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

Example 5a

Example shows impact to service line payment but not the actual allowed amount.

Additional Tax payment at service line level that does not impact claim adjudication but does impact payment.

In this scenario the provider billed $26.20 and the true Allowed is 3.06. The payer is required to make an additional payment of 'tax' to this line to the provider.

In this example the AMT*B6 Allowed does not include the extra tax payable to this provider as per the business situation it is not considered part of the 'allowed' related to the agreement for the services billed.

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*11.06*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*36.20*11.06**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*36.20~

SVC*HC>99214*26.2*3.06~

DTM*472*20170109~

CAS*CO*45*23.2**137*-.06~

REF*6R*B1~

AMT*B6*3~

SVC*HC>36415*10*8~

DTM*472*20170109~

CAS*CO*45*2~

REF*6R*B2~

AMT*B6*8~

SE*35*10060875~

GE*1*12345678~

IEA*1*191511902~