HIPAA 5010 837D Dental Claim

HIPAA 5010 837D Dental Claim Example File

ISA*00*          *00*          *ZZ*1234567        *ZZ*11111          *170508*1141*^*00501*000000101*1*P*:~
GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X224A2~
ST*837*3456*005010X224A2~
BHT*0019*00*0123*20061123*1023*CH~
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
PER*IC*JERRY*TE*7176149999~
NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~
HL*1**20*1~
NM1*85*2*DENTAL ASSOCIATES*****XX*1234567890~
N3*234 SEAWAY ST~
N4*MIAMI*FL*33111~
REF*EI*587654321~
HL*2*1*22*1~
SBR*P********CI~
NM1*IL*1*SMITH*JANE****MI*111223333~
NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~
HL*3*2*23*0~
PAT*19~
NM1*QC*1*SMITH*TED~
N3*236 N MAIN ST~
N4*MIAMI*FL*33413~
DMG*D8*19920501*M~
CLM*26403774*150***11:B:1*Y*A*Y*I~
DTP*472*D8*20061029~
REF*D9*17312345600006351~
NM1*82*1*KILDARE*BEN****XX*9876543210~
PRV*PE*PXC*1223G0001X~
LX*1~
SV3*AD:D2150*100****1~
TOO*JP*12*M:O~
LX*2~
SV3*AD:D1110*50****1~
SE*31*3456~
GE*1*101~
IEA*1*000000101~