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

Example 4: Claim Adjustment Reason Code 45

Claim submitted for participating provider for office visit and other services. Only office visit allowed/reimbursable. All other service have 'zero' allowed due to incidental or not covered. Office visit has allowed of $80 and as the billed is greater than the maximum fee schedule, the difference of $70 is reported with group code of CO and CARC code of 45.

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*10060875~

BPR*I*80.00*C*CHK************20190816~

TRN*1*CK NUMBER 1*1234567890~

REF*EV*FAC~

DTM*405*20190827~

N1*PR*ANY PLAN USA~

N3*1 WALK THIS WAY~

N4*ANYCITY*OH*45209~

PER*CX**TE*8661112222~

PER*BL*EDI*TE*8002223333*EM*EDI.SUPPORT@ANYPAYER.COM~

PER*IC**UR*WWW.ANYPAYER.COM~

N1*PE*PROVIDER*XX*1123454567~

N3*2255 ANY ROAD~

N4*ANY CITY*CA*12211~

REF*TJ*123456789~

LX*1~

CLP*PATACCT*1*400*80**MC*CLAIMNUMBER*11*1~

NM1*QC*1*DOE*JOHN*N***MI*ABC123456789~

REF*1L*12345F~

DTM*050*20190209~

PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004074627~

AMT*AU*150~

SVC*HC|99213*150*80**1~

DTM*472*20190101~

CAS*CO*45*70~

AMT*B6*80~

SVC*HC|85003*100*0**1~

DTM*472*20190101~

CAS*CO*204*100~

SVC*HC|36415*150*0**1~

DTM*472*20190101~

CAS*CO*97*150~

SE*33*10060875~

GE*1*12345678~

IEA*1*191511902~