sita kapoor infotech global inc. 100 franklin square dr. somerset, nj 08873 sk@igiusa

Sita KapoorSita KapoorInfotech Global Inc.Infotech Global Inc.100 Franklin Square Dr.100 Franklin Square Dr.Somerset, NJ 08873Somerset, NJ 08873sk@igiusa.comsk@igiusa.com

Profession Claim exampleProfession Claim example 837 Professional ASC x12N

(004010x098A1)

September 24, 2003

SUBSCRIBER/PATIENT: Ted Smith

ADDRESS: 236 N. Main St., Miami, FL 33413

TELEPHONE NUMBER: 305-555-1111

SEX: Male

DOB: 05/01/1948

GROUP#: 12312-A

SSN: 000-22-1111

DESTINATION PAYER: ACS BENEFITS SERVICES

PAYOR ADDRESS: P O Box 2181, Somerset, NJ 08853

PAYER ID NUMBER: 00520

Claim Information, in EnglishClaim Information, in EnglishClaim Information, in EnglishClaim Information, in English

Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500

BILLING PROVIDER/SENDER: Michael Brenett

ADDRESS: ASSAD, WASSAD NJ 12121212

TIN: 111753453

RENDERING PROVIDER: Michael Brenett

Payer Provider ID: 52054

UPIN ID C68426

PATIENT ACCOUNT NUMBER: SM-192619

CASE: Office Visit DOS=03/21/2003. POS=Office

SERVICES RENDERED:

Office first visit = $40.00

Next CPT Code = $15.00

Next CPT Code = $35.00

Claim Information, in EnglishClaim Information, in EnglishClaim Information, in EnglishClaim Information, in English

Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500Claim Information, in HCFA 1500

V1506

BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*Z9988~PER*IC*MNJY*TE*9089463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*1*BERNETT*MICHAEL****24*111753453~N3*ASSAD~N4*WSDSAD*NJ*12121212~REF*1C*52054~

Claim Information, in x12Claim Information, in x12Claim Information, in x12Claim Information, in x12

HL*2*1*22*0~SBR*P*18**ACS BENEFITS SERVICES*****16~NM1*IL*1*SMITH*TED****MI*000221111~N3*2316 N. MAIN STREET~N4*MIAMI*FL*33413~DMG*D8*19480501*M~REF*1G*12312-A~NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~N3*P O BOX 2181~N4*SOMERSET*NJ*08853~CLM*SM192619*55***22::1*Y*A*Y*A*C~DTP*431*D8*20030321~HI*BF:V1506~NM1*82*1*BERNETT*MICHAEL****ZZ*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~LX*1~SV1*HC:99213*40*UN*1*40**1**Y******0~DTP*472*RD8*20030321-20030321~LX*2~SV1*HC:99214*40*UN*1*15**1**Y******0~DTP*472*D8*20030321~LX*3~SV1*HC:99215*40*UN*1*30**1**Y******0~DTP*472*RD8*20030321-20030323~

Claim Information, in x12Claim Information, in x12Claim Information, in x12Claim Information, in x12

52054 C68426

HL*1**20*1~

NM1*85*1*BERNETT*MICHAEL****24*111753453~

N3*ASSAD~

N4*WSDSAD*NJ*12121212~

REF*1C*52054~

Provider InformationProvider InformationProvider InformationProvider Information

HL*2*1*22*0~

SBR*P*18**ACS BENEFITS SERVICES*****16~

NM1*IL*1*SMITH*TED****MI*000221111~

N3*2316 N. MAIN STREET~

N4*MIAMI*FL*33413~

DMG*D8*19480501*M~

NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~

N3*P O BOX 2181~

N4*SOMERSET*NJ*08853~

Subscriber InformationSubscriber InformationSubscriber InformationSubscriber Information

HL*2*1*22*0~

SBR*P*18**ACS BENEFITS SERVICES*****16~

NM1*IL*1*SMITH*TED****MI*000221111~

N3*2316 N. MAIN STREET~

N4*MIAMI*FL*33413~

DMG*D8*19480501*M~

REF*1G*12312-A~

NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~

N3*P O BOX 2181~

N4*SOMERSET*NJ*08853~

Subscriber InformationSubscriber InformationSubscriber InformationSubscriber Information

The Subscriber is the Patient

The Patient Loop will not be mapped

Patient InformationPatient InformationPatient InformationPatient Information

HL*2*1*22*0~

SBR*P*18**ACS BENEFITS SERVICES*****16~

NM1*IL*1*SMITH*TED****MI*000221111~

N3*2316 N. MAIN STREET~

N4*MIAMI*FL*33413~

DMG*D8*19480501*M~

REF*1G*12312-A~

NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~

N3*P O BOX 2181~

N4*SOMERSET*NJ*08853~

Subscriber Payer InformationSubscriber Payer InformationSubscriber Payer InformationSubscriber Payer Information

CLM*SM192619*85***11::1*Y*A*Y*A*C~

DTP*431*D8*20030321~

HI*BF:V1506~

NM1*82*1*BERNETT*MICHAEL****24*52054~

PRV*PE*ZZ*282N00000X~

REF*1G*C68426~

Original

Claim InformationClaim InformationClaim InformationClaim Information

CLM*SM192619*85***11::1*Y*A*Y*A*C~

DTP*431*D8*20030321~

HI*BF:V1506~

NM1*82*1*BERNETT*MICHAEL****24*52054~

PRV*PE*ZZ*282N00000X~

REF*1G*C68426~

Original

OfficeVisit

Original

Claim InformationClaim InformationClaim InformationClaim Information

V1506

LX*1~

SV1*HC:99213*40*UN*1*06**1**Y******0~

DTP*472*RD8*20030321-20030321~

LX*2~

SV1*HC:99214*40*UN*1*06**1**Y******0~

DTP*472*D8*20030321~

LX*3~

SV1*HC:99215*40*UN*2*06**1**Y******0~

DTP*472*RD8*20030321-20030323~

Service Line InformationService Line InformationService Line InformationService Line Information

BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*Z9988~PER*IC*MNJY*TE*9089463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*1*BERNETT*MICHAEL****24*111753453~N3*ASSAD~N4*WSDSAD*NJ*12121212~REF*1C*52054~HL*2*1*22*0~SBR*P*18*000221111*ACS BENEFITS SERVICES*****MB~NM1*IL*1*SMITH*TEX*S***MI*000221111~N3*2316 N. MAIN STREET~N4*MIAMI*FL*33413~REF*87*3053331111~DMG*D8*19480501*M~NM1*PR*2*ACS BENEFITS SERVICES*****PI*00520~N3*P O BOX 1181~N4*SOMERSET*NJ*08853~CLM*1154748*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030321~HI*BF:V1506~NM1*82*1*BERNETT*MICHAEL****24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~LX*1~SV1*HC:99213*40*UN*1*40**1**Y******0~DTP*472*RD8*20030321-20030321~LX*2~SV1*HC:99214*40*UN*1*15**1**Y******0~DTP*472*D8*20030321~LX*3~SV1*HC:99215*40*UN*1*30**1**Y******0~DTP*472*RD8*20030321-20030323~

EDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N format

EDI TransactionEDI Transaction

Control SegmentsControl Segments

Control EnvelopesControl EnvelopesControl EnvelopesControl Envelopes

Control Envelopes – ISA / IEAISA / IEA

• Interchange envelope

– GS / GEGS / GE• Functional group envelope

– ST / SEST / SE• Transaction set envelope

(One Business Document)(One Business Document)

EQUALSEQUALS

HCFA1500

Functions of the Transaction Set Functions of the Transaction Set (ST/SE) Control Envelope(ST/SE) Control Envelope

SE *SE *

0101 0202

**

~~

EDI Data - Claim #1EDI Data - Claim #1Transaction SetTransaction Set

ST *ST *

0101 0202

**

~~

EDI Transaction Set with Control Envelope

Control EnvelopeControl Envelope

ST*837*1234~BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~ NM1*40*2*BCBS*****46*980005420~HL*1**20*1~NM1*85*2*IGI HOSPITAL & NURSING HOME*****24*980S57F237~

{cont}

SE*14*1234~ST*837*1235~

BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~ NM1*40*2*BCBS*****46*980005420~HL*1**20*1~NM1*85*2*IGI HOSPITAL & NURSING HOME*****24*980S57F237~

{cont}

SE*14*1235~

Transaction Set (ST/SE) Transaction Set (ST/SE) Control EnvelopeControl Envelope

Transaction Set (ST/SE) Transaction Set (ST/SE) Control EnvelopeControl Envelope

Functional Groups

HCFA15001500

HCFA15001500

HCFA1500

Transaction Sets

To

: : Pa

yer A

Cla

ims P

ay a

ble

To

: Pa

yer A

Cla

ims R

ep

ortin

g

EQUALS

Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope

Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope

FFUUNNCCTTIIOONNAALL

EDI Data – Claims (charges)EDI Data – Claims (charges)

EDI Data – Claims (reporting) EDI Data – Claims (reporting)

GS *GS *

GE *GE *

0101

0101

0505 0606 0707 0808

040403030202

0202

Trans SetTrans Set

Trans SetTrans Set

STST

STST

SESE

SESE

** ** ** **

** ** **

****

~~

~~~~

Control EnvelopeControl EnvelopeControl EnvelopeControl Envelope

GS*HC*ZZ576*00520*20030923*1933*20030923*X*004010X098A1~ ST*837*1234~

BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~

SE*1000*1234~ ST*837*1235~

BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~

SE*26*1234~GE*2*20030923~

Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope

Functional Group (GS/GE) Functional Group (GS/GE) Control EnvelopeControl Envelope

HCFA15001500

HCFA15001500

EligibilityInformation

EXPRESS DELIVERY

Sender:

Dr Jones345 laneNJ 99893

Receiver:

BSBC OF CA232 LNCA 09393

Tracking #: 000000000177975 021760 7

Transaction Sets

Functional Groups

Interchange

To

: : Pa

yer A

Cla

ims P

ay a

ble

To

: : Pa

yer A

Me

mb

er E

nro

l lme

nt

Interchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control EnvelopeInterchange (ISA/IEA) Control Envelope

FFUUNNCCTTIIOONNAALL

GGRROOUUPP

GE GE

EDI Data – HCFA SET #1EDI Data – HCFA SET #1Trans SetTrans Set

STST

SESE

GS GS

IEA *IEA * 0101 0202** ~~

ISAISA 0101 040403030202** ** ** ** 0505 06 07 08** ** **

~0909 121211111010** ** ** ** 13 14 15 16** ** ****

**

Control EnvelopeControl EnvelopeControl EnvelopeControl Envelope

EDI Data – HCFA SET #2EDI Data – HCFA SET #2Trans SetTrans Set

STST

SESE

EDI Data Eligibility Info #1EDI Data Eligibility Info #1Trans SetTrans Set

STST

SESE

GS GS

GE GE

IINNTTEERRCCHHAANNGGEE

ISA*00*0000000001*00*0000000001*ZZ*E1576 *30*00520 *200309*1933*U*00401*000000001*1*T*:~

Interchange (ISA/IEA) Interchange (ISA/IEA) Control EnvelopeControl Envelope

Interchange (ISA/IEA) Interchange (ISA/IEA) Control EnvelopeControl Envelope

IEA*1*000000001~

GS*HC*E1576*00520*20030923*1933*20030923*X*004010X098A1~ ST*837*1234~

BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~

SE*1000*1234~ ST*837*1235~

BHT*0019*00*20030923*20030923*1933*RP~REF*87*004010X098DA1~NM1*41*2*IGI HOSPITAL & NURSING HOME*****46*ZZZ98576~PER*IC*MARY*TE*7322710600~

SE*26*1234~GE*2*20030923~

ISA*00*0000000001*00*0000000001*ZZ*E1576 *30*00520 *200309*1933*U*00401*000000001*1*T*:~GS*HC*E1576*00520*20030923*1933*20030923*X*004010X098A1~ST*837*00001~BHT*0019*00*20030923*20030923*1933*CH~REF*87*004010X098DA1~NM1*41*2*DEWITT HOSPITAL & NURSING HOME*****46*E1576~PER*IC*SUSAN*TE*8709463571~NM1*40*2*BCBS*****46*00520~HL*1**20*1~NM1*85*2*DEWITT HOSPITAL & NURSING HOME*****24*57237~N3*P.O. BOX 32~N4*DE WITT*AR*72042~REF*1C*57237~HL*2*1*22*0~SBR*P*18*XCAV71748*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*DEBERRY*WILLIAM*S***MI*XCAV71748~N3*90 SAM DEBERRY RD~N4*DEWITT*AR*720420000~DMG*D8*19530817*M~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154748*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030726~HI*BK:9895*BF:72981*BF:E9053*BF:V1506~NM1*DN*1*BURLESON*STAN*W***24*D04410~REF*1B*X~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*22**1:2:3:4**Y******0~DTP*472*RD8*20030726-20030726~HL*3*1*22*0~SBR*P*18*431356390*AMCO/AHA-1ST SOURCE REPRICI*****MB~PAT*~NM1*IL*1*JAMES*KELLY****MI*431356390~N3*813 W GIBSON~N4*DEWITT*AR*72042~DMG*D8*19721113*F~NM1*PR*2*AMCO/AHA-1ST SOURCE REPRICI*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722032181~CLM*1154754*55***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030726~HI*BK:7840*BF:78701~NM1*DN*1*GUSTAVUS*JOHN*L***24*C68426~REF*1B*52054~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*22**1:2**Y******0~DTP*472*RD8*20030726-20030726~HL*4*1*22*0~SBR*P*18*HIP431310803-00*BLUE ADVANTAGE ADMINISTRATO*****MB~PAT*~NM1*IL*1*PADGETT*DELORES****MI*HIP431310803-00~N3*P.O.BOX 56~N4*ETHEL*AR*72048~DMG*D8*19400405*F~NM1*PR*2*BLUE ADVANTAGE ADMINISTRATO*****PI*00520~N3*P.O. BOX 1460~N4*LITTLE ROCK*AR*722030000~CLM*1154731*100***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030725~HI*BK:78902*BF:78701*BF:7936*BF:V1005~NM1*DN*1*GUSTAVUS*JOHN*L***24*C68426~REF*1B*52054~NM1*82*1*GUSTAVUS*JOHN*L***24*52054~PRV*PE*ZZ*282N00000X~REF*1G*C68426~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99284*100*UN*1*22**1:2:3:4**Y******0~DTP*472*RD8*20030725-20030725~HL*5*1*22*0~SBR*P*18*XCJ990004117*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*ESTES*LARRY****MI*XCJ990004117~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*853101*198***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030730~HI*BK:41091*BF:3051~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99223*198*UN*1*22**1:2**Y******0~DTP*472*RD8*20030730-20030730~HL*6*1*22*0~SBR*P*18*XCSL83633*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*FLY*CYNTHIA****MI*XCSL83633~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154898*75***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030801~HI*BK:5920~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*22**1**Y******0~DTP*472*RD8*20030801-20030801~HL*7*1*22*0~SBR*P*18*XCAC77095*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*WRINKLE*KENNETH*G***MI*XCAC77095~N3*BOX 471~N4*GILLETT*AR*720550000~DMG*D8*19401206*M~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1154810*35***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030728~HI*BK:9181*BF:E9289~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99281*35*UN*1*22**1:2**Y******0~DTP*472*RD8*20030728-20030728~HL*8*1*22*0~SBR*P*18*431-35-6390*AMCO/AHA-1ST SOURCE REPRICI*****MB~PAT*~NM1*IL*1*JAMES*KELLY****MI*431-35-6390~N3*813 W GIBSON~N4*DEWITT*AR*72042~DMG*D8*19721113*F~NM1*PR*2*AMCO/AHA-1ST SOURCE REPRICI*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722032181~CLM*1153840*75***22::1*Y*A*Y*A*C******P~DTP*431*D8*20030606~HI*BK:4660~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*22**1**Y******0~DTP*472*RD8*20030606-20030606~HL*9*1*22*0~SBR*P*18*XCP990105122*FIRST SOURCE*****MB~PAT*~NM1*IL*1*SIEBER*LESTER****MI*XCP990105122~N3*1206 S ADAMS~N4*DEWITT*AR*720420000~DMG*D8*19991104*M~NM1*PR*2*FIRST SOURCE*****PI*00520~N3*PO BOX 2181~N4*LITTLE ROCK*AR*720990000~CLM*1155171*55***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030815~HI*BK:9895*BF:7295*BF:E9053~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99282*55*UN*1*23**1:2:3**Y******0~DTP*472*RD8*20030815-20030815~HL*10*1*22*0~SBR*P*18*XCP990105122*FIRST SOURCE*****MB~PAT*~NM1*IL*1*SIEBER*LESTER****MI*XCP990105122~NM1*PR*2*FIRST SOURCE*****PI*00520~N3*PO BOX 2181~N4*LITTLE ROCK*AR*720990000~CLM*1155172*75***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030815~HI*BK:9895*BF:78609*BF:7872*BF:7295~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*23**1:2:3:4**Y******0~DTP*472*RD8*20030815-20030815~HL*11*1*22*0~SBR*P*18*ASB4305410001*AR BLUE CROSS/BLUE SHIELD*****MB~PAT*~NM1*IL*1*WATSON*KEITH****MI*ASB4305410001~NM1*PR*2*AR BLUE CROSS/BLUE SHIELD*****PI*00520~N3*P O BOX 2181~N4*LITTLE ROCK*AR*722030000~CLM*1155162*75***23::1*Y*A*Y*A*C******P~DTP*431*D8*20030816~HI*BK:2554~NM1*DN*1*TRACY*WALLACE*LEE***24*E02920~REF*1B*50594~NM1*82*1*TRACY*WALLACE*LEE***24*50594~PRV*PE*ZZ*282N00000X~REF*1G*E02920~NM1*FA*2*DEWITT HOSPITAL & NURSING HOME~N3*P.O. BOX 32~N4*DE WITT*AR*72042~LX*1~SV1*HC:99283*75*UN*1*23**1**Y******0~DTP*472*RD8*20030816-20030816~SE*240*00001~GE*1*20030923~IEA*1*000000001~

EDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N formatEDI Claim in the x12N format