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

Example 8a: Claim submitted with incorrect subscriber as patient and incorrect ID

837 claim submitted as follows:

  • Marvin Masters submitted as patient
  • Mabel Cable submitted as the insured with an ID of 80444444403
  • Marvin Masters is actually both the patient and insured with an ID of 80444444401. Mable Cable was submitted incorrectly as the Insured/Subscriber.

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*120.03*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*04777796TLC777122*1*155*120.03**13*8838888212*11*1~

NM1*QC*1*MASTERS*MARVIN*L****MI*80444444403~

NM1*IL*1*CABLE*MABEL****MI*80444444403~

NM1*74*1*MASTERS*MARVIN****C*80444444401~

NM1*82*1*SHELTON MD*BLAKE****XX*1666666666~

REF*1L*28~

REF*CE*HSOAP-LAOA~

REF*TJ*555555555 ~

DTM*232*20191114~

DTM*233*20181114~

DTM*050*20181119~

AMT*AU*155~

SVC*HC|99393*155*120.03**1~

DTM*472*20181114~

CAS*CO*45*34.97~

REF*LU*11~

REF*6R*22261822~

AMT*B6*120.03~

SE*35*10060875~

GE*1*12345678~

IEA*1*191511902~