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

Example 8b: Claim submitted with incorrect subscriber name and ID

837 claim submitted as follows:

  • Jason Thomas Submitted as Subscriber with ID of 80000006006
  • Alex Keaton was submitted as patient
  • Jerome is the correct subscriber per membership with an ID of 80000006001

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*35.06*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*02333TLC222222*1*115*35.06*35*13*8333333214*11*1~

NM1*QC*1*KEATON*ALEX*P****MI*80000006006~

NM1*IL*1*THOMAS*JASON****MI*80000006006~

NM1*74*1**JEROME****C*80000006001~

NM1*82*1*BLOOD MD*RED N****XX*1888888886~

REF*1L*28~

REF*CE*OAPOS-LAOA~

DTM*232*20191113~

DTM*233*20191113~

DTM*050*20191119~

AMT*AU*115~

SVC*HC|99213*115*35.06**1~

DTM*472*20191113~

CAS*CO*45*44.94~

CAS*PR*3*35~

REF*LU*11~

REF*6R*22261389~

AMT*B6*70.06~

SE*35*10060875~

GE*1*12345678~

IEA*1*191511902~