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

Example 8c: Claim submitted with for subscriber missing the Middle initial

Claim submitted with for subscriber missing the Middle initial:

  • Fern Laplante submitted with no middle initial
  • Per Membership the middle initial is R

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*2415.25*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*05444444TLC999999*1*3903*2415.25**13*8777777782*21*1~

NM1*QC*1*GONZALES*SAMMY****MI*80455555502~

NM1*IL*1*LAPLANTE*FERN****MI*80455555502~

NM1*74*1***R~

NM1*82*1*GOOD MD*ROBERT B****XX*19999999987~

REF*1L*28~

REF*CE*OAPOS-LAOA~

DTM*232*20191101~

DTM*233*20191101~

DTM*050*20191114~

AMT*AU*3903~

AMT*F5*150~

SVC*HC|59400*3903*2415.25**1~

DTM*472*20191101~

CAS*CO*45*1487.75~

REF*LU*21~

REF*6R*22215592~

AMT*B6*2415.25~

SE*35*10060875~

GE*1*12345678~

IEA*1*191511902~