Section title: X12 EDI Examples
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ASC X12 Version: 005010 | Transaction Set: 835 | TR3 ID: 005010X221

Example 2: Multiple Claims Single Check

This 835 scenario shows multiple claims (9 claims) on a single check where the amount submitted for all claims was $2,819.00 and the payer paid amount was $810.80 total.

Transmission

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPAYER       *190827*0212*^*00501*191511902*0*P*:~

GS*HP*ABCD*ABCD*20190827*12345678*12345678*X*005010X221A1~

ST*835*35681~

BPR*I*810.8*C*CHK************20190331~

TRN*1*12345*1512345678~

REF*EV*XYZ CLEARINGHOUSE~

N1*PR*DENTAL OF ABC~

N3*225 MAIN STREET~

N4*CENTERVILLE*PA*17111~

PER*BL*JANE DOE*TE*9005555555~

N1*PE*BAN DDS LLC*XX*9999947036~

REF*TJ*212121212~

LX*1~

CLP*7722337*1*226*132**12*119932404007801*11*1~

NM1*QC*1*DOE*SANDY****MI*SJD11112~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*132~

SVC*AD:D0120*46*25~

DTM*472*20190324~

CAS*CO*45*21~

AMT*B6*25~

SVC*AD:D0220*25*14~

DTM*472*20190324~

CAS*CO*45*11~

AMT*B6*14~

SVC*AD:D0230*22*10~

DTM*472*20190324~

CAS*CO*45*12~

AMT*B6*10~

SVC*AD:D0274*60*34~

DTM*472*20190324

CAS*CO*45*26~

AMT*B6*34~

SVC*AD:D1110*73*49~

DTM*472*20190324~

CAS*CO*45*24~

AMT*B6*49~

CLP*7722337*1*119*74**12*119932404007801*11*1~

NM1*QC*1*DOE*SALLY****MI*SJD11111~

NM1*IL*1*DOE*JOHN****MI*SJD11111~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*74~

SVC*AD:D0120*46*25~

DTM*472*20190324~

CAS*CO*45*21~

AMT*B6*25~

SVC*AD:D1110*73*49~

DTM*472*20190324~

CAS*CO*45*24~

AMT*B6*49~

CLP*7722337*1*226*108*24*12*119932404007801*11*1~

NM1*QC*1*SMITH*SALLY****MI*SJD11113~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*132~

SVC*AD:D0120*46*25~

DTM*472*20190324~

CAS*CO*45*21~

AMT*B6*25~

SVC*AD:D0220*25*0~

DTM*472*20190324~

CAS*PR*3*14~

CAS*CO*45*11~

AMT*B6*14~

SVC*AD:D0230*22*0~

DTM*472*20190324~

CAS*PR*3*10~

CAS*CO*45*12~

AMT*B6*10~

SVC*AD:D0274*60*34~

DTM*472*20190324~

CAS*CO*45*26~

AMT*B6*34~

SVC*AD:D1110*73*49~

DTM*472*20190324~

CAS*CO*45*24~

AMT*B6*49~

CLP*7722337*1*1145*14*902*12*119932404007801*11*1~

NM1*QC*1*SMITH*SAM****MI*SJD11116~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*14~

SVC*AD:D0220*25*14~

DTM*472*20190324~

CAS*CO*45*11~

AMT*B6*14~

SVC*AD:D2790*940*0~

DTM*472*20190324~

CAS*PR*3*756~

CAS*CO*45*184~

SVC*AD:D2950*180*0~

DTM*472*20190324~

CAS*PR*3*146~

CAS*CO*45*34~

CLP*7722337*1*348*16.8*44.2*12*119932404007801*11*1~

NM1*QC*1*JONES*SAM****MI*SJD11122~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*28~

SVC*AD:D4342*125*0~

DTM*472*20190313~

CAS*CO*45*125~

SVC*AD:D4381*43*0~

DTM*472*20190313~

CAS*PR*3*33~

CAS*CO*45*10~

SVC*AD:D2950*180*16.8~

DTM*472*20190313~

CAS*PR*3*11.2~

CAS*CO*45*152~

AMT*B6*28~

CLP*7722337*1*226*132**12*119932404007801*11*1~

NM1*QC*1*JONES*SALLY****MI*SJD11133~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*132~

SVC*AD:D0120*46*25~

DTM*472*20190321~

CAS*CO*45*21~

AMT*B6*25~

SVC*AD:D0220*25*14~

DTM*472*20190321~

CAS*CO*45*11~

AMT*B6*14~

SVC*AD:D0230*22*10~

DTM*472*20190321~

CAS*CO*45*12~

AMT*B6*10~

SVC*AD:D0274*60*34~

DTM*472*20190321~

CAS*CO*45*26~

AMT*B6*34~

SVC*AD:D1110*73*49~

DTM*472*20190321~

CAS*CO*45*24~

AMT*B6*49~

CLP*7722337*1*179*108**12*119932404007801*11*1~

NM1*QC*1*DOE*SAM****MI*SJD99999~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*108~

SVC*AD:D0120*46*25~

DTM*472*20190324~

CAS*CO*45*21~

AMT*B6*25~

SVC*AD:D0274*60*34~

DTM*472*20190324~

CAS*CO*45*26~

AMT*B6*34~

SVC*AD:D1110*73*49~

DTM*472*20190324~

CAS*CO*45*24~

AMT*B6*49~

CLP*7722337*1*129*82**12*119932404007801*11*1~

NM1*QC*1*DOE*SUE****MI*SJD88888~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*82~

SVC*AD:D0120*46*25~

DTM*472*20190324~

CAS*CO*45*21~

AMT*B6*25~

SVC*AD:D1120*54*37~

DTM*472*20190324~

CAS*CO*45*17~

AMT*B6*37~

SVC*AD:D1208*29*20~

DTM*472*20190324~

CAS*CO*45*9~

AMT*B6*20~

CLP*7722337*1*221*144**12*119932404007801*11*1~

NM1*QC*1*DOE*DONNA****MI*SJD77777~

NM1*82*1*BAN*ERIN****XX*1811901945~

AMT*AU*144~

SVC*AD:D0120*46*25~

DTM*472*20190324~

CAS*CO*45*21~

AMT*B6*25~

SVC*AD:D0330*92*62~

DTM*472*20190324~

CAS*CO*45*30~

AMT*B6*62~

SVC*AD:D1120*54*37~

DTM*472*20190324~

CAS*CO*45*17~

AMT*B6*37~

SVC*AD:D1208*29*20~

DTM*472*20190324~

CAS*CO*45*9~

AMT*B6*20~

SE*182*35681~

GE*1*12345678~

IEA*1*191511902~