EDI 837 Professional. Version 005010X222A1
Example 12: Billing Provider Complete Information -> Bill with Group NPI
ISA*00* *00* *ZZ*111134 *01*zirmed *200218*0749*^*00501*796000000*0*P*:
GS*HC*111134*zirmed*20200218*0749*796*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20200218*0749*CH
NM1*41*2*Demo Practice*****46*111134
PER*IC*William Richard*TE*2025550170*FX*2025550179
NM1*40*2*zirmed*****46*zirmed
HL*1**20*1
NM1*85*2*Demo Clinic*****XX*1215099528
N3*2486 NORTH UNIVERSITY DRIVE*APT E10
N4*WestField*NY*14787
REF*EI*222222222
REF*OB*731232
REF*1G*523123232
PER*IC*John Mike*TE*9165423443*FX*1234567890*EM*xyz@abc.com*EX*5412
HL*2*1*22*0
SBR*P*18*K34532*GFAMPLAN*****BL
NM1*IL*1*XXXXX*XXXXX****MI*XXXXXX
N3*8367 ALIQUAM ROAD*AP #117-8770
N4*XXXX land*CA*743434232
DMG*D8*19451122*M
NM1*PR*2*Blue Choice*****PI*9393
N3*4787 BLUFF STREET
N4*Blue bell*TX*74102
CLM*124304*60***11:B:1*Y*A*Y*Y*P
HI*ABK:A05
NM1*82*1*XXXXX*XXXX****XX*6565656565
NM1*77*2*NY Office*****XX*1336177328
N3*5081 Tellus. Avenue
N4*White Plains*NY*809051232
LX*1
SV1*HC:99214*60*UN*1*11**1
DTP*472*RD8*20190516-20190516
REF*6R*75965
SE*33*0001
GE*1*796
IEA*1*796000000
HTML Version
Interchange Control Header
Authorization Qualifier | 00 |
Security Qualifier | 00 |
Interchange ID Qualifier Sender | ZZ |
Submitter ID | 111134 |
Interchange ID Qualifier Receiver | 01 |
Receiver ID | zirmed |
Interchange Date | 02/18/2020 |
InterChange Time (HHMM) | 07:49 |
Repetition Seperator | ^ |
Control Number | 796000000 |
Acknowledgement Requested | 0 |
Usage Indicator | P |
Functional Group Header
Application Sender Code | 111134 |
Application Receiver Code | zirmed |
Group Transaction Date | 02/18/2020 |
Group Transaction Time (HHMM) | 07:49 |
Group Control Number | 796 |
EDI Version | 005010X222A1 |
Transaction Set Header
Transaction set | 837 |
Transaction Control Number | 0001 |
Hierarchical Transaction
Application Transaction Number | 0001 |
Transaction Date | 02/18/2020 |
Transaction Time (HHMM) | 0749 |
Submitter Entity | Organization |
Organization Name | Demo Practice |
Etin Number | 111134 |
Contact Name | William Richard |
Contact Phone | 2025550170 |
Contact Fax | 2025550179 |
Receiver Name | zirmed |
Receiver Etin Number | zirmed |
Billing Provider
Entity Type | 2 |
Last or Organization Name | Demo Clinic |
Address1 | 2486 NORTH UNIVERSITY DRIVE |
Address2 | APT E10 |
City | WestField |
State | NY |
Zip | 14787 |
NPI | 1215099528 |
Tax ID | 222222222 |
State License Number (0B) | 731232 |
UPIN Number (1G) | 523123232 |
Contact Name | John Mike |
Contact Phone | 9165423443 |
Contact Fax | 1234567890 |
Contact Email | xyz@abc.com |
Subscriber information
Payer Responsbility | P |
Insured Relationship | 18 |
Group Number | K34532 |
Group Name | GFAMPLAN |
Claim Filling Indicator | BL |
Subscriber Name
Entity Type | 1 |
Last or Organization Name | XXXXX |
First Name | XXXXX |
DOB | 11/22/1945 |
Gender | M |
Policy No | XXXXXX |
Address1 | 8367 ALIQUAM ROAD |
Address2 | AP #117-8770 |
City | XXXX land |
State | CA |
Zip | 743434232 |
Payer
Name | Blue Choice |
Address1 | 4787 BLUFF STREET |
City | Blue bell |
State | TX |
Zip | 74102 |
Payer ID | 9393 |
Claim Information
Claim No | 124304 |
Billed Amount | 60 |
Claim Type | 1 |
Provider Sign Indicator | Y |
Provider Accept Assignment Code | A |
Benefits Assignment Indicator | Y |
Release of information | Y |
Patient Signature Code | P |
ICD Information
ICD Code 1 | A05 |
Rendering Provider
Entity Type | 1 |
Last or Organization Name | XXXXX |
First Name | XXXX |
NPI | 6565656565 |
Facility
Name | NY Office |
Address1 | 5081 Tellus. Avenue |
City | White Plains |
State | NY |
Zip | 809051232 |
NPI | 1336177328 |
Line Item : 1
Line Item ID | 75965 |
Procedure Code | 99214 |
Units Code | UN |
Units | 1 |
Charges | 60.00 |
ICD Pointers | 1 |
Service From Date | 05/16/2019 |
Service To Date | 05/16/2019 |
POS | 11 |