Pay to Address
Once the claims reach the carriers and they complete processing, they issue a check and prepare an Explanation of Benefits (EOB). The checks and the EOBs would be sent to the pay-to address with the carrier or in the HCFA. Pay-to address is the common address that the provider has set up to receive checks and EOBs from carriers and patients. This is most likely a PO Box address set up in arrangement with the bank where the provider has an account.
Here is an example of EDI 837 with Pay to Address Loop
EDI 837 Professional. Version 005010X222A1
Example 4: Outpatient Visit with Pay to address
1) Patient is same person as subscriber.
2) Payer is commercial health insurance Company
ISA*00* *00* *ZZ*123123 *01*241232 *210504*0902*^*00501*420535900*1*T*:
GS*HC*123123*241232*20210504*0902*4205359*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210504*0902*CH
NM1*41*2*ABC Submitter*****46*7342343
PER*IC*John Mike*TE*1214151617
NM1*40*2*Zirmed*****46*12345
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
NM1*87*2
N3*P.O. BOX 100190
N4*Columbia*SC*12345
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*20201204*M
NM1*PR*2*CIGNA*****PI*81400
N3*PO BOX 660044
N4*DALLAS*TX*75266
CLM*10421*100.00***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*50.00*UN*1.00***1:2
DTP*472*D8*20201204
REF*6R*6001
LX*2
SV1*HC:87070*50.00*UN*1.00***1:2
DTP*472*D8*20201204
REF*6R*6002
SE*38*0001
GE*1*4205359
IEA*1*420535900
HTML Version
Interchange Control Header
| AuthorizationQualifier | 00 |
| Submitter ID | 123123 |
| Interchange ID Qualifier | 01 |
| Receiver ID | 241232 |
| Interchange Date | 05/04/2021 |
| InterChange Time (HHMM) | 09:02 |
| Repetition Seperator | ^ |
| Control Number | 420535900 |
| Acknowledgement Requested | 1 |
| Usage Indicator | T |
Functional Group Header
| Application Sender Code | 123123 |
| Application Receiver Code | 241232 |
| Group Transaction Date | 05/04/2021 |
| Group Transaction Time (HHMM) | 09:02 |
| Group Control Number | 4205359 |
| EDI Version | 005010X222A1 |
Transaction Set Header
| Transaction set | 837 |
| Transaction Control Number | 0001 |
Hierarchical Transaction
| Application Transaction Number | 0001 |
| Transaction Date | 05/04/2021 |
| Transaction Time (HHMM) | 09:02 |
| Submitter Entity | Organization |
| Organization Name | ABC Submitter |
| Etin Number | 7342343 |
| Contact Name | John Mike |
| Contact Phone | 1214151617 |
| Receiver Name | Zirmed |
| Receiver Etin Number | 12345 |
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 |
Billing Provider Pay to Address
| Entity Type | 2 |
| Address1 | P.O. BOX 100190 |
| City | Columbia |
| State | SC |
| Zip | 12345 |
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 | 12/04/2020 |
| 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 | 100.00 |
| 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 |
Line Item : 1
| Line Item ID | 6001 |
| Procedure Code | 99213 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 50.00 |
| ICD Pointers | 1,2 |
| Service From Date | 12/04/2020 |
| Service To Date | 12/04/2020 |
Line Item : 2
| Line Item ID | 6002 |
| Procedure Code | 87070 |
| Units Code | UN |
| Units | 1.00 |
| Charges | 50.00 |
| ICD Pointers | 1,2 |
| Service From Date | 12/04/2020 |
| Service To Date | 12/04/2020 |
CMS 1500 Form Preview for the above EDI File
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