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    Edi Example File 837

    Uploaded by

    ArindamDuttaChoudhury
    This document contains an 837 healthcare claim transaction with 2 separate medical claims. The first claim is for patient DJ Dimpson for office visits and a procedure on 10/31/2005 by provider Bruno Moglie and Associated Medical Group. The second claim is also for patient DJ Dimpson for the same services on 10/30/2005 by the same provider and medical group. Both claims are being submitted to Heisman Insurance Company for processing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as TXT, PDF, TXT or read online from Scribd

    Edi Example File 837

    Uploaded by

    ArindamDuttaChoudhury
    322 views2 pages
    This document contains an 837 healthcare claim transaction with 2 separate medical claims. The first claim is for patient DJ Dimpson for office visits and a procedure on 10/31/2005 by provider Bruno Moglie and Associated Medical Group. The second claim is also for patient DJ Dimpson for the same services on 10/30/2005 by the same provider and medical group. Both claims are being submitted to Heisman Insurance Company for processing.

    Original Description:

    EDI 837

    Original Title

    Edi Example file 837

    Copyright

    © Attribution Non-Commercial (BY-NC)

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    TXT, PDF, TXT or read online from Scribd

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    This document contains an 837 healthcare claim transaction with 2 separate medical claims. The first claim is for patient DJ Dimpson for office visits and a procedure on 10/31/2005 by provider Bruno Moglie and Associated Medical Group. The second claim is also for patient DJ Dimpson for the same services on 10/30/2005 by the same provider and medical group. Both claims are being submitted to Heisman Insurance Company for processing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as TXT, PDF, TXT or read online from Scribd
    Download as txt, pdf, or txt
    322 views2 pages

    Edi Example File 837

    Uploaded by

    ArindamDuttaChoudhury
    This document contains an 837 healthcare claim transaction with 2 separate medical claims. The first claim is for patient DJ Dimpson for office visits and a procedure on 10/31/2005 by provider Bruno Moglie and Associated Medical Group. The second claim is also for patient DJ Dimpson for the same services on 10/30/2005 by the same provider and medical group. Both claims are being submitted to Heisman Insurance Company for processing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as TXT, PDF, TXT or read online from Scribd
    Download as txt, pdf, or txt
    of 2

    ISA*00*

    *00*
    *14*
    *01*604083246
    7*^*00501*000000115*0*T*:
    GS*HC*000213215*604083246*20060512*1130*128*X*005010X222
    ST*837*0021*005010X222
    BHT*0019*00*0125*20051111*1524*CH
    NM1*41*2*ASSOCIATED MEDICAL GROUP*****46*1253695747
    PER*IC*JANICE HENDRIX*TE*2125557987
    NM1*40*2*HEISMAN INSURANCE COMPANY*****46*999888777
    HL*1**20*1
    NM1*85*2*ASSOCIATED MEDICAL GROUP*****XX*1253695747
    N3*10 1/2 SHOEMAKER STREET
    N4*COBBLER*CA*99997
    REF*EI*579999999
    HL*2*1*22*1
    SBR*P********AM
    NM1*IL*1*HOWLING*HAL****MI*B99977791G
    N3*101 EAST BANGALORE STREET
    N4*JOHNY TOWN*IL*99699
    NM1*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777
    N4*COBBLER*CA*99997
    HL*3*2*23*0
    PAT*21
    NM1*QC*1*DIMPSON*DJ
    N3*32 BUFFALO RUN
    N4*ROCKING HORSE*CA*99666
    DMG*D8*19480601*M
    REF*Y4*32323232
    PER*IC*DJ DIMPSON*TE*8157665902
    CLM*900000032*185***11:B:1*Y*A*Y*Y**AA:::CA
    DTP*439*D8*20051031
    DTP*444*D8*20051031
    HI*BK:8540
    NM1*82*1*MOGLIE*BRUNO****XX*2366552595
    PRV*PE*PXC*208D00000X
    NM1*77*2*ASSOCIATED MEDICAL GROUP*****XX*1235767887
    N3*101 EAST PRYOR STREET
    N4*LOMA LINDA*CA*99622
    PER*IC*KAREN SPARKLE*TE*3425557987
    LX*1
    SV1*HC:99201*150*UN*1***1**Y
    DTP*472*D8*20051031
    LX*2
    SV1*HC:26010*35*UN*1***1**Y
    DTP*472*D8*20051031
    CLM*900000033*185***11:B:1*Y*A*Y*Y**AA:::CA
    DTP*439*D8*20051030
    DTP*444*D8*20051030
    HI*BK:8541
    NM1*82*1*MOGLIE*BRUNO****XX*2366552595
    PRV*PE*PXC*208D00000X
    NM1*77*2*ASSOCIATED MEDICAL GROUP*****XX*1235767887
    N3*101 EAST PRYOR STREET
    N4*LOMA LINDA*CA*99622
    PER*IC*KAREN SPARKLE*TE*3425557987
    LX*1
    SV1*HC:99201*150*UN*1***1**Y
    DTP*472*D8*20051030
    LX*2
    SV1*HC:26010*35*UN*1***1**Y
    DTP*472*D8*20051030

    *030513*134

    SE*58*0021
    GE*1*128
    IEA*1*000000115

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