tag:blogger.com,1999:blog-25845311581373384192024-03-23T15:46:14.132+05:30Healthcare IT EMR PMSTechno-functional 15 Years EMR/PMS experience.Love to work in EMR, e-Prescription, HL7, Medical Billing, EDI 4010, EDI 5010, CMS 1500 FORM, etc.
Email : vbsenthilinnet@gmail.com
Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comBlogger388125tag:blogger.com,1999:blog-2584531158137338419.post-14989473103353145902024-02-03T22:37:00.003+05:302024-02-04T06:22:06.920+05:30Difference between Billing Provider and Rendering Provider<a name='more'></a> <div class="separator" style="clear: both;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpQ4fzNJZsZPB7ks6kz-JTiZTCwyTfmAGrrVZXmWQpK6CWoKv0-D87UWC86qxGKE3s-BPUf8VDQTR9k-WIajmalTFG-kpT-KuOqzGM3F8WPiRVLKTtD7r9aAp9UkA9qjvFsZRKZjPNFfqa8BfqjtUe_y7g4lD07kJKEtdCqBqyQ6rvdK76k7v7uSLPji78/s1600/Difference%20between%20Billing%20and%20Rendering%20Providerf.png" style="display: block; padding: 1em 0px; text-align: center;"><img alt="" border="0" data-original-height="1080" data-original-width="1080" height="476" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgpQ4fzNJZsZPB7ks6kz-JTiZTCwyTfmAGrrVZXmWQpK6CWoKv0-D87UWC86qxGKE3s-BPUf8VDQTR9k-WIajmalTFG-kpT-KuOqzGM3F8WPiRVLKTtD7r9aAp9UkA9qjvFsZRKZjPNFfqa8BfqjtUe_y7g4lD07kJKEtdCqBqyQ6rvdK76k7v7uSLPji78/w476-h476/Difference%20between%20Billing%20and%20Rendering%20Providerf.png" width="476" /></a></div>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-21786203893857540952023-07-26T14:59:00.000+05:302023-07-26T15:00:02.662+05:30X12 EDI Examples–EDI 837 D One Claim with 12 Procedure Codes<a name='more'></a> <p><span style="font-size: small;"><strong>EDI 837 Dental. Version 005010X224A2</strong></span></p> <p><span style="font-size: small;"><strong>Example:  One Claim with 12 Procedure Codes</strong></span></p> <p>ISA*00*          *00*          *ZZ*submitterID    *ZZ*receiverID     *230726*0323*^*00501*263232200*1*T*: <br /> GS*HC*submitterID*receiverID*20230726*0323*2632322*X*005010X224A2 <br /> ST*837*0001*005010X224A2 <br /> BHT*0019*00*0001*20230726*0323*CH <br /> NM1*41*2*Demo Practice*****46*submitterID <br /> PER*IC*John*TE*2025550170 <br /> NM1*40*2*MyClearingHouse*****46*receiverID <br /> HL*1**20*1 <br /> PRV*BI*PXC*208500000X <br /> NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692 <br /> N3*3937  Kenwood Place <br /> N4*Orlando*FL*32801 <br /> REF*EI*813777631 <br /> HL*2*1*22*0 <br /> SBR*P*18*92291223*AED12342*****ZZ <br /> NM1*IL*1*BAKER*Alyssa****MI*723223232 <br /> N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St <br /> N4*HOUSTON*TX*77833 <br /> DMG*D8*20200412*M <br /> NM1*PR*2*CIGNA*****PI*81400 <br /> N3*PO BOX 660044 <br /> N4*DALLAS*TX*75266 <br /> CLM*101121*1810***11:B:1*Y*A*Y*Y <br /> HI*ABK:K001*ABF:Z464*ABF:Z298 <br /> NM1*82*1*Nelson*Romer****XX*1023555349 <br /> NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059 <br /> N3*6100 W CREEK RD SUITE 35 <br /> N4*Independence*OH*44131 <br /> LX*1 <br /> SV3*AD:D5214*50****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7001 <br /> LX*2 <br /> SV3*AD:D2750*50****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7002 <br /> LX*3 <br /> SV3*AD:D0364*150****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7003 <br /> LX*4 <br /> SV3*AD:D0366*140****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7004 <br /> LX*5 <br /> SV3*AD:D0460*72****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7005 <br /> LX*6 <br /> SV3*AD:D0502*42****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7006 <br /> LX*7 <br /> SV3*AD:D2393*242****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7007 <br /> LX*8 <br /> SV3*AD:D3222*112****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7008 <br /> LX*9 <br /> SV3*AD:D3502*12****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7009 <br /> LX*10 <br /> SV3*AD:D4276*120****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7010 <br /> LX*11 <br /> SV3*AD:D5422*520****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7011 <br /> LX*12 <br /> SV3*AD:D5924*300****1*****1:2:3 <br /> DTP*472*D8*20200412 <br /> REF*6R*7012 <br /> SE*75*0001 <br /> GE*1*2632322 <br /> IEA*1*263232200 <br /> <br /><strong><span style="font-size: medium;">Are you looking for a JSON to EDI solution or vice versa?</span></strong></p> <p><strong><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><span style="color: rgb(0, 0, 255); font-size: small;">EDI RESTful Web Service API</span></a><span style="color: rgb(0, 0, 255);"> </span></strong> <br /><strong><a href="https://youtube.com/playlist?list=PLLi-le77HGDZWbQ0jinryMcERYXttnpC5" target="_blank"><span style="color: rgb(0, 0, 255); font-size: small;">Explore Our Nagata EDI Tool - JSON to EDI and vice versa</span></a></strong></p> <p> <br /><strong><span style="font-size: medium;"><strong>Looking for more examples? Login into our EDI Tool </strong></span> <br /><strong><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><span style="color: rgb(0, 0, 255);">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</span></a></strong></strong></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-19637049021500987982023-07-12T08:05:00.002+05:302023-07-26T14:51:51.356+05:30X12 EDI Examples–EDI 837 D Orthodontic-treatment-plan<a name='more'></a> <p><span style="font-size: small;"><strong>EDI 837 Dental. Version 005010X224A2</strong></span></p> <p><span style="font-size: small;"><strong>Example:  Orthodontic treatment plan </strong></span></p> <p>ISA*00*          *00*          *ZZ*123456789012345*ZZ*123456789012346*080503*1705*>*00501*000010216*0*T*: <br />GS*HC*1234567890*1234567890*20080503*1705*20213*X*005010X224A2 <br />ST*837*0322*005010X224A2 <br />BHT*0019*00*0123*20061123*1023*CH <br />NM1*41*2*JOHN DOE*****46*940001 <br />PER*IC*SALLY*TE*7175555555 <br />NM1*40*2*KEY INSURANCE COMPANY*****46*999996666 <br />HL*1**20*1 <br />PRV*BI*PXC*1223G0001X <br />NM1*85*1*JOHN*DOE****XX*2345678901 <br />N3*123 TOOTH DRIVE <br />N4*MIAMI*FL*33411 <br />REF*EI*587654321 <br />HL*2*1*22*0 <br />SBR*P*18*******CI <br />NM1*IL*1*SMITH*JANE****MI*111223333 <br />N3*236 N MAIN ST <br />N4*MIAMI*FL*33413 <br />DMG*D8*19911029*M <br />NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666 <br />CLM*SMITH788*4000***11:B:1*Y*A*Y*I <br />DTP*452*D8*20061115 <br /><span style="color: rgb(255, 0, 0);">DN1*36</span> <br />LX*1 <br />SV3*AD:D8080*4000****1 <br />SE*24*0322 <br />GE*1*20213 <br />IEA*1*000010216 <br /> <br /> <br />JSON used to create the above EDI Message</p> <p> </p> <p>{ <br />  "doValidation": "Yes", <br />  "assignDefaultValues": "Yes", <br />  "interChangeHeader": { <br />    "authorizationQualifier": "00", <br />    "securityQualifier": "00", <br />    "interChangeIDQualifierSender": "ZZ", <br />    "interChangeIDQualifierReceiver": "ZZ", <br />     "submitterID": "123456789012345", <br />    "receiverID": "123456789012346", <br />    "interChangeDate": "080503", <br />    "interChangeTime": "1705", <br />    "ediControlNumber": "000010216", <br />    "repetitionSeparator": "\u003e", <br />    "acknowledgementRequested": "0", <br />    "usageIndicator": "T", <br />    "componentElementSeparator": ":", <br />    "controlVersionNumber": "00501" <br />  }, <br />  "groupHeader": { <br />    "groupTransactionDate": "20080503", <br />    "applicationSenderCode": "1234567890", <br />    "applicationReceiverCode": "1234567890", <br />    "groupTransactionTime": "1705", <br />    "groupControlNumber": "20213", <br />    "ediVersion": "005010X224A2", <br />    "functionalIdentifierCode": "HC", <br />    "responsibleAgencyCode": "X" <br />  }, <br />  "transactionSets": [ <br />    { <br />      "ediTransactionSet": "837", <br />      "transactionControlNumber": "0322", <br />      "originatorAppTransNumber": "0123", <br />       "transactionDate": "20061123", <br />      "transactionTime": "1023", <br />      "transactionPurposeCode": "00", <br />      "transactionTypeCode": "CH", <br />      "implementationVersion": "005010X224A2", <br />      "hierarchicalStructureCode": "0019", <br />      "receiver": { <br />         "etinNumber": "999996666", <br />        "entityType": "2", <br />        "lastName": "KEY INSURANCE COMPANY", <br />        "identifierCode": "46", <br />        "identifierValue": "999996666", <br />        "entityIdentifierCode": "40" <br />      }, <br />      "submitter": { <br />        "etinNumber": "940001", <br />        "contactName": "SALLY", <br />        "contactPhone": "7175555555", <br />        "entityType": "2", <br />        "lastName": "JOHN DOE", <br />        "identifierCode": "46", <br />        "identifierValue": "940001", <br />        "entityIdentifierCode": "41" <br />      }, <br />      "claimsList": [ <br />        { <br />          "claimIndex": 1, <br />           "claimNo": "SMITH788", <br />          "billedAmount": "4000", <br />          "pos": "11", <br />          "claimType": "1", <br />          "providerSignIndicator": "Y", <br />          "providerAcceptAssCode": "A", <br />          "benefitAssIndicator": "Y", <br />          "releaseInfoCode": "I", <br />          "billingProviderDTO": { <br />            "entityType": "1", <br />            "lastName": "JOHN", <br />            "firstName": "DOE", <br />            "npi": "2345678901", <br />            "address1": "123 TOOTH DRIVE", <br />            "city": "MIAMI", <br />             "state": "FL", <br />            "taxonomyCode": "1223G0001X", <br />             "zip": "33411", <br />            "taxNo": "587654321" <br />           }, <br />          "payerDTO": { <br />            "entityIdentifierCode": "PR", <br />            "name": "KEY INSURANCE COMPANY", <br />            "payerID": "999996666" <br />          }, <br />          "subscriberDTO": { <br />            "entityType": "1", <br />            "lastName": "SMITH", <br />            "firstName": "JANE", <br />            "address1": "236 N MAIN ST", <br />            "city": "MIAMI", <br />            "state": "FL", <br />            "zip": "33413", <br />            "dob": "19911029", <br />             "gender": "M", <br />            "payerRespon": "P", <br />             "claimFillingIndicator": "CI", <br />            "policyNo": "111223333", <br />            "insuredRelation": "18" <br />          }, <br />           "appliancePlacementDate": "20061115", <br />          "orthoDonticTotalMonths": "36", <br />          "lineItems": [ <br />            { <br />               "claimIndex": 1, <br />              "claimNo": "SMITH788", <br />              "lineItemIndex": 1, <br />              "procedureCode": "D8080", <br />              "procedureType": "AD", <br />              "billedAmount": "4000", <br />              "chargesPerUnit": "4000", <br />               "units": "1", <br />              "lineItemId": "" <br />             } <br />          ], <br />          "claimICDs": " " <br />        } <br />      ] <br />    } <br />  ] <br /> }</p> <p> <br /> <br /></p> <p><strong><span style="font-size: medium;">Are you looking for JSON to EDI solution?</span></strong></p> <p><strong><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><span style="color: rgb(0, 0, 255); font-size: small;">EDI RESTful Web Service API</span></a><span style="color: rgb(0, 0, 255);"> </span> <br /><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><span style="color: rgb(0, 0, 255); font-size: small;">JSON To EDI 837 Professional</span></strong></a> </strong></p> <p><strong><a href="https://youtube.com/playlist?list=PLLi-le77HGDZWbQ0jinryMcERYXttnpC5" target="_blank"><span style="color: rgb(0, 0, 255); font-size: small;">Explore Our Nagata EDI Tool - JSON to EDI and vice versa</span></a> <br /> <br /><span style="font-size: medium;"><strong>Looking for more examples? Login into our EDI Tool </strong></span> <br /><strong><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><span style="color: rgb(0, 0, 255);">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</span></a></strong></strong></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-53529766723666046772022-08-14T08:57:00.005+05:302022-08-14T10:02:38.571+05:30Assignment of Benefits - CMS 1500 Box 27<div class="post"></div> <a name='more'></a> <div class="post"> What is Assignment of Benefits ?</div> <p align="justify">An assignment of benefits is a legal contract used to transfer the rights to benefits under a health care plan from the insured to the health care provider. If there is an assignment of benefits, the health plan will pay its portion  of the fee (the benefits) directly to the provider. It eliminates the need for the insured to pay the provider in full and then seek reimbursement of the allowed amount under the policy. <br /> <br />This agreement is signed by the patient as a request to pay the designated amount to the health care provider for the health benefits he/she may have received. On the patient’s request the insurance payer makes the payment to the hospital/doctor. <br /> <br />While signing the form, the patient also authorizes the insurance company to release any and all written information that is required by the hospital for reimbursement purposes. This also means that any medical billing and collection company  hired by the hospital is free to use the released information for billing purposes. In addition to this, the patient agrees to appoint anyone from the hospital as a representative on his/her behalf to seek payment from the insurance payer. In other words, once the document has been signed, the patient is no longer required to deal directly with the insurance company or its representative, unless asked to do so</p> <p>By law, the providers or types of services listed below MUST also accept assignment:</p> <ul> <li>Clinical diagnostic laboratory services;</li> <li>Physician services to individuals dually entitled to Medicare and Medicaid;</li> <li>Services of physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, certified registered nurse anaesthetists, clinical psychologists, and clinical social workers;</li> <li>Ambulatory surgical centre services for covered ASC procedures;</li> <li>Home dialysis supplies and equipment paid under Method II;</li> <li>Ambulance services;</li> <li>Drugs and biologicals; and</li> <li>Simplified Billing Roster for influenza virus vaccine and pneumococcal vaccine.</li> </ul> <p> <br /><strong>CMS 1500</strong> <br /> <br />Item 27 on the CMS-1500 claim form allows the provider to indicate whether they accept or do not accept assignment. When accepting assignment, the beneficiary may be billed for the 20% coinsurance, any unmet deductible and for services not covered by Payer <br /> <br /><a href="https://drive.google.com/uc?id=1GNjYiwRwHVPRnb3aqDe3OTFBmqMbpy5Y"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=1plq2PQpBaP6ARgTzRSHotEt1m4y8Epij" width="1028" height="203" /></a> <p> <br /><strong>EDI 837</strong> <br />Loop 2300, Claim Information <br /> <br /> <br /><a href="https://drive.google.com/uc?id=159GtUm-ed50T3KRpQ5NUPWThPSwiqMLN"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=1c_ongUfKiD04W-BXu2LVP2KQgcs-XkI4" width="644" height="413" /></a> <p> <br />Example: <br /> <br />If assignment of Benefit is yes, then <br />CLM*124304*60.00***11:B:1*Y*A*Y*Y <br /> <br /><a href="https://drive.google.com/uc?id=1Z_jUFdwtLn-9w-qOHQREFNWm7tqCQphX"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=1LnC8LMQOWnUi-G2MHshIsN9T0jgyjWcD" width="644" height="217" /></a> <p> </p> </p> eClaimManager <br />Let us see how we can change this value in eClaimManager Practice Management System <br /> <br /> <div id="scid:0ABB7CC8-30EB-4F34-8080-22DA77ED20C3:b20c8027-7f95-4d66-bba9-2e2ab796bc3e" class="wlWriterEditableSmartContent" style="margin: 0px; padding: 0px; float: none; display: inline;"><div><iframe src="http://www.youtube.com/embed/iNV3_xIbSuo" width="425" height="239" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe></div><div style="width:425px;clear:both;font-size:.8em">For monthly subscription, email to vbsenthilinnet@gmail.com</div></div> <br /> <br /> <br /> <br /> <br /></p> <p><font size="3"><strong>Looking for JSON to EDI solution ?</strong></font></p> <h5><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" color="#0000ff" size="2">EDI RESTful Web Service API</font></a><font color="#0000ff"> <br /></font><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><font color="#0000ff" size="2">JSON To EDI 837 Professional</font></strong></a> <br /></h5> <h5><a href="https://youtube.com/playlist?list=PLLi-le77HGDZWbQ0jinryMcERYXttnpC5" target="_blank"><font color="#0000ff" size="2">Explore Our Nagata EDI Tool - JSON to EDI and vice versa</font></a> <br /> <br /><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong></font> <br /><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><font color="#0000ff">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</font></a></b></h5></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-72856194172033830202022-07-06T18:59:00.005+05:302022-07-06T20:22:30.530+05:30Claim Life Cycle–Payer<p> </p> <a name='more'></a> <p><strong>What is claims processing?</strong> <br />Claims processing is an intricate workflow involving 20+ checkpoints that every claim must go through before it’s approved. If a claim makes it through all these checkpoints without issues, the insurance company approves it and processes any insurance payments. If it doesn’t, it gets denied or sent back for more information. <br /></p> <p><strong>What happens to a claim after it gets submitted?</strong> <br />The easiest way to understand claims processing is to follow a claim through the system. </p> <p> </p> <p> </p> <p><a href="https://drive.google.com/uc?id=136RV3LvIdSsEjjpAsu9m-7zu6ILv01hA"><img title="Claim Life Cycle - Payer" style="border: 0px currentcolor; display: inline; background-image: none;" border="0" alt="Claim Life Cycle - Payer" src="https://drive.google.com/uc?id=1hMVCGX7D63_hU8o-sYtGJR00gSgxiDsg" width="664" height="1181" /></a></p> <p> </p> <p> <br /><a href="https://drive.google.com/uc?id=1cFx0WEtUEmdmI3Dw-2hVfGd7LSR0Pn-q"><img title="Claim Life Cycle - Payer" style="border: 0px currentcolor; display: inline; background-image: none;" border="0" alt="Claim Life Cycle - Payer" src="https://drive.google.com/uc?id=18-6QbAzPQVNlIIk-jvW8mnagukHk25b8" width="664" height="1181" /></a></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-6906973901384230442022-06-22T09:51:00.003+05:302022-06-22T10:38:47.289+05:30X12 EDI Examples–EDI 837 NDC Drug<a name='more'></a> <p> <br /><font size="2"><strong>EDI 837 Professional. Version 005010X222A1 <br /></strong></font> <br /><strong>Billing for Physician Administered Drugs and NDC Reporting</strong></p> <p>Providers are required to report the National Drug Code (NDC) supplemental information in addition to the procedure <br /> code (CPT or HCPCS) when billing for a physician administered drug on the electronic and paper claim formats.</p> <p>When billing  physician administered drugs, in addition to the appropriate CPT or HCPCS codes, the following must be <br /> reported on the claim: <br />• the 11-digit NDC number; <br />• the unit price (EDI only); <br />• the 2-digit unit of measure code, e.g. GR (Gram), ML (Milliliter), UN (Unit); and <br />• the quantity dispensed.</p> <p> </p> <p><strong>LIN Segment</strong></p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="160">LIN02</td> <td valign="top" width="246">N4</td> <td valign="top" width="604">N4 Qualifier identifies the NDC being billed</td> </tr> <tr> <td valign="top" width="166">LIN03</td> <td valign="top" width="246">Actual NDC e.g., 01234567891</td> <td valign="top" width="604">Report the NDC in the 11 digit format.Do not use hyphens or spaces</td> </tr> </tbody></table> <p> <br /><strong>CTP Segment</strong></p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="160">CTP03</td> <td valign="top" width="246">Unit Price</td> <td valign="top" width="604">e.g., 2.50</td> </tr> <tr> <td valign="top" width="166">CTP04</td> <td valign="top" width="246">Dispensing Quantity</td> <td valign="top" width="604">e.g., 2</td> </tr> <tr> <td valign="top" width="166">CTP05</td> <td valign="top" width="246">Unit of Measure Value</td> <td valign="top" width="604"> <p>Values are: <br /> F2 = International Unit GR = Gram <br /> ML = Millimeter <br />UN = Unit</p> </td> </tr> </tbody></table> <p> <br /><strong>Example EDI 837</strong> <br /><strong>Please note : All the information used in this example are dummy data. <br /> <br /></strong></p> <p>ISA*00*          *00*          *ZZ*ukgesglgpa     *01*bxwtirveg      *220622*0410*^*00501*999      *1*P*: <br /> GS*HC*ukgesglgpa*bxwtirveg*20220622*0410*999*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*999*20220622*0410*CH <br /> NM1*41*2*Richey*****46*1070414647 <br /> PER*IC*Padgett Gilles*TE*1013444785*FX*1027086334 <br /> NM1*40*2*Barlow*****46*394332591 <br /> HL*1**20*1 <br /> PRV*BI*PXC*193200000X <br /> NM1*85*2*Demo LLC*****XX*1306854021 <br /> N3*762 Broad Fifth <br /> N4*Whitehouse*IL*246181682 <br /> REF*EI*775925470 <br /> HL*2*1*22*0 <br /> SBR*P*18*******ZZ <br /> NM1*IL*1*Soileau*Sheela****MI*327383761 <br /> N3*P.O. Box 86570 <br /> N4*Hufman*IL*11909 <br /> DMG*D8*19920608*M <br /> NM1*PR*2*AETNA BETTER HEALTH OF ILLINOIS*****PI*68024 <br /> CLM*FR100110*509.00***11:B:7*Y*A*Y*Y <br /> REF*F8*1347204412 <br /> HI*ABK:R079*ABF:R0600*ABF:Z308 <br /> NM1*82*1*Webster*Niel****XX*1049086189 <br /> PRV*PE*PXC*207Q00000X <br /> NM1*77*2*Krieger*****XX*1167726079 <br /> N3*346 Cotton Common Crossroad <br /> N4*Soileau*IL*163417061 <br /> LX*1 <br /> SV1*HC:99214:25*209.00*UN*1***1:2:3 <br /> DTP*472*RD8*20210602-20210602 <br /> REF*6R*163038 <br /> LX*2 <br /> SV1*HC:J1050*300.00*UN*150***3 <br /> DTP*472*RD8*20210602-20210602 <br /> REF*6R*163039 <br /><strong>LIN**N4*00009737611 <br /> CTP****150.00*ML</strong> <br /> SE*37*0001 <br /> GE*1*999 <br /> IEA*1*999      <br /> <br />  </p> <p><span style="color: rgb(51, 102, 255);"><strong> Interchange Control Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Authorization Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Security Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Sender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Submitter ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ukgesglgpa </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Receiver</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">01</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">bxwtirveg </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/22/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">InterChange Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">04:10</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Repetition Seperator </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">^</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">999 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Acknowledgement Requested</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Usage Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Functional Group Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Sender Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ukgesglgpa</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Application Receiver Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">bxwtirveg</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/22/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">04:10</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Control Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">999</span></strong></td> </tr> <tr> <td style="width: 200.29px;">EDI Version </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">005010X222A1</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Transaction Set Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Transaction set </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">837</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Hierarchical Transaction</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Transaction Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">999</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/22/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0410</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Submitter Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Submitter Entity </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Organization</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Organization Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Richey</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1070414647</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Padgett Gilles</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Phone </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1013444785</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Fax</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1027086334</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Receiver Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Receiver Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Barlow</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">394332591</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Billing Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Demo LLC</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">762 Broad Fifth</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Whitehouse</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">IL</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">246181682</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1306854021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Tax ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">775925470</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Taxonomy Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">193200000X</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Payer Responsbility</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Insured Relationship</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">18</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Filling Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber Name</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Soileau</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Sheela</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DOB</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/08/1992</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Gender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">M</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Policy No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">327383761</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P.O. Box 86570</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Hufman</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">IL</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">11909</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Payer</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">AETNA BETTER HEALTH OF ILLINOIS</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Payer ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">68024</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Claim Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Claim No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">FR100110</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Billed Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">509.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">7</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Sign Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Accept Assignment Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Benefits Assignment Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Release of information</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Payer Claim Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1347204412</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> ICD Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">ICD Code 1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">R079</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Code 2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">R0600</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Code 3</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Z308</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Rendering Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Webster</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Niel</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1049086189</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Taxonomy Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">207Q00000X</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Facility</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Krieger</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">346 Cotton Common Crossroad</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Soileau</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">IL</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">163417061</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1167726079</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 1</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">163038</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">99214</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Modifier 1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">25</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">209.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1,2,3</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/02/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/02/2021</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 2</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">163039</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">J1050</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">150</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">3</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/02/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/02/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Drug Product ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">N4</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NDC Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00009737611</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Drug Unit</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">150.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Drug UOM</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ML</span></strong></td> </tr> </tbody></table> <p><font size="3"><strong>Looking for JSON to EDI solution ?</strong></font></p> <h5><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" color="#0000ff" size="2">EDI RESTful Web Service API</font></a><font color="#0000ff"> <br /></font><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><font color="#0000ff" size="2">JSON To EDI 837 Professional</font></strong></a> <br /></h5> <h5><a href="https://youtube.com/playlist?list=PLLi-le77HGDZWbQ0jinryMcERYXttnpC5" target="_blank"><font color="#0000ff" size="2">Explore Our Nagata EDI Tool - JSON to EDI and vice versa</font></a> <br /> <br /><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong></font> <br /><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><font color="#0000ff">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</font></a></b></h5>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-13904886004826800382022-06-13T07:14:00.014+05:302022-07-12T19:20:05.698+05:30Rejection Followup Using Claim Acknowledgement EDI 277CA<a name='more'></a> <p>Claims rejections occur when the clearinghouse or the payer stop a claim from entering their processing system. This is typically due to missing, incomplete, outdated, or incorrect information included in the claim. When claims fail to enter the payer’s processing system, providers do not receive an explanation of benefits or remittance advice for the rejection. Depending on the processor, providers may or may not receive a rejection notice from the clearinghouse or other electronic system.</p> <p>When the statuses of claims go unmonitored, rejections can pose an especially problematic effect for providers, their patients and patient’s families. It is not uncommon for providers to wait for a notification to trigger action on unpaid claims, naturally so, in the instance of a rejection that does not include a follow up notice, a significant amount of time may go by before realizing a claim went unreceived. At this point, deadlines for timely filing requirements may have passed for the payer. Unfortunately, timely filing denials are rarely overturned when appealed; therefore, it is very important that as part of a claims review process, providers have a method for monitoring rejections.</p> <p>As soon as claim submitted, clearing house response with EDI 277CA. The purpose of the 277CA (Claims Acknowledgement) transaction is to provide a claim level acknowledgement of all claims received in the pre-processing system before submitting claims into a payer’s adjudication system. <br /> <br /><b>Common examples of incorrect information that can cause rejections include: <br /></b>Insurance information</p> <ul> <li>Incorrect member ID</li> <li>Incorrect payer ID</li> </ul> <p>Demographic information</p> <ul> <li>Incorrect date of birth</li> <li>Misspelled name</li> <li>Incorrect address</li> </ul> <p>Diagnosis/billing information</p> <ul> <li>Invalid or outdated ICD code</li> <li>Invalid CPT code</li> <li>Incorrect modifier or lack of a required modifier <br /></li> </ul> <p><b>Sample workflow</b></p> <p>Provider Smith uses ABC Billing Software aka Practice Management Software (RCM) and he has account with XYZ Clearing house for submitting its claims.</p> <ul> <li> RCM System every day generates claims electronically (Professional or Institutional or Dental) using X12 EDI 837 and push into clearing house FTP.</li> <li> After few min, the clearing house response with EDI 999 Acknowledgement file in their FTP download folder. For this example, we will assume that EDI File is accepted with no errors<b>. If there is syntax error in the EDI 837 File, then no EDI 277CA File will be generated.</b></li> <li> Now clearing house will scrub the claims for validation and response with an EDI 277CA File in their FTP Download folder. The EDI 277CA file will contain either accepted or rejected status for each claim submitted. These are called as claim rejections from the clearing house side.</li> <li> All the accepted claims are forwarded to payer. Rejected claims will not be forwarded, provider office must act and resubmit the claims.</li> <li> Once claim is received at the payer, then the payer system will scrub the claims for validation. Again, payer will generate EDI 277CA with accepted or rejected claims and forward to the clearing house download folder. If the claims are rejected, then they are called as Payer Level Rejections.</li> <li> If there is no error found during payer scrubbing, then all the claims will enter payer’s adjudication system and then payer process the payment. <br /> <br /></li> </ul> <p><a href="https://drive.google.com/uc?id=1BWNBn6F7Yg3Z8EG2mzdZpDd8NGewuYen"><img title="clip_image002" style="display: inline; background-image: none;" border="0" alt="clip_image002" src="https://drive.google.com/uc?id=1NPyk9I38DpGHPjqPak-nG22uMj0zYKlJ" width="1028" height="140" /></a>      <br />     <br />   <br />   <a href="https://drive.google.com/uc?id=18n32gpapViH51ARUtrz6cWptRIZORQF6"><img title="BillingFlow" style="border: 0px currentcolor; display: inline; background-image: none;" border="0" alt="BillingFlow" src="https://drive.google.com/uc?id=10oIiB6vtjfzz6oBxBOmvTXRF3jIWpoE1" width="826" height="1168" /></a> </p> <p> </p> <a href="https://drive.google.com/uc?id=1Poy1hqqCzDTRrDRUCw26TziVu8BoF2Dl"><img title="BillingFlow" style="display: inline; background-image: none;" border="0" alt="BillingFlow" src="https://drive.google.com/uc?id=1Md0Xue-AumqNtjabBDY8H6zOs4MqRbj-" width="830" height="1170" /></a> <p> </p>    <p> </p> <br /> <p> </p> <br /> <br />Sample EDI 277CA Rejected <p> </p> <p>ISA*00*          *00*          *01*030240928      *ZZ*AV09999999     *220513*1547*^*00501*332975623*0*P*: <br /> GS*HN*030240928*1101957*20220513*1547*332122998*X*005010X214 <br /> ST*277*1001*005010X214 <br /> BHT*0085*08*3215872084*20220513*154703*TH <br /> HL*1**20*1 <br /> NM1*AY*2*Clearing House LLC*****46*030240928 <br /> TRN*1*2022051315470395 <br /> DTP*050*D8*20220513 <br /> DTP*009*D8*20220513 <br /> HL*2*1*21*1 <br /> NM1*41*2*XYZ CLINIC*****46*AV09999999 <br /> TRN*2*17145 <br /> STC*A1:20*20220513*WQ*625 <br /> QTY*90*0 <br /> QTY*AA*1 <br /> AMT*YY*625 <br /> HL*3*2*19*1 <br />NM1*85*2*XYZ CLINIC*****XX*2222222222 <br /> TRN*1*0 <br /> REF*TJ*363290656 <br /> QTY*QA*0 <br /> QTY*QC*1 <br /> AMT*YU*625 <br /> AMT*YY*625 <br /> HL*4*3*PT <br /> NM1*QC*1*John*Mike****MI*1111111111 <br /> TRN*2*FR126904 <br /> STC*A3:21*20220513*U*625********ALL PROPERTY AND CASUALTY CLAIMS REQUIRE A DATE OF INJURY. <br /> REF*D9*NA <br /> DTP*472*RD8*20220308-20220308 <br /> SE*30*1001 <br />GE*1*332122998 <br /> IEA*1*332975623 <br /></p> <p> </p> <p>HTML <br />   <br /></p> <p><span style="color: rgb(51, 102, 255);"><strong> Interchange Control Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Authorization Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Security Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Sender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">01</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Submitter ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">030240928 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Receiver</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">AV09999999 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/13/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">InterChange Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">15:47</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Repetition Seperator </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">^</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">332975623</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Acknowledgement Requested</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Usage Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Functional Group Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Sender Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">030240928</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Application Receiver Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1101957</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/13/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">15:47</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Control Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">332122998</span></strong></td> </tr> <tr> <td style="width: 200.29px;">EDI Version </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">005010X214</span></strong></td> </tr> </tbody></table> <hr noshade="noshade" /> <p><span style="color: rgb(51, 102, 255);"><strong> Transaction Set Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Transaction set </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">277</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1001</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/13/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">154703</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Source</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Source Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Clearing House LLC</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Identifier Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">46</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Identifier Type Desc</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ETIN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Identifier value</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">030240928</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Trace Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2022051315470395</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Batch Received Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/13/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Batch Processed Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/13/2022</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Receiver</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XYZ CLINIC</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XYZ CLINIC</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Trace Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">17145</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Accepted Claims</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Rejected Claims</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Billed Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">625</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Rejected Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">625</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">20</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status Description </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Accepted for processing.</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status Category</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status Category Description </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Acknowledgement/Receipt-The claim/encounter has been received. This does not mean that the claim has been accepted for adjudication.</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Action</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">WQ - Batch Accepted</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status Effective Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/13/2022</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Billing Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XYZ CLINIC</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2222222222</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Accepted Claims</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Rejected Claims</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Accepted Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">625</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Rejected Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">625</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Claim Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Claim Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">FR126904</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Clearing House Trace Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">NA</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Patient Last Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">John</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Patient First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Mike</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DB Batch Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">277CA_1655086607069</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DB Claim Number Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">FR1269041655086607070</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status Source</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">277CA</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status Category</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A3</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status Category Description</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Acknowledgement/Returned as unprocessable claim-The claim/encounter has been rejected and has not been entered into the adjudication system.</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">21</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Status Description </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Missing or invalid information. Usage: At least one other status code is required to identify the missing or invalid information.</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Action</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">U - Claim Rejected</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Notes</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">ALL PROPERTY AND CASUALTY CLAIMS REQUIRE A DATE OF INJURY.</td> </tr> </tbody></table> <br /> <p><font size="3"><strong>Looking for JSON to EDI solution ?</strong></font></p> <h5><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" color="#0000ff" size="2">EDI RESTful Web Service API</font></a><font color="#0000ff"> <br /></font><a href="https://youtu.be/1edkLO13_v4" target="_blank"><font style="font-weight: bold;" color="#0000ff">Parse 277ca to HTML</font></a><font color="#0000ff" size="2"></font><font style="font-weight: bold;"> </font> <br /></h5> <h5><a href="https://youtube.com/playlist?list=PLLi-le77HGDZWbQ0jinryMcERYXttnpC5" target="_blank"><font color="#0000ff" size="2">Explore Our Nagata EDI Tool - JSON to EDI and vice versa</font></a> <br /> <br /><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong></font> <br /><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><font color="#0000ff">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</font></a></b></h5>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-21734128172152138102022-05-30T06:27:00.000+05:302022-05-30T06:38:27.115+05:30X12 EDI Examples–EDI 837 Claim Note<a name='more'></a> <p><font size="2"><strong>EDI 837 Professional. Version 005010X222A1</strong></font></p> <p>In some cases, additional message or notes need to be communicated with the payer. The 837 format has a Claim Level and Claim Line Level File Note (NTE) Segment which can be used for communicating such messages <br /> <br />At the claim level, we can use the following any of the following as note code reference.</p> <p>ADD     Additional Information <br /> CER     Certification Narrative <br /> DCP     Goals, Rehabilitation Potential, or Discharge Plans <br /> DGN     Diagnosis Description <br /> TPO     Third Party Organization Notes</p> <p> </p> <p>At the line item level, we can use the following any of the following as note code reference.</p> <p>ADD     Additional Information <br /> DCP     Goals, Rehabilitation Potential, or Discharge Plans <br /></p> Apartment from the above, we can also use TPO as separate segment in the line item level. <br /> <br /><strong>Example 1 : Claim Level Note</strong> <br /> Please note : All the information used in this example are dummy data. <br /> <br /> <p>ISA*00*          *00*          *ZZ*123123         *ZZ*241232         *220530*0637*^*00501*292232520*1*T*: <br /> GS*HC*123123*241232*20220530*0637*29223252*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*29223252*20220530*0637*CH <br /> NM1*41*2*ABC Submitter*****46*7342343 <br /> PER*IC*John Mike*TE*1214151617 <br /> NM1*40*2*Zirmed*****46*12345 <br /> HL*1**20*1 <br /> PRV*BI*PXC*208500000X <br /> NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692 <br /> N3*3937  Kenwood Place <br /> N4*Orlando*FL*32801 <br /> REF*EI*81-3777631 <br /> HL*2*1*22*0 <br /> SBR*P*18*92291223*AED12342*****ZZ <br /> NM1*IL*1*BAKER*Alyssa****MI*723223232 <br /> N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St <br /> N4*HOUSTON*TX*77833 <br /> DMG*D8*20201204*M <br /> NM1*PR*2*CIGNA*****PI*81400 <br /> N3*PO BOX 660044 <br /> N4*DALLAS*TX*75266 <br /> CLM*10421*100***11:B:1*Y*A*Y*Y*Y <br /><strong><font color="#ff0000">NTE*CER*CER Certification Info goes here</font></strong> <br /> HI*ABK:R1013*ABF:E860 <br /> NM1*82*1*Nelson*Romer****XX*1023555349 <br /> NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059 <br /> N3*6100 W CREEK RD SUITE 35 <br /> N4*Independence*OH*44131 <br /> LX*1 <br /> SV1*HC:99213*50*UN*1***1:2 <br /> DTP*472*D8*20201204 <br /> REF*6R*6001 <br /> LX*2 <br /> SV1*HC:87070*50*UN*1***1:2 <br /> DTP*472*D8*20201204 <br /> REF*6R*6002 <br /> SE*36*0001 <br /> GE*1*29223252 <br /> IEA*1*292232520 <br /> <br /> <br /> <br /></p> <strong>Example 2 : Line Item Level Note</strong> <br /> Please note : All the information used in this example are dummy data. <br /> <br /> <p>ISA*00*          *00*          *ZZ*111134         *ZZ*zirmed         *220530*0637*^*00501*796000000*0*P*: <br /> GS*HC*111134*zirmed*20220530*0637*796000000*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*0001*20220530*0637*CH <br /> NM1*41*2*Demo Practice*****46*111134 <br /> PER*IC*William Richard*TE*2025550170*FX*2025550179 <br /> NM1*40*2*zirmed*****46*zirmed <br /> HL*1**20*1 <br /> NM1*85*2*Demo Clinic*****XX*1215099528 <br /> N3*2486 NORTH UNIVERSITY DRIVE*APT E10 <br /> N4*WestField*NY*14787 <br /> REF*EI*222222222 <br /> HL*2*1*22*0 <br /> SBR*P*18*K34532*GFAMPLAN*****BL <br /> NM1*IL*1*Simmons*Foster****MI*Y333RF3333 <br /> N3*8367 ALIQUAM ROAD*AP #117-8770 <br /> N4*Sugar land*CA*743434232 <br /> DMG*D8*19451123*M <br /> NM1*PR*2*Blue Choice*****PI*9393 <br /> N3*4787  BLUFF STREET <br /> N4*Blue bell*TX*74102 <br /> CLM*124304*60***11:B:1*Y*A*Y*Y*P <br /> HI*ABK:A05 <br /> NM1*82*1*Sean*Smith****XX*6565656565 <br /> NM1*77*2*NY Office*****XX*1336177328 <br /> N3*5081 Tellus. Avenue <br /> N4*White Plains*NY*809051232 <br /> LX*1 <br /> SV1*HC:99214*60*UN*1*11**1 <br /> DTP*472*D8*20190517 <br /> REF*6R*75965 <br /><strong><font color="#ff0000">NTE*DCP*DCP goes here <br /> NTE*TPO*Addtional Notes goes here</font></strong> <br /> SE*32*0001 <br /> GE*1*796000000 <br /> IEA*1*796000000 <br /></p> <p><font size="3"><strong>Looking for JSON to EDI solution ?</strong></font></p> <h5><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" color="#0000ff" size="2">EDI RESTful Web Service API</font></a><font color="#0000ff"> <br /></font><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><font color="#0000ff" size="2">JSON To EDI 837 Professional</font></strong></a> <br /></h5> <h5><a href="https://youtube.com/playlist?list=PLLi-le77HGDZWbQ0jinryMcERYXttnpC5" target="_blank"><font color="#0000ff" size="2">Explore Our Nagata EDI Tool - JSON to EDI and vice versa</font></a> <br /> <br /><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong></font> <br /><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><font color="#0000ff">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</font></a></b></h5>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-73607714548969979322022-05-29T14:15:00.005+05:302022-05-29T14:28:39.281+05:30X12 EDI Examples - K3– File Information<a name='more'></a> <p><font size="2"><strong>EDI 837 Professional. Version 005010X222A1</strong></font></p> <p>In some cases, additional message or notes need to be communicated with the payer. The 837 format has a Claim Level and Claim Line Level File Information segment (“K3”) which can be used for communicating such messages. The K3 segment can repeat up to 10 times.</p> <p> <br /><strong>Example 1 : Claim Level K3 Segment</strong> <br /> Please note : All the information used in this example are dummy data.</p> <p>ISA*00*          *00*          *ZZ*111134         *01*zirmed         *200219*0749*^*00501*796000000*0*P*: <br /> GS*HC*111134*zirmed*20200219*0749*796*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*0001*20200219*0749*CH <br /> NM1*41*2*Demo Practice*****46*111134 <br /> PER*IC*William Richard*TE*2025550170*FX*2025550179 <br /> NM1*40*2*zirmed*****46*zirmed <br /> HL*1**20*1 <br /> NM1*85*2*Demo Clinic*****XX*1215099528 <br /> N3*2486 NORTH UNIVERSITY DRIVE*APT E10 <br /> N4*WestField*NY*14787 <br /> REF*EI*222222222 <br /> HL*2*1*22*0 <br /> SBR*P*18*K34532*GFAMPLAN*****BL <br /> NM1*IL*1*XXXXX*XXXXX****MI*XXXXXX <br /> N3*8367 ALIQUAM ROAD*AP #117-8770 <br /> N4*XXXX land*CA*743434232 <br /> DMG*D8*19451123*M <br /> NM1*PR*2*Blue Choice*****PI*9393 <br /> N3*4787  BLUFF STREET <br /> N4*Blue bell*TX*74102 <br /> CLM*124304*60***11:B:1*Y*A*Y*Y*P <br /><font color="#ff0000">K3*File Information 1 goes here <br /> K3*File Information 2 goes here</font> <br /> HI*ABK:A05 <br /> NM1*82*1*XXXXX*XXXX****XX*6565656565 <br /> NM1*77*2*NY Office*****XX*1336177328 <br /> N3*5081 Tellus. Avenue <br />N4*White Plains*NY*809051232 <br /> LX*1 <br /> SV1*HC:99214*60*UN*1*11**1 <br />DTP*472*RD8*20190517-20190517 <br /> REF*6R*75965 <br /> SE*32*0001 <br /> GE*1*796 <br /> IEA*1*796000000</p> <p> <br /><strong>Example 2 : Line Item Level K3 Segment</strong> <br /> Please note : All the information used in this example are dummy data.</p> <p>ISA*00*          *00*          *ZZ*123123         *ZZ*241232         *220528*1046*^*00501*298522000*1*T*: <br /> GS*HC*123123*241232*20220528*1046*298522*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*298522*20220528*1046*CH <br /> NM1*41*2*ABC Submitter*****46*7342343 <br /> PER*IC*John Mike*TE*1214151617 <br /> NM1*40*2*Zirmed*****46*12345 <br /> HL*1**20*1 <br /> PRV*BI*PXC*208500000X <br /> NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692 <br /> N3*3937  Kenwood Place <br /> N4*Orlando*FL*32801 <br /> REF*EI*81-3777631 <br /> HL*2*1*22*0 <br /> SBR*P*18*92291223*AED12342*****ZZ <br /> NM1*IL*1*BAKER*Alyssa****MI*723223232 <br /> N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St <br /> N4*HOUSTON*TX*77833 <br /> DMG*D8*20201203*M <br /> NM1*PR*2*CIGNA*****PI*81400 <br /> N3*PO BOX 660044 <br /> N4*DALLAS*TX*75266 <br /> CLM*10421*100***11:B:1*Y*A*Y*Y*Y <br /> HI*ABK:R1013*ABF:E860 <br /> NM1*82*1*Nelson*Romer****XX*1023555349 <br /> NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059 <br /> N3*6100 W CREEK RD SUITE 35 <br /> N4*Independence*OH*44131 <br /> LX*1 <br /> SV1*HC:99213*50*UN*1***1:2 <br /> DTP*472*D8*20201203 <br /> REF*6R*6001 <br /><font color="#ff0000">K3*Line Item 1 File Information 1 goes here <br /> K3*Line Item 1 File Information 2 goes here</font> <br /> LX*2 <br /> SV1*HC:87070*50*UN*1***1:2 <br /> DTP*472*D8*20201203 <br /> REF*6R*6002 <br /><font color="#ff0000">K3*Line Item 2 File Information 1 goes here <br /> K3*Line Item 2 File Information 2 goes here</font> <br /> SE*39*0001 <br /> GE*1*298522 <br /> IEA*1*298522000</p> <br /> <br /> <p><font size="3"><strong>Looking for JSON to EDI solution ?</strong></font></p> <h5><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" color="#0000ff" size="2">EDI RESTful Web Service API</font></a><font color="#0000ff"> <br /></font><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><font color="#0000ff" size="2">JSON To EDI 837 Professional</font></strong></a> <br /></h5> <h5><a href="https://youtube.com/playlist?list=PLLi-le77HGDZWbQ0jinryMcERYXttnpC5" target="_blank"><font color="#0000ff" size="2">Explore Our Nagata EDI Tool - JSON to EDI and vice versa</font></a> <br /> <br /><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong></font> <br /><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><font color="#0000ff">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</font></a></b></h5>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-80988003266348962442022-05-28T21:38:00.002+05:302022-05-28T21:46:25.348+05:30X12 EDI 837p Patient is a different person than the Subscriber<a name='more'></a> <p><strong>Patient is a different person than the Subscriber.</strong></p> <p>if the patient is a different person than the Subscriber, then we need provide patient details in the EDI 837 along with subscriber information. Loop 2000C and 2010CA  will be added</p> <p>In Medicare, the Subscriber is always the Patient. Therefore, loop 2000C and loop 2010CA should not be reported or a rejection will occur on the 277 Claims Acknowledgement (277CA). </p> <p>Here is an example for EDI 837 for Patient is a different person than the Subscriber. In this example , 01 stands for Spouse in the following line <br />PAT*01</p> <p><strong>Please note : All the information used in this example are dummy data.</strong></p> <p> <br />ISA*00*          *00*          *ZZ*111134         *ZZ*zirmed         *220528*0405*^*00501*814000000*0*P*: <br />GS*HC*111134*zirmed*20220528*0405*814000000*X*005010X222A1 <br />ST*837*0001*005010X222A1 <br />BHT*0019*00*0001*20220528*0405*CH <br />NM1*41*2*Demo Practice*****46*111134 <br />PER*IC*John Richard*TE*2025550170*FX*2025550179 <br />NM1*40*2*zirmed*****46*zirmed <br />HL*1**20*1 <br />PRV*BI*PXC*207NP0225X <br />NM1*85*2*Demo Clinic*****XX*1211111111 <br />N3*319 16th Ave*APT E10 <br />N4*WestField*NY*14787 <br />REF*EI*222222222 <br />NM1*87*2 <br />N3*21208 Creekside Dr <br />N4*Leander*TX*20720 <br />HL*2*1*22*1 <br />SBR*P********ZZ <br />NM1*IL*1*Aliza*Bins*D***MI*XYZ312322 <br />N3*4229  SNIDER STREET <br />N4*Englewood*CO*80112 <br />DMG*D8*19550607*M <br />NM1*PR*2*AETNA*****PI*60054 <br />N3*PO BOX 14770 <br />N4*Lexington*KY*12345 <br /><font color="#ff0000"><strong>HL*3*2*23*0 <br /></strong></font><font color="#ff0000"><strong>PAT*01 <br />NM1*QC*1*Misty*MOSLEY <br />N3*724 Central Ave SE <br />N4*Sheffield*IA*10475 <br />DMG*D8*19550612*F</strong></font><font color="#ff0000"> </font><font color="#ff0000"></font> <br />CLM*124309*120***11:B:1*Y*A*Y*Y*P <br />HI*ABK:A032 <br />NM1*82*1*Sean*Smith****XX*6565656565 <br />NM1*77*2*NY Office*****XX*1336177328 <br />N3*5081 Tellus. Avenue <br />N4*White Plains*NY*809051232 <br />LX*1 <br />SV1*HC:99214*120*UN*1*11**1 <br />DTP*472*D8*20190604 <br />REF*6R*75982 <br />SE*40*0001 <br />GE*1*814000000 <br />IEA*1*814000000</p> <p> </p> <p> </p> <p><strong>HTML Version</strong></p> <p><span style="color: rgb(51, 102, 255);"><strong>Interchange Control Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Authorization Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Security Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Sender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Submitter ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">111134 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Receiver</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">zirmed </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/28/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">InterChange Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">04:05</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Repetition Seperator </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">^</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">814000000</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Acknowledgement Requested</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Usage Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong>Functional Group Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Sender Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">111134</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Application Receiver Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">zirmed</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/28/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">04:05</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Control Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">814000000</span></strong></td> </tr> <tr> <td style="width: 200.29px;">EDI Version </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">005010X222A1</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Transaction Set Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Transaction set </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">837</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Hierarchical Transaction</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Transaction Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/28/2022</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0405</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Submitter Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Submitter Entity </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Organization</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Organization Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Demo Practice</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">111134</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">John Richard</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Phone </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2025550170</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Fax</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2025550179</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Receiver Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Receiver Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">zirmed</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">zirmed</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Billing Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Demo Clinic</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">319 16th Ave</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">APT E10</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">WestField</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">NY</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">14787</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1211111111</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Tax ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">222222222</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Taxonomy Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">207NP0225X</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Billing Provider Pay to Address</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">21208 Creekside Dr</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Leander</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">TX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">20720</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Payer Responsbility</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Insured Relationship</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">01</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Filling Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber Name</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Aliza</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Bins</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Middle Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">D</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DOB</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/07/1955</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Gender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">M</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Policy No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XYZ312322</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">4229 SNIDER STREET</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Englewood</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">CO</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">80112</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Payer</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">AETNA</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">PO BOX 14770</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Lexington</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">KY</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12345</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Payer ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">60054</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Patient Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Last Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Misty</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">MOSLEY</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DOB</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/12/1955</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Gender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">F</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">724 Central Ave SE</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Sheffield</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">IA</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10475</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Claim Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Claim No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">124309</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Billed Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">120</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Sign Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Accept Assignment Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Benefits Assignment Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Release of information</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Patient Signature Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> ICD Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">ICD Code 1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A032</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Rendering Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Sean</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Smith</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6565656565</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Facility</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">NY Office</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">5081 Tellus. Avenue</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">White Plains</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">NY</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">809051232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1336177328</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 1</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">75982</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">99214</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">120.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/04/2019</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/04/2019</span></strong></td> </tr> <tr> <td style="width: 200.29px;">POS </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">11</span></strong></td> </tr> </tbody></table> <p> <br /></p> <p><strong><font size="3">Looking for JSON to EDI Solution ?</font></strong></p> <p><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" size="3">EDI RESTful Web Service API</font></a><font size="3"> <br /> <br /></font><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><font size="3">JSON To EDI 837 Professional</font></strong></a><font size="5"> <br /> <br /></font><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong> <br /></font><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><font size="3">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</font></a></b></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-59216984566218996152022-04-14T19:49:00.001+05:302022-04-14T20:11:05.503+05:30VS Code–GoLang<a name='more'></a> <h3><font style="font-weight: bold;">VSCode: Could not import Golang package <br /> <br /></font>You may get a warning in VSCode as follows <br /> <br /><a href="https://drive.google.com/uc?id=1x1a_oalcCyd_BChfI3TuPcRiEvS1j3wm"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=1LOmBOcZMBFx9277uInRIng2EEsuNRpjt" width="644" height="253" /></a> <p> </p> </h3> <p>Let us see how to resolve this warning. Take a look at the directory structure.</p> <a href="https://drive.google.com/uc?id=1cnlUc5yVlCvslIA3m76NNJbfuIYH2ilt"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=16iQUiMcjkDB1u4VkSpJRKv1k3DOU_z-W" width="644" height="333" /></a> <p> </p> <p>You can see , there is root folder called “GOSamples” and inside we have folder called workspace and its structure as follows</p> <p><a href="https://drive.google.com/uc?id=1ddtalXfhsTp79zf0Y4tqTpWO7wkWPBj_"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=112uuVW-6m5D8K1tRuribqB96n8OdWZ33" width="554" height="484" /></a></p> <p> </p> <p>You can see, there is warning showing on main.go , but the program works without any issue, that you can see in the output.</p> <a href="https://drive.google.com/uc?id=1Jiu13oWKeX4nd_JU_nKbwAIfQzd14Dt9"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=162tUMsDc6516lB8NC9oDxu3XnXpvM3up" width="537" height="484" /></a> <p> </p> <p><a href="https://drive.google.com/uc?id=1LILz7F44Ah9mY9sNxGUEtqWdo-YLsr1y"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=1L1WC6lgjgkp3Onrs47SQxiMz6jX-VPoe" width="644" height="229" /></a></p> <p> </p> <p>This is just a warning and VS Code does not understand the latest go Modules changes. We can resolve, by opening the VS Code IDE from the workspace folder as shown here</p> <a href="https://drive.google.com/uc?id=132IFm7bVqXYoECjkOQnu_7CAqmSfznSl"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=1KWgysxKjaEB5cLUF6qjQS-MF375ZxLx0" width="644" height="348" /></a> <p> </p> <p>Now you can see there is no red mark or any warning on the import statement.</p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-7431984083474793532022-04-11T21:13:00.000+05:302022-04-11T21:15:24.420+05:30Struct examples<a name='more'></a> <ul> <li><strong><a href="https://emrpms.blogspot.com/2022/04/slices-of-struct_10.html" target="_blank">Slices of Struct</a></strong></li> </ul>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-84112310522912536872022-04-10T09:22:00.001+05:302022-04-10T09:22:52.672+05:30Slices of Struct<a name='more'></a> <br /><font size="3"><strong>Example to create Slices of Struct</strong></font> <br /> <br /><link rel="stylesheet" type="text/css" href="http://www.freecodeformat.com/js/syntaxhighlighter_3.0.83/styles/shCoreDefault.css" /> <div id="highlighter_609963" class="syntaxhighlighter java"> <div class="toolbar"><span><a class="toolbar_item command_help help" href="#">?</a></span></div> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td class="gutter"> <div class="line number1 index0 alt2">1</div> <div class="line number2 index1 alt1">2</div> <div class="line number3 index2 alt2">3</div> <div class="line number4 index3 alt1">4</div> <div class="line number5 index4 alt2">5</div> <div class="line number6 index5 alt1">6</div> <div class="line number7 index6 alt2">7</div> <div class="line number8 index7 alt1">8</div> <div class="line number9 index8 alt2">9</div> <div class="line number10 index9 alt1">10</div> <div class="line number11 index10 alt2">11</div> <div class="line number12 index11 alt1">12</div> <div class="line number13 index12 alt2">13</div> <div class="line number14 index13 alt1">14</div> <div class="line number15 index14 alt2">15</div> <div class="line number16 index15 alt1">16</div> <div class="line number17 index16 alt2">17</div> <div class="line number18 index17 alt1">18</div> <div class="line number19 index18 alt2">19</div> </td> <td class="code"> <div class="container"> <div class="line number1 index0 alt2"><code class="java keyword">package</code> <code class="java plain">main</code></div> <div class="line number2 index1 alt1"> </div> <div class="line number3 index2 alt2"><code class="java keyword">import</code> <code class="java string">"fmt"</code></div> <div class="line number4 index3 alt1"> </div> <div class="line number5 index4 alt2"><code class="java plain">type Claims struct {</code></div> <div class="line number6 index5 alt1"><code class="java spaces">    </code><code class="java plain">ClaimNumber string</code></div> <div class="line number7 index6 alt2"><code class="java spaces">    </code><code class="java plain">BatchName   string</code></div> <div class="line number8 index7 alt1"><code class="java spaces">    </code><code class="java plain">bookmarks   []string</code></div> <div class="line number9 index8 alt2"><code class="java plain">}</code></div> <div class="line number10 index9 alt1"> </div> <div class="line number11 index10 alt2"><code class="java plain">func main() {</code></div> <div class="line number12 index11 alt1"><code class="java spaces">    </code><code class="java plain">fmt.Println(</code><code class="java string">"Welcome to Struct "</code><code class="java plain">)</code></div> <div class="line number13 index12 alt2"><code class="java spaces">    </code><code class="java plain">myclaims := []Claims{</code></div> <div class="line number14 index13 alt1"><code class="java spaces">        </code><code class="java plain">{</code><code class="java string">"PC101"</code><code class="java plain">, </code><code class="java string">"Batch101"</code><code class="java plain">, []string{</code><code class="java string">"Denied,OutOfNetwork"</code><code class="java plain">}},</code></div> <div class="line number15 index14 alt2"><code class="java spaces">        </code><code class="java plain">{</code><code class="java string">"PC102"</code><code class="java plain">, </code><code class="java string">"Batch101"</code><code class="java plain">, []string{</code><code class="java string">"Denied,onHold"</code><code class="java plain">}},</code></div> <div class="line number16 index15 alt1"><code class="java spaces">    </code><code class="java plain">}</code></div> <div class="line number17 index16 alt2"> </div> <div class="line number18 index17 alt1"><code class="java spaces">    </code><code class="java plain">fmt.Printf(</code><code class="java string">"%s"</code><code class="java plain">, myclaims)</code></div> <div class="line number19 index18 alt2"><code class="java plain">}</code></div> </div> </td> </tr> </tbody></table> </div>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-230469042933780452022-04-09T12:03:00.002+05:302022-04-14T20:17:24.018+05:30Go Lang Examples<a name="more"></a> <ul> <li><a href="https://emrpms.blogspot.com/2022/04/slices-of-struct_10.html" target="_blank"><font size="4">Struct</font></a></li> <li><a href="http://emrpms.blogspot.com/2021/07/how-to-iterate-over-map-using-for-loop.html" target="_blank"><font size="4">Map</font></a></li> <li><a href="http://emrpms.blogspot.com/2022/04/vs-codegolang.html" target="_blank">VS Code–GoLang</a></li> </ul>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-43438606245656858912021-12-29T08:51:00.016+05:302021-12-29T17:56:32.125+05:30Primary, Secondary and Tertiary Insurance Policies<a name='more'></a> <p><strong>As first note, let us understand Medicare insurance.</strong> </p> <p>Medicare is the federal government program that provides health care coverage for the following people,</p> <ul> <li>People who are 65 or older</li> <li>Certain younger people with disabilities</li> <li>People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)</li> </ul> <p>The program is funded US Government.</p> <p> </p> <p> <hr /> <br />In most cases, patient have only one insurance (called as primary insurance)  and normally the claim is sent to primary insurance via CMS 1500 Form or EDI.  After primary insurance process, if there is balance left in the claim, then it is collected from the patient.  <br /> <br />In some cases, the patient may more than one insurance policy and  billing office(Front desk or reception)  in the doctor office responsibility to identify which needs to bill first and then second and so on. </p> <p> <br /><strong>What it means to primary/secondary insurance policy ?</strong></p> <p>The insurance that pays first (primary payer) pays up to the limits of its coverage. <br /> The one that pays second (secondary payer) only pays if there are costs the primary insurer didn't cover. <br /> <br /><strong>Here is some guideline how to identify  the primary, secondary, etc if the patient has more than one insurance policies</strong></p> <p> <br />1) If the patient is working and less than 65 years old and spouse is also working, if both are covered by their employer,  they may both have family policies , so they are covered under each other employer plan. In this case, patient employer insurance would be primary and spouse employer insurance will be secondary. <br /></p> <p>2) If the patient is retired  and 65 years old. Then federal Medicare coverage is available for him. If the patient spouse still working and having a family policy coverage by their employer, then spouse plan would be primary and medicare becomes secondary.</p> <p>3) In the above case, if the patient is retired from military services and still covered by military insurance, then that would be third (Tertiary) insurance. <br /></p> <p>4) If the patient is still working and is also eligible for Medicare and has insurance through their employer, the employer insurance is primary and Medicare is secondary. <br /></p> <p>5) If the patient is covered by Medicare and have group health coverage from his former employer, then Medicare becomes primary and former employer insurance becomes secondary. <br /> <br />6) The following are the scenarios where Medicare is primary : <br /></p> <ul> <li>An individual who is working for an employer with twenty employees or fewer</li> <li>An individual who is covered by another policy that is not a group policy</li> <li>An individual who is enrolled in Part B but not Part A of the Medicare program</li> <li>An individual who must pay premiums to receive Part A coverage</li> <li>An individual who is retired and receiving coverage under a previous employer’s group policy</li> </ul> <p> </p> <p>7) Medicare (and private insurance) is always the secondary payer when treatment is for an accident-related claim, whether automobile, no-fault (injuries that occur on private property, regardless of who is at fault), or liability (injuries that occur on private property when a party is held responsible) <br /> <br /><strong>These are not hard-and-fast rules though, it is better to double check with all insurance companies to see exactly which is primary and secondary.</strong> <br /> <br /> <br /></p> <p><a href="http://emrpms.blogspot.com/2013/03/medical-billingpatient-insurance.html" target="_blank"><img src="http://icons.iconarchive.com/icons/oxygen-icons.org/oxygen/32/Actions-go-previous-icon.png" /></a>     <a href="http://emrpms.blogspot.com/2012/03/medical-billing.html" target="_blank"><img src="http://icons.iconarchive.com/icons/double-j-design/origami-colored-pencil/32/blue-home-icon.png" /></a>    <a href="http://emrpms.blogspot.com/2013/03/electronic-claim-submission.html" target="_blank"><img src="http://icons.iconarchive.com/icons/oxygen-icons.org/oxygen/32/Actions-go-next-icon.png" /></a></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-33355993540186327072021-12-23T23:02:00.003+05:302021-12-23T23:45:49.704+05:30X12 EDI 837 Examples Billing Provider Complete Information<p>  </p> <a name='more'></a> <p> <br /><strong><font size="2">EDI 837 Professional. Version 005010X222A1</font></strong></p> <font size="3"></font> <p><font size="3"><font size="2"><strong>Example 12: </strong>  Billing Provider Complete Information  ->  Bill with Group NPI</font></font></p> <p><font size="2"> <br /></font></p> <p>ISA*00*          *00*          *ZZ*111134         *01*zirmed         *200218*0749*^*00501*796000000*0*P*: <br /> GS*HC*111134*zirmed*20200218*0749*796*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*0001*20200218*0749*CH <br />NM1*41*2*Demo Practice*****46*111134 <br />PER*IC*William Richard*TE*2025550170*FX*2025550179 <br /> NM1*40*2*zirmed*****46*zirmed <br /> HL*1**20*1 <br /><font color="#ff0000"><strong>NM1*85*2*Demo Clinic*****XX*1215099528 <br /> N3*2486 NORTH UNIVERSITY DRIVE*APT E10 <br /> N4*WestField*NY*14787 <br /> REF*EI*222222222 <br /> REF*OB*731232 <br /> REF*1G*523123232 <br /> PER*IC*John Mike*TE*9165423443*FX*1234567890*EM*xyz@abc.com*EX*5412</strong> </font> <br /> HL*2*1*22*0 <br /> SBR*P*18*K34532*GFAMPLAN*****BL <br /> NM1*IL*1*XXXXX*XXXXX****MI*XXXXXX <br /> N3*8367 ALIQUAM ROAD*AP #117-8770 <br /> N4*XXXX land*CA*743434232 <br /> DMG*D8*19451122*M <br /> NM1*PR*2*Blue Choice*****PI*9393 <br /> N3*4787  BLUFF STREET <br /> N4*Blue bell*TX*74102 <br /> CLM*124304*60***11:B:1*Y*A*Y*Y*P <br /> HI*ABK:A05 <br /> NM1*82*1*XXXXX*XXXX****XX*6565656565 <br /> NM1*77*2*NY Office*****XX*1336177328 <br /> N3*5081 Tellus. Avenue <br /> N4*White Plains*NY*809051232 <br /> LX*1 <br /> SV1*HC:99214*60*UN*1*11**1 <br /> DTP*472*RD8*20190516-20190516 <br />REF*6R*75965 <br /> SE*33*0001 <br /> GE*1*796 <br /> IEA*1*796000000 <br /> <br /><strong>HTML Version  <br /></strong></p> <p><span style="color: rgb(51, 102, 255);"><strong> Interchange Control Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Authorization Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Security Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Sender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Submitter ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">111134 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Receiver</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">01</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">zirmed </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">02/18/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">InterChange Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">07:49</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Repetition Seperator </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">^</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">796000000</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Acknowledgement Requested</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Usage Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Functional Group Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Sender Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">111134</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Application Receiver Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">zirmed</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">02/18/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">07:49</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Control Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">796</span></strong></td> </tr> <tr> <td style="width: 200.29px;">EDI Version </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">005010X222A1</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Transaction Set Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Transaction set </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">837</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Hierarchical Transaction</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Transaction Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">02/18/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0749</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Submitter Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Submitter Entity </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Organization</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Organization Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Demo Practice</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">111134</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">William Richard</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Phone </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2025550170</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Fax</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2025550179</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Receiver Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Receiver Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">zirmed</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">zirmed</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Billing Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><font color="#ff0000"></font><tbody><font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Entity Type</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">2</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Last or Organization Name</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">Demo Clinic</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Address1</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">2486 NORTH UNIVERSITY DRIVE</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Address2</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">APT E10</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">City</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">WestField</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">State</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">NY</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Zip</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">14787</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">NPI</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">1215099528</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Tax ID</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">222222222</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">State License Number (0B)</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">731232</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">UPIN Number (1G)</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">523123232</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Contact Name</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">John Mike</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Contact Phone </font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">9165423443</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Contact Fax</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">1234567890</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font> <tr><font color="#ff0000"></font> <td style="width: 200.29px;"><font color="#ff0000">Contact Email</font></td> <font color="#ff0000"></font> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);"><font color="#ff0000">xyz@abc.com</font></span></strong></td> <font color="#ff0000"></font></tr> <font color="#ff0000"></font></tbody><font color="#ff0000"></font></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Payer Responsbility</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Insured Relationship</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">18</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">K34532</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">GFAMPLAN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Filling Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">BL</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber Name</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XXXXX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XXXXX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DOB</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">11/22/1945</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Gender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">M</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Policy No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XXXXXX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">8367 ALIQUAM ROAD</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">AP #117-8770</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XXXX land</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">CA</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">743434232</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Payer</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Blue Choice</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">4787 BLUFF STREET</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Blue bell</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">TX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">74102</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Payer ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">9393</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Claim Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Claim No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">124304</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Billed Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">60</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Sign Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Accept Assignment Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Benefits Assignment Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Release of information</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Patient Signature Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> ICD Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">ICD Code 1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A05</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Rendering Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XXXXX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">XXXX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6565656565</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Facility</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">NY Office</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">5081 Tellus. Avenue</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">White Plains</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">NY</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">809051232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1336177328</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 1</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">75965</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">99214</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">60.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/16/2019</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/16/2019</span></strong></td> </tr> <tr> <td style="width: 200.29px;">POS </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">11</span></strong></td> </tr> </tbody></table>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-90265793932188886402021-12-23T18:49:00.001+05:302021-12-23T23:49:53.882+05:30CMS 1500 Form, Box No 33: Billing Provider Information<a name='more'></a> <h3><strong><span style="font-family: arial,helvetica,sans-serif;">Box 33 requires a mailing address where the provider wants the payments to go. Billing Provider can be a business, group, or facility. The Billing Provider is instructing the insurance payor who is submitting the claims for payment and where reimbursement should be sent</span></strong></h3> <p><font size="3"><font face="Calibri"><span style="font-family: arial,helvetica,sans-serif;"><em><font face="Calibri">Enter the provider’s or supplier’s billing name, address, ZIP code, and phone number. <br /> The phone number is to be entered in the area to the right of the field title. Enter the name and address information in the following format:</font> <br /> <br /></em><font face="Calibri"><em>1st Line – Name <br /> 2nd Line – Address <br /> 3rd Line – City, State, and ZIP Code <br /> <br /></em>Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between the town name and state code; do not include a comma. Report a nine-digit ZIP code, including the hyphen. Do not use a hyphen or space as a separator within the telephone number. If reporting a foreign address, contact the payer for specific reporting instructions</font></span> <br />  </font></font></p> <font size="3"></font> <p><span style="font-family: arial,helvetica,sans-serif;"><font face="Calibri"><font size="3">Item 33 identifies the provider that is requesting</font></font><font size="3" face="Calibri"> to be paid for the services rendered and should always be completed.  <br /> This field allows for the entry of the following: 3 characters for area code, 9 characters for phone number, and 87 characters in the Billing Provider Info area.</font></span> <br /><font size="3"> <br /> A</font></p> <p><a href="https://drive.google.com/uc?id=1ioh63dzVsMlnYLI2EhNY2uPABgUMYSE-"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=1QOiUimJnPtblyj6i4ZmLhuto7i9N-L2a" width="244" height="74" /></a> <p> <br />Example For Group NPI organization</p> <a href="https://drive.google.com/uc?id=1vCMwSCyiL6XyKzqJYjIAFj1Ev00-j7b4"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=13ptmLE0HOhbvwbZNfJc3TOhcfXpm-cUf" width="244" height="71" /></a> <p> </p> <br /> <br /><font size="4"><font face="Calibri"><span style="font-size: 14px;"><strong><span style="font-family: arial,helvetica,sans-serif;"><font size="4">EDI 837P Mapping</font></span></strong></span> <br /><strong><span style="font-size: 12px;"><font size="3">Loop Name: 2010AA Billing Provider Name  -> 1st Line in CMS 1500 Box 33             <br /></font></span></strong></font></font></p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="110"><strong>Segment ID</strong></td> <strong></strong> <td valign="top" width="385"><strong>Segment Name</strong></td> <strong></strong> <td valign="top" width="797"><strong>Value</strong></td> </tr> <tr> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">NM101</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  Entity Identifier Code</font></td> <font size="2"></font> <td valign="top" width="797"><font size="2"> 85</font></td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">NM102</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  Entity Type Qualifier</font></td> <font size="2"></font> <td valign="top" width="797"><font size="2"> 1 or 2  : 1 Stands for Person and 2 Stands for Non-Person Entity</font></td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">NM103</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  Name Last or Organization Name</font></td> <font size="2"></font> <td valign="top" width="797"> </td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(51, 102, 255);"><font size="2">NM104</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  First Name</font></td> <font size="2"></font> <td valign="top" width="797"><font size="2">Required when NM102 = 1 (person) and the person has a first name</font></td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(51, 102, 255);"><font size="2">NM105</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  Middle Name</font></td> <font size="2"></font> <td valign="top" width="797"><font size="2">Required when NM102 = 1 (person) and the middle name or initial of the person is needed to identify the individual</font></td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(51, 102, 255);"><font size="2">NM106</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  Prefix Name</font></td> <font size="2"></font> <td valign="top" width="797"><font size="2">Not used</font></td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(51, 102, 255);"><font size="2">NM107</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  Suffix Name</font></td> <font size="2"></font> <td valign="top" width="797"><font size="2">Required when NM102 = 1 (person) and the name suffix of the person is needed to identify the individual</font></td> </tr> </tbody></table> <p><span style="font-size: 14px;"><strong>  <br /><strong><span style="font-size: 12px;"><font size="3">Loop Name: 2010AA N3 Billing Provider Address  -> 2nd  Line in CMS 1500 Box 33             </font></span></strong> <br /> </strong></span></p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="110"><strong>Segment ID</strong></td> <strong></strong> <td valign="top" width="385"><strong>Segment Name</strong></td> <strong></strong> <td valign="top" width="797"><strong>Value</strong></td> </tr> <tr> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">N301</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  Billing Provider Address Line 1</font></td> <font size="2"></font> <td valign="top" width="797"> </td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">N302</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2">  Billing Provider Address Line 2</font></td> <font size="2"></font> <td valign="top" width="797"> </td> <font size="2"></font></tr> <font size="2"></font><font size="2"></font><font size="2"></font><font size="2"></font><font size="2"></font></tbody></table> <p><span style="font-size: 14px;"><strong> <br /><strong><span style="font-size: 12px;"><font size="3">Loop Name: 2010AA N3 Billing  Provider City, State ,zip Code –> 3nd Line in CMS 1500 Box 33             <br /></font></span></strong></strong></span></p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="110"><strong>Segment ID</strong></td> <strong></strong> <td valign="top" width="385"><strong>Segment Name</strong></td> <strong></strong> <td valign="top" width="797"><strong>Value</strong></td> </tr> <tr> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">N401</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2"> Billing Provider City Name</font></td> <font size="2"></font> <td valign="top" width="797"> </td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">N402</font></span></td> <font size="2"></font> <td valign="top" width="385"> Billing Provider State</td> <font size="2"></font> <td valign="top" width="797"> </td> <font size="2"></font></tr> <tr> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">N403</font></span></td> <td valign="top" width="385"> Billing Provider City</td> <td valign="top" width="797"> </td> </tr> <tr> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">N404</font></span></td> <td valign="top" width="385"> Billing Provider Postal Code</td> <td valign="top" width="797"> </td> </tr> <font size="2"></font><font size="2"></font><font size="2"></font><font size="2"></font><font size="2"></font></tbody></table> <p><span style="font-size: 14px;"><strong><strong><span style="font-size: 12px;"><font size="3"> <br /><strong><span style="font-size: 12px;"><font size="3">Loop Name: 2010AA PER Billing Provider Contact Information –>  Phone Number Field in CMS 1500 Box 33       <br /></font></span></strong></font></span></strong></strong></span></p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="110"><strong>Segment ID</strong></td> <strong></strong> <td valign="top" width="385"><strong>Segment Name</strong></td> <strong></strong> <td valign="top" width="797"><strong>Value</strong></td> </tr> <tr> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">PER01</font></span></td> <font size="2"></font> <td valign="top" width="385"><font size="2"> Contact Function Code</font></td> <font size="2"></font> <td valign="top" width="797">IC</td> <font size="2"></font></tr> <font size="2"></font> <tr><font size="2"></font> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">PER02</font></span></td> <font size="2"></font> <td valign="top" width="385"> Billing Provider Contact Name</td> <font size="2"></font> <td valign="top" width="797"> </td> <font size="2"></font></tr> <tr> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">PER03</font></span></td> <td valign="top" width="385"> Communication Number Qualifier</td> <td valign="top" width="797">EM –> Electronic Mail or FX –> Fax or TE – Telephone</td> </tr> <tr> <td valign="top" width="110"><span style="color: rgb(41, 128, 185);"><font size="2">PER04</font></span></td> <td valign="top" width="385"> Communication Number</td> </tr> </tbody></table> <p><span style="font-size: 14px;"><strong><strong><span style="font-size: 12px;"><span style="font-family: verdana; font-size: small;"><strong><font color="#000000">2010AA Billing Provider – Sample </font></strong></span></span></strong></strong></span></p> <div style="text-align: left;" dir="ltr" trbidi="on"></div> <div style="text-align: left;" dir="ltr" trbidi="on"><strong><span style="font-family: verdana; font-size: small;"><font color="#000000">Test data</font></span></strong></div> <table style="width: 754px;" cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td style="background: rgb(254, 102, 2); border-right-color: rgb(221, 221, 221); border-bottom-color: rgb(221, 221, 221); border-right-width: 1px; border-bottom-width: 1px; border-right-style: solid; border-bottom-style: solid;" width="291" top="top"><span style="font-family: verdana;">Field</span></td> <td style="background: rgb(254, 102, 2); border-right-color: rgb(221, 221, 221); border-bottom-color: rgb(221, 221, 221); border-right-width: 1px; border-bottom-width: 1px; border-right-style: solid; border-bottom-style: solid;" width="317" top="top"><span style="font-family: verdana;">Value</span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Practice Name</font></span></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">XYZ Practice</font></span></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Practice Address 1</font></span></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"></span><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">6623 REACH BLVD</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Practice Address 2</font></span></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">APT E10</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Practice City</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Brooklyn</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Practice State</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">NY</font></span></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Practice Zip code</font></span></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">112304444</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Practice NPI or Group NPI</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">8585858585</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2"></font></span></span></td> <td valign="top" width="317"><span style="font-size: x-small;"><font size="2"><font color="#000000"><span style="color: rgb(34, 34, 34);"></span><span style="font-family: verdana; font-size: x-small;"></span></font></font></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider First Name</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Smith</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider Middle Name</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">K</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider Last Name</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Sean</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider Address 1</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">5537 KINGS HIGHWAY</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider Address 2</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">APT 6G</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider City</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Frisco City</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider State</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">NY</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider Zip Code</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">112348888</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">Provider NPI Number</font></span></span></td> <td valign="top" width="317"><span style="font-family: verdana; font-size: x-small;"><span style="font-size: x-small;"><font color="#000000" size="2">6565656565</font></span></span></td> </tr> <tr> <td valign="top" width="291"><span style="font-family: verdana; font-size: x-small;"><font color="#000000" size="2"></font></span></td> <td valign="top" width="317"> </td> </tr> </tbody></table> <div style="text-align: left;" dir="ltr" trbidi="on"></div> <div style="text-align: left;" dir="ltr" trbidi="on"></div> <div style="text-align: left;" dir="ltr" trbidi="on"><span style="font-family: raavi;"><span style="font-family: verdana; font-size: x-small;"><strong><span style="font-size: small;"> <br /><font color="#000000">Use case 1 :</font></span></strong></span> <br /><span style="font-family: verdana; font-size: x-small;"><span style="font-weight: normal;"><span style="font-size: x-small;"><font color="#000000" size="2"> <br />If the practice is enrolled with the insurance company under the practice name (or Bill with Group NPI) , then the following will be printed.</font></span></span></span></span></div> <span style="color: blue; font-family: verdana; font-size: small;"><strong>NM1*85*2*XYZ Practice*****XX*8585858585~ <br />N3*6623 REACH BLVD*APT E10~ <br />N4*Brooklyn*NY*11230-4444~</strong></span> <br /> <br /> <div style="text-align: left;" dir="ltr" trbidi="on"> </div> <div style="text-align: left;" dir="ltr" trbidi="on"><span style="font-weight: normal;"><span style="font-family: verdana; font-size: small;"><strong><font color="#000000">Use case : 2</font></strong></span></span></div> <div style="text-align: left;" dir="ltr" trbidi="on"><span style="font-weight: normal;"><font color="#000000" size="2">If the Provider is enrolled with the Insurance company under the provider name (or Bill with Individual NPI), then the following will be printed.</font></span></div> <div style="text-align: left;" dir="ltr" trbidi="on"><span style="color: blue; font-family: verdana; font-size: small;"><strong><span style="font-size: small;"> <br />NM1*85*1*Sean*Smith*K***XX*6565656565~ <br />N3*5537 KINGS HIGHWAY*APT 6G~ <br />N4*Frisco City*NY*11234-8888~</span></strong></span></div> <strong> <hr /></strong> <p><a href="$cms1500-2021-05-12-4-35-am-14.jpg"><span style="font-size: medium;"><strong>Looking for JSON to EDI solution?</strong></span>    </a></p> <p><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><span style="font-size: small;">EDI RESTful Web Service API</span></a> <br /><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><span style="font-size: small;">JSON To EDI 837 Professional</span></strong></a> <br /> <br /><span style="font-size: medium;"><strong>Looking for more examples? Login into our EDI Tool </strong></span> <br /><strong><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</a>        </strong></p> <p><a href="http://emrpms.blogspot.com/2021/04/x12-edi-examples_24.html" target="_blank">X12 EDI Examples</a></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-27194001594979201742021-07-19T09:34:00.001+05:302021-07-19T12:05:58.849+05:30X12 EDI 837 example for payer secondary Identification<a name='more'></a> <p><strong><font size="2">EDI 837 Professional. Version 005010X222A1</font></strong></p> <font size="3"></font> <p><font size="3"><strong><font size="2">Example 9: </font></strong>  Payer Secondary Identification</font></p> <p><font size="3">Some payer need additional identifiers other than payer ID. Here are those available option in EDI 837 , you can submit additional numbers </font></p> <table style="width: 668px;" cellspacing="1" cellpadding="1" border="1"><tbody> <tr> <td style="width: 103px;"><strong><span style="color: rgb(51, 102, 255);">2U</span></strong></td> <td style="width: 550px;"><strong>Payer Identification Number</strong></td> </tr> <tr> <td style="width: 103px;"><span style="color: rgb(51, 102, 255);"><strong>EI</strong></span></td> <td style="width: 550px;"><strong>Employer’s Identification Number</strong></td> </tr> <tr> <td style="width: 103px;"><strong><span style="color: rgb(51, 102, 255);">FY</span></strong></td> <td style="width: 550px;"><strong>Claim Office Number</strong></td> </tr> <tr> <td style="width: 103px;"><strong><span style="color: rgb(51, 102, 255);">NF</span></strong></td> <td style="width: 550px;"><strong>National Association of Insurance Commissioners (NAIC) Code</strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"> </span></p> <p>MEDICAID IL, required 2U Number, if that is missing, then the following error will be thrown.</p> <p>MEDICAID IL NON-PRIMARY CLAIMS REQUIRE A 5-DIGIT NUMERIC SECONDARY PAYER NUMBER WITH A 2U TYPE FOR THE OTHER POLICIES. THIS NUMBER SHOULD BE THE 3-DIGIT TPL CODE FOLLOWED BY THE 2-DIGIT STATUS CODE ASSIGNED BY HFS <br /> <br />Here is an example of EDI 837 message which contains Payer secondary information</p> <p> </p> <p>ISA*00*          *00*          *ZZ*123123         *ZZ*241232         *210719*0950*^*00501*199509000*1*T*: <br /> GS*HC*123123*241232*20210719*0950*199509*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*199509*20210719*0950*CH <br /> NM1*41*2*ABC Submitter*****46*7342343 <br /> PER*IC*John Mike*TE*1214151617 <br /> NM1*40*2*Zirmed*****46*12345 <br /> HL*1**20*1 <br />PRV*BI*PXC*208500000X <br /> NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692 <br /> N3*3937  Kenwood Place <br /> N4*Orlando*FL*32801 <br /> REF*EI*81-3777631 <br /> HL*2*1*22*0 <br /> SBR*P*18*92291223*AED12342*****ZZ <br /> NM1*IL*1*BAKER*Alyssa****MI*723223232 <br /> N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St <br /> N4*HOUSTON*TX*77833 <br /> DMG*D8*20201204*M <br /> NM1*PR*2*CIGNA*****PI*81400 <br /> N3*PO BOX 660044 <br /> N4*DALLAS*TX*75266 <br /><strong><font color="#0000ff">REF*2U*412412 <br /> REF*EI*124567890 <br /> REF*FY*21212 <br /> REF*NF*32122222</font></strong> <br /> CLM*10421*100.00***11:B:1*Y*A*Y*Y*P <br /> HI*ABK:R1013*ABF:E860 <br /> NM1*82*1*Nelson*Romer****XX*1023555349 <br /> NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059 <br /> N3*6100 W CREEK RD SUITE 35 <br /> N4*Independence*OH*44131 <br />LX*1 <br /> SV1*HC:99213*50.00*UN*1.00***1:2 <br /> DTP*472*D8*20201204 <br /> REF*6R*6001 <br /> LX*2 <br /> SV1*HC:87070*50.00*UN*1.00***1:2 <br /> DTP*472*D8*20201204 <br />REF*6R*6002 <br /> SE*39*0001 <br /> GE*1*199509 <br /> IEA*1*199509000 <br /> <br /> <br /><strong>HTML Version   </strong></p> <p><span style="color: rgb(51, 102, 255);"><strong> Interchange Control Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Authorization Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Security Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Sender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Submitter ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">123123 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Receiver</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">241232 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">07/19/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">InterChange Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">09:50</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Repetition Seperator </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">^</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">199509000</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Acknowledgement Requested</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Usage Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">T</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Functional Group Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Sender Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">123123</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Application Receiver Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">241232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">07/19/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">09:50</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Control Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">199509</span></strong></td> </tr> <tr> <td style="width: 200.29px;">EDI Version </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">005010X222A1</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Transaction Set Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Transaction set </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">837</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Hierarchical Transaction</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Transaction Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">199509</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">07/19/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">09:50</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Submitter Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Submitter Entity </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Organization</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Organization Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ABC Submitter</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">7342343</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">John Mike</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Phone </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1214151617</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Receiver Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Receiver Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Zirmed</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12345</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Billing Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Get Well Family Clinic LLC</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">3937 Kenwood Place</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Orlando</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">FL</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">32801</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1740713692</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Tax ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">81-3777631</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Taxonomy Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">208500000X</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Payer Responsbility</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Insured Relationship</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">18</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">92291223</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">AED12342</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Filling Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber Name</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">BAKER</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Alyssa</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DOB</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Gender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">M</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Policy No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">723223232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">197800 Atascocita Shores Dr</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">302 12 N. Mcgraw St</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">HOUSTON</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">TX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">77833</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Payer</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">CIGNA</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">PO BOX 660044</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">DALLAS</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">TX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">75266</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Payer ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">81400</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Payer Identification Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">412412</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Employer’s Identification Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">124567890</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Office Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">21212</span></strong></td> </tr> <tr> <td style="width: 200.29px;">National Association of Insurance Commissioners (NAIC) Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">32122222</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Claim Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Claim No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10421</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Billed Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">100.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Sign Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Accept Assignment Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Benefits Assignment Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Release of information</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> ICD Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">ICD Code 1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">R1013</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Code 2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">E860</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Rendering Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Nelson</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Romer</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1023555349</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Facility</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Clinic For Pain And Anxiety </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6100 W CREEK RD SUITE 35</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Independence</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">OH</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">44131</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1396885059</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 1</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6001</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">99213</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">50.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1,2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 2</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6002</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">87070</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">50.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1,2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> </tbody></table> <p> </p> <p> </p> <a href="file:///C:/Users/senthil/AppData/Local/Temp/OpenLiveWriter700344844/supfiles58A3D36/cms1500-2021-05-12-4-35-am-14.jpg"><font size="3"><strong>Looking for JSON to EDI solution ?</strong></font>    <h5></h5> </a> <h5><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" size="2">EDI RESTful Web Service API</font></a> <br /><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><font size="2">JSON To EDI 837 Professional</font></strong></a> <br /> <br /><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong></font> <br /><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</a>        </b></h5> <p><a href="http://emrpms.blogspot.com/2021/04/x12-edi-examples_24.html" target="_blank">X12 EDI Examples</a></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-78187105777735955082021-07-09T11:46:00.000+05:302021-07-09T21:34:55.585+05:30X12 EDI 837 Submitting corrected Claims<a name='more'></a> <p>Corrected claims can be submitted electronically as an EDI 837 transaction with the appropriate frequency code as follows. <br /></p> <p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="72">Code</td> <td valign="top" width="704">Description</td> </tr> <tr> <td valign="top" width="72">1</td> <td valign="top" width="704">Indicates the claim is an original claim </td> </tr> <tr> <td valign="top" width="72">7</td> <td valign="top" width="704">Indicates the new claim is a replacement or corrected claim – the information present on this bill represents a complete replacement of the previously issued bill. </td> </tr> <tr> <td valign="top" width="72">8</td> <td valign="top" width="704">Indicates the claim is a voided/cancelled claim </td> </tr> </tbody></table> </p> <p> <br />This value should be passed in the Claim Segment CLM  in CLM05- as shown here <br />CLM*10421*100.00***11:B:<strong><font color="#ff0000">7</font></strong>*Y*A*Y*Y*P <br /> <br />When submitting claims noted with claim frequency code 7 or 8, the original Payer claim number, also referred to as the Document Control Number (DCN) must be submitted in Loop 2300 REF02 – Payer Claim Control Number <br /> with qualifier F8 in REF01. The DCN can be obtained from the 835 Electronic Remittance Advice (ERA) or Electronic Payment Summary (EPS). Without the original DCN, adjustment requests will generate a compliance error and the claim will reject. </p> <p> <br />Here is example with DCN Number <br /> <br />CLM*10421*100.00***11:B:7*Y*A*Y*Y*P <br /> REF*F8*X1231232</p> <p> <br /> In order to void/cancel the previously submitted claim , File electronically, as usual. Include all <br /> charges that were on the original claim and with claim frequency code  8 .</p> <p>CLM* PUBLICJQ-00100*468*13:A:8*Y**Y*********Y~ <br /> REF*F8*71125008000000300</p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-319352004638223192021-07-05T09:51:00.009+05:302021-09-26T12:36:57.013+05:30Understanding EDI 999 functional Acknowledgement<a name='more'></a> <a href="https://drive.google.com/uc?id=1-w2x6TSVuSfWPnWQ27Zq4NS3iDx4WRHI"><img title="EDI99EX1" style="display: inline; background-image: none;" border="0" alt="EDI99EX1" src="https://drive.google.com/uc?id=1P7d80SZygPEbQUjBMtv2lRnkFwa8KxmR" width="644" height="164" /></a> <p> </p> <p>Example 1: <br /> <br />Let us understand EDI 999 Segments with real world examples.  <br />Problem Description.  The submitted EDI 837 P contains invalid character (space) in one of the ICD Code and here is the response EDI 999 which states the error in detail.</p> <p>   <br />    <br />ISA*00*          *00*          *01*030240928      *ZZ*AV09311993     *210629*0925*^*00501*149978100*0*P*:~ <br /> GS*FA*030240928*AV01101957*20210629*092500*1*X*005010X231A1~ <br /> ST*999*1001*005010X231A1~ <br /><strong><font color="#0000ff">AK1*HC*1675*005010X222A1~ <br /> AK2*837*0001*005010X222A1~ <br />IK3*HI*757*2300*8~ <br /> CTX*CLM01:FR101881~ <br /> IK4*1:2*1271*6~ <br /> IK5*R*5~ <br />AK9*R*1*1*0~ <br /></font></strong>SE*9*1001~ <br /> GE*1*1~ <br /> IEA*1*149978100~</p> <p> </p> <p>Let us understand the following AK1 Segment </p> <p><font color="#0000ff"><strong>AK1*HC*1675*005010X222A1~ <br /></strong><font color="#0000ff"></font></font></p> <font color="#0000ff"><font color="#0000ff"> <table cellspacing="0" cellpadding="2" border="1"><strong></strong><tbody><strong></strong> <tr><strong></strong> <td valign="top" width="206"><font color="#000000">1675</font></td> <strong></strong> <td valign="top" width="991"><font color="#000000">This is the Batch or Group Control Number that present in the original EDI 837 File. <strong>It is recommend to store the EDI 837 File generated from the Medical billing application to debug the error information when 999 file arrives</strong>. For example, here is the original EDI 837 File for which we get the above 999 Acknowledgement file <br /> <br />ISA*00*          *00*          *ZZ*AV09311993     *01*030240928      *210629*0123*^*00501*167500000*1*P*: <br /> GS*HC*AV09311993*030240928*20210629*0123*<strong><font color="#0000ff">1675</font></strong>*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*1675*20210629*0123*CH <br /> <br />As you can see the GS6 contains 1675 which is the batch number and the same number is echo backed in the EDI 999 File. This help the EDI Developers to identify for which 837 EDI File, we got the EDI 999 file. <br /></font> <br /><font color="#000000">Please refer the following link for more details on GS Segment</font> <br /><a href="http://emrpms.blogspot.com/2012/09/edi-5010-documentation837-gs-functional.html" target="_blank"><font color="#0000ff">GS – Functional Group Header</font></a> <br /> <br /></td> <strong></strong></tr> <strong></strong> <tr><strong></strong> <td valign="top" width="212">005010X222A1</td> <strong></strong> <td valign="top" width="997"><font color="#000000">This is the version number and same value in GS08 from the functional group of the original EDI File to which this 999 transaction set is responding. <br /> <br /><font color="#000000">For example, here is the original EDI 837 File for which we get the above 999 Acknowledgement file <br /> <br />ISA*00*          *00*          *ZZ*AV09311993     *01*030240928      *210629*0123*^*00501*167500000*1*P*: <br />GS*HC*AV09311993*030240928*20210629*0123*<font color="#000000">1675</font>*X*<font color="#0000ff"><strong>005010X222A1</strong></font> <br />ST*837*0001*005010X222A1 <br />BHT*0019*00*1675*20210629*0123*CH</font> <br /></font></td> <strong></strong></tr> <strong></strong></tbody><strong></strong></table> <strong> <br /></strong></font><font color="#0000ff"> <br /><font color="#000000">Let us understand the following AK2 Segment</font> <br /> <br /><strong>AK2*837*0001*005010X222A1~</strong> <br /> <br /> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="202">837</td> <font color="#000000"></font> <td valign="top" width="994"><font color="#000000">This is the transaction set code . This value is same from the original EDI 837 File ST01 element</font><font color="#000000"><font color="#000000"> <br /> <br /><font color="#000000"><font color="#000000">ISA*00*          *00*          *ZZ*AV09311993     *01*030240928      *210629*0123*^*00501*167500000*1*P*: <br />GS*HC*AV09311993*030240928*20210629*0123*<font color="#000000">1675</font>*X*<font color="#000000">005010X222A1</font> <br />ST*<strong><font color="#0000ff">837</font></strong>*0001*005010X222A1 <br />BHT*0019*00*1675*20210629*0123*CH</font></font> <br /></font></font><font color="#000000"> <br /><font color="#000000">Please refer the following link for more details on ST Segment</font> <br /><strong><a href="http://emrpms.blogspot.com/2012/09/edi-5010-documentation837-sttransaction.html" target="_blank"><font color="#0000ff">ST – Transaction Set Header</font></a></strong> <br /></font></td> </tr> <tr> <td valign="top" width="208">0001</td> <td valign="top" width="1000"><font color="#000000">Transaction control Number . This value is same from original EDI 837 File ST02 element. <br /> <br /><font color="#000000"><font color="#000000"><font color="#000000"><font color="#000000">ISA*00*          *00*          *ZZ*AV09311993     *01*030240928      *210629*0123*^*00501*167500000*1*P*: <br />GS*HC*AV09311993*030240928*20210629*0123*<font color="#000000">1675</font>*X*<font color="#000000">005010X222A1</font> <br />ST*<font color="#000000">837</font>*<strong><font color="#0000ff">0001</font></strong>*005010X222A1 <br />BHT*0019*00*1675*20210629*0123*CH</font></font> <br /></font></font><font color="#000000"> <br /><font color="#000000">Please refer the following link for more details on ST Segment</font> <br /><strong><a href="http://emrpms.blogspot.com/2012/09/edi-5010-documentation837-sttransaction.html" target="_blank"><font color="#0000ff">ST – Transaction Set Header</font></a></strong></font> <br /></font></td> </tr> <tr> <td valign="top" width="214">005010X222A1</td> <td valign="top" width="1006"><font color="#000000">ST03 Value from the original EDI 837 File</font><font color="#000000"> </font> <br /> <br /><font color="#000000"><font color="#000000"><font color="#000000"><font color="#000000"><font color="#000000">ISA*00*          *00*          *ZZ*AV09311993     *01*030240928      *210629*0123*^*00501*167500000*1*P*: <br />GS*HC*AV09311993*030240928*20210629*0123*<font color="#000000">1675</font>*X*<font color="#000000">005010X222A1</font> <br />ST*<font color="#000000">837</font>*<font color="#000000">0001</font>*<strong><font color="#0000ff">005010X222A1</font></strong> <br />BHT*0019*00*1675*20210629*0123*CH</font></font> <br /></font></font><font color="#000000"> <br /><font color="#000000">Please refer the following link for more details on ST Segment</font> <br /><strong><a href="http://emrpms.blogspot.com/2012/09/edi-5010-documentation837-sttransaction.html" target="_blank"><font color="#0000ff">ST – Transaction Set Header</font></a></strong></font></font> <br /></td> </tr> </tbody></table>           <br /></font></font><font color="#000000">Let us understand the following AK2 Segment</font> <br /> <br /><strong><font color="#0000ff">IK3*HI*757*2300*8~</font></strong> <p><font color="#0000ff"><font color="#0000ff">This is the error identification information         <br />        <font color="#0000ff"><font color="#0000ff">       </font></font></font></font></p> <font color="#0000ff"><font color="#0000ff"><font color="#0000ff"><font color="#0000ff"> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="230">IK3</td> <td valign="top" width="962"> <p><font color="#000000">This value identifies the segment with errors.If multiple segments have errors, you will see multiple IK3 lines. A segment is a string of data that begins with capital letters and numbers such as NM1, PER, REF and CLM in your claim.IK3 First Value (IK301)</font></p> </td> </tr> <tr> <td valign="top" width="236">HI</td> <td valign="top" width="968"><font color="#000000">Segment code. This is the segment code present in the original EDI 837 File</font><font color="#000000"> . Here HI refers the problem in the Health care diagnosis code. This is the first step to conclude the problem in the EDI 837 File. Here it says we have a problem in ICD Code segment</font></td> </tr> <tr> <td valign="top" width="242">757</td> <td valign="top" width="974"><font color="#000000">This is the important key to narrow down the problem in the file. It identifies the line number is the file. Open the submitted EDI 837 file in the Notepad++.  Actually we need add +2 to this number to reach the actual line in the submitted EDI 837 File.</font> <br /><font color="#000000">Please follow the steps as described in the bottom how to open the file in Notepad++.  After open the file go to line # 759 and that is the line which contains problem.</font> <br /></td> </tr> <tr> <td valign="top" width="248">2300</td> <td valign="top" width="980"><font color="#000000">EDI 837 Loop # . This value identifies the loop number where the segment in error is located. This loop number corresponds to a section of the claim. Here the 999 File says we have a problem in Loop # 2300 which is a claim information loop.  For complete set of Loops , please refer below</font> <br /><a href="http://emrpms.blogspot.com/2020/03/edi-837-professional-segments.html" target="_blank"><font color="#0000ff">EDI 837 Professional Loops</font></a> <br /></td> </tr> <tr> <td valign="top" width="254">8</td> <td valign="top" width="986"><font color="#000000">This value identifies the type of the error at the segment level. Use the following  table to decode the number in this field <br /></font> <table cellspacing="0" cellpadding="2" border="0"><font color="#000000"></font><tbody><font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="96"><font color="#000000">1</font></td> <font color="#000000"></font> <td valign="top" width="631"><font color="#000000">Unrecognized segment ID</font></td> <font color="#000000"></font></tr> <font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="103"><font color="#000000">2</font></td> <font color="#000000"></font> <td valign="top" width="638"><font color="#000000">Unexpected segment</font></td> <font color="#000000"></font></tr> <tr> <td valign="top" width="110"><font color="#000000">3</font></td> <td valign="top" width="645"><font color="#000000">Mandatory segment missing</font></td> </tr> <tr> <td valign="top" width="117"><font color="#000000">4</font></td> <td valign="top" width="652"><font color="#000000">Loop Occurs Over Maximum Times</font></td> </tr> <tr> <td valign="top" width="124"><font color="#000000">5</font></td> <td valign="top" width="659"><font color="#000000">Segment Exceeds Maximum Use</font></td> </tr> <tr> <td valign="top" width="131"><font color="#000000">6</font></td> <td valign="top" width="666"><font color="#000000">Segment Not in Defined Transaction Set</font></td> </tr> <tr> <td valign="top" width="138"><font color="#000000">7</font></td> <td valign="top" width="673"><font color="#000000">Segment Not in Proper Sequence</font></td> </tr> <tr> <td valign="top" width="145"><font color="#0000ff">8</font></td> <td valign="top" width="680"><font color="#0000ff">Segment Has Field Errors</font></td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><font color="#000000">Let us understand the following AK2 Segment</font> </p> <p>CTX*CLM01:FR101881~ <br /> <br /><font color="#000000">Note : It is recommend to keep a unique claim number for claim in the Practice management system and pass that number in the CLM Segment of 837. <br />For more information, please refer here </font><a href="http://emrpms.blogspot.com/2012/07/edi-5010-documentation-837-professional.html" target="_blank">Loop 2300 Claim Information</a></p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="230">CLM01</td> <td valign="top" width="962"> <p><font color="#000000">It says, the number next to this value is same as the number present in the original submitted EDI 837 File CLM01 Element. So the value  FR101881 is the claim number which contains the actual error. <br /> <br />Here is the submitted file information <br /> <br />Line No                        EDI Segment</font></p> <p><font color="#000000">755                                NM1*PR*2*MEDICARE PART B*****PI*06102 <br /> 756                                N3*PO BOX 6475 <br /> 757                                N4*Indianapolis*IN*46206 <br />758                                CLM*FR101881*209.00***11:B:1*Y*A*Y*Y <br /> 759                                HI*ABK:F329 *ABF:G40909*ABF:M1990</font></p> <p><font color="#000000">As you can see, line Number 759 is our target which contains the error. So what is the error and which element it has error ? Look at the next segment description in EDI 999 <br /> <br /></font></p> </td> </tr> </tbody></table> <p> <br /><font color="#000000">Let us understand the following AK2 Segment</font>   </p> <p>IK4*1:2*1271*6~ </p> <p>This is the detail level description of the error within the loop and segment described in IK3 Segment. <br /> <br /></p> <table cellspacing="0" cellpadding="2" border="1"><tbody> <tr> <td valign="top" width="230">1:2</td> <td valign="top" width="962"> <p><font color="#000000">The exact position in segment in the submitted file.  It says, position at 1:2 the error occurs</font></p> </td> </tr> <tr> <td valign="top" width="236">1271</td> <td valign="top" width="968"><font color="#000000"> Data element reference number as per EDI 837 implementation guide. For each code sets, X12 EDI defines a number to identify the coding system. Here 1271 indicates ICD Code <br /> <br /><a href="https://drive.google.com/uc?id=1KJW6qFHZsWK93PY_Tp6UIdbJ8jzxOjN7"><img title="image" style="display: inline; background-image: none;" border="0" alt="image" src="https://drive.google.com/uc?id=1LeZ9v6FU5iZKe_fhu1KPoOuxXH0hgFNq" width="644" height="118" /></a> <p> </p> </font></td> </tr> <tr> <td valign="top" width="242">6</td> <td valign="top" width="974"><font color="#000000">This value identifies the type of the error at the segment level. Use the following  table to decode the number in this field <br /></font> <table cellspacing="0" cellpadding="2" border="0"><font color="#000000"></font><tbody><font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="96"><font color="#000000">1</font></td> <font color="#000000"></font> <td valign="top" width="631"><font color="#000000">Required Data Element Missing</font></td> </tr> <font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="103"><font color="#000000">2</font></td> <font color="#000000"></font> <td valign="top" width="638"><font color="#000000">Conditional Required Data Element Missing</font></td> </tr> <font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="110"><font color="#000000">3</font></td> <font color="#000000"></font> <td valign="top" width="645"><font color="#000000">Too Many data Elements</font></td> </tr> <font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="117"><font color="#000000">4</font></td> <font color="#000000"></font> <td valign="top" width="652"><font color="#000000">Data Element Too Short</font></td> </tr> <font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="124"><font color="#000000">5</font></td> <font color="#000000"></font> <td valign="top" width="659"><font color="#000000">Data Element Too Long</font></td> </tr> <font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="131"><strong><font color="#0000ff">6</font></strong></td> <font color="#000000"></font> <td valign="top" width="666"><strong><font color="#0000ff">Invalid Character In Data Element</font></strong></td> </tr> <font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="138"><font color="#000000">7</font></td> <font color="#000000"></font> <td valign="top" width="673"><font color="#000000">Invalid Code Value</font></td> </tr> <font color="#000000"></font> <tr><font color="#000000"></font> <td valign="top" width="145"><font color="#000000">8</font></td> <font color="#000000"></font> <td valign="top" width="680"><font color="#000000">Invalid Date</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">9</font></td> <td valign="top" width="680"><font color="#000000">Invalid Time</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">10</font></td> <td valign="top" width="680"><font color="#000000">Exclusion Condition Violated</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">12</font></td> <td valign="top" width="680"><font color="#000000">Too Many Repetitions</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">13</font></td> <td valign="top" width="680"><font color="#000000">Too Many Components</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">I10</font></td> <td valign="top" width="680"><font color="#000000">Implementation “Not Used” Data Element Present</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">I11</font></td> <td valign="top" width="680"><font color="#000000">Implementation Too Few Repetitions</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">I12</font></td> <td valign="top" width="680"><font color="#000000">Implementation Pattern Match Failure</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">I13</font></td> <td valign="top" width="680"> <p><font color="#000000">Implementation Dependent “Not Used” Data <br /> Element Present</font></p> </td> </tr> <tr> <td valign="top" width="145"><font color="#000000">I6</font></td> <td valign="top" width="680"><font color="#000000">Code Value Not Used in Implementation</font></td> </tr> <tr> <td valign="top" width="145"><font color="#000000">I9</font></td> <td valign="top" width="680"><font color="#000000">Implementation Dependent Data Element Missing</font></td> </tr> </tbody></table> </td> </tr> </tbody></table> <p> <br />So what is the error. On HI Segment, on the first element of ICD Codes, there is some invalid character. Here is the actual submitted data which contains the error (one space at the end) <br />After F329, there is one additional space which cause the problem to reject the entire file. <br /> <br /><strong><font color="#0000ff" size="5">HI*ABK:F329 *ABF:G40909*ABF:M1990</font></strong> <br /> <br /></p> <h5><font color="#000000" size="3">How to Read and Understand an EDI File ?</font></h5> <p><font color="#000000">1.First Open the EDI File in Notepad ++ <br />2.Copy the Character at Column 106. Mostly the Character will be tilde (~)</font></p> <p><a href="https://lh3.googleusercontent.com/-dM2AtMzC1vs/WA8ys3k6aDI/AAAAAAAAITs/sxdV2on8W1Y/s1600-h/image%25255B3%25255D.png"><img title="image" border="0" alt="image" src="https://lh3.googleusercontent.com/-ONpBDzDb60M/WA8yxj_SneI/AAAAAAAAITw/cxRji1B8LLM/image_thumb%25255B1%25255D.png?imgmax=800" width="644" height="82" /></a> <br /><font color="#000000">3.Then go to Search -> Replace Menu in Notepad ++ <br />4.Paste the Character ~ in the Find What and Replace With "\n"</font> <br /><a href="https://lh3.googleusercontent.com/-ELTcNsDGp1c/WA8y0VKkvmI/AAAAAAAAIT0/TAjsHnX6H50/s1600-h/image%25255B7%25255D.png"><img title="image" border="0" alt="image" src="https://lh3.googleusercontent.com/-KtZyMKpJWJs/WA8y2w4TTnI/AAAAAAAAIT4/3gu9tYnh1qw/image_thumb%25255B3%25255D.png?imgmax=800" width="644" height="282" /></a> <br /><font color="#000000">5.Click Replace All.</font></p> <p> <br /> <br /></p> <p> </p> <p> </p> <p> </p>     </font></font></font></font>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-37535455523215424582021-07-01T22:14:00.010+05:302022-04-13T23:20:34.001+05:30Maps in Golang<a name='more'></a> <strong>How to iterate over a Map using for loop in Go</strong> <link rel="stylesheet" type="text/css" href="http://www.freecodeformat.com/js/syntaxhighlighter_3.0.83/styles/shCoreEclipse.css" /> <div id="highlighter_797870" class="syntaxhighlighter java"> <div class="toolbar"><span><a class="toolbar_item command_help help" href="#">?</a></span></div> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td class="gutter"> <div class="line number1 index0 alt2">1</div> <div class="line number2 index1 alt1">2</div> <div class="line number3 index2 alt2">3</div> <div class="line number4 index3 alt1">4</div> <div class="line number5 index4 alt2">5</div> <div class="line number6 index5 alt1">6</div> <div class="line number7 index6 alt2">7</div> <div class="line number8 index7 alt1">8</div> <div class="line number9 index8 alt2">9</div> <div class="line number10 index9 alt1">10</div> <div class="line number11 index10 alt2">11</div> <div class="line number12 index11 alt1">12</div> <div class="line number13 index12 alt2">13</div> <div class="line number14 index13 alt1">14</div> <div class="line number15 index14 alt2">15</div> <div class="line number16 index15 alt1">16</div> <div class="line number17 index16 alt2">17</div> </td> <td class="code"> <div class="container"> <div class="line number1 index0 alt2"><code class="java keyword">package</code> <code class="java plain">main</code></div> <div class="line number2 index1 alt1"> </div> <div class="line number3 index2 alt2"><code class="java keyword">import</code> <code class="java string">"fmt"</code></div> <div class="line number4 index3 alt1"> </div> <div class="line number5 index4 alt2"><code class="java plain">func main() {</code></div> <div class="line number6 index5 alt1"><code class="java spaces">    </code><code class="java plain">fmt.Println(</code><code class="java string">"Welcome to goLang Maps"</code><code class="java plain">)</code></div> <div class="line number7 index6 alt2"> </div> <div class="line number8 index7 alt1"><code class="java spaces">    </code><code class="java plain">languages := make(map[string]string)</code></div> <div class="line number9 index8 alt2"><code class="java spaces">    </code><code class="java plain">languages[</code><code class="java string">"JS"</code><code class="java plain">] = </code><code class="java string">"Javascript"</code></div> <div class="line number10 index9 alt1"><code class="java spaces">    </code><code class="java plain">languages[</code><code class="java string">"JA"</code><code class="java plain">] = </code><code class="java string">"Java"</code></div> <div class="line number11 index10 alt2"><code class="java spaces">    </code><code class="java plain">languages[</code><code class="java string">"PY"</code><code class="java plain">] = </code><code class="java string">"Python"</code></div> <div class="line number12 index11 alt1"> </div> <div class="line number13 index12 alt2"><code class="java spaces">    </code><code class="java keyword">for</code> <code class="java plain">key, element := range languages {</code></div> <div class="line number14 index13 alt1"><code class="java spaces">        </code><code class="java plain">fmt.Println(</code><code class="java string">"Key:"</code><code class="java plain">, key, </code><code class="java string">"=>"</code><code class="java plain">, </code><code class="java string">"Element:"</code><code class="java plain">, element)</code></div> <div class="line number15 index14 alt2"><code class="java spaces">    </code><code class="java plain">}</code></div> <div class="line number16 index15 alt1"> </div> <div class="line number17 index16 alt2"><code class="java plain">}</code></div> </div> </td> </tr> </tbody></table> </div> <p><strong>How to write map values into a file</strong></p> <link rel="stylesheet" type="text/css" href="http://www.freecodeformat.com/js/syntaxhighlighter_3.0.83/styles/shCoreEclipse.css" /> <div id="highlighter_289885" class="syntaxhighlighter java"> <div class="toolbar"><span><a class="toolbar_item command_help help" href="#">?</a></span></div> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td class="gutter"> <div class="line number1 index0 alt2">1</div> <div class="line number2 index1 alt1">2</div> <div class="line number3 index2 alt2">3</div> <div class="line number4 index3 alt1">4</div> <div class="line number5 index4 alt2">5</div> <div class="line number6 index5 alt1">6</div> <div class="line number7 index6 alt2">7</div> <div class="line number8 index7 alt1">8</div> <div class="line number9 index8 alt2">9</div> <div class="line number10 index9 alt1">10</div> <div class="line number11 index10 alt2">11</div> <div class="line number12 index11 alt1">12</div> <div class="line number13 index12 alt2">13</div> <div class="line number14 index13 alt1">14</div> <div class="line number15 index14 alt2">15</div> <div class="line number16 index15 alt1">16</div> <div class="line number17 index16 alt2">17</div> <div class="line number18 index17 alt1">18</div> <div class="line number19 index18 alt2">19</div> <div class="line number20 index19 alt1">20</div> <div class="line number21 index20 alt2">21</div> <div class="line number22 index21 alt1">22</div> <div class="line number23 index22 alt2">23</div> <div class="line number24 index23 alt1">24</div> <div class="line number25 index24 alt2">25</div> <div class="line number26 index25 alt1">26</div> <div class="line number27 index26 alt2">27</div> <div class="line number28 index27 alt1">28</div> <div class="line number29 index28 alt2">29</div> <div class="line number30 index29 alt1">30</div> <div class="line number31 index30 alt2">31</div> <div class="line number32 index31 alt1">32</div> <div class="line number33 index32 alt2">33</div> <div class="line number34 index33 alt1">34</div> </td> <td class="code"> <div class="container"> <div class="line number1 index0 alt2"><code class="java keyword">package</code> <code class="java plain">main</code></div> <div class="line number2 index1 alt1"> </div> <div class="line number3 index2 alt2"><code class="java keyword">import</code> <code class="java plain">(</code></div> <div class="line number4 index3 alt1"><code class="java spaces">    </code><code class="java string">"fmt"</code></div> <div class="line number5 index4 alt2"><code class="java spaces">    </code><code class="java string">"log"</code></div> <div class="line number6 index5 alt1"><code class="java spaces">    </code><code class="java string">"os"</code></div> <div class="line number7 index6 alt2"><code class="java plain">)</code></div> <div class="line number8 index7 alt1"> </div> <div class="line number9 index8 alt2"><code class="java plain">func main() {</code></div> <div class="line number10 index9 alt1"><code class="java spaces">    </code><code class="java plain">fmt.Println(</code><code class="java string">"Welcome to goLang Maps"</code><code class="java plain">)</code></div> <div class="line number11 index10 alt2"> </div> <div class="line number12 index11 alt1"><code class="java spaces">    </code><code class="java plain">languages := make(map[string]string)</code></div> <div class="line number13 index12 alt2"><code class="java spaces">    </code><code class="java plain">languages[</code><code class="java string">"JS"</code><code class="java plain">] = </code><code class="java string">"Javascript"</code></div> <div class="line number14 index13 alt1"><code class="java spaces">    </code><code class="java plain">languages[</code><code class="java string">"JA"</code><code class="java plain">] = </code><code class="java string">"Java"</code></div> <div class="line number15 index14 alt2"><code class="java spaces">    </code><code class="java plain">languages[</code><code class="java string">"PY"</code><code class="java plain">] = </code><code class="java string">"Python"</code></div> <div class="line number16 index15 alt1"> </div> <div class="line number17 index16 alt2"><code class="java spaces">    </code><code class="java plain">f, err := os.Create(</code><code class="java string">"test.txt"</code><code class="java plain">)</code></div> <div class="line number18 index17 alt1"><code class="java spaces">    </code><code class="java keyword">if</code> <code class="java plain">err != nil {</code></div> <div class="line number19 index18 alt2"><code class="java spaces">        </code><code class="java plain">fmt.Println(err)</code></div> <div class="line number20 index19 alt1"><code class="java spaces">        </code><code class="java keyword">return</code></div> <div class="line number21 index20 alt2"><code class="java spaces">    </code><code class="java plain">}</code></div> <div class="line number22 index21 alt1"> </div> <div class="line number23 index22 alt2"><code class="java spaces">    </code><code class="java comments">// remember to close the file</code></div> <div class="line number24 index23 alt1"><code class="java spaces">    </code><code class="java plain">defer f.Close()</code></div> <div class="line number25 index24 alt2"> </div> <div class="line number26 index25 alt1"><code class="java spaces">    </code><code class="java keyword">for</code> <code class="java plain">key, element := range languages {</code></div> <div class="line number27 index26 alt2"><code class="java spaces">        </code><code class="java plain">fmt.Println(</code><code class="java string">"Key:"</code><code class="java plain">, key, </code><code class="java string">"=>"</code><code class="java plain">, </code><code class="java string">"Element:"</code><code class="java plain">, element)</code></div> <div class="line number28 index27 alt1"><code class="java spaces">        </code><code class="java plain">_, err := f.WriteString(key + </code><code class="java string">","</code> <code class="java plain">+ element + </code><code class="java string">"\n"</code><code class="java plain">)</code></div> <div class="line number29 index28 alt2"><code class="java spaces">        </code><code class="java keyword">if</code> <code class="java plain">err != nil {</code></div> <div class="line number30 index29 alt1"><code class="java spaces">            </code><code class="java plain">log.Fatal(err)</code></div> <div class="line number31 index30 alt2"><code class="java spaces">        </code><code class="java plain">}</code></div> <div class="line number32 index31 alt1"><code class="java spaces">    </code><code class="java plain">}</code></div> <div class="line number33 index32 alt2"> </div> <div class="line number34 index33 alt1"><code class="java plain">}</code></div> </div> </td> </tr> </tbody></table> </div> <p><strong>How to read line by line from a file and create map values </strong></p> <link rel="stylesheet" type="text/css" href="http://www.freecodeformat.com/js/syntaxhighlighter_3.0.83/styles/shCoreEclipse.css" /> <div id="highlighter_104151" class="syntaxhighlighter java"> <div class="toolbar"><span><a class="toolbar_item command_help help" href="#">?</a></span></div> <table cellspacing="0" cellpadding="0" border="0"><tbody> <tr> <td class="gutter"> <div class="line number1 index0 alt2">1</div> <div class="line number2 index1 alt1">2</div> <div class="line number3 index2 alt2">3</div> <div class="line number4 index3 alt1">4</div> <div class="line number5 index4 alt2">5</div> <div class="line number6 index5 alt1">6</div> <div class="line number7 index6 alt2">7</div> <div class="line number8 index7 alt1">8</div> <div class="line number9 index8 alt2">9</div> <div class="line number10 index9 alt1">10</div> <div class="line number11 index10 alt2">11</div> <div class="line number12 index11 alt1">12</div> <div class="line number13 index12 alt2">13</div> <div class="line number14 index13 alt1">14</div> <div class="line number15 index14 alt2">15</div> <div class="line number16 index15 alt1">16</div> <div class="line number17 index16 alt2">17</div> <div class="line number18 index17 alt1">18</div> <div class="line number19 index18 alt2">19</div> <div class="line number20 index19 alt1">20</div> <div class="line number21 index20 alt2">21</div> <div class="line number22 index21 alt1">22</div> <div class="line number23 index22 alt2">23</div> <div class="line number24 index23 alt1">24</div> <div class="line number25 index24 alt2">25</div> <div class="line number26 index25 alt1">26</div> <div class="line number27 index26 alt2">27</div> <div class="line number28 index27 alt1">28</div> <div class="line number29 index28 alt2">29</div> <div class="line number30 index29 alt1">30</div> <div class="line number31 index30 alt2">31</div> <div class="line number32 index31 alt1">32</div> <div class="line number33 index32 alt2">33</div> <div class="line number34 index33 alt1">34</div> <div class="line number35 index34 alt2">35</div> <div class="line number36 index35 alt1">36</div> <div class="line number37 index36 alt2">37</div> </td> <td class="code"> <div class="container"> <div class="line number1 index0 alt2"><code class="java keyword">package</code> <code class="java plain">main</code></div> <div class="line number2 index1 alt1"> </div> <div class="line number3 index2 alt2"><code class="java keyword">import</code> <code class="java plain">(</code></div> <div class="line number4 index3 alt1"><code class="java spaces">    </code><code class="java string">"bufio"</code></div> <div class="line number5 index4 alt2"><code class="java spaces">    </code><code class="java string">"fmt"</code></div> <div class="line number6 index5 alt1"><code class="java spaces">    </code><code class="java string">"log"</code></div> <div class="line number7 index6 alt2"><code class="java spaces">    </code><code class="java string">"os"</code></div> <div class="line number8 index7 alt1"><code class="java spaces">    </code><code class="java string">"strings"</code></div> <div class="line number9 index8 alt2"><code class="java plain">)</code></div> <div class="line number10 index9 alt1"> </div> <div class="line number11 index10 alt2"><code class="java plain">func main() {</code></div> <div class="line number12 index11 alt1"><code class="java spaces">    </code><code class="java plain">fmt.Println(</code><code class="java string">"Welcome to goLang Maps"</code><code class="java plain">)</code></div> <div class="line number13 index12 alt2"> </div> <div class="line number14 index13 alt1"><code class="java spaces">    </code><code class="java plain">languages := make(map[string]string)</code></div> <div class="line number15 index14 alt2"> </div> <div class="line number16 index15 alt1"><code class="java spaces">    </code><code class="java plain">file, err := os.Open(</code><code class="java string">"test.txt"</code><code class="java plain">)</code></div> <div class="line number17 index16 alt2"><code class="java spaces">    </code><code class="java keyword">if</code> <code class="java plain">err != nil {</code></div> <div class="line number18 index17 alt1"><code class="java spaces">        </code><code class="java plain">log.Fatal(err)</code></div> <div class="line number19 index18 alt2"><code class="java spaces">    </code><code class="java plain">}</code></div> <div class="line number20 index19 alt1"> </div> <div class="line number21 index20 alt2"><code class="java spaces">    </code><code class="java comments">// remember to close the file</code></div> <div class="line number22 index21 alt1"><code class="java spaces">    </code><code class="java plain">defer file.Close()</code></div> <div class="line number23 index22 alt2"> </div> <div class="line number24 index23 alt1"><code class="java spaces">    </code><code class="java plain">scanner := bufio.NewScanner(file)</code></div> <div class="line number25 index24 alt2"><code class="java spaces">    </code><code class="java keyword">for</code> <code class="java plain">scanner.Scan() {</code></div> <div class="line number26 index25 alt1"><code class="java spaces">        </code><code class="java plain">keyvalue := scanner.Text()</code></div> <div class="line number27 index26 alt2"><code class="java spaces">        </code><code class="java plain">keypairs := strings.Split(keyvalue, </code><code class="java string">","</code><code class="java plain">)</code></div> <div class="line number28 index27 alt1"><code class="java spaces">        </code><code class="java plain">languages[keypairs[</code><code class="java value">0</code><code class="java plain">]] = keypairs[</code><code class="java value">1</code><code class="java plain">]</code></div> <div class="line number29 index28 alt2"><code class="java spaces">    </code><code class="java plain">}</code></div> <div class="line number30 index29 alt1"> </div> <div class="line number31 index30 alt2"><code class="java spaces">    </code><code class="java plain">fmt.Println(languages)</code></div> <div class="line number32 index31 alt1"> </div> <div class="line number33 index32 alt2"><code class="java spaces">    </code><code class="java keyword">if</code> <code class="java plain">err := scanner.Err(); err != nil {</code></div> <div class="line number34 index33 alt1"><code class="java spaces">        </code><code class="java plain">log.Fatal(err)</code></div> <div class="line number35 index34 alt2"><code class="java spaces">    </code><code class="java plain">}</code></div> <div class="line number36 index35 alt1"> </div> <div class="line number37 index36 alt2"><code class="java plain">}</code></div> </div> </td> </tr> </tbody></table> </div>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-30177891841639059722021-06-28T08:41:00.003+05:302021-07-19T08:59:28.144+05:30X12 EDI 837 Examples Billing Laboratory Claims Electronically<a name='more'></a> <p><strong><font size="2">EDI 837 Professional. Version 005010X222A1</font></strong></p> <font size="3"></font> <p><font size="3"><font size="2"><strong>Example 10: </strong>  Billing Laboratory Claims Electronically <br /> <br />When laboratory claims are billed electronically the Clinical Laboratory Improvement Act (CLIA) Number must be included in the claims. For reference laboratory claims, Modifier 90 is required as well.    <br /> The ANSI Implementation Guide requires the CLIA number on all laboratory claims billed to Medicare.</font> <br /> <br /><strong>Example: REF*X4*12D4567890 <br /></strong> <br /></font><font size="2">• The CLIA number is required on all laboratory claims billed to Medicare. <br />• The CLIA number is submitted in Loop 2300 (Claim Information) and/or Loop 2400 (Service Line Information). <br />• The CLIA number is submitted in a REF (Reference Identification) segment. <br />• The Reference Identification Qualifier must be submitted as X4. <br /> Note: <br /> For reference laboratory claims, two CLIA numbers must be submitted. The billing laboratory CLIA number must be submitted in a REF segment in the 2300 loop with an X4 qualifier and the reference laboratory CLIA number  <br /> (the CLIA number for the lab who performed the service) must be submitted in a REF segment in the 2400 loop with an F4 qualifier. The billing laboratory CLIA number must be different than the CLIA number of the reference laboratory since they are two separate entities. If these two numbers are the same, claims will be denied.</font></p> <p> <br />Here is an example of EDI 837 with referring and referring Laboratory claims. <br /> <br /></p> <p>ISA*00*          *00*          *ZZ*123123         *ZZ*241232         *210628*1045*^*00501*283181800*1*T*: <br /> GS*HC*123123*241232*20210628*1045*2831818*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*2831818*20210628*1045*CH <br /> NM1*41*2*ABC Submitter*****46*7342343 <br /> PER*IC*John Mike*TE*1214151617 <br /> NM1*40*2*Zirmed*****46*12345 <br />HL*1**20*1 <br /> PRV*BI*PXC*208500000X <br /> NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692 <br /> N3*3937  Kenwood Place <br /> N4*Orlando*FL*32801 <br /> REF*EI*81-3777631 <br /> HL*2*1*22*0 <br /> SBR*P*18*92291223*AED12342*****ZZ <br /> NM1*IL*1*BAKER*Alyssa****MI*723223232 <br /> N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St <br /> N4*HOUSTON*TX*77833 <br /> DMG*D8*20201204*M <br /> NM1*PR*2*CIGNA*****PI*81400 <br /> N3*PO BOX 660044 <br /> N4*DALLAS*TX*75266 <br /> CLM*10421*100.00***11:B:1*Y*A*Y*Y*P <br /><strong><font color="#ff0000">REF*X4*X562123232</font></strong> <br /> HI*ABK:R1013*ABF:E860 <br /> NM1*82*1*Nelson*Romer****XX*1023555349 <br /> NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059 <br /> N3*6100 W CREEK RD SUITE 35 <br /> N4*Independence*OH*44131 <br /> LX*1 <br />SV1*HC:U0003*60.00*UN*1.00***1 <br /> DTP*472*D8*20190517 <br /> REF*6R*111 <br /><strong><font color="#ff0000">REF*F4*X13412312</font></strong> <br /> SE*33*0001 <br /> GE*1*2831818 <br /> IEA*1*283181800 <br /> <br /> <br /><strong>HTML Version   <br /> <br /></strong> <br /></p> <p><span style="color: rgb(51, 102, 255);"><strong> Interchange Control Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Authorization Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Security Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Sender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Submitter ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">123123 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Receiver</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">241232 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/28/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">InterChange Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10:45</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Repetition Seperator </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">^</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">283181800</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Acknowledgement Requested</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Usage Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">T</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Functional Group Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Sender Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">123123</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Application Receiver Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">241232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/28/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10:45</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Control Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2831818</span></strong></td> </tr> <tr> <td style="width: 200.29px;">EDI Version </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">005010X222A1</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Transaction Set Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Transaction set </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">837</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Hierarchical Transaction</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Transaction Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2831818</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">06/28/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10:45</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Submitter Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Submitter Entity </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Organization</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Organization Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ABC Submitter</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">7342343</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">John Mike</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Phone </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1214151617</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Receiver Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Receiver Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Zirmed</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12345</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Billing Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Get Well Family Clinic LLC</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">3937 Kenwood Place</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Orlando</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">FL</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">32801</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1740713692</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Tax ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">81-3777631</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Taxonomy Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">208500000X</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Payer Responsbility</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Insured Relationship</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">18</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">92291223</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">AED12342</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Filling Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber Name</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">BAKER</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Alyssa</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DOB</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Gender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">M</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Policy No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">723223232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">197800 Atascocita Shores Dr</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">302 12 N. Mcgraw St</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">HOUSTON</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">TX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">77833</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Payer</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">CIGNA</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">PO BOX 660044</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">DALLAS</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">TX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">75266</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Payer ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">81400</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Claim Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Claim No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10421</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Billed Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">100.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Clia Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">X562123232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Sign Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Accept Assignment Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Benefits Assignment Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Release of information</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> ICD Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">ICD Code 1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">R1013</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Code 2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">E860</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Rendering Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Nelson</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Romer</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1023555349</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Facility</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Clinic For Pain And Anxiety </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6100 W CREEK RD SUITE 35</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Independence</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">OH</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">44131</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1396885059</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 1</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">111</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">U0003</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">60.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/17/2019</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/17/2019</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Referring Clia Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">X13412312</span></strong></td> </tr> </tbody></table> <p> <br /> <br /></p> <a href="file:///C:/Users/senthil/AppData/Local/Temp/OpenLiveWriter700344844/supfiles58A3D36/cms1500-2021-05-12-4-35-am-14.jpg"><font size="3"><strong>Looking for JSON to EDI solution ?</strong></font>    <h5></h5> </a> <h5><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" size="2">EDI RESTful Web Service API</font></a> <br /><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><font size="2">JSON To EDI 837 Professional</font></strong></a> <br /> <br /><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong></font> <br /><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</a>        </b></h5> <p><a href="http://emrpms.blogspot.com/2021/04/x12-edi-examples_24.html" target="_blank">X12 EDI Examples</a></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-70890903851342479872021-06-21T09:56:00.005+05:302021-06-22T06:18:27.883+05:30Difference between claims and encounters EDI 837 transactions<a name='more'></a> <ol> <li>Claims and encounters are created using the same EDI Transaction set 837.</li> <li>Claims are submitted to payer and request for payments for the service has been rendered by the provider</li> <li>Encounters are submitted to the payer for reporting purposes only.</li> <li>Encounter Services are reported under a capitated agreement in which payment is made outside of the delivery of the service as in a standard Fee For Service arrangement. The encounter is proof that the service was rendered by the provider.</li> <li>The EDI transaction sets such as the 837 Professional allows for the distinction of a claim and an encounter by indicating a "CH" (Chargeable) or "RP" (Reportable) in the sixth element of the BHT segment.</li> </ol> <p>Example :</p> <p><strong><font size="2">Claim Information <br /> BHT*0019*00*0001*20200219*0749*CH</font></strong></p> <strong><font size="2"></font></strong> <p><strong><font size="2">Encounters <br /> BHT*0019*00*0001*20200219*0749*RP <br /> <br />Interest to see the real world example, try our EDI Tool here</font></strong></p> <p><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><strong>https://demo.nagatabilling.com/NagataEDITool/login.zhtml</strong></a> <br /> <br /></p> <h3>JSON TO EDI 837p</h3> <div id="scid:0ABB7CC8-30EB-4F34-8080-22DA77ED20C3:899076bf-e258-4139-9a6e-72369882e569" class="wlWriterEditableSmartContent" style="margin: 0px; padding: 0px; float: none; display: inline;"><div><iframe src="http://www.youtube.com/embed/SiMpGQ_Tvhg" width="425" height="239" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe></div></div> <p>For Medical Billing software or Medical Billing software consultation,  <br />please contact <a>vbsenthilinnet@gmail.com</a></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-65008118969920744242021-06-19T11:14:00.004+05:302021-06-19T11:57:23.612+05:30Understanding EDI 835 Health Care Claim Payment/Advice Transaction<a name='more'></a> <p>The EDI 835 transaction set is most commonly used by healthcare insurance plans to make payments to providers or provide Explanations of Benefits (EOB’s), or both. The EDI 835 File also referred as era files in the industry.</p> <p>EDI 835 ERA file may contain one or checks information in one single file. This business scenario is very normal in the EDI Transactions</p> <p> <br />Following steps will help to identify whether ERA File contains information about one check or multiple check payment.</p> <p>1. Download <a href="https://notepad-plus-plus.org/downloads/" target="_blank"><font color="#0000ff">Notepad ++</font></a> <br />2. Open the ERA File in the notepad++. <br />3. If the file content are already shown as line by line, then skip the next step. <br />4. If the entire file content are shown in single line, then this <a href="http://emrpms.blogspot.com/2013/12/how-to-read-and-understand-edi-file.html" target="_blank"><font color="#0000ff"><strong>link</strong></font></a> will help you to break into lines <br />5. Search for Text <strong>BPR</strong>. Each BPR is a check and information next to BPR contains the payment information.</p> <p> <br />Sample EDI 835 File with more than one BPR Information</p> <p>ISA*00*          *00*          *01*030240928      *ZZ*XXXXX     *210618*0331*U*00401*143809974*0*P*:~ <br /> GS*HP*XXXX*XXXXX*20210618*0331*1*X*004010X091A1~ <br /> ST*835*1001~ <br /><strong><font color="#0000ff">BPR*I*-8.4*C*CHK************XXXXX~</font></strong> <br /> TRN*1*XXXX*XXXXX*800967178~ <br /> DTM*405*20210617~ <br /> N1*PR*XXXXX XXXXXXXX XXXX XXXXX XXXXX XXXXX~ <br /> N3*XXXX E XXXXXX ST~ <br /> N4*XXXXX*IL*1234~ <br /> REF*2U*36396~ <br /> N1*PE*XXXX XXXXX CLINIC*FI*XXXXXX~ <br /> N3*XXXX XXX XXX XXX XX*XXX 251~ <br /> N4*XXXXX*IL*1234~ <br /> LX*1~ <br /> CLP*XXXXXX*22*-35*-8.4**15*XXXXX*23*8~ <br /> NM1*QC*1*XXXXX*XXXXXX*D***MI*XXXXX~ <br /> NM1*82*1*XXXXX*XXXX****XX*XXXXXXX~ <br /> REF*1L*494830~ <br /> AMT*AU*-8.4~ <br /> SVC*HC:93010*-35*-8.4**1~ <br /> DTM*472*20210303~ <br /> CAS*CO*45*-26.6~ <br /> AMT*B6*-8.4~ <br /> SE*22*1001~ <br /> ST*835*1002~ <br /><strong><font color="#0000ff">BPR*H*0*C*NON************20210616~</font></strong> <br /> TRN*1*20210617093730919*1800967178*800967178~ <br /> DTM*405*20210617~ <br /> N1*PR*XXXX XXXXX XXXX XXXXX XXXXX XXXXX~ <br /> N3*630 XXXX XXXXX ST~ <br /> N4*XXXX*IL*1234~ <br /> REF*2U*36396~ <br /> N1*PE*XXXXX XXXXX XXXXX*XX*XXXXX~ <br /> N3*xxxxxS xxxxxx xxxxxx xxxxxx*xxxxx251~ <br /> N4*XXXXX*IL*1232~ <br /> REF*TJ*23423434~ <br /> LX*1~ <br /> CLP*XXXXX*4*44*0**15*XXXX*11*1~ <br /> NM1*QC*1*XXXX*XXX****MI*XXXX   02~ <br /> NM1*IL*1*XXXX*XXX****MI*XXXXX~ <br /> NM1*82*1*XXXX*XXX****XX*XXXXX~ <br /> REF*1L*494411~ <br /> SVC*HC:0012A*44*0**1~ <br /> DTM*472*20210426~ <br /> CAS*CO*B11*44~ <br /> SE*22*1002~ <br /> ST*835*1003~ <br /><strong><font color="#0000ff">BPR*I*8.4*C*CHK************123213~</font></strong> <br /> TRN*1*2121467*33333*2123232~ <br /> DTM*405*20210617~ <br /> N1*PR*XXXX XXX XXX XXXX XXXX XXXX~ <br /> N3*630 XXX XXXX XXX~ <br /> N4*XXXXX*IL*1234~ <br /> REF*2U*36396~ <br /> N1*PE*XXXXX XXXXX XXXX*FI*XXXXXX~ <br /> N3*3333 XXXX XXX XXXX XXX*3333 XXXX~ <br /> N4*XXXXX*IL*1234~ <br /> LX*1~ <br /> CLP*ADFDFDFDF*1*35*8.4**15*3333333*23*1~ <br /> NM1*QC*1*XXXX*XXXX*D***MI*XXXXXXXX~ <br /> NM1*82*1*XXXXX*XXXX****XX*XXXXX~ <br /> REF*1L*494830~ <br /> AMT*AU*8.4~ <br /> SVC*HC:93010*35*8.4**1~ <br /> DTM*472*20210303~ <br /> CAS*CO*45*26.6~ <br /> AMT*B6*8.4~ <br /> SE*22*1003~ <br /> GE*3*1~ <br /> IEA*1*143809974~ <br /></p> <p> </p> <p>Interest to see the real world example, try our EDI Tool here</p> <p><a title="https://demo.nagatabilling.com/NagataEDITool/login.zhtml" href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml"><font color="#0000ff"><strong>https://demo.nagatabilling.com/NagataEDITool/login.zhtml</strong></font></a></p> <p> <br /> <div id="scid:0ABB7CC8-30EB-4F34-8080-22DA77ED20C3:d730faf7-05e9-4c99-ab7c-fdcea62a0395" class="wlWriterEditableSmartContent" style="margin: 0px; padding: 0px; float: none; display: inline;"><div><iframe src="http://www.youtube.com/embed/C2xBOTSwhnM" width="425" height="239" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe></div></div> </p> <p><font size="4">For Medical Billing software or Medical Billing software consultation,  <br />please contact </font><a><font size="4">vbsenthilinnet@gmail.com</font></a></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.comtag:blogger.com,1999:blog-2584531158137338419.post-90492702842572695262021-05-25T10:06:00.000+05:302021-07-19T08:59:54.535+05:30X12 EDI 837 Examples with Facility secondary Identification<a name='more'></a> <p><strong><font size="2">EDI 837 Professional. Version 005010X222A1</font></strong></p> <font size="3"></font> <p><font size="3"><strong><font size="2">Example 9: </font></strong>  Facility Secondary Identification</font></p> <p><font size="3">Here is an example of EDI 837 with Facility secondary ID numbers such as State license Number,Commercial G2 Number, etc</font></p> <p><font size="3"> <br /></font></p> <p>ISA*00*          *00*          *ZZ*123123         *ZZ*241232         *210525*1010*^*00501*251094700*1*T*: <br /> GS*HC*123123*241232*20210525*1010*2510947*X*005010X222A1 <br /> ST*837*0001*005010X222A1 <br /> BHT*0019*00*0001*20210525*1010*CH <br /> NM1*41*2*ABC Submitter*****46*7342343 <br /> PER*IC*John Mike*TE*1214151617 <br /> NM1*40*2*Zirmed*****46*12345 <br /> HL*1**20*1 <br /> PRV*BI*PXC*208500000X <br />NM1*85*2*Get Well Family Clinic LLC*****XX*1740713692 <br /> N3*3937  Kenwood Place <br /> N4*Orlando*FL*32801 <br /> REF*EI*81-3777631 <br /> HL*2*1*22*0 <br /> SBR*P*18*92291223*AED12342*****ZZ <br /> NM1*IL*1*BAKER*Alyssa****MI*723223232 <br /> N3*197800 Atascocita Shores Dr*302 12 N. Mcgraw St <br /> N4*HOUSTON*TX*77833 <br /> DMG*D8*20201204*M <br /> NM1*PR*2*CIGNA*****PI*81400 <br /> N3*PO BOX 660044 <br /> N4*DALLAS*TX*75266 <br /> CLM*10421*100.00***11:B:1*Y*A*Y*Y*P <br /> HI*ABK:R1013*ABF:E860 <br /> NM1*82*1*Nelson*Romer****XX*1023555349 <br /> NM1*77*2*Clinic For Pain And Anxiety *****XX*1396885059 <br /> N3*6100 W CREEK RD SUITE 35 <br /> N4*Independence*OH*44131 <br /><font color="#ff0000"><strong>REF*OB*434134124 <br /> REF*G2*D413DS3SD3</strong></font> <br /> LX*1 <br /> SV1*HC:99213*50.00*UN*1.00***1:2 <br /> DTP*472*D8*20201204 <br /> REF*6R*6001 <br /> LX*2 <br /> SV1*HC:87070*50.00*UN*1.00***1:2 <br /> DTP*472*D8*20201204 <br />REF*6R*6002 <br /> SE*37*0001 <br /> GE*1*2510947 <br /> IEA*1*251094700</p> <p><font size="3"> <br /><strong>HTML Version   </strong>   <font size="3">  </font></font></p> <font size="3"> <p> </p> </font> <p><span style="color: rgb(51, 102, 255);"><strong> Interchange Control Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Authorization Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Security Qualifier</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Sender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Submitter ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">123123 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange ID Qualifier Receiver</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">241232 </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Interchange Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/25/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">InterChange Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10:10</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Repetition Seperator </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">^</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">251094700</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Acknowledgement Requested</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Usage Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">T</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Functional Group Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Sender Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">123123</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Application Receiver Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">241232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/25/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10:10</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Control Number </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2510947</span></strong></td> </tr> <tr> <td style="width: 200.29px;">EDI Version </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">005010X222A1</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Transaction Set Header</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Transaction set </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">837</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Control Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Hierarchical Transaction</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Application Transaction Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">0001</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Date </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">05/25/2021</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Transaction Time (HHMM) </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10:10</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Submitter Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Submitter Entity </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Organization</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Organization Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ABC Submitter</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">7342343</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Name </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">John Mike</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Contact Phone </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1214151617</span></strong></td> </tr> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <p><span style="color: rgb(51, 102, 255);"><strong> Receiver Information</strong></span> </p> </tbody></table> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Receiver Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Zirmed</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Receiver Etin Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12345</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Billing Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Get Well Family Clinic LLC</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">3937 Kenwood Place</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Orlando</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">FL</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">32801</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1740713692</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Tax ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">81-3777631</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Taxonomy Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">208500000X</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Payer Responsbility</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">P</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Insured Relationship</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">18</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Number</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">92291223</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Group Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">AED12342</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Filling Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">ZZ</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Subscriber Name</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">BAKER</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Alyssa</span></strong></td> </tr> <tr> <td style="width: 200.29px;">DOB</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Gender</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">M</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Policy No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">723223232</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">197800 Atascocita Shores Dr</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">302 12 N. Mcgraw St</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">HOUSTON</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">TX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">77833</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Payer</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">CIGNA</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">PO BOX 660044</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">DALLAS</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">TX</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">75266</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Payer ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">81400</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Claim Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Claim No</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">10421</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Billed Amount</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">100.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Claim Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Sign Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Accept Assignment Code</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">A</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Benefits Assignment Indicator</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Release of information</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Y</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> ICD Information</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">ICD Code 1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">R1013</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Code 2</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">E860</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Rendering Provider</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Entity Type</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Last or Organization Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Nelson</span></strong></td> </tr> <tr> <td style="width: 200.29px;">First Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Romer</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1023555349</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Facility</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Name</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Clinic For Pain And Anxiety </span></strong></td> </tr> <tr> <td style="width: 200.29px;">Address1</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6100 W CREEK RD SUITE 35</span></strong></td> </tr> <tr> <td style="width: 200.29px;">City</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">Independence</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">OH</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Zip</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">44131</span></strong></td> </tr> <tr> <td style="width: 200.29px;">NPI</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1396885059</span></strong></td> </tr> <tr> <td style="width: 200.29px;">State License Number (0B)</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">434134124</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Provider Commercial Number (G2)</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">D413DS3SD3</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 1</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6001</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">99213</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">50.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1,2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> </tbody></table> <p><span style="color: rgb(51, 102, 255);"><strong> Line Item : 2</strong></span></p> <table style="width: 565px;" cellspacing="4" cellpadding="4" border="2"><tbody> <tr> <td style="width: 200.29px;">Line Item ID</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">6002</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Procedure Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">87070</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units Code </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">UN</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Units </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Charges </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">50.00</span></strong></td> </tr> <tr> <td style="width: 200.29px;">ICD Pointers </td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">1,2</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service From Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> <tr> <td style="width: 200.29px;">Service To Date</td> <td style="width: 364.7px;"><strong><span style="color: rgb(0, 0, 255);">12/04/2020</span></strong></td> </tr> </tbody></table> <p> <br /> <br /><strong>1500 Form Preview for the above EDI File</strong> <br /><a href="https://drive.google.com/uc?id=1vjw7JRdDLKdh-2zuMCYfjG7sK6FUKkjy"><img title="cms1500-2021-05-25-10-29-am-1" style="border: 0px currentcolor; display: inline; background-image: none;" border="0" alt="cms1500-2021-05-25-10-29-am-1" src="https://drive.google.com/uc?id=1jOQeS5SXXgEhaKDdZvgDFTmPTIH__-vi" width="466" height="658" /></a> </p> <p> </p> <a href="file:///C:/Users/senthil/AppData/Local/Temp/OpenLiveWriter700344844/supfiles58A3D36/cms1500-2021-05-12-4-35-am-14.jpg"><font size="3"><strong>Looking for JSON to EDI solution ?</strong></font>    <h5></h5> </a> <h5><a href="http://emrpms.blogspot.com/2020/04/edi-restful-web-service-api.html" target="_blank"><font style="font-weight: bold;" size="2">EDI RESTful Web Service API</font></a> <br /><a href="https://www.youtube.com/watch?v=LiAnO1w4kfQ" target="_blank"><strong><font size="2">JSON To EDI 837 Professional</font></strong></a> <br /> <br /><font size="3"><strong>Looking for more examples ? Login into our EDI Tool </strong></font> <br /><b><a href="https://demo.nagatabilling.com/NagataEDITool/login.zhtml">https://demo.nagatabilling.com/NagataEDITool/login.zhtml</a>        </b></h5> <p><a href="http://emrpms.blogspot.com/2021/04/x12-edi-examples_24.html" target="_blank">X12 EDI Examples</a></p>Senthil Muthiahhttp://www.blogger.com/profile/00658517416141667025noreply@blogger.com