HIPAA 5010 837P Professional Claim Example File
ISA*00* *00* *ZZ*1234567 *ZZ*11111 *170508*1141*^*00501*000000101*1*P*:~ GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X222A1~ ST*837*1239*005010X222A1~ BHT*0019*00*010*20170617*1741*CH~ NM1*41*2*SUBMITTER*****46*ABC123~ PER*IC*BOB SMITH*TE*4805551212~ NM1*40*2*RECEIVER*****46*44556~ HL*1**20*1~ NM1*85*2*BILLING PROVIDER*****XX*1122334455~ N3*1234 SOME ROAD~ N4*CHICAGO*IL*606739999~ REF*EI*999999999~ HL*2*1*22*0~ SBR*P*18*******12~ NM1*IL*1*BLOGGS*JOE****MI*1234567890~ N3*1 SOME BLVD~ N4*CHICAGO*IL*606129998~ DMG*D8*19570111*M~ NM1*PR*2*PAYER*****PI*12345~ N3*1 PAYER WAY~ N4*ST LOUIS*MO*212441850~ REF*2U*W1014~ CLM*1000A*140***19:B:1*Y*A*Y*Y~ HI*ABK:I10~ LX*1~ SV1*HC:99213*140*UN*1***1~ DTP*472*D8*20151124~ HL*3*1*22*0~ SBR*P*18*******12~ NM1*IL*1*BLOGGS*FRED****MI*9876543201~ N3*1 ANOTHER STR~ N4*CHICAGO*IL*606129998~ DMG*D8*19700601*M~ NM1*PR*2*PAYER*****PI*12345~ N3*1 PAYER WAY~ N4*ST LOUIS*MO*212441850~ REF*2U*W1014~ CLM*1001A*140***19:B:1*Y*A*Y*Y~ HI*ABK:I10~ LX*1~ SV1*HC:99213*140*UN*1***1~ DTP*472*D8*20151124~ SE*41*1239~ GE*1*101~ IEA*1*000000101~