EDI 837 Professional. Version 005010X222A1
Example 6: Prior Authorization
There are certain services that require pre-certification, pre-notification or pre-authorization from the insurance company. On the insurance verification process, we can ensure whether a particular service requires pre-authorization or not. Though pre-authorization does not guarantee reimbursement, the absence of pre-authorization can surely result in claim denials or non-reimbursement. Once you acquire pre-authorization from a payer, you will get a pre-authorization number. This number must be included in your claims to avoid unnecessary denials. If your claims are denied based on the lack of medical necessity, you should append this pre-authorization number while preparing an appeal letter.
ISA*00* *00* *ZZ*123123 *ZZ*241232 *210510*0744*^*00501*107435800*1*T*:
GS*HC*123123*241232*20210510*0744*1074358*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210510*0744*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
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*100.00***11:B:1*Y*A*Y*Y*P
REF*G1*X4124124
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*20201203
REF*6R*6001
LX*2
SV1*HC:87070*50.00*UN*1.00***1:2
DTP*472*D8*20201203
REF*6R*6002
SE*36*0001
GE*1*1074358
IEA*1*107435800
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 | 05/10/2021 |
| InterChange Time (HHMM) | 07:44 |
| Repetition Seperator | ^ |
| Control Number | 107435800 |
| Acknowledgement Requested | 1 |
| Usage Indicator | T |
Functional Group Header
| Application Sender Code | 123123 |
| Application Receiver Code | 241232 |
| Group Transaction Date | 05/10/2021 |
| Group Transaction Time (HHMM) | 07:44 |
| Group Control Number | 1074358 |
| EDI Version | 005010X222A1 |
Transaction Set Header
| Transaction set | 837 |
| Transaction Control Number | 0001 |
Hierarchical Transaction
| Application Transaction Number | 0001 |
| Transaction Date | 05/10/2021 |
| Transaction Time (HHMM) | 07:44 |
| 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 |
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 | 100.00 |
| Claim Type | 1 |
| Provider Sign Indicator | Y |
| Provider Accept Assignment Code | A |
| Benefits Assignment Indicator | Y |
| Release of information | Y |
| Prior Authorization Number | X4124124 |
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 | 12/03/2020 |
| Service To Date | 12/03/2020 |
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 | 12/03/2020 |
| Service To Date | 12/03/2020 |
CMS 1500 Form Preview for the above EDI File
Looking for JSON to EDI solution ?