HIPAA 5010 837I Institutional Claim Example File
ISA*00* *00* *ZZ*1234567 *ZZ*11111 *170508*1141*^*00501*000000101*1*P*:~ GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X223A2~ ST*837*987654*005010X223A2~ BHT*0019*00*0123*19960918*0932*CH~ NM1*41*2*JONES HOSPITAL*****46*12345~ PER*IC*JANE DOE*TE*9005555555~ NM1*40*2*MEDICARE*****46*00120~ HL*1**20*1~ PRV*BI*PXC*203BA0200N~ NM1*85*2*JONES HOSPITAL*****XX*9876540809~ N3*225 MAIN STREET BARKLEY BUILDING~ N4*CENTERVILLE*PA*17111~ REF*EI*567891234~ PER*IC*CONNIE*TE*3055551234~ HL*2*1*22*0~ SBR*P*18*******MB~ NM1*IL*1*DOE*JOHN*T***MI*030005074A~ N3*125 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ DMG*D8*19261111*M~ NM1*PR*2*MEDICARE B*****PI*00435~ REF*G2*330127~ CLM*756048Q*89.93**14:A:1*A*Y*Y~ DTP*434*RD8*19960911~ CL1*3**01~ HI*BK:3669~ HI*BF:4019*BF:79431~ HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J~ REF*1G*B99937~ SBR*S*01*351630*STATE TEACHERS*****CI~ OI***Y***Y~ NM1*IL*1*DOE*JANE*S***MI*222004433~ N3*125 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ NM1*PR*2*STATE TEACHERS*****PI*1135~ LX*1~ SV2*0305*HC:85025*13.39*UN*1~ DTP*472*D8*19960911~ LX*2~ SV2*0730*HC:93005*76.54*UN*3~ DTP*472*D8*19960911~ SE*42*987654~ GE*1*101~ GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X223A2~ ST*837*987654*005010X223A2~ BHT*0019*00*0123*19960918*0932*CH~ NM1*41*2*JONES HOSPITAL*****46*12345~ PER*IC*JANE DOE*TE*9005555555~ NM1*40*2*MEDICARE*****46*00120~ HL*1**20*1~ PRV*BI*PXC*203BA0200N~ NM1*85*2*JONES HOSPITAL*****XX*9876540809~ N3*225 MAIN STREET BARKLEY BUILDING~ N4*CENTERVILLE*PA*17111~ REF*EI*567891234~ PER*IC*CONNIE*TE*3055551234~ HL*2*1*22*0~ SBR*P*18*******MB~ NM1*IL*1*DOE*JOHN*T***MI*030005074A~ N3*125 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ DMG*D8*19261111*M~ NM1*PR*2*MEDICARE B*****PI*00435~ REF*G2*330127~ CLM*756048Q*89.93**14:A:1*A*Y*Y~ DTP*434*RD8*19960911~ CL1*3**01~ HI*BK:3669~ HI*BF:4019*BF:79431~ HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~ HI*BE:A2:::15.31~ HI*BG:09~ NM1*71*1*JONES*JOHN*J~ REF*1G*B99937~ SBR*S*01*351630*STATE TEACHERS*****CI~ OI***Y***Y~ NM1*IL*1*DOE*JANE*S***MI*222004433~ N3*125 CITY AVENUE~ N4*CENTERVILLE*PA*17111~ NM1*PR*2*STATE TEACHERS*****PI*1135~ LX*1~ SV2*0305*HC:85025*13.39*UN*1~ DTP*472*D8*19960911~ LX*2~ SV2*0730*HC:93005*76.54*UN*3~ DTP*472*D8*19960911~ SE*42*987654~ GE*1*101~ IEA*1*000000101~