Section title: X12 EDI Examples
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X12 Version: 008060 | Transaction Set: 835 | TR3 ID: 008060X322

Example 06: Not Covered/Not Authorized Inpatient Facility claim days

Claim submitted for 5 day inpatient stay.

  • Claim billed for 5 day stay
  • Pre-Authorization was approved for 4 day
  • Claim adjudication will approve and reimburse 4 days and Deny 1 Day as not authorized
  • Per diem rate is $2000 – for total paid of $8000
  • $2000 denied not authorized
  • Covered days shows 4

Transmission

ISA*00*          *00*          *ZZ*ABCPAYER       *ZZ*ABCPROVIDER    *250827*0212*^*00806*191511902*0*P*|~

GS*HP*ABCD*ABCD*20250827*12345678*12345678*X*008060X322~

ST*835*10060875~

BPR*I*8000.00*C*CHK************20250816~

TRN*1*CK NUMBER 1*1234567890~

REF*EV*FAC~

DTM*405*20250827~

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*40000*8000**MC*CLAIMNUMBER*11*1*******11~

RAS*2000*CO*197*1*3000*45~

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

REF*1L*12345F~

DTM*232*20250101~

DTM*233*20250105~

DTM*050*20250209~

PER*CX*G CUSTOMER SERVICE DEPARTMENT*TE*8004001212~

AMT*AU*38000~

QTY*CA*4~

SE*27*10060875~

GE*1*12345678~

IEA*1*191511902~