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

Example 5b

Example shows additional line payment amount: Provider Performance bonus paid at the service line level.

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*12.00*C*CHK************20250827~

TRN*1*CK002*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*PCN*1*25*12*10*12*CLAIMNUMB*11*1*******11~

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

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

LQ*HE*N25~

REF*1L*102345~

REF*EA*065789~

DTM*050*20250713~

AMT*AU*25~

SVC*HC>99214*25*12~

DTM*472*20250709~

RAS*5*CO*45**-2*161~

RAS*10*PR*3~

REF*6R*123~

AMT*B6*20~

SE*31*10060875~

GE*1*12345678~

IEA*1*191511902~