EDI 837 Professional. Version 005010X222A1
Example 8: Billing Provider Secondary Identification
Here is an example of EDI 837 with Billing Provider secondary ID numbers such as State license Number, UPIN Number, and Taxonomy Code
ISA*00* *00* *ZZ*123123 *ZZ*241232 *210513*1103*^*00501*131125800*1*T*:
GS*HC*123123*241232*20210513*1103*1311258*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210513*1103*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
REF*OB*X4123412
REF*1G*U34C3353D
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*37*0001
GE*1*1311258
IEA*1*131125800
HTML Version
Interchange Control Header
| Authorization Qualifier | 00 |
| Security Qualifier | 00 |
| Interchange ID Qualifier Sender | ZZ |
| Submitter ID | 123123 |
| Interchange ID Qualifier Receiver | ZZ |
| Receiver ID | 241232 |
| Interchange Date | 05/13/2021 |
| InterChange Time (HHMM) | 11:03 |
| Repetition Seperator | ^ |
| Control Number | 131125800 |
| Acknowledgement Requested | 1 |
| Usage Indicator | T |
Functional Group Header
| Application Sender Code | 123123 |
| Application Receiver Code | 241232 |
| Group Transaction Date | 05/13/2021 |
| Group Transaction Time (HHMM) | 11:03 |
| Group Control Number | 1311258 |
| EDI Version | 005010X222A1 |
Transaction Set Header
| Transaction set | 837 |
| Transaction Control Number | 0001 |
Hierarchical Transaction
| Application Transaction Number | 0001 |
| Transaction Date | 05/13/2021 |
| Transaction Time (HHMM) | 11:03 |
| 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 |
| State License Number (0B) | X4123412 |
| UPIN Number (1G) | U34C3353D |
| 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 | 12/04/2020 |
| 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
