HIPAA 5010 835 Payment Example File
ISA*00* *00* *ZZ*1234567 *ZZ*11111 *170508*1141*^*00501*000000101*1*P*:~ GS*HC*XXXXXXX*XXXXX*20170617*1741*101*X*005010X221A1~ ST*835*0001~ BPR*I*34.00*C*CHK************20050318~ TRN*1*0063158ABC*1566339911~ REF*EV*030240928~ DTM*405*20050318~ N1*PR*YOUR TAX DOLLARS AT WORK~ N3*481A00 DEER RUN ROAD~ N4*WEST PALM BCH*FL*11114~ PER*BL*JOHN WAYNE*TE*8005551212*EX*123~ N1*PE*ATONEWITHHEALTH*FI*3UR334563~ N3*3501 JOHNSON STREET~ N4*SUNSHINE*FL*12345~ REF*PQ*11861~ LX*1~ CLP*0001000055*2*541*34**12*50650619501~ NM1*QC*1*BURCK*RAYMOND*W***MI*987654321~ NM1*82*2*PROFESSIONAL TEST 1*****BS*34426~ DTM*232*20050202~ DTM*233*20050202~ SVC*HC:55669*541*34*1~ DTM*472*20050202~ CAS*OA*23*516~ CAS*OA*94*-9~ REF*1B*44280~ AMT*B6*550~ SE*26*0001~ GE*1*101~ IEA*1*000000101~