EDI 837 Professional. Version 005010X222A1
Example 1: Outpatient Visit
1) Patient is same person as subscriber.
2) Payer is commercial health insurance Company
EDI File
ISA*00* *00* *ZZ*123123 *01*241232 *210420*0417*^*00501*204717000*1*T*:
GS*HC*123123*241232*20210420*0417*204717*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210420*0417*CH
NM1*41*2*ABC Submitter*****46*123123
PER*IC*John Mike*TE*1214151617
NM1*40*2*241232*****46*241232
HL*1**20*1
PRV*BI*PXC*208500000X
NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692
N3*3937 Kenwood Place
N4*Orlando*FL*32801
REF*EI*81-3777631
HL*2*1*22*0
SBR*P*18*92291223*AED12342*****ZZ
NM1*IL*1*BAKER*Alyssa****MI*723223232
N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St
N4*HOUSTON*TX*77833
DMG*D8*20201203*M
NM1*PR*2*CIGNA*****PI*81400
N3*PO BOX 660044
N4*DALLAS*TX*75266
CLM*10421*85.00***11:B:1*Y*A*Y*Y*P
HI*ABK:R1013*ABF:E860
NM1*82*1*Nelson*Romer****XX*1023555349
NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059
N3*6100 W CREEK RD SUITE 35
N4*Independence*OH*44131
LX*1
SV1*HC:99213*40.00*UN*1.00*11**1:2
DTP*472*RD8*20201215-20201215
REF*6R*73334
LX*2
SV1*HC:87070*45.00*UN*1.00*11**1:2
DTP*472*RD8*20201215-20201215
REF*6R*73335
SE*35*0001
GE*1*204717
IEA*1*204717000
HTML Version
Submitter Information
| Transaction Date | 04/20/2021 |
| Transaction Time (HHMM) | 04:17 |
| EDI Version | 005010X222A1 |
| EDI Transaction set | 837 |
| Submitter Entity | Organization |
| Organization Name | ABC Submitter |
| Contact Name | John Mike |
| Contact Phone | 1214151617 |
| Submitter ID | 123123 |
| Receiver ID | 241232 |
| AuthorizationQualifier | 00 |
| Control Number | 204717000 |
| Usage Indicator | T |
| Acknowledgement Requested | 1 |
Billing Provider
| Entity Type | 2 |
| Last or Organization Name | Get Well Family Clinic LLC |
| Address1 | 3937 Kenwood Place |
| City | Orlando |
| State | FL |
| Zip | 32801 |
| NPI | 1740713692 |
| Tax ID | 81-3777631 |
| Taxonomy Code | 208500000X |
Subscriber information
| Payer Responsbility | P |
| Insured Relationship | 18 |
| Group Number | 92291223 |
| Group Name | AED12342 |
| Claim Filling Indicator | ZZ |
Subscriber Name
| Entity Type | 1 |
| Last or Organization Name | BAKER |
| First Name | Alyssa |
| DOB | 12/03/2020 |
| Gender | M |
| Policy No | 723223232 |
| Address1 | 197800 Atascocita Shores Dr |
| Address2 | 302 12 N. Mcgraw St |
| City | HOUSTON |
| State | TX |
| Zip | 77833 |
Payer
| Name | CIGNA |
| Address1 | PO BOX 660044 |
| City | DALLAS |
| State | TX |
| Zip | 75266 |
| Payer ID | 81400 |
Claim Information
| Claim No | 10421 |
| Billed Amount | 85.00 |
| Claim Type | 1 |
| Provider Sign Indicator | Y |
| Provider Accept Assignment Code | A |
| Benefits Assignment Indicator | Y |
| Release of information | Y |
ICD Information
| ICD Code 1 | R1013 |
| ICD Code 2 | E860 |
Rendering Provider
| Entity Type | 1 |
| Last or Organization Name | Nelson |
| First Name | Romer |
| NPI | 1023555349 |
Facility
| Name | Clinic For Pain And Anxiety |
| Address1 | 6100 W CREEK RD SUITE 35 |
| City | Independence |
| State | OH |
| Zip | 44131 |
| NPI | 1396885059 |
| POS | 11 |
Line Item : 1
| Line Item ID | 73334 |
| Procedure Code | 99213 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 40 |
| ICD Pointers | 1,2 |
| Service From Date | 12/15/2020 |
| Service To Date | 12/15/2020 |
| POS | 11 |
Line Item : 2
| Line Item ID | 73335 |
| Procedure Code | 87070 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 45 |
| ICD Pointers | 1,2 |
| Service From Date | 12/15/2020 |
| Service To Date | 12/15/2020 |
| POS | 11 |
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