Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 276/277 | TR3 ID: 005010X212

Example 2a: 276 Request Transmission

The following is the 276 transmission XYZ Services sent to ABC Insurance requesting the status of the claims described in Section 3.2 - Business Scenario 2 -- Provider Level Status:

Transmission

ST*276*0001*005010X212~

BHT*0010*13*ABC276XXX*20050915*1425~

HL*1**20*1~

NM1*PR*2*ABC INSURANCE*****PI*12345~

HL*2*1*21*1~

NM1*41*2*XYZ SERVICE*****46*X67E~

HL*3*2*19*1~

NM1*1P*2*HOME HOSPITAL*****XX*1666666661~

HL*4*3*22*0~

DMG*D8*19301210*M~

NM1*IL*1*SMITH*FRED****MI*123456789A~

TRN*1*ABCXYZ1~

REF*BLT*111~

REF*EJ*SM123456~

AMT*T3*8513.88~

DTP*472*RD8*20050831-20050906~

HL*5*2*19*1~

NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*6166666666~

HL*6*5*22*1~

NM1*IL*1*MANN*JOHN****MI*345678901~

HL*7*6*23~

DMG*D8*19951101*M~

NM1*QC*1*MANN*JOSEPH~

TRN*1*ABCXYZ3~

REF*EJ*MA345678~

SVC*HC:99203*150*****1~

DTP*472*D8*20050501~

SE*28*0001~