X12 EDI Examples

EDI 837 Professional. Version 005010X222A1

Example 1: Outpatient Visit
Example 2: Claim level Attachment (PWK) Example. 
Example 3: Claim with Referring Provider example.  
Example 4: Claim with Pay to Address example.   
Example 5: Claim for Ambulance service. 
Example 6: Claim with Prior Authorization Number. 
Example 7: Claim with Payer Claim Number. 
Example 8: Billing Provider Secondary identification. 
Example 9: Facility with Secondary identification.                     
Example 10: Billing Laboratory Claims Electronically
Example 11: Payer with secondary identification
Example 12: Billing Provider Complete information
Example 13: Patient is a different person than the Subscriber
Example 14:  K3 File Information                                                      
Example 15 : Claim Note NTE Segment
Example 16 : Billing for Physician Administered Drugs and NDC Reporting

EDI 837 Dental . Version 005010X224A2

Example 1: Orthodontic-treatment-plan
Example 2: One Claim with 12 Procedure Codes
               
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Attach supporting document with initial Claim

X12 EDI Examples

Medical Claim Life Cycle

ASC X12 270: Eligibility, Coverage, or Benefit Inquiry.

Difference between 277CA and 277

 

EDI 277 generated by the Payer whereas EDI 277CA generated by clearing house or payer or both.  EDI 277CA will be generated as soon as EDI 837 File is passed whereas  EDI 277 will be generated only upon request by EDI 276 transaction.

EDI 277CA will provide a claim level acknowledgement such as your claim is accepted or rejected.  But it does not guarantee that payment will be made.If accepted, an payer claim number will be generated and the same claim will pass to next level of process in the payer system called adjudication system. EDI 277 will be generated only if the claim is accepted and having an payer claim number.  If the claim is rejected at the 277CA level itself, then we cannot check the claim status because that claim is not in the payer adjudication system.

Today, many insurance companies respond to claims using their own report formats and/or electronic transaction formats. The ASC X12 277CA offers a common interface to the insurance company and the provider, thus standardizing the response. Because a claim may progress through several different statuses before reaching a final processing disposition, a provider may receive multiple ASC X12 277CA transactions for a single claim.

Sample EDI 277CA

ISA*00*          *00*          *ZZ*XXXXXXX        *ZZ*9085           *210301*1322*%*00501*000000000*0*P*:
GS*HN*XXXXXXX*9085*20210301*132234*1*X*005010X214
ST*277*0001*005010X214
BHT*0085*08*0001*20210301*132234*TH
HL*1**20*1
NM1*AY*2*XXXXX.XXXXXX*****46*XXXXX
TRN*1*000000001
DTP*050*D8*20210301
DTP*009*D8*20210301
HL*2*1*21*1
NM1*41*2*XXXXXX XXXXX LLC-TEST ACCOUNT*****46*9085
TRN*2*0001
STC*A1:19*20210301*WQ*120
HL*3*2*19*1
NM1*85*2*DEMO CLINIC*****XX*1215099528
TRN*1*0
HL*4*3*PT
NM1*QC*1*XXXXX*XXXXX****MI*XYZ312322
TRN*2*124309
STC*A7:21*20210301*U*120********Rendering NPI Fails LUHN check.
DTP*472*D8*20190604
SE*20*0001
GE*1*1
IEA*1*000000000

 

Map claim information between EDI 837 and EDI 835

EDI 5010 Documentation 837 Professional - Loop 2300 Date information

 

Payer Claim Number aka Internal Control Number (ICN) or Claim Control Number (CCN)

Payer Claim Number (ICN/CCN) – Understanding Its Importance in Claim Processing

A Payer Claim Number, also known as an Internal Control Number (ICN), Claim Control Number (CCN), or Document Control Number (DCN), is a unique identifier assigned by a payer to track a claim within their internal system.

Significance of the Payer Claim Number in Claim Processing

To fully understand the role of this number, let’s go through the typical claim processing workflow:

1. Healthcare entities such as provider offices, facilities, hospitals, and laboratories generate claims for patients and submit them to payers via Electronic Data Interchange (EDI) or paper claims (CMS-1500 form).
2. Upon receipt, the payer validates the claim, performs necessary error checks, and enters the claim into their internal processing system. At this stage, a unique claim number is generated for future reference.
3. The payer then determines their financial responsibility through a process known as claims adjudication. The claim may be approved for full payment, partially paid, or denied based on coverage and policy rules.
4. An Explanation of Benefits (EOB) is then issued to the provider, detailing the payment decision and any applicable denial reason codes. The payer includes the Payer Claim Number in both the EOB (paper format) and the Electronic Remittance Advice (EDI 835).

Why Is the Payer Claim Number Essential for Claim Resubmissions?

When a claim is denied, the healthcare provider must correct and resubmit it for reconsideration. In this process, the inclusion of the original Payer Claim Number—as provided in the EOB or EDI 835—is mandatory.

This number allows the payer’s system to quickly recognize that the claim is a resubmission rather than a new claim, facilitating efficient processing. Most payers will not accept resubmissions that do not reference the original Payer Claim Number.

For detailed submission guidelines, refer to specific payer instructions such as the BlueCross BlueShield resubmission policy, which mandates the inclusion of the Payer Claim Number.

How to Retrieve the Payer Claim Number from an ERA 835 File

The Payer Claim Number can be located in the CLP segment of the ERA 835 file at the 7th position. Below is an example:

TS3*003448478501*12*20201231*2*96
CLP*143155*19*48*0**HM*20C783340200*12*1
NM1*QC*1*XXXXX*XXXXX M*M***MI*521106302

In this case, 20C783340200 is the Payer Claim Number.

Best Practices for Recording the Payer Claim Number in PMS Software

Most Practice Management Software (PMS) solutions include a designated field for entering the Payer Claim Number during manual payment posting. However, payment posters often overlook this field, leading to inefficiencies in claim tracking.

To ensure accuracy:

• Train payment posting teams on the importance of capturing this number.
• Implement a system validation that requires entry of the Payer Claim Number when processing denied claims.
• For claims with zero payments, enforce the entry of both denial codes and the Payer Claim Number before finalizing the posting.

Including the Payer Claim Number in EDI 837P Resubmissions

When resubmitting a claim via EDI 837P, the Payer Claim Number must be inserted in Loop 2300 REF Segment. Below is a sample format:

CLM*214170*64.00***12:B:7*Y*A*Y*Y
REF*F8*185274314700919

Here, REF*F8*185274314700919 references the original Payer Claim Number within the EDI 837P file.

Conclusion

By ensuring that the Payer Claim Number is accurately recorded and referenced during claim resubmissions, healthcare providers can significantly improve the efficiency of their claim processing and reduce unnecessary denials. Compliance with payer-specific guidelines is key to seamless reimbursement.

Parse EDI 835 Message into JSON

Claim Forward to Other Payer

Understanding X12 EDI Structure

Understanding EDI Structure

Introduction

Before diving into the EDI (Electronic Data Interchange) structure, let's first understand how data is typically structured in a book or a Word document.

Structure of a Page

• Word: A single unit of language separated by space.
• Sentence: A group of words forming a meaningful statement.
• Paragraph: A collection of sentences expressing a complete idea.

Example of Address Representation

Subscriber Information

Carrie J. Brown, DOB 01/13/1953, Male
3360 Lynn Street
Woburn, MA 01801

Company Information

Healthservices LLC, Tax ID: xx1234512
2550 Adamsville Road
Harlingen, TX 78550

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Page vs. EDI Structure

Traditional Document	EDI Structure
Words are separated by spaces	Elements are separated by a delimiter (usually *)
Sentences are separated by lines	Segments are separated by a terminator (usually ~)
Paragraphs are separated by line breaks	Loops do not have defined separators

---

Converting Data to EDI Format

Using EDI formatting, the above address example is converted into:

Carrie*J*Brown*01/13/1953*Male~
3360*Lynn Street~
Woburn*MA*01801~

Healthservices LLC*xx1234512~
2550*Adamsville Road~
Harlingen*TX*78550~

Note: In real-world EDI, this appears as:

Carrie*J*Brown*01/13/1953*Male~3360*Lynn Street~Woburn*MA*01801~Healthservices LLC*xx1234512~2550*Adamsville Road~Harlingen*TX*78550~

---

How Computers Process EDI Data

Computers do not inherently understand the meaning of raw EDI data. To structure it properly, we use:

1. Segment Name - Identifies the type of data.
2. Type Qualifier (Optional) - Specifies what the segment represents.

Rewriting the Example with Proper EDI Segments

NM1*IL*Carrie*J*Brown*01/13/1953*Male~
N3*3360*Lynn Street~
N4*Woburn*MA*01801~

NM1*85*Healthservices LLC*xx1234512~
N3*2550*Adamsville Road~
N4*Harlingen*TX*78550~

Key Points

• ✅ Each segment starts with a segment name (e.g., NM1, N3, N4).
• ✅ Type qualifiers (e.g., IL, 85) differentiate data types.
• ✅ Address segments (N3, N4) do not require a type qualifier.

---

Additional Notes on EDI Messages

• If you need to send a number (NPI, Tax ID, SSN), it must be prefixed with an identifier.

NM1*85*2*Demo Clinic*XX*1215099528

Since segments are groups of elements, some elements may be optional.

• With a middle name:

NM1*IL*Carrie*J*Brown

• Without a middle name:

NM1*IL*Carrie**Brown

---

Conclusion

EDI structures transform unstructured text into computer-readable formats. By using segments, delimiters, and type qualifiers, we create a standardized way to exchange data efficiently.

Before Jumping to EDI Structure, let us understand what is a Page in a book or word document?

Structure of the Page

Word	A word is a single unit of language that can be represented in writing or speech and each word is separated by space.
Sentence	A combination of a group of words that gives a complete meaning and each sentence separated by a line
Paragraph	A combination of a group of sentences that gives a complete meaning

Let us see an example of two addresses using the above structure. Assume that we need a subscriber(insurer) address and Company address in the document.

Let us name the below paragraph as Paragraph 1 and contains Subscriber information.
Carrie J. Brown, DOB 01/13/1953, Male
3360 Lynn Street
Woburn, MA 01801
Let us name the above paragraph as Paragraph 2 and contains Company information with a tax id.
Healthservices LLC, Tax ID: xx1234512
2550 Adamsville Road
Harlingen, TX 78550
 Page Vs EDI

Page in a Book	Message in an EDI
Word	Elements
Sentence	Segments
Paragraph	Loop

Separators

Page in a Book	Message in an EDI
Words are separated by space	Elements as separated by a delimiter. Any Character can be a delimiter, but most used is Asterisk *
Sentence are separated by Line	Segments as separated by the terminator. Any character can be terminator, but most used is ~
Paragraph are separated by one or more lines	There are no separators for Loop

Let us rewrite our examples in EDI Structure.

Carrie*J*Brown*01/13/1953*Male~
3360*Lynn Street~
Woburn*MA*01801~

Healthservices LLC*xx1234512~
2550*Adamsville Road~
Harlingen*TX*78550~

Just for better understanding, the above information is separated with a newline character, but in real-time, it will look as follows

Carrie*J*Brown*01/13/1953*Male~3360*Lynn Street~Woburn*MA*01801~Healthservices LLC*xx1234512~2550*Adamsville Road~Harlingen*TX*78550~

Now let us get into more detail by looking at the above message. There are some issues for the computer to understand as follows.
1) Very first, the computer does not know what we are talking about, but we know that the above is two address representations where one is for the subscriber and one is for the company.
2) So, it is time to give information in a more structured way to the computer about this data.


X12 EDI expects before you start giving information, it needs a segment Name and segment type. Whenever we need to provide information about an entity or person, then the segment name is NM1. Second, we need to inform what is that entity or person, are its Patient details or is it Company Name, etc. That is called type qualifier, for example, for the subscriber, the type qualifier is IL and for Company, the type qualifier is 85, etc

Segments should start with Segment Name, optionally there should be segment type or type qualifier.

Let us rewrite our examples in EDI Structure

NM1*IL*Carrie*J*Brown*01/13/1953*Male~
N3*3360*Lynn Street~
N4*Woburn*MA*01801~

NM1*85*Healthservices LLC*xx1234512~
N3*2550*Adamsville Road~
N4*Harlingen*TX*78550~

As you can see, every segment starts with segment names such as NM1, N3, N4, etc and optionally it also contains type in the second position. An important point to note that is, for address segments, there is no need to provide type.
Other important notes on EDI Message
1) If you want to send any number such as NPI or tax ID or SSN, then before that number we need to tell what that number is. For example, the provider contains NPI number, so before we put the actual NPI number, it should be prefixed by XX as follows1) If you want to send any number such as NPI or tax ID or SSN, then before that number we need to tell what that number is. For example, provider contains NPI number, so before we put the actual NPI number, it should be prefixed by XX as followsNM1*85*2*Demo Clinic*XX*1215099528

JSON to EDI 270 Eligibility and Benefit Inquiry

Summarize all table row-counts in a single query

Provider Identifiers

When we send claims to the insurance companies, it is very important to give the different provider numbers or identifiers for processing the claim. Let us understand different provider numbers.

DEA (Drug Enforcement Administration) Number

This is a unique number that is issued to every provider that prescribes any type of controlled medication.

What is Controlled Medication

Most prescriptions for infections or for chronic conditions are non-controlled. For example, most blood pressure and cholesterol medications, diabetes medications, asthma inhalers, and antibiotics are all non-controlled medications.

Controlled substances are medications that can cause physical and mental dependence, and have restrictions on how they can be filled and refilled. They are regulated and classified by the DEA (Drug Enforcement Administration) based on how likely they are to cause dependence. Some examples of controlled prescription drugs include :Morphine,Oxycodone,etc

EDI 837 Professional Loops

EDI RESTful Web Service API

Are you looking for RESTful Web Service API to generate HIPAA X12 EDI Transactions? Then here is the solution offered. Please contact me for more details

Create an account in our Nagata EDI Tool and check  HIPAA X12 EDI Transactions sets.
Here is the demo link
https://demo.nagatabilling.com/NagataEDITool/login.zhtml 

1. JSON to EDI 270 Eligibility and Benefit Inquiry
2. Create EDI 270 from JSON
   
3. Parse EDI 271 Message to Human Readable Text
4. Parse EDI 277 Message to HTML
5. JSON to EDI 837 Professional Claims
6. Parse EDI 837p Message into JSON
7. Parse EDI 835 Message into JSON   
8. Parse EDI 835 Message to PDF
9. JSON to cms 1500 Form
10. Parse EDI 837p To HTML
11. JSON To EDI 837 Institutional
12. Parse EDI 837I to JSON
13. Parse EDI 837 Institutional To HTML
14. Create CMS 1500 Form using JSON
15. Parse EDI 837p to CMS 1500 Form
    
    
    

 

 

 

 

 

 

ASC X12 270: Eligibility, Coverage, or Benefit Inquiry.
This transaction allows providers to check whether a patient has insurance coverage as of a specified date. This transaction is typically sent by healthcare service providers, such as hospitals or medical facilities, and sent to insurance companies, government agencies like Medicare or Medicaid, or other organizations that would have information about a given policy. 

Minimum information such as Member Name, Date of birth and gender or subscriber ID is required to submit in the 270 message to get the response. If we are doing real time mode, then the expected response time will be  1 to 2 seconds.

Sample Workflow

1. Provider Smith uses ABC Billing Software aka Practice Management Software(PMS).
2. Provider Smith already signed up with XYZ Clearing House and an ID has been assigned to Provider Smith by the clearinghouse.
3. ABC Billing software has the option of generating EDI 270 messages and through web service call, it will send the message to the clearinghouse.
4. XYZ receives a message within a few seconds and then identifies the message for Payer Cigna. Since XYZ already enrolled with Payer Cigna, so it just forwards the message to Payer Cigna via web service.
5. Payer Cigna receives the message and prepares response 271 and sends it back to the clearinghouse. Immediately clearing house forward the response to the Provider Smith’s ABC billing software.
6. ABC Billing software parse the EDI 271 Message into Human-readable text and show it to the user.

 Download sample EDI 270
 Download Sample EDI 271
 Parse EDI 271 To HTML
 Parse EDI 271 To Text
 Parse EDI 271 To JSON

Parse EDI 837p Message into JSON

EDI 837 P Budget Number Example

Hire me

You can hire me for any of the following

1. Training on X12 EDI Transactions to support your current job.
   
   
2. If you already developed EMR and planning to add Billing Component as an integrated solution, then you can hire me to help your team both functionally and technically. 
   
   
3. You already have an inhouse development team and want to work with your team to enable all the EDI transactions, then you can hire me to support both Technical and Functional areas.
   
   
4. You already having an inhouse development team and looking for Restful Webservice API to generate X12 EDI transactions, then you can hire me to deliver the source code for the same. I've developed Restful Webservice API using Latest spring Boot version for all the Healthcare EDI transactions EDI RESTful Web Service API
   
   1. JSON to EDI 270 Eligibility and Benefit Inquiry
   2. JSON to EDI 837 Professional Claims
   3. Parse EDI 837p Message into JSON
   4. Parse EDI 835 Message into JSON

5. If you are having an RCM Billing company and if you would like to automate some of your routine billing works, then you can hire me to develop/design/help for the software. I’ve 5 years of experience as RCM Manager.3 If you are developing or planning to develop EMR/EHR/Medical Billing Application/Practice Management System, you can hire me as a subject matter expert for both Technical and functional areas. I can help to develop the application from scratch To end go-live mode. This arrangement involves the following responsibility

• Database Design (MySQL or SQL Server)
• UI Design Ideas
• Java Spring Boot web API Source code
• Reporting
• Dashboards

Parse EDI 271 Health Care Eligibility Benefit Response

Medical Billing Terminology

Mysql Query for Aging To Count No of records

JSON to EDI 837 P

 

 

Are you looking for creating X12 EDI 837p using JSON Format? Here is the solution offer. Please contact me at vbsenthilinnet@gmail.com for more details.

Sample Webservice Call

Internal Tool demo to Test the Webservice call

Are you looking for a solution to generate 837P or 837I in your medical billing product? Then you are in the right place.

I am Senthil Muthiah, A technology-driven professional with over 20 years of experience including nearly 9 years in Software Development and Business Analysis.  Well versed with US Healthcare Domain – Electronic Medical Record (EMR) & Medical Billing. In particular, 15 years of experience in the Healthcare domain specifically in Claim processing, Claims adjudication, clearing house-related processes.

Consultation Option

1. if your product is in java, then we are very close. You can buy my java Spring Boot API Service source code which converts JSON to EDI and vice versa.

1. JSON to EDI 270 Eligibility and Benefit Inquiry
2. Create EDI 270 from JSON
   
3. Parse EDI 271 Message to Human Readable Text
4. JSON to EDI 837 Professional Claims
5. Parse EDI 837p Message into JSON
6. Parse EDI 835 Message into JSON   
7. Parse EDI 835 Message to PDF
8. JSON to cms 1500 Form
9. Parse EDI 837p To HTML
10. JSON To EDI 837 Institutional
11. Parse EDI 837I to JSON
12. Parse EDI 837 Institutional To HTML
13. Create CMS 1500 Form using JSON
14. Parse EDI 837p to CMS 1500 Form

Here is the demo link
https://demo.nagatabilling.com/NagataEDITool/login.zhtml 

2. if your product in different technology, then I will help your developer to create an EDI file using Pseudo.  Here is a sample Pseudocode 

 For more detailed resume and skills, please refer to the following link

·       Online Resume

·       Linked Profile

My Email ID :  vbsenthilinnet@gmail.com
Mobile : (91)  95351 609 48  (India)

CSS Classes and Styles

Sample UI Design Part 1 : ZK Version 8.5

Sample Screens for Training to Create UI in ZK

Passing Parameter between two files using MVVM

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This examples shows how to pass parameter between two zul screens. In this example, we are passing some parameters from the parent vm to child VM and child VM returns back some information.

ZK 8.5 Component Reference Grid Part 1

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ZK 8.5 Component Reference Textbox Part 2

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ZK 8.5 Component Reference Textbox Part 1

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ZK 8.5 Component Reference Layout - vlayout and hlayout

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ZK 8.5 Component Reference Window - Part 2

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ZK 8.5 Component Reference Window - Part 1

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Create and Run your First ZK 8.5 Application with Eclipse and Maven

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Practice Management software (Medical Billing system)

Practice Management software (Medical Billing system) As a developer, i have written PMS software on different computer Languages for more than 5 times. In the year 2003, started writing coding for Practice management System in Microsoft Visual Basic 6, and then Microsoft access for small providers, and then move to VB.Net and now in 2015, written  a complete Practice Management system, purely using Java and other Open source technologies to achieve the same result in WEB. In 2012,  again I was involved in developing an independent system for PMS using VB6 with SQL server 2005. I really enjoyed myself and love to work/complete that project. One of my best period in my life. But unfortunately,  we could not able to market the product because of VB6 no longer used widely in the industry.

Here are some video demos and screen shots of the PMS software

Video Demo

1. Master Screens

2. Patient Demographics


3. Charge Entry


4. Submit Electronic Claims


5. Reports


Screen shots
1. Practice Management System (PMS) Sample screens Part 1
2. Practice Management System(PMS) Sample Screens Part 2
3. Patient demographics and Patient case screens
4. Charge Entry screen design

Difference Between 837 Institutional and 837 Professional

837 Professional

Professional billing is responsible for the billing of claims generated for work performed by physicians, suppliers and other non-institutional providers for both outpatient and inpatient services. Professional charges are billed on a CMS-1500 form. The electronic version of the CMS-1500 is called the 837-P, the P standing for the professional format.

837 Institutional
Institutional billing is responsible for the billing of claims generated for work performed by hospitals and skilled nursing facilities. Institutional charges are billed on a UB-04.
And also Hospital Billing uses Revenue Codes.

Revenue Codes

Revenue codes are 3-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient. A medical claim will not be paid if this is missing from a bill.

Revenue codes go along with procedure codes. When putting them in a charge master, you would add the correct revenue code to the CPT code you were going to use for a particular department. It's the use of revenue codes which allows hospitals to use the same CPT code in multiple departments because it will show which department the services were provided in.

An easy example to use here would be to match up CPT code 99282, which is for an emergency room visit of low to moderate severity, and revenue code 450, which stands for emergency room. In this case, revenue code 450 is the only code that could be used for this CPT code, thus making this one easy to code.

In short, Revenue Codes are descriptions and dollar amounts charged for hospital services provided to a patient.  The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department.For example, stitches may be given to a patient in the emergency room, or in a completely different area of the hospital like the maternity ward.

837 Specification

Both sets of 837 specifications are same. The only differences would be claim specific data that pertains to a single transaction. All three transactions contain ISA, GS and ST segments but some data and qualifying codes are specific to the type of 837. Another way to quickly identify which type of 837 is being encountered is by the codes sent in the GS-08 or in the ST-03. Professionals use a 005010X222, Institutional uses a 005010X223 and Dental uses a 005010X224.

837 Institutional Transaction Sample

Data Element	Value
Subscriber:	Clark Kent
Subscriber Address:	123 Fake St. Pittsburgh, PA 15123
Sex:	M
DOB:	May 3, 2006
Insurance ID#:	000000001-03
Payer ID #:	987654321
Patient:	Clark Kent
Primary Payer:	UPMC Health Plan
Submitter:	Line Medical Center
EDI #:	111111111
Receiver:	UPMC Health Plan
EDI #:	222222222
Billing Provider:	Line Medical Center
Provider #	111111111
Address:	123 Line Blvd. Pittsburgh, PA 15123
Contact Person and Number	Dr. J, 412-454-1000
Attending Physician:	William J. Line, MD
Attending Physician NPI:	2222222222
UPIN #	P97777
Patient Account Number:	333333
Date of Admission:	04/17/2011
Place of Service:	Hospital
Occurrence Codes and Dates:	41 on 5/1/2010 27 on 7/15/2010 33 on 4/15/2010 C2 on 4/10/2010
Value Code	30
Value Amount	$20.
Condition Codes:	01
ICD-9 Procedure Code and Date:	449.1, 7/30/2010
Principal Diagnosis Code:	250.00
Secondary Diagnosis Codes:	789.01
Revenue Codes	0300 0320 0270
Services:	HC
Institutional Services Rendered:	81000 76092 J1120
Line Item Charge Amounts	$120. $50. $30.
Total Charges:	$200.

 

 

Example 837 Data String
The following transmission sample illustrates the file format used for an EDI transaction, which includes delimiters and data segment symbols. The sample includes the ISA (Interchange Control) and GS (Functional Group) portions of a transmission, and only one ST/SE segment. This sample contains a line break after each tilde to provide an easy illustration of where a new data segment begins.

ISA*00* *00* *ZZ*111111111 *33*7306849549*110418*1336*^*00501*000000312*1*P*:~
GS*HC*111111111*7306849549*20110418*1336*312005010X223~
ST*837*0034*005010X223A1~
BHT*0019*00*3920394930203*20100816*1615*CH~
NM1*41*2* LINE MEDICAL CENTER*****46*111111111~
PER*IC*DR. J*TE*4124541000~
NM1*40*2*UPMCHP*****46*222222222~
HL*1**20*1~
NM1*85*2* LINE MEDICAL CENTER*****XX*1111111111~
N3*123 LINE BLVD~
N4*PITTSBURGH*PA*15123~
REF*EI*111111111~
PER*IC*CLARK KENT*TE*00000000101*FX*6145551212~
HL*2*1*22*0~
SBR*P*18*XYZ1234567******BL~
NM1*IL*1*KENT*CLARK*S**MI*00000000101~
N3*123 FAKE ST~
N4*PITTSBURGH*PA*15123~
DMG*D8*19820503*M~
NM1*PR*2*UPMCHP*****PI*222222222~
CLM*333333 *200***13:A:1***A**Y*Y~
DTP*434*RD8*20110417-20110417~
CL1*1*9*01~
REF*F8*ASD0000123~
HI*BK:25000~
HI*BF:78901~
HI*BR:4491:D8:20100730~
HI*BH:41:D8:20100501*BH:27:D8:20100715*BH:33:D8:20100415*BH:C2:D8:20100410~
HI*BE:30:::20~
HI*BG:01~
NM1*71*1*LINE*WILLIAM*AL***34*2222222222~
REF*1G*P97777~
LX*1~
SV2*0300*HC:81000*120*UN*1~
DTP*472*D8*20100730~
LX*2~
SV2*0320*HC:76092*50*UN*1~
DTP*472*D8*20100730~
LX*3~
SV2*0270*HC:J1120*30*UN*1~
DTP*472*D8*20100730~
SE*41*0001~
GE*1*312~
IEA*1*000000312~

 

Are you looking for a solution to generate 837P or 837I in your medical billing product? Then you are in the right place.

I am Senthil Muthiah, A technology-driven professional with over 20 years of experience including nearly 9 years in Software Development and Business Analysis.  Well versed with US Healthcare Domain – Electronic Medical Record (EMR) & Medical Billing. In particular, 15 years of experience in the Healthcare domain specifically in Claim processing, Claims adjudication, clearing house-related processes.

Consultation Option

1. if your product is in java, then we are very close. You can buy my java Spring Boot API Service source code which converts JSON to EDI and vice versa.

1. JSON to EDI 270 Eligibility and Benefit Inquiry
2. Create EDI 270 from JSON
   
3. Parse EDI 271 Message to Human Readable Text
4. JSON to EDI 837 Professional Claims
5. Parse EDI 837p Message into JSON
6. Parse EDI 835 Message into JSON   
7. Parse EDI 835 Message to PDF
8. JSON to cms 1500 Form
9. Parse EDI 837p To HTML
10. JSON To EDI 837 Institutional
11. Parse EDI 837I to JSON
12. Parse EDI 837 Institutional To HTML
13. Create CMS 1500 Form using JSON
14. Parse EDI 837p to CMS 1500 Form

Here is the demo link
https://demo.nagatabilling.com/NagataEDITool/login.zhtml 
 

2. if your product in different technology, then I will help your developer to create an EDI file using Pseudo.  Here is a sample Pseudocode 

 For more detailed resume and skills, please refer to the following link

·       Online Resume

·       Linked Profile

My Email ID :  vbsenthilinnet@gmail.com

 

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Understanding EDI 835 Electronic Remittance Advice

---

First Let us understand the Workflow

1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.     
          
   
2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc.) and insurance information;
   
   
3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);

4. Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code;

5. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code;

6. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;

7. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
   
   
8. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
   
   
9. Once the Claim is prepared and send to the Insurance company for payment; 
   
   
10. Billing Department using the Practice Management System (PMS), send the claim via EDI File. The EDI Transaction used to create the claim in the Electronic format is EDI 837
    Refer the Following Link to understand more on EDI 837
    What is an EDI ?
    EDI 837 Health Care Claim
    
    
11. Once the 837 EDI File is created, then it will be send to the Clearing House.
    
    
12. Clearing House will validate the EDI File and send to the particular insurance company.
    
    
13. Insurance Company Process the Claim and prepare the Check (Cheque) and Statement(This statement is called Explanation of Benefits OR Remittance Advisory (EOB)          
    Refer the following Link for EOB
    EOB - An explanation of benefits 
    
    
14. Insurance company also generates the EDI 835 File using their System. EDI 835 is electronic version of EOB.
    The Electronic Remittance Advice (ERA), or 835, is the electronic transaction which provides claim payment information in the HIPAA mandated ACSX12 005010X221A1   Format. These files are used by practices, facilities, and billing companies to Auto Posting payments into their systems.
    Refer the following link for Sample
    EDI 835 Health Care Claim Payment/Advice:
    
    
15. Once the Check, Statement (EOB) and ERA File are ready, then insurance company first send the ERA File and EOB to the clearing house.Second , insurance company  will send the Check and copy of the EOB to the billing provider address . Third for each patient in the statement, the copy of the EOB will be emailed.
    
    
16. Now the Billing Team download the EOB and ERA from the clearing house. If the PMS system has Auto Posting Using ERA File, then they will download the EDI File and do auto posting. If there is no auto posting Module, then they will download the EOB PDF and apply posting manually.Remember, some time, ERA/EOB file will be reach the clearing house, even before the insurance company send the payment check to the doctor.

      Are you looking for EDI Integration with the clearing house for EDI 835, then please contact me for more information.
      And also, you can check our Tool which converts EDI 835 to PDF  or Push EDI 835 information into database via JSON.

     Parse EDI 835 into PDF
     Schedule Payment ERA File (EDI 835) Parsing Job

      Here is the demo link
      https://demo.nagatabilling.com/NagataEDITool/login.zhtml 
      User Name: demo, password: demo

     For more detailed resume and skills, please refer to the following link

·       Online Resume

·       Linked Profile

My Email ID :  vbsenthilinnet@gmail.com

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Well, You have learned the basics of ZK Framework and now you are ready to go to develop a Complete commercial Application or Sample Application. But how to start ? You might be end with lot of questions such as “Is there any template available ?”, “any support available for the project template”?, etc.

Here it is. I have developed a small Project start up kit with the following features

1. Menus are Dynamic for N Level support. What does it mean ? Well, in the modern Web application, you might want to visible/invisible Menu by each users type (aka Dynamic Menu). This template has that option . All the Menu caption and levels are Stored in MySQL Database and after login , it will retrieve the menus assigned only for the user.

2. Apart from Menu, You might be interested in giving permission to add/delete/edit for CRUD Based screens. Using this template, you can also control by each user.

3. For all the CRUD Based screens, Export to Excel option template is provided.

4. Sample CRUD Screen are Provided to ready to start.

5. Integrated with Spring Security

6. Integrated with Spring Hibernate Security.

7. Base DAO and DAO implementation classes are provided.

8. Utilising ZK's MVVM databinding.

9. Project comes with 5 different themes . So you can set theme by each user and after login, the selected theme will be applied.

Apart from the above, the Most important option is “ Support!!!!!!!”. Users who buying this kit, unlimited support will be provided to help them to understand the structure. If you are interested in buying this start up kit, please email to me at vbsenthilinnet@gmail.com

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Problem statement: I did not find a way how to catch events from 'select all' checkbox. Actually, I need select all entries (on all pages and not on displayed page!)  when 'select all' checked. And deselect all entries on all pages when 'select all' unchecked.
 
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EDI 835 Health Care Claim Payment/Advice

Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com

If you are new to Medical Billing, then please read this article first.
If you are new to EDI, then  read the following articles

1. What is an EDI ?
2. EDI Transactions 
3. Understanding EDI Structure
4. EDI Instruction

EDI 835 Health Care Claim Payment/Advice

The 835 is used primarily by Healthcare insurance plans to make payments to healthcare providers, to provide Explanations of Benefits (EOBs), or both. When a healthcare service provider submits an 837 Health Care Claim, the insurance plan uses the 835 to detail the payment to that claim, including:

• What charges were paid, reduced or denied
• Whether there was a deductible, co-insurance, co-pay, etc.
• Any bundling or splitting of claims or line items
• How the payment was made, such as through a clearinghouse

A particular 835 document may not necessarily match up one-for-one with a specific 837. In fact, it is not uncommon for multiple 835 transactions to be used in response to a single 837, or for one 835 to address multiple 837 submissions. As a result, the 835 is important to healthcare providers, to track what payments were received for services they provided and billed. And also one EDI 835 File, may contain multiple Checks i.e Multiple EOBs

Before going into detail, Let us understand how insurance Payer make the Payment. Please understand and have good understanding on the following topics.

1. What is Copay, Co Insurance and Deductible in  Insurance Payment Posting ?
2. EOB – Explanation of Benefits

 

The following EDI Parser for 835 Developed by me using java Spring Boot . Please contact me for source code .

 

The following video demo explain how to make restful web service api for the service.

 

Enter video caption here

 

To Demonstrate the various use cases of EDI 835, I've developed an internal Web application tool to test my own API. Here are some use cases.
Example 1:  One Claim with Co-pay Amount

 

Enter video caption here

 

Example 2: Coinsurance and Deductible Example

Enter video caption here

I have developed a small Parsing tool in VB.NET/VB.6/Java . This tool will take the EDI File and convert into PDF File as shown here.

 

Looking for best Practice Management software ? Please email at vbsenthilinnet@gmail.com 

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com

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271–5010 Health Care Eligibility Benefit Response - Subscriber Demographic Information and Subscriber Date –Loop 2100C

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Apply Insurance Payment (EOB) Use case

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