X12 EDI 837 Examples Billing Provider Complete Information

 


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 Information

Submitter Entity Organization
Organization Name Demo Practice
Etin Number 111134
Contact Name William Richard
Contact Phone 2025550170
Contact Fax 2025550179

Receiver Information

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