08853~CLM*1154748*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030321~HI*BF:V1506~NM1*82*1*BERNETT*MICHAEL****24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~LX*1~SV1*HC:99213*40*UN*1*40**1**Y******0~DTP*472*RD8*20030321-20030321~LX*2~SV1*HC:99214*40*UN*1*15**1**Y******0~DTP*472*D8*20030321~LX*3~SV1*HC:99215*40*UN*1*30**1**Y******0~DTP*472*RD8*20030321-20030323~
EDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N format
EDI TransactionEDI Transaction
Control SegmentsControl Segments
Control EnvelopesControl EnvelopesControl EnvelopesControl Envelopes
Control Envelopes – ISA / IEAISA / IEA
• Interchange envelope
– GS / GEGS / GE• Functional group envelope
– ST / SEST / SE• Transaction set envelope
(One Business Document)(One Business Document)
EQUALSEQUALS
HCFA1500
Functions of the Transaction Set Functions of the Transaction Set (ST/SE) Control Envelope(ST/SE) Control Envelope
SE *SE *
0101 0202
**
~~
EDI Data - Claim #1EDI Data - Claim #1Transaction SetTransaction Set
ST *ST *
0101 0202
**
~~
EDI Transaction Set with Control Envelope
Control EnvelopeControl Envelope
ST*837*1234~BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~ NM1*40*2*BCBS*****46*980005420~HL*1**20*1~NM1*85*2*IGI HOSPITAL & NURSING HOME*****24*980S57F237~
{cont}
SE*14*1234~ST*837*1235~
BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~ NM1*40*2*BCBS*****46*980005420~HL*1**20*1~NM1*85*2*IGI HOSPITAL & NURSING HOME*****24*980S57F237~
{cont}
SE*14*1235~
Transaction Set (ST/SE) Transaction Set (ST/SE) Control EnvelopeControl Envelope
Transaction Set (ST/SE) Transaction Set (ST/SE) Control EnvelopeControl Envelope
Functional Groups
HCFA15001500
HCFA15001500
HCFA1500
Transaction Sets
To
: : Pa
yer A
Cla
ims P
ay a
ble
To
: Pa
yer A
Cla
ims R
ep
ortin
g
EQUALS
Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope
Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope
FFUUNNCCTTIIOONNAALL
EDI Data – Claims (charges)EDI Data – Claims (charges)
EDI Data – Claims (reporting) EDI Data – Claims (reporting)
GS *GS *
GE *GE *
0101
0101
0505 0606 0707 0808
040403030202
0202
Trans SetTrans Set
Trans SetTrans Set
STST
STST
SESE
SESE
** ** ** **
** ** **
****
~~
~~~~
Control EnvelopeControl EnvelopeControl EnvelopeControl Envelope
GS*HC*ZZ576*00520*20030923*1933*20030923*X*004010X098A1~ ST*837*1234~
BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~
SE*1000*1234~ ST*837*1235~
BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~
SE*26*1234~GE*2*20030923~
Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope
Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope
HCFA15001500
HCFA15001500
EligibilityInformation
EXPRESS DELIVERY
Sender:
Dr Jones345 laneNJ 99893
Receiver:
BSBC OF CA232 LNCA 09393
Tracking #: 000000000177975 021760 7
Transaction Sets
Functional Groups
Interchange
To
: : Pa
yer A
Cla
ims P
ay a
ble
To
: : Pa
yer A
Me
mb
er E
nro
l lme
nt
Interchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control Envelope
FFUUNNCCTTIIOONNAALL
GGRROOUUPP
GE GE
EDI Data – HCFA SET #1EDI Data – HCFA SET #1Trans SetTrans Set
STST
SESE
GS GS
IEA *IEA * 0101 0202** ~~
ISAISA 0101 040403030202** ** ** ** 0505 06 07 08** ** **
~0909 121211111010** ** ** ** 13 14 15 16** ** ****
**
Control EnvelopeControl EnvelopeControl EnvelopeControl Envelope
EDI Data – HCFA SET #2EDI Data – HCFA SET #2Trans SetTrans Set
STST
SESE
EDI Data Eligibility Info #1EDI Data Eligibility Info #1Trans SetTrans Set
STST
SESE
GS GS
GE GE
IINNTTEERRCCHHAANNGGEE
ISA*00*0000000001*00*0000000001*ZZ*E1576 *30*00520 *200309*1933*U*00401*000000001*1*T*:~
Interchange (ISA/IEA) Interchange (ISA/IEA) Control EnvelopeControl Envelope
Interchange (ISA/IEA) Interchange (ISA/IEA) Control EnvelopeControl Envelope
IEA*1*000000001~
GS*HC*E1576*00520*20030923*1933*20030923*X*004010X098A1~ ST*837*1234~
BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~
SE*1000*1234~ ST*837*1235~
BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~
SE*26*1234~GE*2*20030923~
ISA*00*0000000001*00*0000000001*ZZ*E1576 *30*00520 *200309*1933*U*00401*000000001*1*T*:~GS*HC*E1576*00520*20030923*1933*20030923*X*004010X098A1~ST*837*00001~BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*DEWITT HOSPITAL & NURSING HOME*****46*E1576~PER*IC*SUSAN*TE*8709463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*2*DEWITT HOSPITAL & NURSING HOME*****24*57237~N3*P.O. BOX 32~N4*DE WITT*AR*72042~REF*1C*57237~HL*2*1*22*0~SBR*P*18*XCAV71748*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*DEBERRY*WILLIAM*S***MI*XCAV71748~N3*90 SAM DEBERRY RD~N4*DEWITT*AR*720420000~DMG*D8*19530817*M~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154748*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030726~HI*BK:9895*BF:72981*BF:E9053*BF:V1506~NM1*DN*1*BURLESON*STAN*W***24*D04410~REF*1B*X~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*22**1:2:3:4**Y******0~DTP*472*RD8*20030726-20030726~HL*3*1*22*0~SBR*P*18*431356390*AMCO/AHA-1ST SOURCE REPRICI*****MB~PAT*~NM1*IL*1*JAMES*KELLY****MI*431356390~N3*813 W GIBSON~N4*DEWITT*AR*72042~DMG*D8*19721113*F~NM1*PR*2*AMCO/AHA-1ST SOURCE REPRICI*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722032181~CLM*1154754*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030726~HI*BK:7840*BF:78701~NM1*DN*1*GUSTAVUS*JOHN*L***24*C68426~REF*1B*52054~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*22**1:2**Y******0~DTP*472*RD8*20030726-20030726~HL*4*1*22*0~SBR*P*18*HIP431310803-00*BLUE ADVANTAGE ADMINISTRATO*****MB~PAT*~NM1*IL*1*PADGETT*DELORES****MI*HIP431310803-00~N3*P.O.BOX 56~N4*ETHEL*AR*72048~DMG*D8*19400405*F~NM1*PR*2*BLUE ADVANTAGE ADMINISTRATO*****PI*00520~N3*P.O. BOX 1460~N4*LITTLE ROCK*AR*722030000~CLM*1154731*100***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030725~HI*BK:78902*BF:78701*BF:7936*BF:V1005~NM1*DN*1*GUSTAVUS*JOHN*L***24*C68426~REF*1B*52054~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99284*100*UN*1*22**1:2:3:4**Y******0~DTP*472*RD8*20030725-20030725~HL*5*1*22*0~SBR*P*18*XCJ990004117*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*ESTES*LARRY****MI*XCJ990004117~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*853101*198***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030730~HI*BK:41091*BF:3051~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99223*198*UN*1*22**1:2**Y******0~DTP*472*RD8*20030730-20030730~HL*6*1*22*0~SBR*P*18*XCSL83633*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*FLY*CYNTHIA****MI*XCSL83633~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154898*75***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030801~HI*BK:5920~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*22**1**Y******0~DTP*472*RD8*20030801-20030801~HL*7*1*22*0~SBR*P*18*XCAC77095*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*WRINKLE*KENNETH*G***MI*XCAC77095~N3*BOX 471~N4*GILLETT*AR*720550000~DMG*D8*19401206*M~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154810*35***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030728~HI*BK:9181*BF:E9289~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99281*35*UN*1*22**1:2**Y******0~DTP*472*RD8*20030728-20030728~HL*8*1*22*0~SBR*P*18*431-35-6390*AMCO/AHA-1ST SOURCE REPRICI*****MB~PAT*~NM1*IL*1*JAMES*KELLY****MI*431-35-6390~N3*813 W GIBSON~N4*DEWITT*AR*72042~DMG*D8*19721113*F~NM1*PR*2*AMCO/AHA-1ST SOURCE REPRICI*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722032181~CLM*1153840*75***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030606~HI*BK:4660~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*22**1**Y******0~DTP*472*RD8*20030606-20030606~HL*9*1*22*0~SBR*P*18*XCP990105122*FIRST SOURCE*****MB~PAT*~NM1*IL*1*SIEBER*LESTER****MI*XCP990105122~N3*1206 S ADAMS~N4*DEWITT*AR*720420000~DMG*D8*19991104*M~NM1*PR*2*FIRST SOURCE*****PI*00520~N3*PO BOX 2181~N4*LITTLE ROCK*AR*720990000~CLM*1155171*55***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030815~HI*BK:9895*BF:7295*BF:E9053~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*23**1:2:3**Y******0~DTP*472*RD8*20030815-20030815~HL*10*1*22*0~SBR*P*18*XCP990105122*FIRST SOURCE*****MB~PAT*~NM1*IL*1*SIEBER*LESTER****MI*XCP990105122~NM1*PR*2*FIRST SOURCE*****PI*00520~N3*PO BOX 2181~N4*LITTLE ROCK*AR*720990000~CLM*1155172*75***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030815~HI*BK:9895*BF:78609*BF:7872*BF:7295~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*23**1:2:3:4**Y******0~DTP*472*RD8*20030815-20030815~HL*11*1*22*0~SBR*P*18*ASB4305410001*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*WATSON*KEITH****MI*ASB4305410001~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1155162*75***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030816~HI*BK:2554~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*23**1**Y******0~DTP*472*RD8*20030816-20030816~SE*240*00001~GE*1*20030923~IEA*1*000000001~
EDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N format
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