Section title: X12 EDI Examples
back to previous

ASC X12 Version: 005010 | Transaction Set: 835 | TR3 ID: 005010X221

Example 5c

Example shows line penalty: Provider late filing penalty at the service line level.

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*8.00*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*PCN*1*25*8*10*12*CLAIMNUMB*11*1~

NM1*QC*1*LAST*FIRST*J***MI*123456789~

NM1*82*1******XX*1447481825~

MOA***N25~

REF*1L*102345~

REF*EA*065789~

DTM*050*20170113~

AMT*AU*25~

SVC*HC>99214*25*8~

DTM*472*20170109~

CAS*CO*45*5**B4*2~

CAS*PR*3*10~

REF*6R*123~

AMT*B6*20~

SE*31*10060875~

GE*1*12345678~

IEA*1*191511902~