EDI 837 Data Transformation Documentation

EDI 837 Data Transformation

Create and transform EDI messages using the JSON format of the EDI.

Our current supported EDI version: 005010

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EDI 837 Request to JSON Response

Transforms an EDI 837 message into JSON.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/edi837-to-json

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Sample request (Professional Claim)

EDI 837 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X222~ST*837*0021*005010X222~BHT*0019*00*244579*20061015*1023*CH~NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~PER*IC*JERRY*TE*3055552222*EX*231~NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~HL*1**20*1~PRV*BI*PXC*203BF0100Y~NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~N3*234 SEAWAY ST~N4*MIAMI*FL*33111~REF*EI*587654321~NM1*87*2~N3*2345 OCEAN BLVD~N4*MAIMI*FL*33111~HL*2*1*22*1~SBR*P**2222-SJ******CI~NM1*IL*1*SMITH*JANE****MI*JS00111223333~DMG*D8*19430501*F~NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~REF*G2*KA6663~HL*3*2*23*0~PAT*19~NM1*QC*1*SMITH*TED~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8*19730501*M~CLM*26463774*100***11:B:1*Y*A*Y*I~REF*D9*17312345600006351~HI*BK:0340*BF:V7389~LX*1~SV1*HC:99213*40*UN*1***1~DTP*472*D8*20061003~LX*2~SV1*HC:87070*15*UN*1***1~DTP*472*D8*20061003~LX*3~SV1*HC:99214*35*UN*1***2~DTP*472*D8*20061010~LX*4~SV1*HC:86663*10*UN*1***2~DTP*472*D8*20061010~SE*42*0021~GE*1*1~IEA*1*000000001~

Sample response (Professional Claim)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "XX",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVERCODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X222"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "837",
            "ST_02_TransactionSetControlNumber_AN": "3456",
            "ST_03_ImplementationConventionReference_AN": "005010X222"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0019",
            "BHT_02_TransactionSetPurposeCode_ID": "00",
            "BHT_03_ReferenceIdentification_AN": "0123",
            "BHT_04_Date_DT": "20061123",
            "BHT_05_Time_TM": "1023",
            "BHT_06_TransactionTypeCode_ID": "CH"
          },
          "SubmiterName_Loop_1000A": {
            "SubmiterName": {
              "NM1_01_EntityIdentifierCode_ID": "41",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "PREMIER BILLING SERVICE",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "TGJ23",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            },
            "SubmitterEdiContactInformation": [
              {
                "PER_01_ContactFunctionCode_ID": "IC",
                "PER_02_Name_AN": "JERRY",
                "PER_03_CommunicationNumberQualifier_ID": "TE",
                "PER_04_CommunicationNumber_AN": "7176149999",
                "PER_05_CommunicationNumberQualifier_ID": null,
                "PER_06_CommunicationNumber_AN": null,
                "PER_07_CommunicationNumberQualifier_ID": null,
                "PER_08_CommunicationNumber_AN": null,
                "PER_09_ContactInquiryReference_AN": null
              }
            ]
          },
          "ReceiverName_Loop_1000B": {
            "ReceiverName": {
              "NM1_01_EntityIdentifierCode_ID": "40",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "INSURANCE COMPANY XYZ",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "66783JJT",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            }
          },
          "BillingProviderDetail_Loop_2000A": [
            {
              "BillingProviderHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "1",
                "HL_02_HierarchicalParentIDNumber_AN": null,
                "HL_03_HierarchicalLevelCode_ID": "20",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "BillingProviderSpecialtyInformation": null,
              "ForeignCurrencyInformation": null,
              "BillingProviderName_Loop_2010AA": {
                "BillingProviderName": {
                  "NM1_01_EntityIdentifierCode_ID": "85",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "DENTAL ASSOCIATES",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "XX",
                  "NM1_09_IdentificationCode_AN": "1234567890",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "BillingProviderAddress": {
                  "N3_01_AddressInformation_AN": "234 SEAWAY ST",
                  "N3_02_AddressInformation_AN": null
                },
                "BillingProviderCityStateZipCode": {
                  "N4_01_CityName_AN": "MIAMI",
                  "N4_02_StateOrProvinceCode_ID": "FL",
                  "N4_03_PostalCode_ID": "33111",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "BillingProviderTaxIdentification": {
                  "REF_01_ReferenceIdentificationQualifier_ID": "EI",
                  "REF_02_ReferenceIdentification_AN": "587654321",
                  "REF_03_Description_AN": null,
                  "REF_04_ReferenceIdentifier": null
                },
                "BillingProviderUPINLicenseInformation": null,
                "BillingProviderContactInformation": null
              },
              "PayToAddressName_Loop_2010AB": {
                "PayToAddressName": null,
                "PayToAddressAddress": null,
                "PayToAddressCityStateZipCode": null
              },
              "PayToPlanName_Loop_2010AC": {
                "PayToPlanName": null,
                "PayToPlanAddress": null,
                "PayToPlanCityStateZipCode": null,
                "PayToPlanSecondaryIdentification": null,
                "PayToPlanTaxIdentificationNumber": null
              }
            }
          ],
          "SubscriberDetail_Loop_2000B": [
            {
              "SubscriberHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "22",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "SubscriberInformation": {
                "SBR_01_PayerResponsibilitySequenceNumberCode_ID": "P",
                "SBR_02_IndividualRelationshipCode_ID": null,
                "SBR_03_ReferenceIdentification_AN": null,
                "SBR_04_Name_AN": null,
                "SBR_05_InsuranceTypeCode_ID": null,
                "SBR_06_CoordinationOfBenefitsCode_ID": null,
                "SBR_07_YesNoConditionOrResponseCode_ID": null,
                "SBR_08_EmploymentStatusCode_ID": null,
                "SBR_09_ClaimFilingIndicatorCode_ID": "CI"
              },
              "SubscriberName_Loop_2010BA": {
                "SubscriberName": {
                  "NM1_01_EntityIdentifierCode_ID": "IL",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "JANE",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "MI",
                  "NM1_09_IdentificationCode_AN": "111223333",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "SubscriberAddress": null,
                "SubscriberCityStateZipCode": null,
                "SubscriberDemographicInformation": null,
                "SubscriberSecondaryIdentification": null,
                "PropertyAndCasualtyClaimNumber": null
              },
              "PayerName_Loop_2010BB": {
                "PayerName": {
                  "NM1_01_EntityIdentifierCode_ID": "PR",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "INSURANCE COMPANY XYZ",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "PI",
                  "NM1_09_IdentificationCode_AN": "66783JJT",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PayerAddress": null,
                "PayerCityStateZipCode": null,
                "PayerSecondaryIdentification": null,
                "BillingProviderSecondaryIdentification": null
              }
            }
          ],
          "PatientDetail_Loop_2000C": [
            {
              "PatientHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "3",
                "HL_02_HierarchicalParentIDNumber_AN": "2",
                "HL_03_HierarchicalLevelCode_ID": "23",
                "HL_04_HierarchicalChildCode_ID": "0"
              },
              "PatientInfomation": {
                "PAT_01_IndividualRelationshipCode_ID": "19",
                "PAT_02_PatientLocationCode_ID": null,
                "PAT_03_EmploymentStatusCode_ID": null,
                "PAT_04_StudentStatusCode_ID": null,
                "PAT_05_DateTimePeriodFormatQualifier_ID": null,
                "PAT_06_DateTimePeriod_AN": null,
                "PAT_07_UnitOrBasisForMeasurementCode_ID": null,
                "PAT_08_Weight_R": null,
                "PAT_09_YesNoConditionOrResponseCode_ID": null
              },
              "PatientName_Loop_2010CA": {
                "PatientName": {
                  "NM1_01_EntityIdentifierCode_ID": "QC",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "TED",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": null,
                  "NM1_09_IdentificationCode_AN": null,
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PatientAddress": {
                  "N3_01_AddressInformation_AN": "236 N MAIN ST",
                  "N3_02_AddressInformation_AN": null
                },
                "PatientCityStateZipCode": {
                  "N4_01_CityName_AN": "MIAMI",
                  "N4_02_StateOrProvinceCode_ID": "FL",
                  "N4_03_PostalCode_ID": "33413",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "PatientDemographicInformation": {
                  "DMG_01_DateTimePeriodFormatQualifier_ID": "D8",
                  "DMG_02_DateTimePeriod_AN": "19920501",
                  "DMG_03_GenderCode_ID": "M",
                  "DMG_04_MaritalStatusCode_ID": null,
                  "DMG_05_CompositeRaceOrEthnicityInformation": null,
                  "DMG_06_CitizenshipStatusCode_ID": null,
                  "DMG_07_CountryCode_ID": null,
                  "DMG_08_BasisOfVerificationCode_ID": null,
                  "DMG_09_Quantity_R": null,
                  "DMG_10_CodeListQualifierCode_ID": null,
                  "DMG_11_IndustryCode_AN": null
                },
                "PropertyAndCasualtyClaimNumber": null,
                "PropertyAndCasualtyPatientIdentifier": null
              },
              "ClaimInformation": [
                {
                  "ClaimInfomation": {
                    "CLM_01_ClaimSubmittersIdentifier_AN": "26403774",
                    "CLM_02_MonetaryAmount_R": "150",
                    "CLM_03_ClaimFilingIndicatorCode_ID": null,
                    "CLM_04_NonInstitutionalClaimTypeCode_ID": null,
                    "CLM_05_HealthCareServiceLocationInfomation": {
                      "C023_01_FacilityCodeValue_AN": "11",
                      "C023_02_FacilityCodeQualifier_ID": "B",
                      "C023_03_ClaimFrequencyTypeCode_ID": "1"
                    },
                    "CLM_06_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_07_ProviderAcceptAssignmentCode_ID": null,
                    "CLM_08_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_09_ReleaseOfInfomationCode_ID": "I",
                    "CLM_10_PatientSignatureSourceCode_ID": null,
                    "CLM_11_elatedCausesInfomation": null,
                    "CLM_12_SpecialProgramCode_ID": null,
                    "CLM_13_YesNoConditionOrResponseCode_ID": null,
                    "CLM_14_LevelOfServiceCode_ID": null,
                    "CLM_15_YesNoConditionOrResponseCode_ID": null,
                    "CLM_16_ProviderAgreementCode_ID": null,
                    "CLM_17_ClaimStatusCode_ID": null,
                    "CLM_18_YesNoConditionOrResponseCode_ID": null,
                    "CLM_19_ClaimSubmissionReasonCode_ID": null,
                    "CLM_20_DelayReasonCode_ID": null
                  },
                  "DateAccident": {
                    "DTP_01_DateTimeQualifier_ID": "472",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20061029"
                  },
                  "DateAppliancePlacement": null,
                  "DateServiceDate": null,
                  "DateRepricerReceivedDate": null,
                  "OrthodonticTotalMonthsOfTreatment": null,
                  "ToothStatus": null,
                  "ClaimSupplementalInformation": null,
                  "ContractInformation": null,
                  "PatientAmountPaid": null,
                  "PredeterminationIdentification": {
                    "REF_01_ReferenceIdentificationQualifier_ID": "D9",
                    "REF_02_ReferenceIdentification_AN": "17312345600006351",
                    "REF_03_Description_AN": null,
                    "REF_04_ReferenceIdentifier": null
                  },
                  "ServiceAuthorizationExceptionCode": null,
                  "PayerClaimControlNumber": null,
                  "ReferralNumber": null,
                  "PriorAuthorization": null,
                  "RepricedClaimNumber": null,
                  "AdjustedRepricedClaimNumber": null,
                  "ClaimIdentifierForTransmissionIntermediaries": null,
                  "FileInformation": null,
                  "ClaimNote": null,
                  "HealthcareDiagnosisCode": null,
                  "ClaimPricingRepricingInformation": null,
                  "ReferringProviderName_Loop_2310A": [
                    {
                      "ReferringProviderName": {
                        "NM1_01_EntityIdentifierCode_ID": "82",
                        "NM1_02_EntityTypeQualifier_ID": "1",
                        "NM1_03_NameLastOrOrganizationName_AN": "KILDARE",
                        "NM1_04_NameFirst_AN": "BEN",
                        "NM1_05_NameMiddle_AN": null,
                        "NM1_06_NamePrefix_AN": null,
                        "NM1_07_NameSuffix_AN": null,
                        "NM1_08_IdentificationCodeQualifier_ID": "XX",
                        "NM1_09_IdentificationCode_AN": "9876543210",
                        "NM1_10_EntityRelationshipCode_ID": null,
                        "NM1_11_EntityIdentifierCode_ID": null,
                        "NM1_12_NameLastOrOrganizationName_AN": null
                      },
                      "RefferingProviderSpecialityInformation": {
                        "PRV_01_ProviderCode_ID": "PE",
                        "PRV_02_ReferenceIdentificationQualifier_ID": "PXC",
                        "PRV_03_ReferenceIdentification_AN": "1223G0001X",
                        "PRV_04_StateOrProvinceCode_ID": null,
                        "PRV_05_ProviderSpecialtyInformation": null,
                        "PRV_06_ProviderOrganizationCode_ID": null
                      },
                      "ReferringProviderSecondaryIdentification": null
                    }
                  ],
                  "RenderingProviderName_Loop_2310B": {
                    "RenderingProviderName": null,
                    "RenderingProviderSpecialityInfomation": null,
                    "RenderingProviderSecondaryIdentification": null
                  },
                  "ServiceFacilityLocation_Loop_2310C": {
                    "ServiceFacilityLocationName": null,
                    "ServiceLocationFacilityAddress": null,
                    "ServiceFacilityLocationCityStateZipCode": null,
                    "ServiceFacilityLocationSecondaryIdentification": null
                  },
                  "AssistantSurgeonName_Loop_2310D": {
                    "AssistantSurgeonName": null,
                    "AssistantSurgeonSpecialityInformation": null,
                    "AssistantSurgeonSecondaryIdentification": null
                  },
                  "SupervisingProviderName_Loop_2310E": {
                    "SupervisingProviderName": null,
                    "SupervisingProviderSecondaryIdentification": null
                  },
                  "OtherSubscriberInformation_Loop_2320": [
                    {
                      "OtherSubscriberInfomation": null,
                      "ClaimLevelAdjustment": null,
                      "CoordinationOfBenefitsPayerPaidAmount": null,
                      "RemainingPatientLiability": null,
                      "CoordinationOfBenefitsTotalNonCoveredAmount": null,
                      "OtherInsuranceCoverageInformation": null,
                      "OutpatientAdjudicationInfomation": null,
                      "OtherSubscriberName_Loop_2330A": {
                        "OtherSubscriberName": null,
                        "OtherSubscriberAddress": null,
                        "OtherSubscriberCirtStateZipCode": null,
                        "OtherSubscriberSecondaryIdentification": null
                      },
                      "OtherPayerName_Loop_2330B": {
                        "OtherPayerName": null,
                        "OtherPayerAddress": null,
                        "OtherPayerCityStateZipCode": null,
                        "ClaimCheckOrRemittanceDate": null,
                        "OtherPayerSecondaryIdentification": null,
                        "OtherPayerPriorAuthorizationNumber": null,
                        "OtherPayerReferralNumber": null,
                        "OtherPayerClaimAdjustmentIndicator": null,
                        "OtherPayerPredeterminationIdentification": null,
                        "OtherPayerClaimControlNumber": null
                      },
                      "OtherPayerReferringProvider_Loop_2330C": [
                        {
                          "OtherPayerReferringProvider": null,
                          "OtherPayerReferringProviderSecondaryIdentification": null
                        }
                      ],
                      "OtherPayerRenderingProvider_Loop_2330D": {
                        "OtherPayerRenderingProvider": null,
                        "OtherPayerRenderingProviderSecondaryIdentification": null
                      },
                      "OtherPayerSupervisingProvider_Loop_2330E": {
                        "OtherPayerSupervisingProvider": null,
                        "OtherPayerSupervisingProviderSecondaryIdentification": null
                      },
                      "OtherPayerBillingProvider_Loop_2330F": {
                        "OtherPayerBillingProvider": null,
                        "OtherPayerBillingProviderSecondaryIdentification": null
                      },
                      "OtherPayerServiceFacilityLocation_Loop_2330G": {
                        "OtherPayerServiceFacilityLocation": null,
                        "OtherPayerServiceFacilityLocationSecondaryIdentification": null
                      },
                      "OtherPayerAssistantSurgeon_Loop_2330H": {
                        "OtherPayerAssistantSurgeon": null,
                        "OtherPayerAssistantSurgeonSecondaryIdentification": null
                      }
                    }
                  ],
                  "ServiceLineNumber_Loop_2400": [
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "1"
                      },
                      "DentalService": {
                        "SV3_01_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "AD",
                          "C003_02_ProductServiceID_AN": "D2150",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV3_02_MonetaryAmount_R": "100",
                        "SV3_03_FacilityCodeValue_AN": null,
                        "SV3_04_OralCavityDesignatio": null,
                        "SV3_05_ProsthesisCrownOrInlayCode_ID": null,
                        "SV3_06_Quantity_R": "1",
                        "SV3_07_Description_AN": null,
                        "SV3_08_CopayStatusCode_ID": null,
                        "SV3_09_ProviderAgreementCode_ID": null,
                        "SV3_10_YesNoConditionOrResponseCode_ID": null,
                        "SV3_11_CompositeDiagnosisCodePointer": null
                      },
                      "ToothInformation": [
                        {
                          "TOO_01_CodeListQualifierCode_ID": "JP",
                          "TOO_02_IndustryCode_AN": "12",
                          "Too_03_Tooth_Surface": {
                            "C005_01_ToothSurface_Code_ID": "M",
                            "C005_02_ToothSurfaceCode_ID": "O",
                            "C005_03_ToothSurfaceCode_ID": null,
                            "C005_04_ToothSurfaceCode_ID": null,
                            "C005_05_ToothSurfaceCode_ID": null
                          }
                        }
                      ],
                      "DateServiceDate": null,
                      "DatePriorPlacement": null,
                      "DateAppliancePlacement": null,
                      "DateReplacement": null,
                      "DateTreatmentStart": null,
                      "DateTreatmentCompletion": null,
                      "ContractInformation": null,
                      "ServicePredeterminationIdentification": null,
                      "PriorAuthorization": null,
                      "LineItemControlNumber": null,
                      "RepricedClaimNumber": null,
                      "AdjustedRepricedClaimNumber": null,
                      "ReferralNumber": null,
                      "SalesTaxAmount": null,
                      "FileInformation": null,
                      "LinePricingRepricingInformation": null,
                      "RenderingProviderName_Loop_2420A": {
                        "RenderingProviderName": null,
                        "RenderingProviderSpecialityInformation": null,
                        "RenderingProviderSecondaryIdentification": null
                      },
                      "AssistantSurgeonName_Loop_2420B": {
                        "AssistantSurgeonName": null,
                        "AssistantSurgeonSpecialityInformation": null,
                        "AssistantSurgeonSecondaryIdentification": null
                      },
                      "SupervisingProviderName_Loop_2420C": {
                        "SupervisingProviderName": null,
                        "SupervisingProviderSecondaryIdentification": null
                      },
                      "ServiceFacilityLocationName_Loop_2420D": {
                        "ServiceFacilityLocationName": null,
                        "ServiceFacilityLocationAddress": null,
                        "ServiceFacilityLocationCityStateZipCode": null,
                        "ServiceFacilityLocationSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LinecheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    },
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "2"
                      },
                      "DentalService": {
                        "SV3_01_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "AD",
                          "C003_02_ProductServiceID_AN": "D1110",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV3_02_MonetaryAmount_R": "50",
                        "SV3_03_FacilityCodeValue_AN": null,
                        "SV3_04_OralCavityDesignatio": null,
                        "SV3_05_ProsthesisCrownOrInlayCode_ID": null,
                        "SV3_06_Quantity_R": "1",
                        "SV3_07_Description_AN": null,
                        "SV3_08_CopayStatusCode_ID": null,
                        "SV3_09_ProviderAgreementCode_ID": null,
                        "SV3_10_YesNoConditionOrResponseCode_ID": null,
                        "SV3_11_CompositeDiagnosisCodePointer": null
                      },
                      "ToothInformation": null,
                      "DateServiceDate": null,
                      "DatePriorPlacement": null,
                      "DateAppliancePlacement": null,
                      "DateReplacement": null,
                      "DateTreatmentStart": null,
                      "DateTreatmentCompletion": null,
                      "ContractInformation": null,
                      "ServicePredeterminationIdentification": null,
                      "PriorAuthorization": null,
                      "LineItemControlNumber": null,
                      "RepricedClaimNumber": null,
                      "AdjustedRepricedClaimNumber": null,
                      "ReferralNumber": null,
                      "SalesTaxAmount": null,
                      "FileInformation": null,
                      "LinePricingRepricingInformation": null,
                      "RenderingProviderName_Loop_2420A": {
                        "RenderingProviderName": null,
                        "RenderingProviderSpecialityInformation": null,
                        "RenderingProviderSecondaryIdentification": null
                      },
                      "AssistantSurgeonName_Loop_2420B": {
                        "AssistantSurgeonName": null,
                        "AssistantSurgeonSpecialityInformation": null,
                        "AssistantSurgeonSecondaryIdentification": null
                      },
                      "SupervisingProviderName_Loop_2420C": {
                        "SupervisingProviderName": null,
                        "SupervisingProviderSecondaryIdentification": null
                      },
                      "ServiceFacilityLocationName_Loop_2420D": {
                        "ServiceFacilityLocationName": null,
                        "ServiceFacilityLocationAddress": null,
                        "ServiceFacilityLocationCityStateZipCode": null,
                        "ServiceFacilityLocationSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LinecheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "31",
            "SE_02_TransactionSetControlNumber_AN": "3456"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

Sample request (Insitutional Claim)

EDI 837 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X223A3~ST*837*987654*005010X223A3~BHT*0019*00*0123*19960918*0932*CH~NM1*41*2*JONES HOSPITAL*****46*12345~PER*IC*JANE DOE*TE*9005555555~NM1*40*2*MEDICARE*****46*00120~HL*1**20*1~PRV*BI*PXC*203BA0200N~NM1*85*2*JONES HOSPITAL*****XX*9876540809~N3*225 MAIN STREET BARKLEY BUILDING~N4*CENTERVILLE*PA*17111~REF*EI*567891234~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1*DOE*JOHN*T***MI*030005074A~N3*125 CITY AVENUE~N4*CENTERVILLE*PA*17111~DMG*D8*19261111*M~NM1*PR*2*MEDICARE B*****PI*00435~REF*G2*330127~CLM*756048Q*89.93***14:A:1*Y*A*Y*Y~DTP*434*D8*19960911~CL1*3**01~HI*BK:3669~HI*BF:4019*BF:79431~HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~HI*BE:A2:::15.31~HI*BG:09~NM1*71*1*JONES*JOHN*J~REF*1G*B99937~SBR*S*01*351630*STATE TEACHERS*****CI~OI***Y***Y~NM1*IL*1*DOE*JANE*S***MI*222004433~N3*125 CITY AVENUE~N4*CENTERVILLE*PA*17111~NM1*PR*2*STATE TEACHERS*****PI*1135~LX*1~SV2*0305*HC:85025*13.39*UN*1~DTP*472*D8*19960911~LX*2~SV2*0730*HC:93005*76.54*UN*3~DTP*472*D8*19960911~SE*43*987654~GE*1*1~IEA*1*000000001~

Sample response (Insitutional Claim)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "XX",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVERCODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X223A3"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "837",
            "ST_02_TransactionSetControlNumber_AN": "987654",
            "ST_03_ImplementationConventionReference_AN": "005010X223A3"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0019",
            "BHT_02_TransactionSetPurposeCode_ID": "00",
            "BHT_03_ReferenceIdentification_AN": "0123",
            "BHT_04_Date_DT": "19960918",
            "BHT_05_Time_TM": "0932",
            "BHT_06_TransactionTypeCode_ID": "CH"
          },
          "SubmitterName_Loop_1000A": {
            "SubmitterName": {
              "NM1_01_EntityIdentifierCode_ID": "41",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "JONES HOSPITAL",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "12345",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            },
            "SubmitterEdiContactInfomation": [
              {
                "PER_01_ContactFunctionCode_ID": "IC",
                "PER_02_Name_AN": "JANE DOE",
                "PER_03_CommunicationNumberQualifier_ID": "TE",
                "PER_04_CommunicationNumber_AN": "9005555555",
                "PER_05_CommunicationNumberQualifier_ID": null,
                "PER_06_CommunicationNumber_AN": null,
                "PER_07_CommunicationNumberQualifier_ID": null,
                "PER_08_CommunicationNumber_AN": null,
                "PER_09_ContactInquiryReference_AN": null
              }
            ]
          },
          "ReceiverName_Loop_1000B": {
            "ReceiverName": {
              "NM1_01_EntityIdentifierCode_ID": "40",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "MEDICARE",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "00120",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            }
          },
          "BillingProviderHierarchicalLevel_Loop_2000A": [
            {
              "BillingProviderHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "1",
                "HL_02_HierarchicalParentIDNumber_AN": null,
                "HL_03_HierarchicalLevelCode_ID": "20",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "BillingProviderSpecialityInformation": {
                "PRV_01_ProviderCode_ID": "BI",
                "PRV_02_ReferenceIdentificationQualifier_ID": "PXC",
                "PRV_03_ReferenceIdentification_AN": "203BA0200N",
                "PRV_04_StateOrProvinceCode_ID": null,
                "PRV_05_ProviderSpecialtyInformation": null,
                "PRV_06_ProviderOrganizationCode_ID": null
              },
              "ForeignCurrencyInformation": null,
              "BillingProviderName_Loop_2010AA": {
                "BillingProviderName": {
                  "NM1_01_EntityIdentifierCode_ID": "85",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "JONES HOSPITAL",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "XX",
                  "NM1_09_IdentificationCode_AN": "9876540809",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "BillingProviderAddress": {
                  "N3_01_AddressInformation_AN": "225 MAIN STREET BARKLEY BUILDING",
                  "N3_02_AddressInformation_AN": null
                },
                "BillingProviderCityStateZipCode": {
                  "N4_01_CityName_AN": "CENTERVILLE",
                  "N4_02_StateOrProvinceCode_ID": "PA",
                  "N4_03_PostalCode_ID": "17111",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "BillingProviderTaxIdentification": {
                  "REF_01_ReferenceIdentificationQualifier_ID": "EI",
                  "REF_02_ReferenceIdentification_AN": "567891234",
                  "REF_03_Description_AN": null,
                  "REF_04_ReferenceIdentifier": null
                },
                "BillingProviderContactInformation": null
              },
              "PayToAddressName_Loop_2010AB": {
                "PayToAddressName": null,
                "PayToAddressAddress": null,
                "PayToAddressCityStateZipCode": null
              },
              "PayToPlanName_Loop_2010AC": {
                "PayToPlanName": null,
                "PayToPlanAddress": null,
                "PayToPlanCityStateZipCode": null,
                "PayToPlanSecondaryIdentification": null,
                "PayToPlanTaxIdentificationNumber": null
              }
            }
          ],
          "SubscriberDetail_Loop_2000B": [
            {
              "SubscriberHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "22",
                "HL_04_HierarchicalChildCode_ID": "0"
              },
              "SubscriberInformation": {
                "SBR_01_PayerResponsibilitySequenceNumberCode_ID": "P",
                "SBR_02_IndividualRelationshipCode_ID": "18",
                "SBR_03_ReferenceIdentification_AN": null,
                "SBR_04_Name_AN": null,
                "SBR_05_InsuranceTypeCode_ID": null,
                "SBR_06_CoordinationOfBenefitsCode_ID": null,
                "SBR_07_YesNoConditionOrResponseCode_ID": null,
                "SBR_08_EmploymentStatusCode_ID": null,
                "SBR_09_ClaimFilingIndicatorCode_ID": "MB"
              },
              "SubscriberName_Loop_2010BA": {
                "SubscriberName": {
                  "NM1_01_EntityIdentifierCode_ID": "IL",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "DOE",
                  "NM1_04_NameFirst_AN": "JOHN",
                  "NM1_05_NameMiddle_AN": "T",
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "MI",
                  "NM1_09_IdentificationCode_AN": "030005074A",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "SubscriberAddress": {
                  "N3_01_AddressInformation_AN": "125 CITY AVENUE",
                  "N3_02_AddressInformation_AN": null
                },
                "SubscriberCityStateZipCode": {
                  "N4_01_CityName_AN": "CENTERVILLE",
                  "N4_02_StateOrProvinceCode_ID": "PA",
                  "N4_03_PostalCode_ID": "17111",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "SubscriberDemographicInformation": {
                  "DMG_01_DateTimePeriodFormatQualifier_ID": "D8",
                  "DMG_02_DateTimePeriod_AN": "19261111",
                  "DMG_03_GenderCode_ID": "M",
                  "DMG_04_MaritalStatusCode_ID": null,
                  "DMG_05_CompositeRaceOrEthnicityInformation": null,
                  "DMG_06_CitizenshipStatusCode_ID": null,
                  "DMG_07_CountryCode_ID": null,
                  "DMG_08_BasisOfVerificationCode_ID": null,
                  "DMG_09_Quantity_R": null,
                  "DMG_10_CodeListQualifierCode_ID": null,
                  "DMG_11_IndustryCode_AN": null
                },
                "SubscriberSecondaryIdentification": null,
                "PropertyAndCasualtyClaimNumber": null
              },
              "PayerName_Loop_2010BB": {
                "PayerName": {
                  "NM1_01_EntityIdentifierCode_ID": "PR",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "MEDICARE B",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "PI",
                  "NM1_09_IdentificationCode_AN": "00435",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PayerAddress": null,
                "PayerCityStateZipCode": null,
                "PayerSecondaryIdentification": [
                  {
                    "REF_01_ReferenceIdentificationQualifier_ID": "G2",
                    "REF_02_ReferenceIdentification_AN": "330127",
                    "REF_03_Description_AN": null,
                    "REF_04_ReferenceIdentifier": null
                  }
                ],
                "BillingProviderSecondaryIdentification": null
              }
            }
          ],
          "PatientDetail_Loop_2000C": [
            {
              "PatientHierarchicalLevel": null,
              "PatientInfomation": null,
              "PatientName_Loop_2010CA": {
                "PatientName": null,
                "PatientAddress": null,
                "PatientCityStateZipCode": null,
                "PatientDemographicInformation": null,
                "PropertyAndCasualtyClaimNumber": null,
                "PropertyAndCasualtyPatientIdentifier": null
              },
              "ClaimInformation": [
                {
                  "ClaimInfomation": {
                    "CLM_01_ClaimSubmittersIdentifier_AN": "756048Q",
                    "CLM_02_MonetaryAmount_R": "89.93",
                    "CLM_03_ClaimFilingIndicatorCode_ID": null,
                    "CLM_04_NonInstitutionalClaimTypeCode_ID": null,
                    "CLM_05_HealthCareServiceLocationInfomation": {
                      "C023_01_FacilityCodeValue_AN": "14",
                      "C023_02_FacilityCodeQualifier_ID": "A",
                      "C023_03_ClaimFrequencyTypeCode_ID": "1"
                    },
                    "CLM_06_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_07_ProviderAcceptAssignmentCode_ID": "A",
                    "CLM_08_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_09_ReleaseOfInfomationCode_ID": "Y",
                    "CLM_10_PatientSignatureSourceCode_ID": null,
                    "CLM_11_elatedCausesInfomation": null,
                    "CLM_12_SpecialProgramCode_ID": null,
                    "CLM_13_YesNoConditionOrResponseCode_ID": null,
                    "CLM_14_LevelOfServiceCode_ID": null,
                    "CLM_15_YesNoConditionOrResponseCode_ID": null,
                    "CLM_16_ProviderAgreementCode_ID": null,
                    "CLM_17_ClaimStatusCode_ID": null,
                    "CLM_18_YesNoConditionOrResponseCode_ID": null,
                    "CLM_19_ClaimSubmissionReasonCode_ID": null,
                    "CLM_20_DelayReasonCode_ID": null
                  },
                  "DischargeHour": {
                    "DTP_01_DateTimeQualifier_ID": "434",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "19960911"
                  },
                  "StatementDates": null,
                  "AdmissionDateHour": null,
                  "DateRepricerReceivedDate": null,
                  "InstitutionalClaimCode": {
                    "CL1_01_AdmissionTypeCode_ID": "3",
                    "CL1_02_AdmissionSourceCode_ID": null,
                    "CL1_03_PatientStatusCode_ID": "01",
                    "CL1_04_NursingHomeResidentialStatusCode_ID": null
                  },
                  "ClaimSupplementalInformation": null,
                  "ContractInformation": null,
                  "PatientEstimatedAmountDue": null,
                  "ServiceAuthorizationExceptionCode": null,
                  "ReferralNumber": null,
                  "PriorAuthorization": null,
                  "PayerClaimControlNumber": null,
                  "RepricedClaimNumber": null,
                  "AdjustedRepricedClaimNumber": null,
                  "InvestigationalDeviceExemptionNumber": null,
                  "ClaimIdentifierForTransmissionIntermediaries": null,
                  "AutoAccidentState": null,
                  "MedicalRecordNumber": null,
                  "DemonstrationProjectIdentifier": null,
                  "PeerReviewOrganizationApprovalNumber": null,
                  "FileInformation": null,
                  "ClaimNote": null,
                  "BillingNote": null,
                  "EPSDTDiagnosis": null,
                  "PrincipalDiagnosis": {
                    "HI_01_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BK",
                      "C022_02_IndustryCode_AN": "3669",
                      "C022_03_DateTimePeriodFormatQualifier_ID": null,
                      "C022_04_DateTimePeriod_AN": null,
                      "C022_05_MonetaryAmount_R": null,
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_02_HealthCareCodeInformation": null,
                    "HI_03_HealthCareCodeInformation": null,
                    "HI_04_HealthCareCodeInformation": null,
                    "HI_05_HealthCareCodeInformation": null,
                    "HI_06_HealthCareCodeInformation": null,
                    "HI_07_HealthCareCodeInformation": null,
                    "HI_08_HealthCareCodeInformation": null,
                    "HI_09_HealthCareCodeInformation": null,
                    "HI_10_HealthCareCodeInformation": null,
                    "HI_11_HealthCareCodeInformation": null,
                    "HI_12_HealthCareCodeInformation": null
                  },
                  "AdmittingDiagnosis": {
                    "HI_01_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BF",
                      "C022_02_IndustryCode_AN": "4019",
                      "C022_03_DateTimePeriodFormatQualifier_ID": null,
                      "C022_04_DateTimePeriod_AN": null,
                      "C022_05_MonetaryAmount_R": null,
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_02_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BF",
                      "C022_02_IndustryCode_AN": "79431",
                      "C022_03_DateTimePeriodFormatQualifier_ID": null,
                      "C022_04_DateTimePeriod_AN": null,
                      "C022_05_MonetaryAmount_R": null,
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_03_HealthCareCodeInformation": null,
                    "HI_04_HealthCareCodeInformation": null,
                    "HI_05_HealthCareCodeInformation": null,
                    "HI_06_HealthCareCodeInformation": null,
                    "HI_07_HealthCareCodeInformation": null,
                    "HI_08_HealthCareCodeInformation": null,
                    "HI_09_HealthCareCodeInformation": null,
                    "HI_10_HealthCareCodeInformation": null,
                    "HI_11_HealthCareCodeInformation": null,
                    "HI_12_HealthCareCodeInformation": null
                  },
                  "PatientsReasonForVisit": {
                    "HI_01_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BH",
                      "C022_02_IndustryCode_AN": "A1",
                      "C022_03_DateTimePeriodFormatQualifier_ID": "D8",
                      "C022_04_DateTimePeriod_AN": "19261111",
                      "C022_05_MonetaryAmount_R": null,
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_02_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BH",
                      "C022_02_IndustryCode_AN": "A2",
                      "C022_03_DateTimePeriodFormatQualifier_ID": "D8",
                      "C022_04_DateTimePeriod_AN": "19911101",
                      "C022_05_MonetaryAmount_R": null,
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_03_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BH",
                      "C022_02_IndustryCode_AN": "B1",
                      "C022_03_DateTimePeriodFormatQualifier_ID": "D8",
                      "C022_04_DateTimePeriod_AN": "19261111",
                      "C022_05_MonetaryAmount_R": null,
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_04_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BH",
                      "C022_02_IndustryCode_AN": "B2",
                      "C022_03_DateTimePeriodFormatQualifier_ID": "D8",
                      "C022_04_DateTimePeriod_AN": "19870101",
                      "C022_05_MonetaryAmount_R": null,
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_05_HealthCareCodeInformation": null,
                    "HI_06_HealthCareCodeInformation": null,
                    "HI_07_HealthCareCodeInformation": null,
                    "HI_08_HealthCareCodeInformation": null,
                    "HI_09_HealthCareCodeInformation": null,
                    "HI_10_HealthCareCodeInformation": null,
                    "HI_11_HealthCareCodeInformation": null,
                    "HI_12_HealthCareCodeInformation": null
                  },
                  "ExternalCauseOfInjury": {
                    "HI_01_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BE",
                      "C022_02_IndustryCode_AN": "A2",
                      "C022_03_DateTimePeriodFormatQualifier_ID": null,
                      "C022_04_DateTimePeriod_AN": null,
                      "C022_05_MonetaryAmount_R": "15.31",
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_02_HealthCareCodeInformation": null,
                    "HI_03_HealthCareCodeInformation": null,
                    "HI_04_HealthCareCodeInformation": null,
                    "HI_05_HealthCareCodeInformation": null,
                    "HI_06_HealthCareCodeInformation": null,
                    "HI_07_HealthCareCodeInformation": null,
                    "HI_08_HealthCareCodeInformation": null,
                    "HI_09_HealthCareCodeInformation": null,
                    "HI_10_HealthCareCodeInformation": null,
                    "HI_11_HealthCareCodeInformation": null,
                    "HI_12_HealthCareCodeInformation": null
                  },
                  "DiagnosisRelatedGroupInformation": {
                    "HI_01_HealthCareCodeInformation": {
                      "C022_01_CodeListQualifierCode_ID": "BG",
                      "C022_02_IndustryCode_AN": "09",
                      "C022_03_DateTimePeriodFormatQualifier_ID": null,
                      "C022_04_DateTimePeriod_AN": null,
                      "C022_05_MonetaryAmount_R": null,
                      "C022_06_Quantity_R": null,
                      "C022_07_VersionIdentifier_AN": null,
                      "C022_08_IndustryCode_AN": null,
                      "C022_09_YesNoConditionOrResponseCode_ID": null
                    },
                    "HI_02_HealthCareCodeInformation": null,
                    "HI_03_HealthCareCodeInformation": null,
                    "HI_04_HealthCareCodeInformation": null,
                    "HI_05_HealthCareCodeInformation": null,
                    "HI_06_HealthCareCodeInformation": null,
                    "HI_07_HealthCareCodeInformation": null,
                    "HI_08_HealthCareCodeInformation": null,
                    "HI_09_HealthCareCodeInformation": null,
                    "HI_10_HealthCareCodeInformation": null,
                    "HI_11_HealthCareCodeInformation": null,
                    "HI_12_HealthCareCodeInformation": null
                  },
                  "OtherDiagnosisInformation": null,
                  "PrincipalProcedureInformation": null,
                  "OtherProcedureInformation": null,
                  "OccurrenceSpanInformation": null,
                  "OccurrenceInformation": null,
                  "ValueInformation": null,
                  "ConditionInformation": null,
                  "TreatmentCodeInformation": null,
                  "ClaimPricingRepricingInformation": null,
                  "AttendingProviderName_Loop_2310A": {
                    "AttendingProviderName": {
                      "NM1_01_EntityIdentifierCode_ID": "71",
                      "NM1_02_EntityTypeQualifier_ID": "1",
                      "NM1_03_NameLastOrOrganizationName_AN": "JONES",
                      "NM1_04_NameFirst_AN": "JOHN",
                      "NM1_05_NameMiddle_AN": "J",
                      "NM1_06_NamePrefix_AN": null,
                      "NM1_07_NameSuffix_AN": null,
                      "NM1_08_IdentificationCodeQualifier_ID": null,
                      "NM1_09_IdentificationCode_AN": null,
                      "NM1_10_EntityRelationshipCode_ID": null,
                      "NM1_11_EntityIdentifierCode_ID": null,
                      "NM1_12_NameLastOrOrganizationName_AN": null
                    },
                    "AttendingProviderSpecialityInformation": null,
                    "AttendingProviderSecondaryIdentification": [
                      {
                        "REF_01_ReferenceIdentificationQualifier_ID": "1G",
                        "REF_02_ReferenceIdentification_AN": "B99937",
                        "REF_03_Description_AN": null,
                        "REF_04_ReferenceIdentifier": null
                      }
                    ]
                  },
                  "OperatingPhysicianName_Loop_2310B": {
                    "OperatingPhysicianName": null,
                    "OperatingPhysicianSecondaryIdentification": null
                  },
                  "OtherOperatingPhysicianName_Loop_2310C": {
                    "OtherOperatingPhysicianName": null,
                    "OtherOperatingPhysicianSecondaryIdentification": null
                  },
                  "RenderingProviderName_Loop_2310D": {
                    "RenderingProviderName": null,
                    "RenderingProviderSecondaryIdentification": null
                  },
                  "ServiceFacilityLocation_Loop_2310E": {
                    "ServiceFacilityLocationName": null,
                    "ServiceLocationFacilityAddress": null,
                    "ServiceFacilityLocationCityStateZipCode": null,
                    "ServiceFacilityLocationSecondaryIdentification": null
                  },
                  "ReferringProviderName_Loop_2310F": {
                    "ReferringProviderName": null,
                    "RefferingProviderSecondaryIdentification": null
                  },
                  "OtherSubscriberInformation_Loop_2320": [
                    {
                      "OtherSubscriberInfomation": {
                        "SBR_01_PayerResponsibilitySequenceNumberCode_ID": "S",
                        "SBR_02_IndividualRelationshipCode_ID": "01",
                        "SBR_03_ReferenceIdentification_AN": "351630",
                        "SBR_04_Name_AN": "STATE TEACHERS",
                        "SBR_05_InsuranceTypeCode_ID": null,
                        "SBR_06_CoordinationOfBenefitsCode_ID": null,
                        "SBR_07_YesNoConditionOrResponseCode_ID": null,
                        "SBR_08_EmploymentStatusCode_ID": null,
                        "SBR_09_ClaimFilingIndicatorCode_ID": "CI"
                      },
                      "ClaimLevelAdjustment": null,
                      "CoordinationOfBenefitsPayerPaidAmount": null,
                      "RemainingPatientLiability": null,
                      "CoordinationOfBenefitsTotalNonCoveredAmout": null,
                      "OtherInsuranceCoverageInformation": {
                        "OI_01_ClaimFilingIndicatorCode_ID": null,
                        "OI_02_ClaimSubmissionReasonCode_ID": null,
                        "OI_03_YesNoConditionOrResponseCode_ID": "Y",
                        "OI_04_PatientSignatureSourceCode_ID": null,
                        "OI_05_ProviderAgreementCode_ID": null,
                        "OI_06_ReleaseInformationCode_ID": "Y"
                      },
                      "InpatientAdjudicationInformation": null,
                      "OutpatientAdjudicationInformation": null,
                      "OtherSubscriberName_Loop_2330A": {
                        "OtherSubscriberName": {
                          "NM1_01_EntityIdentifierCode_ID": "IL",
                          "NM1_02_EntityTypeQualifier_ID": "1",
                          "NM1_03_NameLastOrOrganizationName_AN": "DOE",
                          "NM1_04_NameFirst_AN": "JANE",
                          "NM1_05_NameMiddle_AN": "S",
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "MI",
                          "NM1_09_IdentificationCode_AN": "222004433",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        },
                        "OtherSubscriberAddress": {
                          "N3_01_AddressInformation_AN": "125 CITY AVENUE",
                          "N3_02_AddressInformation_AN": null
                        },
                        "OtherSubscriberCityStateZipCode": {
                          "N4_01_CityName_AN": "CENTERVILLE",
                          "N4_02_StateOrProvinceCode_ID": "PA",
                          "N4_03_PostalCode_ID": "17111",
                          "N4_04_CountryCode_ID": null,
                          "N4_05_LocationQualifier_ID": null,
                          "N4_06_LocationIdentifier_AN": null,
                          "N4_07_CountrySubdivisionCode_ID": null
                        },
                        "OtherSubscriberSecondaryIdentification": null
                      },
                      "OtherPayerName_Loop_2330B": {
                        "OtherPayerName": {
                          "NM1_01_EntityIdentifierCode_ID": "PR",
                          "NM1_02_EntityTypeQualifier_ID": "2",
                          "NM1_03_NameLastOrOrganizationName_AN": "STATE TEACHERS",
                          "NM1_04_NameFirst_AN": null,
                          "NM1_05_NameMiddle_AN": null,
                          "NM1_06_NamePrefix_AN": null,
                          "NM1_07_NameSuffix_AN": null,
                          "NM1_08_IdentificationCodeQualifier_ID": "PI",
                          "NM1_09_IdentificationCode_AN": "1135",
                          "NM1_10_EntityRelationshipCode_ID": null,
                          "NM1_11_EntityIdentifierCode_ID": null,
                          "NM1_12_NameLastOrOrganizationName_AN": null
                        },
                        "OtherPayerAddress": null,
                        "OtherPayerCityStateZipCode": null,
                        "ClaimCheckOrRemittanceDate": null,
                        "OtherPayerSecondaryIdentifier": null,
                        "OtherPayerPriorAuthorizationNumber": null,
                        "OtherPayerReferralNumber": null,
                        "OtherPayerClaimAdjustmentIndicator": null,
                        "OtherPayerClaimControlNumber": null
                      },
                      "OtherPayerAttendingProvider_Loop_2330C": {
                        "OtherPayerAttendingProvider": null,
                        "OtherPayerAttendingProviderSecondaryIdentification": null
                      },
                      "OtherPayerOperatingPhysician_Loop_2330D": {
                        "OtherPayerOperatingPhysician": null,
                        "OtherPayerOperatingPhysicianSecondaryIdentification": null
                      },
                      "OtherPayerOtherOperatingPhysician_Loop_2330E": {
                        "OtherPayerOtherOperatingPhysician": null,
                        "OtherPayerOtherOperatingPhysicianSecondaryIdentification": null
                      },
                      "OtherPayerRenderingProviderName_Loop_2330G": {
                        "OtherPayerRenderingProviderName": null,
                        "OtherPayerRenderingProviderNameSecondaryIdentification": null
                      },
                      "OtherPayerReferringProvider_Loop_2330H": {
                        "OtherPayerReferringProvider": null,
                        "OtherPayerReferringProviderSecondaryIdentification": null
                      },
                      "OtherPayerBillingProvider_Loop_2330I": {
                        "OtherPayerBillingProvider": null,
                        "OtherPayerBillingProviderSecondaryIdentification": null
                      }
                    }
                  ],
                  "ServiceLineNumber_Loop_2400": [
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "1"
                      },
                      "InstitutionalServiceLine": {
                        "SV2_01_ProductServiceId_AN": "0305",
                        "SV2_02_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "HC",
                          "C003_02_ProductServiceID_AN": "85025",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV2_03_MonetaryAmount_R": "13.39",
                        "SV2_04_UnitOrBasisForMeasurementCode_ID": "UN",
                        "SV2_05_Quantity_R": "1",
                        "SV2_06_UnitRate_R": null,
                        "SV2_07_MonetaryAmount_R": null,
                        "SV2_08_YesNoConditionOrResponseCode_ID": null,
                        "SV2_09_NursingHomeResidentialStatusCode_ID": null,
                        "SV2_10_LevelOfCareCode_ID": null
                      },
                      "LineSupplementalInformation": null,
                      "DateServiceDate": {
                        "DTP_01_DateTimeQualifier_ID": "472",
                        "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                        "DTP_03_DateTimePeriod_AN": "19960911"
                      },
                      "LineItemControlNumber": null,
                      "RepricedLineItemReferenceNumber": null,
                      "AdjustedRepricedLineItemReferenceNumber": null,
                      "ServiceTaxAmount": null,
                      "FacilityTaxAmount": null,
                      "ThirdPartyOrganizationNotes": null,
                      "LinePricingRepricingInfomation": null,
                      "DrugIdentification_Loop_2410": {
                        "DrugIdentification": null,
                        "DrugQuantity": null,
                        "PrescriptionOrCompundDrugAssociationNumber": null
                      },
                      "OperatingPhysicianName_Loop_2420A": {
                        "OperatingPhysicianName": null,
                        "OperatingPhysicianSecondaryIdentification": null
                      },
                      "OtherOperatingPhysicianName_Loop_2420B": {
                        "OtherOperatingPhysicianName": null,
                        "OtherOperatingPhysicianSecondaryIdentification": null
                      },
                      "RenderingProviderName_Loop_2420C": {
                        "RenderingProviderName": null,
                        "RenderingProviderNameSecondaryIdentification": null
                      },
                      "ReferringProviderName_Loop_2420D": {
                        "ReferringProviderName": null,
                        "ReferringProviderNameSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LineCheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    },
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "2"
                      },
                      "InstitutionalServiceLine": {
                        "SV2_01_ProductServiceId_AN": "0730",
                        "SV2_02_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "HC",
                          "C003_02_ProductServiceID_AN": "93005",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV2_03_MonetaryAmount_R": "76.54",
                        "SV2_04_UnitOrBasisForMeasurementCode_ID": "UN",
                        "SV2_05_Quantity_R": "3",
                        "SV2_06_UnitRate_R": null,
                        "SV2_07_MonetaryAmount_R": null,
                        "SV2_08_YesNoConditionOrResponseCode_ID": null,
                        "SV2_09_NursingHomeResidentialStatusCode_ID": null,
                        "SV2_10_LevelOfCareCode_ID": null
                      },
                      "LineSupplementalInformation": null,
                      "DateServiceDate": {
                        "DTP_01_DateTimeQualifier_ID": "472",
                        "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                        "DTP_03_DateTimePeriod_AN": "19960911"
                      },
                      "LineItemControlNumber": null,
                      "RepricedLineItemReferenceNumber": null,
                      "AdjustedRepricedLineItemReferenceNumber": null,
                      "ServiceTaxAmount": null,
                      "FacilityTaxAmount": null,
                      "ThirdPartyOrganizationNotes": null,
                      "LinePricingRepricingInfomation": null,
                      "DrugIdentification_Loop_2410": {
                        "DrugIdentification": null,
                        "DrugQuantity": null,
                        "PrescriptionOrCompundDrugAssociationNumber": null
                      },
                      "OperatingPhysicianName_Loop_2420A": {
                        "OperatingPhysicianName": null,
                        "OperatingPhysicianSecondaryIdentification": null
                      },
                      "OtherOperatingPhysicianName_Loop_2420B": {
                        "OtherOperatingPhysicianName": null,
                        "OtherOperatingPhysicianSecondaryIdentification": null
                      },
                      "RenderingProviderName_Loop_2420C": {
                        "RenderingProviderName": null,
                        "RenderingProviderNameSecondaryIdentification": null
                      },
                      "ReferringProviderName_Loop_2420D": {
                        "ReferringProviderName": null,
                        "ReferringProviderNameSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LineCheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "43",
            "SE_02_TransactionSetControlNumber_AN": "987654"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

Sample request (Dental Claim)

EDI 837 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X224~ST*837*3456*005010X224~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**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*1~IEA*1*000000001~

Sample response (Dental Claim)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "XX",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVERCODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X224"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "837",
            "ST_02_TransactionSetControlNumber_AN": "3456",
            "ST_03_ImplementationConventionReference_AN": "005010X224"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0019",
            "BHT_02_TransactionSetPurposeCode_ID": "00",
            "BHT_03_ReferenceIdentification_AN": "0123",
            "BHT_04_Date_DT": "20061123",
            "BHT_05_Time_TM": "1023",
            "BHT_06_TransactionTypeCode_ID": "CH"
          },
          "SubmiterName_Loop_1000A": {
            "SubmiterName": {
              "NM1_01_EntityIdentifierCode_ID": "41",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "PREMIER BILLING SERVICE",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "TGJ23",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            },
            "SubmitterEdiContactInformation": [
              {
                "PER_01_ContactFunctionCode_ID": "IC",
                "PER_02_Name_AN": "JERRY",
                "PER_03_CommunicationNumberQualifier_ID": "TE",
                "PER_04_CommunicationNumber_AN": "7176149999",
                "PER_05_CommunicationNumberQualifier_ID": null,
                "PER_06_CommunicationNumber_AN": null,
                "PER_07_CommunicationNumberQualifier_ID": null,
                "PER_08_CommunicationNumber_AN": null,
                "PER_09_ContactInquiryReference_AN": null
              }
            ]
          },
          "ReceiverName_Loop_1000B": {
            "ReceiverName": {
              "NM1_01_EntityIdentifierCode_ID": "40",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "INSURANCE COMPANY XYZ",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "66783JJT",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            }
          },
          "BillingProviderDetail_Loop_2000A": [
            {
              "BillingProviderHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "1",
                "HL_02_HierarchicalParentIDNumber_AN": null,
                "HL_03_HierarchicalLevelCode_ID": "20",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "BillingProviderSpecialtyInformation": null,
              "ForeignCurrencyInformation": null,
              "BillingProviderName_Loop_2010AA": {
                "BillingProviderName": {
                  "NM1_01_EntityIdentifierCode_ID": "85",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "DENTAL ASSOCIATES",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "XX",
                  "NM1_09_IdentificationCode_AN": "1234567890",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "BillingProviderAddress": {
                  "N3_01_AddressInformation_AN": "234 SEAWAY ST",
                  "N3_02_AddressInformation_AN": null
                },
                "BillingProviderCityStateZipCode": {
                  "N4_01_CityName_AN": "MIAMI",
                  "N4_02_StateOrProvinceCode_ID": "FL",
                  "N4_03_PostalCode_ID": "33111",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "BillingProviderTaxIdentification": {
                  "REF_01_ReferenceIdentificationQualifier_ID": "EI",
                  "REF_02_ReferenceIdentification_AN": "587654321",
                  "REF_03_Description_AN": null,
                  "REF_04_ReferenceIdentifier": null
                },
                "BillingProviderUPINLicenseInformation": null,
                "BillingProviderContactInformation": null
              },
              "PayToAddressName_Loop_2010AB": {
                "PayToAddressName": null,
                "PayToAddressAddress": null,
                "PayToAddressCityStateZipCode": null
              },
              "PayToPlanName_Loop_2010AC": {
                "PayToPlanName": null,
                "PayToPlanAddress": null,
                "PayToPlanCityStateZipCode": null,
                "PayToPlanSecondaryIdentification": null,
                "PayToPlanTaxIdentificationNumber": null
              }
            }
          ],
          "SubscriberDetail_Loop_2000B": [
            {
              "SubscriberHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "22",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "SubscriberInformation": {
                "SBR_01_PayerResponsibilitySequenceNumberCode_ID": "P",
                "SBR_02_IndividualRelationshipCode_ID": null,
                "SBR_03_ReferenceIdentification_AN": null,
                "SBR_04_Name_AN": null,
                "SBR_05_InsuranceTypeCode_ID": null,
                "SBR_06_CoordinationOfBenefitsCode_ID": null,
                "SBR_07_YesNoConditionOrResponseCode_ID": null,
                "SBR_08_EmploymentStatusCode_ID": null,
                "SBR_09_ClaimFilingIndicatorCode_ID": "CI"
              },
              "SubscriberName_Loop_2010BA": {
                "SubscriberName": {
                  "NM1_01_EntityIdentifierCode_ID": "IL",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "JANE",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "MI",
                  "NM1_09_IdentificationCode_AN": "111223333",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "SubscriberAddress": null,
                "SubscriberCityStateZipCode": null,
                "SubscriberDemographicInformation": null,
                "SubscriberSecondaryIdentification": null,
                "PropertyAndCasualtyClaimNumber": null
              },
              "PayerName_Loop_2010BB": {
                "PayerName": {
                  "NM1_01_EntityIdentifierCode_ID": "PR",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "INSURANCE COMPANY XYZ",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "PI",
                  "NM1_09_IdentificationCode_AN": "66783JJT",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PayerAddress": null,
                "PayerCityStateZipCode": null,
                "PayerSecondaryIdentification": null,
                "BillingProviderSecondaryIdentification": null
              }
            }
          ],
          "PatientDetail_Loop_2000C": [
            {
              "PatientHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "3",
                "HL_02_HierarchicalParentIDNumber_AN": "2",
                "HL_03_HierarchicalLevelCode_ID": "23",
                "HL_04_HierarchicalChildCode_ID": "0"
              },
              "PatientInfomation": {
                "PAT_01_IndividualRelationshipCode_ID": "19",
                "PAT_02_PatientLocationCode_ID": null,
                "PAT_03_EmploymentStatusCode_ID": null,
                "PAT_04_StudentStatusCode_ID": null,
                "PAT_05_DateTimePeriodFormatQualifier_ID": null,
                "PAT_06_DateTimePeriod_AN": null,
                "PAT_07_UnitOrBasisForMeasurementCode_ID": null,
                "PAT_08_Weight_R": null,
                "PAT_09_YesNoConditionOrResponseCode_ID": null
              },
              "PatientName_Loop_2010CA": {
                "PatientName": {
                  "NM1_01_EntityIdentifierCode_ID": "QC",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "TED",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": null,
                  "NM1_09_IdentificationCode_AN": null,
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PatientAddress": {
                  "N3_01_AddressInformation_AN": "236 N MAIN ST",
                  "N3_02_AddressInformation_AN": null
                },
                "PatientCityStateZipCode": {
                  "N4_01_CityName_AN": "MIAMI",
                  "N4_02_StateOrProvinceCode_ID": "FL",
                  "N4_03_PostalCode_ID": "33413",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "PatientDemographicInformation": {
                  "DMG_01_DateTimePeriodFormatQualifier_ID": "D8",
                  "DMG_02_DateTimePeriod_AN": "19920501",
                  "DMG_03_GenderCode_ID": "M",
                  "DMG_04_MaritalStatusCode_ID": null,
                  "DMG_05_CompositeRaceOrEthnicityInformation": null,
                  "DMG_06_CitizenshipStatusCode_ID": null,
                  "DMG_07_CountryCode_ID": null,
                  "DMG_08_BasisOfVerificationCode_ID": null,
                  "DMG_09_Quantity_R": null,
                  "DMG_10_CodeListQualifierCode_ID": null,
                  "DMG_11_IndustryCode_AN": null
                },
                "PropertyAndCasualtyClaimNumber": null,
                "PropertyAndCasualtyPatientIdentifier": null
              },
              "ClaimInformation": [
                {
                  "ClaimInfomation": {
                    "CLM_01_ClaimSubmittersIdentifier_AN": "26403774",
                    "CLM_02_MonetaryAmount_R": "150",
                    "CLM_03_ClaimFilingIndicatorCode_ID": null,
                    "CLM_04_NonInstitutionalClaimTypeCode_ID": null,
                    "CLM_05_HealthCareServiceLocationInfomation": {
                      "C023_01_FacilityCodeValue_AN": "11",
                      "C023_02_FacilityCodeQualifier_ID": "B",
                      "C023_03_ClaimFrequencyTypeCode_ID": "1"
                    },
                    "CLM_06_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_07_ProviderAcceptAssignmentCode_ID": null,
                    "CLM_08_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_09_ReleaseOfInfomationCode_ID": "I",
                    "CLM_10_PatientSignatureSourceCode_ID": null,
                    "CLM_11_elatedCausesInfomation": null,
                    "CLM_12_SpecialProgramCode_ID": null,
                    "CLM_13_YesNoConditionOrResponseCode_ID": null,
                    "CLM_14_LevelOfServiceCode_ID": null,
                    "CLM_15_YesNoConditionOrResponseCode_ID": null,
                    "CLM_16_ProviderAgreementCode_ID": null,
                    "CLM_17_ClaimStatusCode_ID": null,
                    "CLM_18_YesNoConditionOrResponseCode_ID": null,
                    "CLM_19_ClaimSubmissionReasonCode_ID": null,
                    "CLM_20_DelayReasonCode_ID": null
                  },
                  "DateAccident": {
                    "DTP_01_DateTimeQualifier_ID": "472",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20061029"
                  },
                  "DateAppliancePlacement": null,
                  "DateServiceDate": null,
                  "DateRepricerReceivedDate": null,
                  "OrthodonticTotalMonthsOfTreatment": null,
                  "ToothStatus": null,
                  "ClaimSupplementalInformation": null,
                  "ContractInformation": null,
                  "PatientAmountPaid": null,
                  "PredeterminationIdentification": {
                    "REF_01_ReferenceIdentificationQualifier_ID": "D9",
                    "REF_02_ReferenceIdentification_AN": "17312345600006351",
                    "REF_03_Description_AN": null,
                    "REF_04_ReferenceIdentifier": null
                  },
                  "ServiceAuthorizationExceptionCode": null,
                  "PayerClaimControlNumber": null,
                  "ReferralNumber": null,
                  "PriorAuthorization": null,
                  "RepricedClaimNumber": null,
                  "AdjustedRepricedClaimNumber": null,
                  "ClaimIdentifierForTransmissionIntermediaries": null,
                  "FileInformation": null,
                  "ClaimNote": null,
                  "HealthcareDiagnosisCode": null,
                  "ClaimPricingRepricingInformation": null,
                  "ReferringProviderName_Loop_2310A": [
                    {
                      "ReferringProviderName": {
                        "NM1_01_EntityIdentifierCode_ID": "82",
                        "NM1_02_EntityTypeQualifier_ID": "1",
                        "NM1_03_NameLastOrOrganizationName_AN": "KILDARE",
                        "NM1_04_NameFirst_AN": "BEN",
                        "NM1_05_NameMiddle_AN": null,
                        "NM1_06_NamePrefix_AN": null,
                        "NM1_07_NameSuffix_AN": null,
                        "NM1_08_IdentificationCodeQualifier_ID": "XX",
                        "NM1_09_IdentificationCode_AN": "9876543210",
                        "NM1_10_EntityRelationshipCode_ID": null,
                        "NM1_11_EntityIdentifierCode_ID": null,
                        "NM1_12_NameLastOrOrganizationName_AN": null
                      },
                      "RefferingProviderSpecialityInformation": {
                        "PRV_01_ProviderCode_ID": "PE",
                        "PRV_02_ReferenceIdentificationQualifier_ID": "PXC",
                        "PRV_03_ReferenceIdentification_AN": "1223G0001X",
                        "PRV_04_StateOrProvinceCode_ID": null,
                        "PRV_05_ProviderSpecialtyInformation": null,
                        "PRV_06_ProviderOrganizationCode_ID": null
                      },
                      "ReferringProviderSecondaryIdentification": null
                    }
                  ],
                  "RenderingProviderName_Loop_2310B": {
                    "RenderingProviderName": null,
                    "RenderingProviderSpecialityInfomation": null,
                    "RenderingProviderSecondaryIdentification": null
                  },
                  "ServiceFacilityLocation_Loop_2310C": {
                    "ServiceFacilityLocationName": null,
                    "ServiceLocationFacilityAddress": null,
                    "ServiceFacilityLocationCityStateZipCode": null,
                    "ServiceFacilityLocationSecondaryIdentification": null
                  },
                  "AssistantSurgeonName_Loop_2310D": {
                    "AssistantSurgeonName": null,
                    "AssistantSurgeonSpecialityInformation": null,
                    "AssistantSurgeonSecondaryIdentification": null
                  },
                  "SupervisingProviderName_Loop_2310E": {
                    "SupervisingProviderName": null,
                    "SupervisingProviderSecondaryIdentification": null
                  },
                  "OtherSubscriberInformation_Loop_2320": [
                    {
                      "OtherSubscriberInfomation": null,
                      "ClaimLevelAdjustment": null,
                      "CoordinationOfBenefitsPayerPaidAmount": null,
                      "RemainingPatientLiability": null,
                      "CoordinationOfBenefitsTotalNonCoveredAmount": null,
                      "OtherInsuranceCoverageInformation": null,
                      "OutpatientAdjudicationInfomation": null,
                      "OtherSubscriberName_Loop_2330A": {
                        "OtherSubscriberName": null,
                        "OtherSubscriberAddress": null,
                        "OtherSubscriberCirtStateZipCode": null,
                        "OtherSubscriberSecondaryIdentification": null
                      },
                      "OtherPayerName_Loop_2330B": {
                        "OtherPayerName": null,
                        "OtherPayerAddress": null,
                        "OtherPayerCityStateZipCode": null,
                        "ClaimCheckOrRemittanceDate": null,
                        "OtherPayerSecondaryIdentification": null,
                        "OtherPayerPriorAuthorizationNumber": null,
                        "OtherPayerReferralNumber": null,
                        "OtherPayerClaimAdjustmentIndicator": null,
                        "OtherPayerPredeterminationIdentification": null,
                        "OtherPayerClaimControlNumber": null
                      },
                      "OtherPayerReferringProvider_Loop_2330C": [
                        {
                          "OtherPayerReferringProvider": null,
                          "OtherPayerReferringProviderSecondaryIdentification": null
                        }
                      ],
                      "OtherPayerRenderingProvider_Loop_2330D": {
                        "OtherPayerRenderingProvider": null,
                        "OtherPayerRenderingProviderSecondaryIdentification": null
                      },
                      "OtherPayerSupervisingProvider_Loop_2330E": {
                        "OtherPayerSupervisingProvider": null,
                        "OtherPayerSupervisingProviderSecondaryIdentification": null
                      },
                      "OtherPayerBillingProvider_Loop_2330F": {
                        "OtherPayerBillingProvider": null,
                        "OtherPayerBillingProviderSecondaryIdentification": null
                      },
                      "OtherPayerServiceFacilityLocation_Loop_2330G": {
                        "OtherPayerServiceFacilityLocation": null,
                        "OtherPayerServiceFacilityLocationSecondaryIdentification": null
                      },
                      "OtherPayerAssistantSurgeon_Loop_2330H": {
                        "OtherPayerAssistantSurgeon": null,
                        "OtherPayerAssistantSurgeonSecondaryIdentification": null
                      }
                    }
                  ],
                  "ServiceLineNumber_Loop_2400": [
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "1"
                      },
                      "DentalService": {
                        "SV3_01_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "AD",
                          "C003_02_ProductServiceID_AN": "D2150",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV3_02_MonetaryAmount_R": "100",
                        "SV3_03_FacilityCodeValue_AN": null,
                        "SV3_04_OralCavityDesignatio": null,
                        "SV3_05_ProsthesisCrownOrInlayCode_ID": null,
                        "SV3_06_Quantity_R": "1",
                        "SV3_07_Description_AN": null,
                        "SV3_08_CopayStatusCode_ID": null,
                        "SV3_09_ProviderAgreementCode_ID": null,
                        "SV3_10_YesNoConditionOrResponseCode_ID": null,
                        "SV3_11_CompositeDiagnosisCodePointer": null
                      },
                      "ToothInformation": [
                        {
                          "TOO_01_CodeListQualifierCode_ID": "JP",
                          "TOO_02_IndustryCode_AN": "12",
                          "Too_03_Tooth_Surface": {
                            "C005_01_ToothSurface_Code_ID": "M",
                            "C005_02_ToothSurfaceCode_ID": "O",
                            "C005_03_ToothSurfaceCode_ID": null,
                            "C005_04_ToothSurfaceCode_ID": null,
                            "C005_05_ToothSurfaceCode_ID": null
                          }
                        }
                      ],
                      "DateServiceDate": null,
                      "DatePriorPlacement": null,
                      "DateAppliancePlacement": null,
                      "DateReplacement": null,
                      "DateTreatmentStart": null,
                      "DateTreatmentCompletion": null,
                      "ContractInformation": null,
                      "ServicePredeterminationIdentification": null,
                      "PriorAuthorization": null,
                      "LineItemControlNumber": null,
                      "RepricedClaimNumber": null,
                      "AdjustedRepricedClaimNumber": null,
                      "ReferralNumber": null,
                      "SalesTaxAmount": null,
                      "FileInformation": null,
                      "LinePricingRepricingInformation": null,
                      "RenderingProviderName_Loop_2420A": {
                        "RenderingProviderName": null,
                        "RenderingProviderSpecialityInformation": null,
                        "RenderingProviderSecondaryIdentification": null
                      },
                      "AssistantSurgeonName_Loop_2420B": {
                        "AssistantSurgeonName": null,
                        "AssistantSurgeonSpecialityInformation": null,
                        "AssistantSurgeonSecondaryIdentification": null
                      },
                      "SupervisingProviderName_Loop_2420C": {
                        "SupervisingProviderName": null,
                        "SupervisingProviderSecondaryIdentification": null
                      },
                      "ServiceFacilityLocationName_Loop_2420D": {
                        "ServiceFacilityLocationName": null,
                        "ServiceFacilityLocationAddress": null,
                        "ServiceFacilityLocationCityStateZipCode": null,
                        "ServiceFacilityLocationSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LinecheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    },
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "2"
                      },
                      "DentalService": {
                        "SV3_01_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "AD",
                          "C003_02_ProductServiceID_AN": "D1110",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV3_02_MonetaryAmount_R": "50",
                        "SV3_03_FacilityCodeValue_AN": null,
                        "SV3_04_OralCavityDesignatio": null,
                        "SV3_05_ProsthesisCrownOrInlayCode_ID": null,
                        "SV3_06_Quantity_R": "1",
                        "SV3_07_Description_AN": null,
                        "SV3_08_CopayStatusCode_ID": null,
                        "SV3_09_ProviderAgreementCode_ID": null,
                        "SV3_10_YesNoConditionOrResponseCode_ID": null,
                        "SV3_11_CompositeDiagnosisCodePointer": null
                      },
                      "ToothInformation": null,
                      "DateServiceDate": null,
                      "DatePriorPlacement": null,
                      "DateAppliancePlacement": null,
                      "DateReplacement": null,
                      "DateTreatmentStart": null,
                      "DateTreatmentCompletion": null,
                      "ContractInformation": null,
                      "ServicePredeterminationIdentification": null,
                      "PriorAuthorization": null,
                      "LineItemControlNumber": null,
                      "RepricedClaimNumber": null,
                      "AdjustedRepricedClaimNumber": null,
                      "ReferralNumber": null,
                      "SalesTaxAmount": null,
                      "FileInformation": null,
                      "LinePricingRepricingInformation": null,
                      "RenderingProviderName_Loop_2420A": {
                        "RenderingProviderName": null,
                        "RenderingProviderSpecialityInformation": null,
                        "RenderingProviderSecondaryIdentification": null
                      },
                      "AssistantSurgeonName_Loop_2420B": {
                        "AssistantSurgeonName": null,
                        "AssistantSurgeonSpecialityInformation": null,
                        "AssistantSurgeonSecondaryIdentification": null
                      },
                      "SupervisingProviderName_Loop_2420C": {
                        "SupervisingProviderName": null,
                        "SupervisingProviderSecondaryIdentification": null
                      },
                      "ServiceFacilityLocationName_Loop_2420D": {
                        "ServiceFacilityLocationName": null,
                        "ServiceFacilityLocationAddress": null,
                        "ServiceFacilityLocationCityStateZipCode": null,
                        "ServiceFacilityLocationSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LinecheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "31",
            "SE_02_TransactionSetControlNumber_AN": "3456"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

JSON Request to EDI 837 Response

Transforms JSON into an EDI 837 message.

post https://api-edi.splinxtechnologies.com/v1/edi-transformation/json-to-edi837

Request headers

Authentication

To make REST API calls, make sure to include your account's email and password in a Base64 encrypted format in the Basic authentication scheme. The value is <Account-Email> and <Account-Password>

LicenseId

Sample request (Professional Claim)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "XX",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVERCODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X222"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "837",
            "ST_02_TransactionSetControlNumber_AN": "3456",
            "ST_03_ImplementationConventionReference_AN": "005010X222"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0019",
            "BHT_02_TransactionSetPurposeCode_ID": "00",
            "BHT_03_ReferenceIdentification_AN": "0123",
            "BHT_04_Date_DT": "20061123",
            "BHT_05_Time_TM": "1023",
            "BHT_06_TransactionTypeCode_ID": "CH"
          },
          "SubmiterName_Loop_1000A": {
            "SubmiterName": {
              "NM1_01_EntityIdentifierCode_ID": "41",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "PREMIER BILLING SERVICE",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "TGJ23",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            },
            "SubmitterEdiContactInformation": [
              {
                "PER_01_ContactFunctionCode_ID": "IC",
                "PER_02_Name_AN": "JERRY",
                "PER_03_CommunicationNumberQualifier_ID": "TE",
                "PER_04_CommunicationNumber_AN": "7176149999",
                "PER_05_CommunicationNumberQualifier_ID": null,
                "PER_06_CommunicationNumber_AN": null,
                "PER_07_CommunicationNumberQualifier_ID": null,
                "PER_08_CommunicationNumber_AN": null,
                "PER_09_ContactInquiryReference_AN": null
              }
            ]
          },
          "ReceiverName_Loop_1000B": {
            "ReceiverName": {
              "NM1_01_EntityIdentifierCode_ID": "40",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "INSURANCE COMPANY XYZ",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "66783JJT",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            }
          },
          "BillingProviderDetail_Loop_2000A": [
            {
              "BillingProviderHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "1",
                "HL_02_HierarchicalParentIDNumber_AN": null,
                "HL_03_HierarchicalLevelCode_ID": "20",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "BillingProviderSpecialtyInformation": null,
              "ForeignCurrencyInformation": null,
              "BillingProviderName_Loop_2010AA": {
                "BillingProviderName": {
                  "NM1_01_EntityIdentifierCode_ID": "85",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "DENTAL ASSOCIATES",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "XX",
                  "NM1_09_IdentificationCode_AN": "1234567890",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "BillingProviderAddress": {
                  "N3_01_AddressInformation_AN": "234 SEAWAY ST",
                  "N3_02_AddressInformation_AN": null
                },
                "BillingProviderCityStateZipCode": {
                  "N4_01_CityName_AN": "MIAMI",
                  "N4_02_StateOrProvinceCode_ID": "FL",
                  "N4_03_PostalCode_ID": "33111",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "BillingProviderTaxIdentification": {
                  "REF_01_ReferenceIdentificationQualifier_ID": "EI",
                  "REF_02_ReferenceIdentification_AN": "587654321",
                  "REF_03_Description_AN": null,
                  "REF_04_ReferenceIdentifier": null
                },
                "BillingProviderUPINLicenseInformation": null,
                "BillingProviderContactInformation": null
              },
              "PayToAddressName_Loop_2010AB": {
                "PayToAddressName": null,
                "PayToAddressAddress": null,
                "PayToAddressCityStateZipCode": null
              },
              "PayToPlanName_Loop_2010AC": {
                "PayToPlanName": null,
                "PayToPlanAddress": null,
                "PayToPlanCityStateZipCode": null,
                "PayToPlanSecondaryIdentification": null,
                "PayToPlanTaxIdentificationNumber": null
              }
            }
          ],
          "SubscriberDetail_Loop_2000B": [
            {
              "SubscriberHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "22",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "SubscriberInformation": {
                "SBR_01_PayerResponsibilitySequenceNumberCode_ID": "P",
                "SBR_02_IndividualRelationshipCode_ID": null,
                "SBR_03_ReferenceIdentification_AN": null,
                "SBR_04_Name_AN": null,
                "SBR_05_InsuranceTypeCode_ID": null,
                "SBR_06_CoordinationOfBenefitsCode_ID": null,
                "SBR_07_YesNoConditionOrResponseCode_ID": null,
                "SBR_08_EmploymentStatusCode_ID": null,
                "SBR_09_ClaimFilingIndicatorCode_ID": "CI"
              },
              "SubscriberName_Loop_2010BA": {
                "SubscriberName": {
                  "NM1_01_EntityIdentifierCode_ID": "IL",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "JANE",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "MI",
                  "NM1_09_IdentificationCode_AN": "111223333",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "SubscriberAddress": null,
                "SubscriberCityStateZipCode": null,
                "SubscriberDemographicInformation": null,
                "SubscriberSecondaryIdentification": null,
                "PropertyAndCasualtyClaimNumber": null
              },
              "PayerName_Loop_2010BB": {
                "PayerName": {
                  "NM1_01_EntityIdentifierCode_ID": "PR",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "INSURANCE COMPANY XYZ",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "PI",
                  "NM1_09_IdentificationCode_AN": "66783JJT",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PayerAddress": null,
                "PayerCityStateZipCode": null,
                "PayerSecondaryIdentification": null,
                "BillingProviderSecondaryIdentification": null
              }
            }
          ],
          "PatientDetail_Loop_2000C": [
            {
              "PatientHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "3",
                "HL_02_HierarchicalParentIDNumber_AN": "2",
                "HL_03_HierarchicalLevelCode_ID": "23",
                "HL_04_HierarchicalChildCode_ID": "0"
              },
              "PatientInfomation": {
                "PAT_01_IndividualRelationshipCode_ID": "19",
                "PAT_02_PatientLocationCode_ID": null,
                "PAT_03_EmploymentStatusCode_ID": null,
                "PAT_04_StudentStatusCode_ID": null,
                "PAT_05_DateTimePeriodFormatQualifier_ID": null,
                "PAT_06_DateTimePeriod_AN": null,
                "PAT_07_UnitOrBasisForMeasurementCode_ID": null,
                "PAT_08_Weight_R": null,
                "PAT_09_YesNoConditionOrResponseCode_ID": null
              },
              "PatientName_Loop_2010CA": {
                "PatientName": {
                  "NM1_01_EntityIdentifierCode_ID": "QC",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "TED",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": null,
                  "NM1_09_IdentificationCode_AN": null,
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PatientAddress": {
                  "N3_01_AddressInformation_AN": "236 N MAIN ST",
                  "N3_02_AddressInformation_AN": null
                },
                "PatientCityStateZipCode": {
                  "N4_01_CityName_AN": "MIAMI",
                  "N4_02_StateOrProvinceCode_ID": "FL",
                  "N4_03_PostalCode_ID": "33413",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "PatientDemographicInformation": {
                  "DMG_01_DateTimePeriodFormatQualifier_ID": "D8",
                  "DMG_02_DateTimePeriod_AN": "19920501",
                  "DMG_03_GenderCode_ID": "M",
                  "DMG_04_MaritalStatusCode_ID": null,
                  "DMG_05_CompositeRaceOrEthnicityInformation": null,
                  "DMG_06_CitizenshipStatusCode_ID": null,
                  "DMG_07_CountryCode_ID": null,
                  "DMG_08_BasisOfVerificationCode_ID": null,
                  "DMG_09_Quantity_R": null,
                  "DMG_10_CodeListQualifierCode_ID": null,
                  "DMG_11_IndustryCode_AN": null
                },
                "PropertyAndCasualtyClaimNumber": null,
                "PropertyAndCasualtyPatientIdentifier": null
              },
              "ClaimInformation": [
                {
                  "ClaimInfomation": {
                    "CLM_01_ClaimSubmittersIdentifier_AN": "26403774",
                    "CLM_02_MonetaryAmount_R": "150",
                    "CLM_03_ClaimFilingIndicatorCode_ID": null,
                    "CLM_04_NonInstitutionalClaimTypeCode_ID": null,
                    "CLM_05_HealthCareServiceLocationInfomation": {
                      "C023_01_FacilityCodeValue_AN": "11",
                      "C023_02_FacilityCodeQualifier_ID": "B",
                      "C023_03_ClaimFrequencyTypeCode_ID": "1"
                    },
                    "CLM_06_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_07_ProviderAcceptAssignmentCode_ID": null,
                    "CLM_08_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_09_ReleaseOfInfomationCode_ID": "I",
                    "CLM_10_PatientSignatureSourceCode_ID": null,
                    "CLM_11_elatedCausesInfomation": null,
                    "CLM_12_SpecialProgramCode_ID": null,
                    "CLM_13_YesNoConditionOrResponseCode_ID": null,
                    "CLM_14_LevelOfServiceCode_ID": null,
                    "CLM_15_YesNoConditionOrResponseCode_ID": null,
                    "CLM_16_ProviderAgreementCode_ID": null,
                    "CLM_17_ClaimStatusCode_ID": null,
                    "CLM_18_YesNoConditionOrResponseCode_ID": null,
                    "CLM_19_ClaimSubmissionReasonCode_ID": null,
                    "CLM_20_DelayReasonCode_ID": null
                  },
                  "DateAccident": {
                    "DTP_01_DateTimeQualifier_ID": "472",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20061029"
                  },
                  "DateAppliancePlacement": null,
                  "DateServiceDate": null,
                  "DateRepricerReceivedDate": null,
                  "OrthodonticTotalMonthsOfTreatment": null,
                  "ToothStatus": null,
                  "ClaimSupplementalInformation": null,
                  "ContractInformation": null,
                  "PatientAmountPaid": null,
                  "PredeterminationIdentification": {
                    "REF_01_ReferenceIdentificationQualifier_ID": "D9",
                    "REF_02_ReferenceIdentification_AN": "17312345600006351",
                    "REF_03_Description_AN": null,
                    "REF_04_ReferenceIdentifier": null
                  },
                  "ServiceAuthorizationExceptionCode": null,
                  "PayerClaimControlNumber": null,
                  "ReferralNumber": null,
                  "PriorAuthorization": null,
                  "RepricedClaimNumber": null,
                  "AdjustedRepricedClaimNumber": null,
                  "ClaimIdentifierForTransmissionIntermediaries": null,
                  "FileInformation": null,
                  "ClaimNote": null,
                  "HealthcareDiagnosisCode": null,
                  "ClaimPricingRepricingInformation": null,
                  "ReferringProviderName_Loop_2310A": [
                    {
                      "ReferringProviderName": {
                        "NM1_01_EntityIdentifierCode_ID": "82",
                        "NM1_02_EntityTypeQualifier_ID": "1",
                        "NM1_03_NameLastOrOrganizationName_AN": "KILDARE",
                        "NM1_04_NameFirst_AN": "BEN",
                        "NM1_05_NameMiddle_AN": null,
                        "NM1_06_NamePrefix_AN": null,
                        "NM1_07_NameSuffix_AN": null,
                        "NM1_08_IdentificationCodeQualifier_ID": "XX",
                        "NM1_09_IdentificationCode_AN": "9876543210",
                        "NM1_10_EntityRelationshipCode_ID": null,
                        "NM1_11_EntityIdentifierCode_ID": null,
                        "NM1_12_NameLastOrOrganizationName_AN": null
                      },
                      "RefferingProviderSpecialityInformation": {
                        "PRV_01_ProviderCode_ID": "PE",
                        "PRV_02_ReferenceIdentificationQualifier_ID": "PXC",
                        "PRV_03_ReferenceIdentification_AN": "1223G0001X",
                        "PRV_04_StateOrProvinceCode_ID": null,
                        "PRV_05_ProviderSpecialtyInformation": null,
                        "PRV_06_ProviderOrganizationCode_ID": null
                      },
                      "ReferringProviderSecondaryIdentification": null
                    }
                  ],
                  "RenderingProviderName_Loop_2310B": {
                    "RenderingProviderName": null,
                    "RenderingProviderSpecialityInfomation": null,
                    "RenderingProviderSecondaryIdentification": null
                  },
                  "ServiceFacilityLocation_Loop_2310C": {
                    "ServiceFacilityLocationName": null,
                    "ServiceLocationFacilityAddress": null,
                    "ServiceFacilityLocationCityStateZipCode": null,
                    "ServiceFacilityLocationSecondaryIdentification": null
                  },
                  "AssistantSurgeonName_Loop_2310D": {
                    "AssistantSurgeonName": null,
                    "AssistantSurgeonSpecialityInformation": null,
                    "AssistantSurgeonSecondaryIdentification": null
                  },
                  "SupervisingProviderName_Loop_2310E": {
                    "SupervisingProviderName": null,
                    "SupervisingProviderSecondaryIdentification": null
                  },
                  "OtherSubscriberInformation_Loop_2320": [
                    {
                      "OtherSubscriberInfomation": null,
                      "ClaimLevelAdjustment": null,
                      "CoordinationOfBenefitsPayerPaidAmount": null,
                      "RemainingPatientLiability": null,
                      "CoordinationOfBenefitsTotalNonCoveredAmount": null,
                      "OtherInsuranceCoverageInformation": null,
                      "OutpatientAdjudicationInfomation": null,
                      "OtherSubscriberName_Loop_2330A": {
                        "OtherSubscriberName": null,
                        "OtherSubscriberAddress": null,
                        "OtherSubscriberCirtStateZipCode": null,
                        "OtherSubscriberSecondaryIdentification": null
                      },
                      "OtherPayerName_Loop_2330B": {
                        "OtherPayerName": null,
                        "OtherPayerAddress": null,
                        "OtherPayerCityStateZipCode": null,
                        "ClaimCheckOrRemittanceDate": null,
                        "OtherPayerSecondaryIdentification": null,
                        "OtherPayerPriorAuthorizationNumber": null,
                        "OtherPayerReferralNumber": null,
                        "OtherPayerClaimAdjustmentIndicator": null,
                        "OtherPayerPredeterminationIdentification": null,
                        "OtherPayerClaimControlNumber": null
                      },
                      "OtherPayerReferringProvider_Loop_2330C": [
                        {
                          "OtherPayerReferringProvider": null,
                          "OtherPayerReferringProviderSecondaryIdentification": null
                        }
                      ],
                      "OtherPayerRenderingProvider_Loop_2330D": {
                        "OtherPayerRenderingProvider": null,
                        "OtherPayerRenderingProviderSecondaryIdentification": null
                      },
                      "OtherPayerSupervisingProvider_Loop_2330E": {
                        "OtherPayerSupervisingProvider": null,
                        "OtherPayerSupervisingProviderSecondaryIdentification": null
                      },
                      "OtherPayerBillingProvider_Loop_2330F": {
                        "OtherPayerBillingProvider": null,
                        "OtherPayerBillingProviderSecondaryIdentification": null
                      },
                      "OtherPayerServiceFacilityLocation_Loop_2330G": {
                        "OtherPayerServiceFacilityLocation": null,
                        "OtherPayerServiceFacilityLocationSecondaryIdentification": null
                      },
                      "OtherPayerAssistantSurgeon_Loop_2330H": {
                        "OtherPayerAssistantSurgeon": null,
                        "OtherPayerAssistantSurgeonSecondaryIdentification": null
                      }
                    }
                  ],
                  "ServiceLineNumber_Loop_2400": [
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "1"
                      },
                      "DentalService": {
                        "SV3_01_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "AD",
                          "C003_02_ProductServiceID_AN": "D2150",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV3_02_MonetaryAmount_R": "100",
                        "SV3_03_FacilityCodeValue_AN": null,
                        "SV3_04_OralCavityDesignatio": null,
                        "SV3_05_ProsthesisCrownOrInlayCode_ID": null,
                        "SV3_06_Quantity_R": "1",
                        "SV3_07_Description_AN": null,
                        "SV3_08_CopayStatusCode_ID": null,
                        "SV3_09_ProviderAgreementCode_ID": null,
                        "SV3_10_YesNoConditionOrResponseCode_ID": null,
                        "SV3_11_CompositeDiagnosisCodePointer": null
                      },
                      "ToothInformation": [
                        {
                          "TOO_01_CodeListQualifierCode_ID": "JP",
                          "TOO_02_IndustryCode_AN": "12",
                          "Too_03_Tooth_Surface": {
                            "C005_01_ToothSurface_Code_ID": "M",
                            "C005_02_ToothSurfaceCode_ID": "O",
                            "C005_03_ToothSurfaceCode_ID": null,
                            "C005_04_ToothSurfaceCode_ID": null,
                            "C005_05_ToothSurfaceCode_ID": null
                          }
                        }
                      ],
                      "DateServiceDate": null,
                      "DatePriorPlacement": null,
                      "DateAppliancePlacement": null,
                      "DateReplacement": null,
                      "DateTreatmentStart": null,
                      "DateTreatmentCompletion": null,
                      "ContractInformation": null,
                      "ServicePredeterminationIdentification": null,
                      "PriorAuthorization": null,
                      "LineItemControlNumber": null,
                      "RepricedClaimNumber": null,
                      "AdjustedRepricedClaimNumber": null,
                      "ReferralNumber": null,
                      "SalesTaxAmount": null,
                      "FileInformation": null,
                      "LinePricingRepricingInformation": null,
                      "RenderingProviderName_Loop_2420A": {
                        "RenderingProviderName": null,
                        "RenderingProviderSpecialityInformation": null,
                        "RenderingProviderSecondaryIdentification": null
                      },
                      "AssistantSurgeonName_Loop_2420B": {
                        "AssistantSurgeonName": null,
                        "AssistantSurgeonSpecialityInformation": null,
                        "AssistantSurgeonSecondaryIdentification": null
                      },
                      "SupervisingProviderName_Loop_2420C": {
                        "SupervisingProviderName": null,
                        "SupervisingProviderSecondaryIdentification": null
                      },
                      "ServiceFacilityLocationName_Loop_2420D": {
                        "ServiceFacilityLocationName": null,
                        "ServiceFacilityLocationAddress": null,
                        "ServiceFacilityLocationCityStateZipCode": null,
                        "ServiceFacilityLocationSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LinecheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    },
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "2"
                      },
                      "DentalService": {
                        "SV3_01_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "AD",
                          "C003_02_ProductServiceID_AN": "D1110",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV3_02_MonetaryAmount_R": "50",
                        "SV3_03_FacilityCodeValue_AN": null,
                        "SV3_04_OralCavityDesignatio": null,
                        "SV3_05_ProsthesisCrownOrInlayCode_ID": null,
                        "SV3_06_Quantity_R": "1",
                        "SV3_07_Description_AN": null,
                        "SV3_08_CopayStatusCode_ID": null,
                        "SV3_09_ProviderAgreementCode_ID": null,
                        "SV3_10_YesNoConditionOrResponseCode_ID": null,
                        "SV3_11_CompositeDiagnosisCodePointer": null
                      },
                      "ToothInformation": null,
                      "DateServiceDate": null,
                      "DatePriorPlacement": null,
                      "DateAppliancePlacement": null,
                      "DateReplacement": null,
                      "DateTreatmentStart": null,
                      "DateTreatmentCompletion": null,
                      "ContractInformation": null,
                      "ServicePredeterminationIdentification": null,
                      "PriorAuthorization": null,
                      "LineItemControlNumber": null,
                      "RepricedClaimNumber": null,
                      "AdjustedRepricedClaimNumber": null,
                      "ReferralNumber": null,
                      "SalesTaxAmount": null,
                      "FileInformation": null,
                      "LinePricingRepricingInformation": null,
                      "RenderingProviderName_Loop_2420A": {
                        "RenderingProviderName": null,
                        "RenderingProviderSpecialityInformation": null,
                        "RenderingProviderSecondaryIdentification": null
                      },
                      "AssistantSurgeonName_Loop_2420B": {
                        "AssistantSurgeonName": null,
                        "AssistantSurgeonSpecialityInformation": null,
                        "AssistantSurgeonSecondaryIdentification": null
                      },
                      "SupervisingProviderName_Loop_2420C": {
                        "SupervisingProviderName": null,
                        "SupervisingProviderSecondaryIdentification": null
                      },
                      "ServiceFacilityLocationName_Loop_2420D": {
                        "ServiceFacilityLocationName": null,
                        "ServiceFacilityLocationAddress": null,
                        "ServiceFacilityLocationCityStateZipCode": null,
                        "ServiceFacilityLocationSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LinecheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "31",
            "SE_02_TransactionSetControlNumber_AN": "3456"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

Sample response (Professional Claim)

EDI 837 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X222~ST*837*0021*005010X222~BHT*0019*00*244579*20061015*1023*CH~NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~PER*IC*JERRY*TE*3055552222*EX*231~NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~HL*1**20*1~PRV*BI*PXC*203BF0100Y~NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~N3*234 SEAWAY ST~N4*MIAMI*FL*33111~REF*EI*587654321~NM1*87*2~N3*2345 OCEAN BLVD~N4*MAIMI*FL*33111~HL*2*1*22*1~SBR*P**2222-SJ******CI~NM1*IL*1*SMITH*JANE****MI*JS00111223333~DMG*D8*19430501*F~NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~REF*G2*KA6663~HL*3*2*23*0~PAT*19~NM1*QC*1*SMITH*TED~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8*19730501*M~CLM*26463774*100***11:B:1*Y*A*Y*I~REF*D9*17312345600006351~HI*BK:0340*BF:V7389~LX*1~SV1*HC:99213*40*UN*1***1~DTP*472*D8*20061003~LX*2~SV1*HC:87070*15*UN*1***1~DTP*472*D8*20061003~LX*3~SV1*HC:99214*35*UN*1***2~DTP*472*D8*20061010~LX*4~SV1*HC:86663*10*UN*1***2~DTP*472*D8*20061010~SE*42*0021~GE*1*1~IEA*1*000000001~

Sample request (Institutional Claim)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "XX",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVERCODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X223A3"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "837",
            "ST_02_TransactionSetControlNumber_AN": "987654",
            "ST_03_ImplementationConventionReference_AN": "005010X223A3"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0019",
            "BHT_02_TransactionSetPurposeCode_ID": "00",
            "BHT_03_ReferenceIdentification_AN": "0123",
            "BHT_04_Date_DT": "19960918",
            "BHT_05_Time_TM": "0932",
            "BHT_06_TransactionTypeCode_ID": "CH"
          },
          "SubmitterName_Loop_1000A": {
            "SubmitterName": {
              "NM1_01_EntityIdentifierCode_ID": "41",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "JONES HOSPITAL",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "12345",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            },
            "SubmitterEdiContactInfomation": [
              {
                "PER_01_ContactFunctionCode_ID": "IC",
                "PER_02_Name_AN": "JANE DOE",
                "PER_03_CommunicationNumberQualifier_ID": "TE",
                "PER_04_CommunicationNumber_AN": "9005555555",
                "PER_05_CommunicationNumberQualifier_ID": null,
                "PER_06_CommunicationNumber_AN": null,
                "PER_07_CommunicationNumberQualifier_ID": null,
                "PER_08_CommunicationNumber_AN": null,
                "PER_09_ContactInquiryReference_AN": null
              }
            ]
          },
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                        "OtherPayerOtherOperatingPhysicianSecondaryIdentification": null
                      },
                      "OtherPayerRenderingProviderName_Loop_2330G": {
                        "OtherPayerRenderingProviderName": null,
                        "OtherPayerRenderingProviderNameSecondaryIdentification": null
                      },
                      "OtherPayerReferringProvider_Loop_2330H": {
                        "OtherPayerReferringProvider": null,
                        "OtherPayerReferringProviderSecondaryIdentification": null
                      },
                      "OtherPayerBillingProvider_Loop_2330I": {
                        "OtherPayerBillingProvider": null,
                        "OtherPayerBillingProviderSecondaryIdentification": null
                      }
                    }
                  ],
                  "ServiceLineNumber_Loop_2400": [
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "1"
                      },
                      "InstitutionalServiceLine": {
                        "SV2_01_ProductServiceId_AN": "0305",
                        "SV2_02_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "HC",
                          "C003_02_ProductServiceID_AN": "85025",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV2_03_MonetaryAmount_R": "13.39",
                        "SV2_04_UnitOrBasisForMeasurementCode_ID": "UN",
                        "SV2_05_Quantity_R": "1",
                        "SV2_06_UnitRate_R": null,
                        "SV2_07_MonetaryAmount_R": null,
                        "SV2_08_YesNoConditionOrResponseCode_ID": null,
                        "SV2_09_NursingHomeResidentialStatusCode_ID": null,
                        "SV2_10_LevelOfCareCode_ID": null
                      },
                      "LineSupplementalInformation": null,
                      "DateServiceDate": {
                        "DTP_01_DateTimeQualifier_ID": "472",
                        "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                        "DTP_03_DateTimePeriod_AN": "19960911"
                      },
                      "LineItemControlNumber": null,
                      "RepricedLineItemReferenceNumber": null,
                      "AdjustedRepricedLineItemReferenceNumber": null,
                      "ServiceTaxAmount": null,
                      "FacilityTaxAmount": null,
                      "ThirdPartyOrganizationNotes": null,
                      "LinePricingRepricingInfomation": null,
                      "DrugIdentification_Loop_2410": {
                        "DrugIdentification": null,
                        "DrugQuantity": null,
                        "PrescriptionOrCompundDrugAssociationNumber": null
                      },
                      "OperatingPhysicianName_Loop_2420A": {
                        "OperatingPhysicianName": null,
                        "OperatingPhysicianSecondaryIdentification": null
                      },
                      "OtherOperatingPhysicianName_Loop_2420B": {
                        "OtherOperatingPhysicianName": null,
                        "OtherOperatingPhysicianSecondaryIdentification": null
                      },
                      "RenderingProviderName_Loop_2420C": {
                        "RenderingProviderName": null,
                        "RenderingProviderNameSecondaryIdentification": null
                      },
                      "ReferringProviderName_Loop_2420D": {
                        "ReferringProviderName": null,
                        "ReferringProviderNameSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LineCheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    },
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "2"
                      },
                      "InstitutionalServiceLine": {
                        "SV2_01_ProductServiceId_AN": "0730",
                        "SV2_02_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "HC",
                          "C003_02_ProductServiceID_AN": "93005",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV2_03_MonetaryAmount_R": "76.54",
                        "SV2_04_UnitOrBasisForMeasurementCode_ID": "UN",
                        "SV2_05_Quantity_R": "3",
                        "SV2_06_UnitRate_R": null,
                        "SV2_07_MonetaryAmount_R": null,
                        "SV2_08_YesNoConditionOrResponseCode_ID": null,
                        "SV2_09_NursingHomeResidentialStatusCode_ID": null,
                        "SV2_10_LevelOfCareCode_ID": null
                      },
                      "LineSupplementalInformation": null,
                      "DateServiceDate": {
                        "DTP_01_DateTimeQualifier_ID": "472",
                        "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                        "DTP_03_DateTimePeriod_AN": "19960911"
                      },
                      "LineItemControlNumber": null,
                      "RepricedLineItemReferenceNumber": null,
                      "AdjustedRepricedLineItemReferenceNumber": null,
                      "ServiceTaxAmount": null,
                      "FacilityTaxAmount": null,
                      "ThirdPartyOrganizationNotes": null,
                      "LinePricingRepricingInfomation": null,
                      "DrugIdentification_Loop_2410": {
                        "DrugIdentification": null,
                        "DrugQuantity": null,
                        "PrescriptionOrCompundDrugAssociationNumber": null
                      },
                      "OperatingPhysicianName_Loop_2420A": {
                        "OperatingPhysicianName": null,
                        "OperatingPhysicianSecondaryIdentification": null
                      },
                      "OtherOperatingPhysicianName_Loop_2420B": {
                        "OtherOperatingPhysicianName": null,
                        "OtherOperatingPhysicianSecondaryIdentification": null
                      },
                      "RenderingProviderName_Loop_2420C": {
                        "RenderingProviderName": null,
                        "RenderingProviderNameSecondaryIdentification": null
                      },
                      "ReferringProviderName_Loop_2420D": {
                        "ReferringProviderName": null,
                        "ReferringProviderNameSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LineCheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "43",
            "SE_02_TransactionSetControlNumber_AN": "987654"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

Sample response (Institutional Claim)

EDI 837 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X223A3~ST*837*987654*005010X223A3~BHT*0019*00*0123*19960918*0932*CH~NM1*41*2*JONES HOSPITAL*****46*12345~PER*IC*JANE DOE*TE*9005555555~NM1*40*2*MEDICARE*****46*00120~HL*1**20*1~PRV*BI*PXC*203BA0200N~NM1*85*2*JONES HOSPITAL*****XX*9876540809~N3*225 MAIN STREET BARKLEY BUILDING~N4*CENTERVILLE*PA*17111~REF*EI*567891234~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1*DOE*JOHN*T***MI*030005074A~N3*125 CITY AVENUE~N4*CENTERVILLE*PA*17111~DMG*D8*19261111*M~NM1*PR*2*MEDICARE B*****PI*00435~REF*G2*330127~CLM*756048Q*89.93***14:A:1*Y*A*Y*Y~DTP*434*D8*19960911~CL1*3**01~HI*BK:3669~HI*BF:4019*BF:79431~HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~HI*BE:A2:::15.31~HI*BG:09~NM1*71*1*JONES*JOHN*J~REF*1G*B99937~SBR*S*01*351630*STATE TEACHERS*****CI~OI***Y***Y~NM1*IL*1*DOE*JANE*S***MI*222004433~N3*125 CITY AVENUE~N4*CENTERVILLE*PA*17111~NM1*PR*2*STATE TEACHERS*****PI*1135~LX*1~SV2*0305*HC:85025*13.39*UN*1~DTP*472*D8*19960911~LX*2~SV2*0730*HC:93005*76.54*UN*3~DTP*472*D8*19960911~SE*43*987654~GE*1*1~IEA*1*000000001~

Sample request (Dental Claim)

JSON Copy

{
  "InterchangeControlHeaderSegment": {
    "ISA_01_AuthorizationInformationQualifier_ID": "00",
    "ISA_02_AuthorizationInformation_AN": "          ",
    "ISA_03_SecurityInformationQualifier_ID": "00",
    "ISA_04_SecurityInformation_AN": "          ",
    "ISA_05_InterchangeIDQualifier_ID": "ZZ",
    "ISA_06_InterchangeSenderID_AN": "SUBMITTERS ID  ",
    "ISA_07_InterchangeIDQualifier_ID": "ZZ",
    "ISA_08_InterchangeReceiverID_AN": "RECEIVERS ID   ",
    "ISA_09_InterchangeDate_DT": "220412",
    "ISA_10_InterchangeTime_TM": "1253",
    "ISA_11_RepetitionSeparator": "^",
    "ISA_12_InterchangeControlVersionNumber_ID": "00501",
    "ISA_13_InterchangeControlNumber_N": "000000001",
    "ISA_14_AcknowledgmentRequest_ID": "0",
    "ISA_15_InterchangeUsageIndicator_ID": "P",
    "ISA_16_ComponentElementSeparator": ":"
  },
  "FunctionalGroups": [
    {
      "FunctionalGroupHeaderSegment": {
        "GS_01_FunctionalIdentifierCode_ID": "XX",
        "GS_02_ApplicationSendersCode_AN": "SENDER CODE",
        "GS_03_ApplicationReceiversCode_AN": "RECEIVERCODE",
        "GS_04_Date_DT": "20220412",
        "GS_05_Time_TM": "1513",
        "GS_06_GroupControlNumber_N": "1",
        "GS_07_ResponsibleAgencyCode_ID": "X",
        "GS_08_VersionReleaseIndustryIdentifierCode_AN": "005010X224"
      },
      "TransactionSets": [
        {
          "TransactionSetHeader": {
            "ST_01_TransactionSetIdentifierCode_ID": "837",
            "ST_02_TransactionSetControlNumber_AN": "3456",
            "ST_03_ImplementationConventionReference_AN": "005010X224"
          },
          "BeginningOfHierarchicalTransaction": {
            "BHT_01_HierarchicalStructureCode_ID": "0019",
            "BHT_02_TransactionSetPurposeCode_ID": "00",
            "BHT_03_ReferenceIdentification_AN": "0123",
            "BHT_04_Date_DT": "20061123",
            "BHT_05_Time_TM": "1023",
            "BHT_06_TransactionTypeCode_ID": "CH"
          },
          "SubmiterName_Loop_1000A": {
            "SubmiterName": {
              "NM1_01_EntityIdentifierCode_ID": "41",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "PREMIER BILLING SERVICE",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "TGJ23",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            },
            "SubmitterEdiContactInformation": [
              {
                "PER_01_ContactFunctionCode_ID": "IC",
                "PER_02_Name_AN": "JERRY",
                "PER_03_CommunicationNumberQualifier_ID": "TE",
                "PER_04_CommunicationNumber_AN": "7176149999",
                "PER_05_CommunicationNumberQualifier_ID": null,
                "PER_06_CommunicationNumber_AN": null,
                "PER_07_CommunicationNumberQualifier_ID": null,
                "PER_08_CommunicationNumber_AN": null,
                "PER_09_ContactInquiryReference_AN": null
              }
            ]
          },
          "ReceiverName_Loop_1000B": {
            "ReceiverName": {
              "NM1_01_EntityIdentifierCode_ID": "40",
              "NM1_02_EntityTypeQualifier_ID": "2",
              "NM1_03_NameLastOrOrganizationName_AN": "INSURANCE COMPANY XYZ",
              "NM1_04_NameFirst_AN": null,
              "NM1_05_NameMiddle_AN": null,
              "NM1_06_NamePrefix_AN": null,
              "NM1_07_NameSuffix_AN": null,
              "NM1_08_IdentificationCodeQualifier_ID": "46",
              "NM1_09_IdentificationCode_AN": "66783JJT",
              "NM1_10_EntityRelationshipCode_ID": null,
              "NM1_11_EntityIdentifierCode_ID": null,
              "NM1_12_NameLastOrOrganizationName_AN": null
            }
          },
          "BillingProviderDetail_Loop_2000A": [
            {
              "BillingProviderHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "1",
                "HL_02_HierarchicalParentIDNumber_AN": null,
                "HL_03_HierarchicalLevelCode_ID": "20",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "BillingProviderSpecialtyInformation": null,
              "ForeignCurrencyInformation": null,
              "BillingProviderName_Loop_2010AA": {
                "BillingProviderName": {
                  "NM1_01_EntityIdentifierCode_ID": "85",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "DENTAL ASSOCIATES",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "XX",
                  "NM1_09_IdentificationCode_AN": "1234567890",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "BillingProviderAddress": {
                  "N3_01_AddressInformation_AN": "234 SEAWAY ST",
                  "N3_02_AddressInformation_AN": null
                },
                "BillingProviderCityStateZipCode": {
                  "N4_01_CityName_AN": "MIAMI",
                  "N4_02_StateOrProvinceCode_ID": "FL",
                  "N4_03_PostalCode_ID": "33111",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "BillingProviderTaxIdentification": {
                  "REF_01_ReferenceIdentificationQualifier_ID": "EI",
                  "REF_02_ReferenceIdentification_AN": "587654321",
                  "REF_03_Description_AN": null,
                  "REF_04_ReferenceIdentifier": null
                },
                "BillingProviderUPINLicenseInformation": null,
                "BillingProviderContactInformation": null
              },
              "PayToAddressName_Loop_2010AB": {
                "PayToAddressName": null,
                "PayToAddressAddress": null,
                "PayToAddressCityStateZipCode": null
              },
              "PayToPlanName_Loop_2010AC": {
                "PayToPlanName": null,
                "PayToPlanAddress": null,
                "PayToPlanCityStateZipCode": null,
                "PayToPlanSecondaryIdentification": null,
                "PayToPlanTaxIdentificationNumber": null
              }
            }
          ],
          "SubscriberDetail_Loop_2000B": [
            {
              "SubscriberHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "2",
                "HL_02_HierarchicalParentIDNumber_AN": "1",
                "HL_03_HierarchicalLevelCode_ID": "22",
                "HL_04_HierarchicalChildCode_ID": "1"
              },
              "SubscriberInformation": {
                "SBR_01_PayerResponsibilitySequenceNumberCode_ID": "P",
                "SBR_02_IndividualRelationshipCode_ID": null,
                "SBR_03_ReferenceIdentification_AN": null,
                "SBR_04_Name_AN": null,
                "SBR_05_InsuranceTypeCode_ID": null,
                "SBR_06_CoordinationOfBenefitsCode_ID": null,
                "SBR_07_YesNoConditionOrResponseCode_ID": null,
                "SBR_08_EmploymentStatusCode_ID": null,
                "SBR_09_ClaimFilingIndicatorCode_ID": "CI"
              },
              "SubscriberName_Loop_2010BA": {
                "SubscriberName": {
                  "NM1_01_EntityIdentifierCode_ID": "IL",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "JANE",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "MI",
                  "NM1_09_IdentificationCode_AN": "111223333",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "SubscriberAddress": null,
                "SubscriberCityStateZipCode": null,
                "SubscriberDemographicInformation": null,
                "SubscriberSecondaryIdentification": null,
                "PropertyAndCasualtyClaimNumber": null
              },
              "PayerName_Loop_2010BB": {
                "PayerName": {
                  "NM1_01_EntityIdentifierCode_ID": "PR",
                  "NM1_02_EntityTypeQualifier_ID": "2",
                  "NM1_03_NameLastOrOrganizationName_AN": "INSURANCE COMPANY XYZ",
                  "NM1_04_NameFirst_AN": null,
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": "PI",
                  "NM1_09_IdentificationCode_AN": "66783JJT",
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PayerAddress": null,
                "PayerCityStateZipCode": null,
                "PayerSecondaryIdentification": null,
                "BillingProviderSecondaryIdentification": null
              }
            }
          ],
          "PatientDetail_Loop_2000C": [
            {
              "PatientHierarchicalLevel": {
                "HL_01_HierarchicalIDNumber_AN": "3",
                "HL_02_HierarchicalParentIDNumber_AN": "2",
                "HL_03_HierarchicalLevelCode_ID": "23",
                "HL_04_HierarchicalChildCode_ID": "0"
              },
              "PatientInfomation": {
                "PAT_01_IndividualRelationshipCode_ID": "19",
                "PAT_02_PatientLocationCode_ID": null,
                "PAT_03_EmploymentStatusCode_ID": null,
                "PAT_04_StudentStatusCode_ID": null,
                "PAT_05_DateTimePeriodFormatQualifier_ID": null,
                "PAT_06_DateTimePeriod_AN": null,
                "PAT_07_UnitOrBasisForMeasurementCode_ID": null,
                "PAT_08_Weight_R": null,
                "PAT_09_YesNoConditionOrResponseCode_ID": null
              },
              "PatientName_Loop_2010CA": {
                "PatientName": {
                  "NM1_01_EntityIdentifierCode_ID": "QC",
                  "NM1_02_EntityTypeQualifier_ID": "1",
                  "NM1_03_NameLastOrOrganizationName_AN": "SMITH",
                  "NM1_04_NameFirst_AN": "TED",
                  "NM1_05_NameMiddle_AN": null,
                  "NM1_06_NamePrefix_AN": null,
                  "NM1_07_NameSuffix_AN": null,
                  "NM1_08_IdentificationCodeQualifier_ID": null,
                  "NM1_09_IdentificationCode_AN": null,
                  "NM1_10_EntityRelationshipCode_ID": null,
                  "NM1_11_EntityIdentifierCode_ID": null,
                  "NM1_12_NameLastOrOrganizationName_AN": null
                },
                "PatientAddress": {
                  "N3_01_AddressInformation_AN": "236 N MAIN ST",
                  "N3_02_AddressInformation_AN": null
                },
                "PatientCityStateZipCode": {
                  "N4_01_CityName_AN": "MIAMI",
                  "N4_02_StateOrProvinceCode_ID": "FL",
                  "N4_03_PostalCode_ID": "33413",
                  "N4_04_CountryCode_ID": null,
                  "N4_05_LocationQualifier_ID": null,
                  "N4_06_LocationIdentifier_AN": null,
                  "N4_07_CountrySubdivisionCode_ID": null
                },
                "PatientDemographicInformation": {
                  "DMG_01_DateTimePeriodFormatQualifier_ID": "D8",
                  "DMG_02_DateTimePeriod_AN": "19920501",
                  "DMG_03_GenderCode_ID": "M",
                  "DMG_04_MaritalStatusCode_ID": null,
                  "DMG_05_CompositeRaceOrEthnicityInformation": null,
                  "DMG_06_CitizenshipStatusCode_ID": null,
                  "DMG_07_CountryCode_ID": null,
                  "DMG_08_BasisOfVerificationCode_ID": null,
                  "DMG_09_Quantity_R": null,
                  "DMG_10_CodeListQualifierCode_ID": null,
                  "DMG_11_IndustryCode_AN": null
                },
                "PropertyAndCasualtyClaimNumber": null,
                "PropertyAndCasualtyPatientIdentifier": null
              },
              "ClaimInformation": [
                {
                  "ClaimInfomation": {
                    "CLM_01_ClaimSubmittersIdentifier_AN": "26403774",
                    "CLM_02_MonetaryAmount_R": "150",
                    "CLM_03_ClaimFilingIndicatorCode_ID": null,
                    "CLM_04_NonInstitutionalClaimTypeCode_ID": null,
                    "CLM_05_HealthCareServiceLocationInfomation": {
                      "C023_01_FacilityCodeValue_AN": "11",
                      "C023_02_FacilityCodeQualifier_ID": "B",
                      "C023_03_ClaimFrequencyTypeCode_ID": "1"
                    },
                    "CLM_06_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_07_ProviderAcceptAssignmentCode_ID": null,
                    "CLM_08_YesNoConditionOrResponseCode_ID": "Y",
                    "CLM_09_ReleaseOfInfomationCode_ID": "I",
                    "CLM_10_PatientSignatureSourceCode_ID": null,
                    "CLM_11_elatedCausesInfomation": null,
                    "CLM_12_SpecialProgramCode_ID": null,
                    "CLM_13_YesNoConditionOrResponseCode_ID": null,
                    "CLM_14_LevelOfServiceCode_ID": null,
                    "CLM_15_YesNoConditionOrResponseCode_ID": null,
                    "CLM_16_ProviderAgreementCode_ID": null,
                    "CLM_17_ClaimStatusCode_ID": null,
                    "CLM_18_YesNoConditionOrResponseCode_ID": null,
                    "CLM_19_ClaimSubmissionReasonCode_ID": null,
                    "CLM_20_DelayReasonCode_ID": null
                  },
                  "DateAccident": {
                    "DTP_01_DateTimeQualifier_ID": "472",
                    "DTP_02_DateTimePeriodFormatQualifier_ID": "D8",
                    "DTP_03_DateTimePeriod_AN": "20061029"
                  },
                  "DateAppliancePlacement": null,
                  "DateServiceDate": null,
                  "DateRepricerReceivedDate": null,
                  "OrthodonticTotalMonthsOfTreatment": null,
                  "ToothStatus": null,
                  "ClaimSupplementalInformation": null,
                  "ContractInformation": null,
                  "PatientAmountPaid": null,
                  "PredeterminationIdentification": {
                    "REF_01_ReferenceIdentificationQualifier_ID": "D9",
                    "REF_02_ReferenceIdentification_AN": "17312345600006351",
                    "REF_03_Description_AN": null,
                    "REF_04_ReferenceIdentifier": null
                  },
                  "ServiceAuthorizationExceptionCode": null,
                  "PayerClaimControlNumber": null,
                  "ReferralNumber": null,
                  "PriorAuthorization": null,
                  "RepricedClaimNumber": null,
                  "AdjustedRepricedClaimNumber": null,
                  "ClaimIdentifierForTransmissionIntermediaries": null,
                  "FileInformation": null,
                  "ClaimNote": null,
                  "HealthcareDiagnosisCode": null,
                  "ClaimPricingRepricingInformation": null,
                  "ReferringProviderName_Loop_2310A": [
                    {
                      "ReferringProviderName": {
                        "NM1_01_EntityIdentifierCode_ID": "82",
                        "NM1_02_EntityTypeQualifier_ID": "1",
                        "NM1_03_NameLastOrOrganizationName_AN": "KILDARE",
                        "NM1_04_NameFirst_AN": "BEN",
                        "NM1_05_NameMiddle_AN": null,
                        "NM1_06_NamePrefix_AN": null,
                        "NM1_07_NameSuffix_AN": null,
                        "NM1_08_IdentificationCodeQualifier_ID": "XX",
                        "NM1_09_IdentificationCode_AN": "9876543210",
                        "NM1_10_EntityRelationshipCode_ID": null,
                        "NM1_11_EntityIdentifierCode_ID": null,
                        "NM1_12_NameLastOrOrganizationName_AN": null
                      },
                      "RefferingProviderSpecialityInformation": {
                        "PRV_01_ProviderCode_ID": "PE",
                        "PRV_02_ReferenceIdentificationQualifier_ID": "PXC",
                        "PRV_03_ReferenceIdentification_AN": "1223G0001X",
                        "PRV_04_StateOrProvinceCode_ID": null,
                        "PRV_05_ProviderSpecialtyInformation": null,
                        "PRV_06_ProviderOrganizationCode_ID": null
                      },
                      "ReferringProviderSecondaryIdentification": null
                    }
                  ],
                  "RenderingProviderName_Loop_2310B": {
                    "RenderingProviderName": null,
                    "RenderingProviderSpecialityInfomation": null,
                    "RenderingProviderSecondaryIdentification": null
                  },
                  "ServiceFacilityLocation_Loop_2310C": {
                    "ServiceFacilityLocationName": null,
                    "ServiceLocationFacilityAddress": null,
                    "ServiceFacilityLocationCityStateZipCode": null,
                    "ServiceFacilityLocationSecondaryIdentification": null
                  },
                  "AssistantSurgeonName_Loop_2310D": {
                    "AssistantSurgeonName": null,
                    "AssistantSurgeonSpecialityInformation": null,
                    "AssistantSurgeonSecondaryIdentification": null
                  },
                  "SupervisingProviderName_Loop_2310E": {
                    "SupervisingProviderName": null,
                    "SupervisingProviderSecondaryIdentification": null
                  },
                  "OtherSubscriberInformation_Loop_2320": [
                    {
                      "OtherSubscriberInfomation": null,
                      "ClaimLevelAdjustment": null,
                      "CoordinationOfBenefitsPayerPaidAmount": null,
                      "RemainingPatientLiability": null,
                      "CoordinationOfBenefitsTotalNonCoveredAmount": null,
                      "OtherInsuranceCoverageInformation": null,
                      "OutpatientAdjudicationInfomation": null,
                      "OtherSubscriberName_Loop_2330A": {
                        "OtherSubscriberName": null,
                        "OtherSubscriberAddress": null,
                        "OtherSubscriberCirtStateZipCode": null,
                        "OtherSubscriberSecondaryIdentification": null
                      },
                      "OtherPayerName_Loop_2330B": {
                        "OtherPayerName": null,
                        "OtherPayerAddress": null,
                        "OtherPayerCityStateZipCode": null,
                        "ClaimCheckOrRemittanceDate": null,
                        "OtherPayerSecondaryIdentification": null,
                        "OtherPayerPriorAuthorizationNumber": null,
                        "OtherPayerReferralNumber": null,
                        "OtherPayerClaimAdjustmentIndicator": null,
                        "OtherPayerPredeterminationIdentification": null,
                        "OtherPayerClaimControlNumber": null
                      },
                      "OtherPayerReferringProvider_Loop_2330C": [
                        {
                          "OtherPayerReferringProvider": null,
                          "OtherPayerReferringProviderSecondaryIdentification": null
                        }
                      ],
                      "OtherPayerRenderingProvider_Loop_2330D": {
                        "OtherPayerRenderingProvider": null,
                        "OtherPayerRenderingProviderSecondaryIdentification": null
                      },
                      "OtherPayerSupervisingProvider_Loop_2330E": {
                        "OtherPayerSupervisingProvider": null,
                        "OtherPayerSupervisingProviderSecondaryIdentification": null
                      },
                      "OtherPayerBillingProvider_Loop_2330F": {
                        "OtherPayerBillingProvider": null,
                        "OtherPayerBillingProviderSecondaryIdentification": null
                      },
                      "OtherPayerServiceFacilityLocation_Loop_2330G": {
                        "OtherPayerServiceFacilityLocation": null,
                        "OtherPayerServiceFacilityLocationSecondaryIdentification": null
                      },
                      "OtherPayerAssistantSurgeon_Loop_2330H": {
                        "OtherPayerAssistantSurgeon": null,
                        "OtherPayerAssistantSurgeonSecondaryIdentification": null
                      }
                    }
                  ],
                  "ServiceLineNumber_Loop_2400": [
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "1"
                      },
                      "DentalService": {
                        "SV3_01_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "AD",
                          "C003_02_ProductServiceID_AN": "D2150",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV3_02_MonetaryAmount_R": "100",
                        "SV3_03_FacilityCodeValue_AN": null,
                        "SV3_04_OralCavityDesignatio": null,
                        "SV3_05_ProsthesisCrownOrInlayCode_ID": null,
                        "SV3_06_Quantity_R": "1",
                        "SV3_07_Description_AN": null,
                        "SV3_08_CopayStatusCode_ID": null,
                        "SV3_09_ProviderAgreementCode_ID": null,
                        "SV3_10_YesNoConditionOrResponseCode_ID": null,
                        "SV3_11_CompositeDiagnosisCodePointer": null
                      },
                      "ToothInformation": [
                        {
                          "TOO_01_CodeListQualifierCode_ID": "JP",
                          "TOO_02_IndustryCode_AN": "12",
                          "Too_03_Tooth_Surface": {
                            "C005_01_ToothSurface_Code_ID": "M",
                            "C005_02_ToothSurfaceCode_ID": "O",
                            "C005_03_ToothSurfaceCode_ID": null,
                            "C005_04_ToothSurfaceCode_ID": null,
                            "C005_05_ToothSurfaceCode_ID": null
                          }
                        }
                      ],
                      "DateServiceDate": null,
                      "DatePriorPlacement": null,
                      "DateAppliancePlacement": null,
                      "DateReplacement": null,
                      "DateTreatmentStart": null,
                      "DateTreatmentCompletion": null,
                      "ContractInformation": null,
                      "ServicePredeterminationIdentification": null,
                      "PriorAuthorization": null,
                      "LineItemControlNumber": null,
                      "RepricedClaimNumber": null,
                      "AdjustedRepricedClaimNumber": null,
                      "ReferralNumber": null,
                      "SalesTaxAmount": null,
                      "FileInformation": null,
                      "LinePricingRepricingInformation": null,
                      "RenderingProviderName_Loop_2420A": {
                        "RenderingProviderName": null,
                        "RenderingProviderSpecialityInformation": null,
                        "RenderingProviderSecondaryIdentification": null
                      },
                      "AssistantSurgeonName_Loop_2420B": {
                        "AssistantSurgeonName": null,
                        "AssistantSurgeonSpecialityInformation": null,
                        "AssistantSurgeonSecondaryIdentification": null
                      },
                      "SupervisingProviderName_Loop_2420C": {
                        "SupervisingProviderName": null,
                        "SupervisingProviderSecondaryIdentification": null
                      },
                      "ServiceFacilityLocationName_Loop_2420D": {
                        "ServiceFacilityLocationName": null,
                        "ServiceFacilityLocationAddress": null,
                        "ServiceFacilityLocationCityStateZipCode": null,
                        "ServiceFacilityLocationSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LinecheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    },
                    {
                      "ServiceLineNumber": {
                        "LX_01_AssignedNumber_N": "2"
                      },
                      "DentalService": {
                        "SV3_01_CompositeMedicalProcedureIdentifier": {
                          "C003_01_ProductServiceIDQualifier_ID": "AD",
                          "C003_02_ProductServiceID_AN": "D1110",
                          "C003_03_ProcedureModifier_AN": null,
                          "C003_04_ProcedureModifier_AN": null,
                          "C003_05_ProcedureModifier_AN": null,
                          "C003_06_ProcedureModifier_AN": null,
                          "C003_07_Description_AN": null,
                          "C003_08_ProductServiceID_AN": null
                        },
                        "SV3_02_MonetaryAmount_R": "50",
                        "SV3_03_FacilityCodeValue_AN": null,
                        "SV3_04_OralCavityDesignatio": null,
                        "SV3_05_ProsthesisCrownOrInlayCode_ID": null,
                        "SV3_06_Quantity_R": "1",
                        "SV3_07_Description_AN": null,
                        "SV3_08_CopayStatusCode_ID": null,
                        "SV3_09_ProviderAgreementCode_ID": null,
                        "SV3_10_YesNoConditionOrResponseCode_ID": null,
                        "SV3_11_CompositeDiagnosisCodePointer": null
                      },
                      "ToothInformation": null,
                      "DateServiceDate": null,
                      "DatePriorPlacement": null,
                      "DateAppliancePlacement": null,
                      "DateReplacement": null,
                      "DateTreatmentStart": null,
                      "DateTreatmentCompletion": null,
                      "ContractInformation": null,
                      "ServicePredeterminationIdentification": null,
                      "PriorAuthorization": null,
                      "LineItemControlNumber": null,
                      "RepricedClaimNumber": null,
                      "AdjustedRepricedClaimNumber": null,
                      "ReferralNumber": null,
                      "SalesTaxAmount": null,
                      "FileInformation": null,
                      "LinePricingRepricingInformation": null,
                      "RenderingProviderName_Loop_2420A": {
                        "RenderingProviderName": null,
                        "RenderingProviderSpecialityInformation": null,
                        "RenderingProviderSecondaryIdentification": null
                      },
                      "AssistantSurgeonName_Loop_2420B": {
                        "AssistantSurgeonName": null,
                        "AssistantSurgeonSpecialityInformation": null,
                        "AssistantSurgeonSecondaryIdentification": null
                      },
                      "SupervisingProviderName_Loop_2420C": {
                        "SupervisingProviderName": null,
                        "SupervisingProviderSecondaryIdentification": null
                      },
                      "ServiceFacilityLocationName_Loop_2420D": {
                        "ServiceFacilityLocationName": null,
                        "ServiceFacilityLocationAddress": null,
                        "ServiceFacilityLocationCityStateZipCode": null,
                        "ServiceFacilityLocationSecondaryIdentification": null
                      },
                      "LineAdjudicationInformation_Loop_2430": [
                        {
                          "LineAdjudicationInformation": null,
                          "LineAdjustment": null,
                          "LinecheckOrRemittanceDate": null,
                          "RemainingPatientLiability": null
                        }
                      ]
                    }
                  ]
                }
              ]
            }
          ],
          "TransactionSetTrailer": {
            "SE_01_NumberOfIncludedSegments_N": "31",
            "SE_02_TransactionSetControlNumber_AN": "3456"
          }
        }
      ],
      "FunctionalGroupTrailerSegment": {
        "GE_01_NumberOfTransactionSetsIncluded_N": "1",
        "GE_02_GroupControlNumber_N": "1"
      }
    }
  ],
  "InterchangeControlTrailerSegment": {
    "IEA_01_NumberOfIncludedFunctionalGroups_N": "1",
    "IEA_02_InterchangeControlNumber_N": "000000001"
  }
}

Sample response (Dental Claim)

EDI 837 Copy

ISA*00*          *00*          *ZZ*SUBMITTERS ID  *ZZ*RECEIVERS ID   *220412*1253*^*00501*000000001*0*P*:~GS*XX*SENDER CODE*RECEIVERCODE*20220412*1513*1*X*005010X224~ST*837*3456*005010X224~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**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*1~IEA*1*000000001~

Healthcare EDIs

EDI 270 ^SJ (Patient Eligibility Request)

EDI 271 ^SJ (Patient Eligibility Request)

EDI 276 (Claim Status Request)

EDI 277 (Claim Status Response)

EDI 834 (Patient Enrollment)

EDI 835 ^SJ (Claim Payment and Advice)

EDI 837 (Claims)

Acknowledgment EDIs

EDI 997 ^SJ (Functional Acknowledgment)

EDI 999 ^SJ (Implementation Acknowledgment)

Freight and Shipping EDIs

EDI 404 (Rail Carrier Shipment Information)

EDI 410 (Rail Carrier Freight Details and Invoice)