EDI 837 Dental. Version 005010X224A2
Example: One Claim with 12 Procedure Codes
ISA*00* *00* *ZZ*submitterID *ZZ*receiverID *230726*0323*^*00501*263232200*1*T*:
GS*HC*submitterID*receiverID*20230726*0323*2632322*X*005010X224A2
ST*837*0001*005010X224A2
BHT*0019*00*0001*20230726*0323*CH
NM1*41*2*Demo Practice*****46*submitterID
PER*IC*John*TE*2025550170
NM1*40*2*MyClearingHouse*****46*receiverID
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*813777631
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*20200412*M
NM1*PR*2*CIGNA*****PI*81400
N3*PO BOX 660044
N4*DALLAS*TX*75266
CLM*101121*1810***11:B:1*Y*A*Y*Y
HI*ABK:K001*ABF:Z464*ABF:Z298
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
SV3*AD:D5214*50****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7001
LX*2
SV3*AD:D2750*50****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7002
LX*3
SV3*AD:D0364*150****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7003
LX*4
SV3*AD:D0366*140****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7004
LX*5
SV3*AD:D0460*72****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7005
LX*6
SV3*AD:D0502*42****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7006
LX*7
SV3*AD:D2393*242****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7007
LX*8
SV3*AD:D3222*112****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7008
LX*9
SV3*AD:D3502*12****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7009
LX*10
SV3*AD:D4276*120****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7010
LX*11
SV3*AD:D5422*520****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7011
LX*12
SV3*AD:D5924*300****1*****1:2:3
DTP*472*D8*20200412
REF*6R*7012
SE*75*0001
GE*1*2632322
IEA*1*263232200
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