[ X12 Examples ]
Com1 Software 837P Professional Claims Example
Posted: Friday, November 04 2022 5:15:45 PM
Com1 Software, Inc.
P.O. Box 482
Hudson, Ohio 44236
(330) 653-3771
information@com1software.com
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[ com1software.com ]
Support :
[support.com1software.com]
X12 Examples :
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837P Professional Claims Example
837P Professional Claims source file.
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *080319*2327*U*00501*002721171*0*P*:~ GS*HC*SENDER*RECEIVER*20080319*2327*27211711*X*005010X222A1~ ST*837*0021~ BHT*0019*00*0123*19981015*1023*RP~ REF*87*004010X098~ NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~ PER*IC*JERRY*TE*3055552222*EX*231~ NM1*40*2*REPRICER XYZ*****46*66783JJT~ HL*1**20*1~ NM1*85*2*PREMIER BILLING SERVICE*****24*587654321~ N3*234 Seaway St~ N4*Miami*FL*33111~ NM1*87*2*KILDARE ASSOC*****24*581234567~ N3*2345 OCEAN BLVD~ N4*MIAMI*FL*33111~ HL*2*1*22*0~ SBR*P*18*12312-A******HM~ NM1*IL*1*SMITH*TED****34*000221111~ N3*236 N MAIN ST~ N4*MIAMI*FL*33413~ DMG*D8*19430501*M~ NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~ N2*COMPANY~ PAT*20~ NM1*QC*1*SMITH*JAN****34*000221111~ N3*236 N MAIN ST~ N4*MIAMI*FL*33413~ DMG*D8*19450203*F~ REF*Y4*1000020212345678~ CLM*26462967*100***11::1*Y*A*Y*Y*C*OA~ DTP*431*D8*19981003~ DTP*439*D8*19981103~ DTP*469*D8*19981203~ DTP*558*D8*19981203~ DTP*RRM*D8*19981403~ PWK*OZ*EL***AC*ZZY~ REF*D9*17312345600006351~ REF*G1*1WW06351~ K3*2222222222222222~ NTE*TPO*12345~ HI*BK:0340*BF:V7389~ NM1*82*1*KILDARE*BEN****XX*112233334~ PRV*PE*ZZ*203BF0100Y~ NM1*77*2*KILDARE ASSOCIATES*****24*581234567~ N3*2345 OCEAN BLVD~ N4*MIAMI*FL*33111~ LX*1~ SV1*HC:99213*40*UN*1***1**N~ DTP*472*D8* 19981003~ LX*2~ SV1*HC:99214*15*UN*1***1**N~ DTP*472* D8*19981003~ LX*3~ SV1*HC:87072*35*UN*1***2**N~ DTP*472*D8*19981003~ LX*4~ SV1*HC:86663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*5~ SV1*HC:86664*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*6~ SV1*HC:55563*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*7~ SV1*HC:16663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*8~ SV1*HC:23663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*9~ SV1*HC:55663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*10~ SV1*HC:87763*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*11~ SV1*HC:88963*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*12~ SV1*HC:12663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*13~ SV1*HC:36663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*14~ SV1*HC:46663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*15~ SV1*HC:56663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*16~ SV1*HC:66663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*17~ SV1*HC:76663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*18~ SV1*HC:86663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*19~ SV1*HC:96663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*20~ SV1*HC:10663*10*UN*1***2**N~ DTP*472*D8*19981010~ HL*3*1*22*0~ SBR*P*18*12312-A******HM~ NM1*IL*1*Jones*Tom****34*000221111~ N3*236 N MAIN ST~ N4*MIAMI*FL*33413~ DMG*D8*19430501*M~ NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~ N2*COMPANY~ PAT*20~ NM1*QC*1*SMITH*JAN****34*000221111~ N3*236 N MAIN ST~ N4*MIAMI*FL*33413~ DMG*D8*19450203*F~ REF*Y4*1000020212345678~ CLM*26462967*100***11::1*Y*A*Y*Y*C*OA~ DTP*431*D8*19981003~ DTP*439*D8*19981103~ DTP*469*D8*19981203~ DTP*558*D8*19981203~ DTP*RRM*D8*19981403~ PWK*OZ*EL***AC*ZZY~ REF*D9*17312345600006351~ REF*G1*1WW06351~ K3*2222222222222222~ NTE*TPO*12345~ HI*BK:0340*BF:V7389~ NM1*82*1*KILDARE*BEN****XX*112233334~ PRV*PE*ZZ*203BF0100Y~ NM1*77*2*KILDARE ASSOCIATES*****24*581234567~ N3*2345 OCEAN BLVD~ N4*MIAMI*FL*33111~ LX*1~ SV1*HC:99213*40*UN*1***1**N~ DTP*472*D8* 19981003~ LX*2~ SV1*HC:99214*15*UN*1***1**N~ DTP*472* D8*19981003~ LX*3~ SV1*HC:87072*35*UN*1***2**N~ DTP*472*D8*19981003~ LX*4~ SV1*HC:86663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*5~ SV1*HC:86664*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*6~ SV1*HC:55563*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*7~ SV1*HC:16663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*8~ SV1*HC:23663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*9~ SV1*HC:55663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*10~ SV1*HC:87763*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*11~ SV1*HC:88963*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*12~ SV1*HC:12663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*13~ SV1*HC:36663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*14~ SV1*HC:46663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*15~ SV1*HC:56663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*16~ SV1*HC:66663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*17~ SV1*HC:76663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*18~ SV1*HC:86663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*19~ SV1*HC:96663*10*UN*1***2**N~ DTP*472*D8*19981010~ LX*20~ SV1*HC:10663*10*UN*1***2**N~ DTP*472*D8*19981010~ SE*43*0021~ GE*1*27211711~ IEA*1*002721171~
Basic Inline
Base Mapping for the 837P
************************************************** ********* 837P Claim Submission Configuration ************************************************** X12TRANSACTIONTYPE=837P KEYHEADERFIELD=HL,,,20 KEYFIELD=HL,,,22 KEYLINEFIELD=SV1 FIELD=SUBID,16,NM1,IL,2,9 FIELD=PRIMARYCOV,1,SBR,P,2,1 FIELD=SECONDARYCOV,1,SBR,S,2,1 FIELD=TERTIARYCOV,1,SBR,T,2,1 FIELD=SUBLNAME,32,NM1,IL,2,3,,SUBID FIELD=SUBFNAME,32,NM1,IL,2,4,,SUBID FIELD=SUBMI,1,NM1,IL,2,5,,SUBID FIELD=SUBADDR1,30,N3,,,1,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBADDR2,30,N3,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBCITY,30,N4,,,1,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBST,2,N4,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBZIP,10,N4,,,3,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBSEX,1,DMG,,,3,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBMSTATUS,1,DMG,,,4,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBDOB,10,DMG,,,2,,SUBID,,,,,,,,NM1,IL,2,PAYERID FIELD=SUBREL,3,SBR,,,2,,SUBID FIELD=SUBORDER,1,SBR,,,1,,SUBID FIELD=PAYERID,16,NM1,PR,2,9,,SUBID FIELD=PAYERNAME,32,NM1,PR,2,3,,PAYERID FIELD=PAYERADDR1,30,N3,,,1,,PAYERID FIELD=PAYERADDR2,30,N3,,,2,,PAYERID FIELD=PAYERCITY,30,N4,,,1,,PAYERID FIELD=PAYERST,2,N4,,,2,,PAYERID FIELD=PAYERZIP,10,N4,,,3,,PAYERID FIELD=PRIMARYSUBID,16,NM1,IL,2,9,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBLNAME,32,NM1,IL,2,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBFNAME,32,NM1,IL,2,4,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBMI,1,NM1,IL,2,5,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBADDR1,30,N3,,,1,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBADDR2,30,N3,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBCITY,30,N4,,,1,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBST,2,N4,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBZIP,10,N4,,,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBSEX,1,DMG,,,3,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBMSTATUS,1,DMG,,,4,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBDOB,10,DMG,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYSUBREL,3,SBR,,,2,,PRIMARYCOV,,,,,,,,SBR,P,2,PRIMARYPAYERID FIELD=PRIMARYPAYERID,16,NM1,PR,2,9,,PRIMARYCOV FIELD=PRIMARYPAYERNAME,32,NM1,PR,2,3,,PRIMARYCOV FIELD=PRIMARYPAYERADDR1,30,N3,,,1,,PRIMARYCOV FIELD=PRIMARYPAYERADDR2,30,N3,,,2,,PRIMARYCOV FIELD=PRIMARYPAYERCITY,30,N4,,,1,,PRIMARYCOV FIELD=PRIMARYPAYERST,2,N4,,,2,,PRIMARYCOV FIELD=PRIMARYPAYERZIP,10,N4,,,3,,PRIMARYCOV FIELD=SECONDARYSUBID,16,NM1,IL,2,9,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBLNAME,32,NM1,IL,2,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBFNAME,32,NM1,IL,2,4,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBMI,1,NM1,IL,2,5,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBADDR1,30,N3,,,1,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBADDR2,30,N3,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBCITY,30,N4,,,1,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBST,2,N4,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBZIP,10,N4,,,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBSEX,1,DMG,,,3,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBMSTATUS,1,DMG,,,4,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBDOB,10,DMG,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYSUBREL,3,SBR,,,2,,SECONDARYCOV,,,,,,,,SBR,S,2,SECONDARYPAYERID FIELD=SECONDARYPAYERID,16,NM1,PR,2,9,,SECONDARYCOV FIELD=SECONDARYPAYERNAME,32,NM1,PR,2,3,,SECONDARYCOV FIELD=SECONDARYPAYERADDR1,30,N3,,,1,,SECONDARYCOV FIELD=SECONDARYPAYERADDR2,30,N3,,,2,,SECONDARYCOV FIELD=SECONDARYPAYERCITY,30,N4,,,1,,SECONDARYCOV FIELD=SECONDARYPAYERST,2,N4,,,2,,SECONDARYCOV FIELD=SECONDARYPAYERZIP,10,N4,,,3,,SECONDARYCOV FIELD=TERTIARYSUBID,16,NM1,IL,2,9,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBLNAME,32,NM1,IL,2,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBFNAME,32,NM1,IL,2,4,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBMI,1,NM1,IL,2,5,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBADDR1,30,N3,,,1,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBADDR2,30,N3,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBCITY,30,N4,,,1,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBST,2,N4,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBZIP,10,N4,,,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBSEX,1,DMG,,,3,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBMSTATUS,1,DMG,,,4,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBDOB,10,DMG,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYSUBREL,3,SBR,,,2,,TERTIARYCOV,,,,,,,,SBR,T,2,TERTIARYPAYERID FIELD=TERTIARYPAYERID,16,NM1,PR,2,9,,TERTIARYCOV FIELD=TERTIARYPAYERNAME,32,NM1,PR,2,3,,TERTIARYCOV FIELD=TERTIARYPAYERADDR1,30,N3,,,1,,TERTIARYCOV FIELD=TERTIARYPAYERADDR2,30,N3,,,2,,TERTIARYCOV FIELD=TERTIARYPAYERCITY,30,N4,,,1,,TERTIARYCOV FIELD=TERTIARYPAYERST,2,N4,,,2,,TERTIARYCOV FIELD=TERTIARYPAYERZIP,10,N4,,,3,,TERTIARYCOV FIELD=PATID,16,NM1,QC,2,9 FIELD=PATLNAME,32,NM1,QC,2,3 FIELD=PATFNAME,32,NM1,QC,2,4 FIELD=PATMI,1,NM1,QC,2,5 FIELD=PATADDR1SUBADDR1,30,N3,,,1,,PATLNAME FIELD=PATADDR2SUBADDR2,30,N3,,,2,,PATLNAME FIELD=PATCITY,30,N4,,,1,,PATLNAME FIELD=PATST,2,N4,,,2,,PATLNAME FIELD=PATZIP,10,N4,,,3,,PATLNAME FIELD=PATSEX,1,DMG,,,3,,PATLNAME FIELD=PATMSTAT,1,DMG,,,4,,PATLNAME FIELD=PATDOB,10,DMG,,,2,,PATLNAME FIELD=PATREL,1,PAT,,,2,,PATLNAME FIELD=CLAIMID,20,CLM,,,1,,SUBID FIELD=CLAIMAMT,20,CLM,,,2,,SUBID FIELD=PROVSIGNATUREONFILE,4,CLM,,,7,,SUBID FIELD=PROVACCEPTASSIGNMENTCODE,4,CLM,,,8,,SUBID FIELD=BENEFITINDICATOR,4,CLM,,,9,,SUBID FIELD=RELEASEOFINFORMATION,2,CLM,,,10,,SUBID FIELD=RELATEDCAUSE,20,CLM,,,12,,SUBID FIELD=FACILITYCODEVALUE,3,CLM,,,5,1,SUBID FIELD=FACILITYCODEQUALIFIER,3,CLM,,,5,2,SUBID FIELD=FREQUENCYTYPECODE,3,CLM,,,5,3,SUBID FIELD=MEDICALRECORDNUMBER,10,REF,EA,2,2,,SUBID FIELD=CLAIMNUMBER,10,REF,D9,2,2,,SUBID FIELD=PRIORAUTH,10,REF,G1,2,2,,SUBID FIELD=K3DATA,20,K3,,,1,,SUBID FIELD=NOTECODE,4,NTE,,,1,,SUBID FIELD=NOTEDESC,4,NTE,,,2,,SUBID FIELD=SUPPLEMENTALINFOTYPE,4,PWK,,,1,,SUBID FIELD=SUPPLEMENTALINFOTRANS,4,PWK,,,2,,SUBID FIELD=SUPPLEMENTALINFODESC,4,PWK,,,6,,SUBID FIELD=DX1,6,HI,,,1,2,SUBID FIELD=DX2,6,HI,,,2,2,SUBID FIELD=DX3,6,HI,,,3,2,SUBID FIELD=DX4,6,HI,,,4,2,SUBID FIELD=DX5,6,HI,,,5,2,SUBID FIELD=REFERRINGID,16,NM1,DN,2,9,,SUBID FIELD=REFERRINGLNAME,32,NM1,DN,2,3,,SUBID FIELD=REFERRINGFNAME,32,NM1,DN,2,4,,SUBID FIELD=REFERRINGMNAME,32,NM1,DN,2,5,,SUBID FIELD=REFERRINGPREFIX,32,NM1,DN,2,6,,SUBID FIELD=REFERRINGSUFFIX,32,NM1,DN,2,7,,SUBID FIELD=REFERRINGIDCODE,4,NM1,DN,2,8,,SUBID FIELD=REFERRINGTYPE,2,NM1,DN,2,1,,SUBID FIELD=RENDERINGID,16,NM1,82,2,9,,SUBID FIELD=RENDERINGLNAME,32,NM1,82,2,3,,SUBID FIELD=RENDERINGFNAME,32,NM1,82,2,4,,SUBID FIELD=RENDERINGMNAME,32,NM1,82,2,5,,SUBID FIELD=RENDERINGPREFIX,32,NM1,82,2,6,,SUBID FIELD=RENDERINGSUFFIX,32,NM1,82,2,7,,SUBID FIELD=RENDERINGIDCODE,4,NM1,82,2,8,,SUBID FIELD=RENDERINGTYPE,2,NM1,82,2,1,,SUBID FIELD=SUPERVISINGID,16,NM1,DQ,2,9,,SUBID FIELD=SUPERVISINGLNAME,32,NM1,DQ,2,3,,SUBID FIELD=SUPERVISINGFNAME,32,NM1,DQ,2,4,,SUBID FIELD=SUPERVISINGMNAME,32,NM1,DQ,2,5,,SUBID FIELD=SUPERVISINGPREFIX,32,NM1,DQ,2,6,,SUBID FIELD=SUPERVISINGSUFFIX,32,NM1,DQ,2,7,,SUBID FIELD=SUPERVISINGIDCODE,4,NM1,DQ,2,8,,SUBID FIELD=SUPERVISINGTYPE,2,NM1,DQ,2,1,,SUBID FIELD=SERVICEFACILITYNAME,32,NM1,77,2,3,,SUBID FIELD=SERVICEFACILIYID,16,NM1,77,2,9,,SUBID FIELD=PROC1,10,SV1,,,1,2,SUBID,,,1 FIELD=MODA1,3,SV1,,,1,3,SUBID,,,1 FIELD=MODB1,3,SV1,,,1,4,SUBID,,,1 FIELD=MODC1,3,SV1,,,1,5,SUBID,,,1 FIELD=MODD1,3,SV1,,,1,6,SUBID,,,1 FIELD=AMT1,10,SV1,,,2,,SUBID,,,1 FIELD=UNITS1,10,SV1,,,3,,SUBID,,,1 FIELD=QTY1,15,SV1,,,4,,SUBID,,,1 FIELD=FACILITYCODE1,2,SV1,,,5,,SUBID,,,1 FIELD=DCPA1,1,SV1,,,7,1,SUBID,,,1 FIELD=DCPB1,1,SV1,,,7,2,SUBID,,,1 FIELD=DCPC1,1,SV1,,,7,3,SUBID,,,1 FIELD=DCPD1,1,SV1,,,7,4,SUBID,,,1 FIELD=DOS1,10,DTP,472,2,3,,SUBID,,,1 FIELD=PROC2,10,SV1,,,1,2,SUBID,,,2 FIELD=MODA2,3,SV1,,,1,3,SUBID,,,2 FIELD=MODB2,3,SV1,,,1,4,SUBID,,,2 FIELD=MODC2,3,SV1,,,1,5,SUBID,,,2 FIELD=MODD2,3,SV1,,,1,6,SUBID,,,2 FIELD=AMT2,10,SV1,,,2,,SUBID,,,2 FIELD=UNITS2,10,SV1,,,3,,SUBID,,,2 FIELD=QTY2,15,SV1,,,4,,SUBID,,,2 FIELD=FACILITYCODE2,2,SV1,,,5,,SUBID,,,2 FIELD=DCPA2,1,SV1,,,7,1,SUBID,,,2 FIELD=DCPB2,1,SV1,,,7,2,SUBID,,,2 FIELD=DCPC2,1,SV1,,,7,3,SUBID,,,2 FIELD=DCPD2,1,SV1,,,7,4,SUBID,,,2 FIELD=DOS2,10,DTP,472,2,3,,SUBID,,,2 FIELD=PROC3,10,SV1,,,1,2,SUBID,,,3 FIELD=MODA3,3,SV1,,,1,3,SUBID,,,3 FIELD=MODB3,3,SV1,,,1,4,SUBID,,,3 FIELD=MODC3,3,SV1,,,1,5,SUBID,,,3 FIELD=MODD3,3,SV1,,,1,6,SUBID,,,3 FIELD=AMT3,10,SV1,,,2,,SUBID,,,3 FIELD=UNITS3,10,SV1,,,3,,SUBID,,,3 FIELD=QTY3,15,SV1,,,4,,SUBID,,,3 FIELD=FACILITYCODE3,2,SV1,,,5,,SUBID,,,3 FIELD=DCPA3,1,SV1,,,7,1,SUBID,,,3 FIELD=DCPB3,1,SV1,,,7,2,SUBID,,,3 FIELD=DCPC3,1,SV1,,,7,3,SUBID,,,3 FIELD=DCPD3,1,SV1,,,7,4,SUBID,,,3 FIELD=DOS3,10,DTP,472,2,3,,SUBID,,,3 FIELD=PROC4,10,SV1,,,1,2,SUBID,,,4 FIELD=MODA4,3,SV1,,,1,3,SUBID,,,4 FIELD=MODB4,3,SV1,,,1,4,SUBID,,,4 FIELD=MODC4,3,SV1,,,1,5,SUBID,,,4 FIELD=MODD4,3,SV1,,,1,6,SUBID,,,4 FIELD=AMT4,10,SV1,,,2,,SUBID,,,4 FIELD=UNITS4,10,SV1,,,3,,SUBID,,,4 FIELD=QTY4,15,SV1,,,4,,SUBID,,,4 FIELD=FACILITYCODE4,2,SV1,,,5,,SUBID,,,4 FIELD=DCPA4,1,SV1,,,7,1,SUBID,,,4 FIELD=DCPB4,1,SV1,,,7,2,SUBID,,,4 FIELD=DCPC4,1,SV1,,,7,3,SUBID,,,4 FIELD=DCPD4,1,SV1,,,7,4,SUBID,,,4 FIELD=DOS4,10,DTP,472,2,3,,SUBID,,,4 FIELD=PROC5,10,SV1,,,1,2,SUBID,,,5 FIELD=MODA5,3,SV1,,,1,3,SUBID,,,5 FIELD=MODB5,3,SV1,,,1,4,SUBID,,,5 FIELD=MODC5,3,SV1,,,1,5,SUBID,,,5 FIELD=MODD5,3,SV1,,,1,6,SUBID,,,5 FIELD=AMT5,10,SV1,,,2,,SUBID,,,5 FIELD=UNITS5,10,SV1,,,3,,SUBID,,,5 FIELD=QTY5,15,SV1,,,4,,SUBID,,,5 FIELD=FACILITYCODE5,2,SV1,,,5,,SUBID,,,5 FIELD=DCPA5,1,SV1,,,7,1,SUBID,,,5 FIELD=DCPB5,1,SV1,,,7,2,SUBID,,,5 FIELD=DCPC5,1,SV1,,,7,3,SUBID,,,5 FIELD=DCPD5,1,SV1,,,7,4,SUBID,,,5 FIELD=DOS5,10,DTP,472,2,3,,SUBID,,,5 FIELD=PROC6,10,SV1,,,1,2,SUBID,,,6 FIELD=MODA6,3,SV1,,,1,3,SUBID,,,6 FIELD=MODB6,3,SV1,,,1,4,SUBID,,,6 FIELD=MODC6,3,SV1,,,1,5,SUBID,,,6 FIELD=MODD6,3,SV1,,,1,6,SUBID,,,6 FIELD=AMT6,10,SV1,,,2,,SUBID,,,6 FIELD=UNITS6,10,SV1,,,3,,SUBID,,,6 FIELD=QTY6,15,SV1,,,4,,SUBID,,,6 FIELD=FACILITYCODE6,2,SV1,,,5,,SUBID,,,6 FIELD=DCPA6,1,SV1,,,7,1,SUBID,,,6 FIELD=DCPB6,1,SV1,,,7,2,SUBID,,,6 FIELD=DCPC6,1,SV1,,,7,3,SUBID,,,6 FIELD=DCPD6,1,SV1,,,7,4,SUBID,,,6 FIELD=DOS6,10,DTP,472,2,3,,SUBID,,,6 FIELD=PROC7,10,SV1,,,1,2,SUBID,,,7 FIELD=MODA7,3,SV1,,,1,3,SUBID,,,7 FIELD=MODB7,3,SV1,,,1,4,SUBID,,,7 FIELD=MODC7,3,SV1,,,1,5,SUBID,,,7 FIELD=MODD7,3,SV1,,,1,6,SUBID,,,7 FIELD=AMT7,10,SV1,,,2,,SUBID,,,7 FIELD=UNITS7,10,SV1,,,3,,SUBID,,,7 FIELD=QTY7,15,SV1,,,4,,SUBID,,,7 FIELD=FACILITYCODE7,2,SV1,,,5,,SUBID,,,7 FIELD=DCPA7,1,SV1,,,7,1,SUBID,,,7 FIELD=DCPB7,1,SV1,,,7,2,SUBID,,,7 FIELD=DCPC7,1,SV1,,,7,3,SUBID,,,7 FIELD=DCPD7,1,SV1,,,7,4,SUBID,,,7 FIELD=DOS7,10,DTP,472,2,3,,SUBID,,,7 FIELD=PROC8,10,SV1,,,1,2,SUBID,,,8 FIELD=MODA8,3,SV1,,,1,3,SUBID,,,8 FIELD=MODB8,3,SV1,,,1,4,SUBID,,,8 FIELD=MODC8,3,SV1,,,1,5,SUBID,,,8 FIELD=MODD8,3,SV1,,,1,6,SUBID,,,8 FIELD=AMT8,10,SV1,,,2,,SUBID,,,8 FIELD=UNITS8,10,SV1,,,3,,SUBID,,,8 FIELD=QTY8,15,SV1,,,4,,SUBID,,,8 FIELD=FACILITYCODE8,2,SV1,,,5,,SUBID,,,8 FIELD=DCPA8,1,SV1,,,7,1,SUBID,,,8 FIELD=DCPB8,1,SV1,,,7,2,SUBID,,,8 FIELD=DCPC8,1,SV1,,,7,3,SUBID,,,8 FIELD=DCPD8,1,SV1,,,7,4,SUBID,,,8 FIELD=DOS8,10,DTP,472,2,3,,SUBID,,,8 FIELD=PROC9,10,SV1,,,1,2,SUBID,,,9 FIELD=MODA9,3,SV1,,,1,3,SUBID,,,9 FIELD=MODB9,3,SV1,,,1,4,SUBID,,,9 FIELD=MODC9,3,SV1,,,1,5,SUBID,,,9 FIELD=MODD9,3,SV1,,,1,6,SUBID,,,9 FIELD=AMT9,10,SV1,,,2,,SUBID,,,9 FIELD=UNITS9,10,SV1,,,3,,SUBID,,,9 FIELD=QTY9,15,SV1,,,4,,SUBID,,,9 FIELD=FACILITYCODE9,2,SV1,,,5,,SUBID,,,9 FIELD=DCPA9,1,SV1,,,7,1,SUBID,,,9 FIELD=DCPB9,1,SV1,,,7,2,SUBID,,,9 FIELD=DCPC9,1,SV1,,,7,3,SUBID,,,9 FIELD=DCPD9,1,SV1,,,7,4,SUBID,,,9 FIELD=DOS9,10,DTP,472,2,3,,SUBID,,,9 FIELD=PROC10,10,SV1,,,1,2,SUBID,,,10 FIELD=MODA10,3,SV1,,,1,3,SUBID,,,10 FIELD=MODB10,3,SV1,,,1,4,SUBID,,,10 FIELD=MODC10,3,SV1,,,1,5,SUBID,,,10 FIELD=MODD10,3,SV1,,,1,6,SUBID,,,10 FIELD=AMT10,10,SV1,,,2,,SUBID,,,10 FIELD=UNITS10,10,SV1,,,3,,SUBID,,,10 FIELD=QTY10,15,SV1,,,4,,SUBID,,,10 FIELD=FACILITYCODE10,2,SV1,,,5,,SUBID,,,10 FIELD=DCPA10,1,SV1,,,7,1,SUBID,,,10 FIELD=DCPB10,1,SV1,,,7,2,SUBID,,,10 FIELD=DCPC10,1,SV1,,,7,3,SUBID,,,10 FIELD=DCPD10,1,SV1,,,7,4,SUBID,,,10 FIELD=DOS10,10,DTP,472,2,3,,SUBID,,,10 FIELD=BILLINGPROVIDERID,16,NM1,85,2,9,,,,2 FIELD=BILLINGPROVIDERNAME,32,NM1,85,2,3,,,,2 FIELD=BILLINGPROVIDERADDR1,30,N3,,,1,,BILLINGPROVIDERNAME,,2 FIELD=BILLINGPROVIDERADDR2,30,N3,,,2,,BILLINGPROVIDERNAME,,2 FIELD=BILLINGPROVIDERCITY,30,N4,,,1,,BILLINGPROVIDERNAME,,2 FIELD=BILLINGPROVIDERST,2,N4,,,2,,BILLINGPROVIDERNAME,,2 FIELD=BILLINGPROVIDERZIP,10,N4,,,3,,BILLINGPROVIDERNAME,,2 FIELD=PAYTOPROVIDERID,16,NM1,87,2,9,,SUBID FIELD=PAYTOPROVIDERNAME,32,NM1,87,2,3,,SUBID FIELD=PAYTOPROVIDERADDR1,30,N3,,,1,,PAYTOPROVIDERNAME FIELD=PAYTOPROVIDERADDR2,30,N3,,,2,,PAYTOPROVIDERNAME FIELD=PAYTOPROVIDERCITY,30,N4,,,1,,PAYTOPROVIDERNAME FIELD=PAYTOPROVIDERST,2,N4,,,2,,PAYTOPROVIDERNAME FIELD=PAYTOPROVIDERZIP,10,N4,,,3,,PAYTOPROVIDERNAME FIELD=SUBMITTERID,16,NM1,41,2,9 FIELD=SUBMITTERNAME,32,NM1,41,2,3,,SUBMITTERID FIELD=SUBMITTERADDR1,30,N3,,,1,,SUBMITTERNAME FIELD=SUBMITTERADDR2,30,N3,,,2,,SUBMITTERNAME FIELD=SUBMITTERCITY,30,N4,,,1,,SUBMITTERNAME FIELD=SUBMITTERST,2,N4,,,2,,SUBMITTERNAME FIELD=SUBMITTERZIP,10,N4,,,3,,SUBMITTERNAME FIELD=TRANSACTIONSETCODE,10,BHT,,,2,,,,1 FIELD=TRANSACTIONID,20,BHT,,,3,,,,1 FIELD=TRANSACTIONDATE,10,BHT,,,4,,,,1 FIELD=TRANSACTIONTIME,10,BHT,,,5,,,,1 FIELD=TRANSACTIONTYPE,10,BHT,,,6,,,,1 SEGMENT=1,BHT,0019,$TRANSACTIONSETCODE,$TRANSACTIONID,$TRANSACTIONDATESEGMENT=1,REF,87,004010X98SEGMENT=1,NM1,41,$SUBMITTERNAME SEGMENT=1,N3,$SUBMITTERADDRESS1,$SUBMITTERADDRESS2 SEGMENT=1,N4,$SUBMITTERCITY,$SUBMITTERERST,$SUBMITTERZIP SEGMENT=1,HL,&HL,,20,1 SEGMENT=1,NM1,85,$BILLINGPROVIDERNAME SEGMENT=1,N3,$BILLINGPROVIDERADDRESS1,$BILLINGPROVIDERADDRESS2 SEGMENT=1,N4,$BILLINGPROVIDERCITY,$BILLINGPROVIDERERST,$BILLINGPROVIDERZIP SEGMENT=1,NM1,87,$PAYTOPROVIDERNAME SEGMENT=1,N3,$PAYTOPROVIDERADDRESS1,$PAYTOPROVIDERADDRESS2 SEGMENT=1,N4,$PAYTOPROVIDERCITY,$PAYTOPROVIDERERST,$PAYTOPROVIDERZIP SEGMENT=2,HL,&HL,1,22,0 SEGMENT=2,SBR,P,18 SEGMENT=2,NM1,IL,1,$SUBLNAME,$SUBFNAME,$SUBMI,,,XX,$SUBID SEGMENT=2,N3,$SUBADDRESS1,$SUBADDRESS2 SEGMENT=2,N4,$SUBCITY,$SUBERST,$SUBZIP SEGMENT=2,CLM,$CLAIMID,$CLAIMAMT,,,Y,A,Y,Y,C SEGMENT=2,HI,%BK;$DX1 SEGMENT=3,SV1,%HC;$PROC,$AMT,$UNITS,$QTY SEGMENT=3,DTM,472,D8,$DOS