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Sample EDI 837

The document contains an EDI submission file with patient and insurance claim information. It includes a submitter ID, receiver ID, contact information, a claim for a patient with diagnosis and procedure codes, rendering and billing provider details, and line item information. Subscriber, payer and facility details are also present for the claim.

Uploaded by

Subodh Bopche
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348 views

Sample EDI 837

The document contains an EDI submission file with patient and insurance claim information. It includes a submitter ID, receiver ID, contact information, a claim for a patient with diagnosis and procedure codes, rendering and billing provider details, and line item information. Subscriber, payer and facility details are also present for the claim.

Uploaded by

Subodh Bopche
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as TXT, PDF, TXT or read online on Scribd
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{

"ediSubmitterDTO": {
"submitterID": "111134 ",
"receiverID": "53589",
"authorizationQualifier": "00",
"ediControlNumber": "796000000",
"usageIndicator": "P",
"acknowledgementRequested": "0",
"contactName": "S Martinez",
"contactPhone": "2025550170",
"entityType": "2",
"lastName": "Demo Practice",
"contactFax": "2025550179"
},
"claimsList": [
{
"claimNo": "124304",
"billedAmount": 60.00,
"icd1": "A05",
"providerSignIndicator": "Y",
"claimType": "1",
"providerAcceptAssCode": "A",
"benefitAssIndicator": "Y",
"releaseInfoCode": "Y",
"pos": "11",
"facilityDTO": {
"name": "NY Office",
"npi": "1821689787",
"address1": "30,Tonto Apache Reservation",
"city": "Payson",
"state": "AZ",
"zip": "855415556"
},
"renderingProviderDTO": {
"entityType": "1",
"lastName": "Borak",
"firstName": "Steve",
"npi": "1821689787"
},
"subscriberDTO": {
"entityType": "1",
"lastName": "Doe",
"firstName": "John",
"address1": "30, Tonto Apache Reservation",
"address2": "Payson",
"city": "Payson",
"state": "AZ",
"zip": "855415556",
"dob": "11/23/1945",
"gender": "M",
"groupNumber": "TAT102",
"groupName": "GFAMPLAN",
"payerRespon": "P",
"claimFillingIndicator": "BL",
"policyNo": "Y333RF3333",
"insuredRelation": "18"
},
"payerDTO": {
"name": "Blue Choice",
"address1": "4787 BLUFF STREET",
"city": "Blue bell",
"state": "TX",
"zip": "74102",
"payerID": "53589"
},
"lineItems": [
{
"procedureCode": "99214",
"chargesPerUnit": 60,
"serviceFromDate": "05/17/2019",
"serviceToDate": "05/17/2019",
"units": 1.00,
"icdPointers": "1",
"lineItemId": "75965",
"pos": "11"
}
],
"billingProviderDTO": {
"entityType": "2",
"lastName": "Tonto Apache Healthcare LLC",
"npi": "1447843651",
"address1": "30, tonto Apache Reservation",
"address2": "",
"city": "Payson",
"state": "AZ",
"zip": "855415556",
"taxNo": "222222222"
}
}
]
}

==========================================================

ISA*00* *00* *ZZ*111134 *ZZ*53589


*210816*0431*^*00501*796000000*0*P*:
GS*HC*111134*53589*20210816*0431*796000000*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210816*0431*CH
NM1*41*2*Demo Practice*****46*111134
PER*IC*S Martinez*TE*2025550170*FX*2025550179
NM1*40*2*53589*****46*53589
HL*1**20*1
NM1*85*2*Tonto Apache Healthcare LLC*****XX*1447843651
N3*30, tonto Apache Reservation
N4*Payson*AZ*855415556
REF*EI*222222222
HL*2*1*22*0
SBR*P*18*TAT102*GFAMPLAN*****BL
NM1*IL*1*Doe*John****MI*Y333RF3333
N3*30, Tonto Apache Reservation*Payson
N4*Payson*AZ*855415556
DMG*D8*19451122*M
NM1*PR*2*Blue Choice*****PI*53589
N3*4787 BLUFF STREET
N4*Blue bell*TX*74102
CLM*124304*60***11:B:1*Y*A*Y*Y*P
HI*ABK:A05
NM1*82*1*Borak*Steve****XX*1821689787
NM1*77*2*NY Office*****XX*1821689787
N3*30,Tonto Apache Reservation
N4*Payson*AZ*855415556
LX*1
SV1*HC:99214*60*UN*1*11**1
DTP*472*D8*20190516
REF*6R*75965
SE*30*0001
GE*1*796000000
IEA*1*796000000

==========================================================

https://demo.nagatabilling.com/NagataEDITool/zk/main/main.zul

[email protected]

dee11741

-----------------------------------------------------------------------------------
-----
Insurance verification
EDI 270
EDI 271

Preauth
EDI

Claim
EDI 837P
EDI 837I

Remittance
EDI 835

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