The Outbound 837P, completed in Exercise 1, was sent on to Blue Cross the payer. The Claim was adjudicated and Blue Cross has transmitted the 835 5010A1 transaction directly to the receiving billing provider, Abuncha Physicians.
Within the transaction are also two additional claims for the same patient, from claims sent previously.
Check #: EFT20160114006979 dated: 01/14/2016 Check total: $85.25 Deposit (ACH)
The objective here is to translate the Inbound 835 005010X221A1 transaction and fill in the missing data, EOB payments and adjustments.
CLP01 Claim Submitter ID (Same as CLM01 on submitted 837) aka Patient Acct. No or Invoice
ISA*00* *00* *ZZ*BCBS_FL *ZZ*ABUNCHA *110114*1150*^*00501*000000001*0*P*:~
GS*HP*BCBS_FL*ABUNCHA*20160114*1150*1*X*004010X091A1
ST*835*0001~
BPR*I*105.5*C*ACH*CCP*01*099000025*DA*170999028999*111234567**01*1111234567*DA*1122334455*20160114~
TRN*1*EFT20160114006979*741234*1116754321~
DTM*405*20160112~
N1*PR*BLUECROSS BLUESHIELD~ Payer
N3*P.O. BOX 12345~
N4*ORLANDO*FL*334131234~
PER*CX**TE*8006655044~
N1*PE*ABUNCHA PHYSICIANS*XX*4121212121~ Payee
N3*PO BOX 12333~
N4*MIAMI*FL*33111~
REF*TJ*1111234567~ Payee Tax ID
LX*1~
CLP*A126462967*1*100*55.25*10*HM*BCBS_CLAIM12*11~1st Claim (Paid as Primary CLP02 = 1)
NM1*QC*1*DUCK*DAISY****MI*DDD0221111-02~
NM1*IL*1*DUCK*DONALD*D***MI*DDD0221111-01~
NM1*82*1*KILDARE*BEN****XX*1122333344~
REF*9A*REPRICED_CLAIM12~
DTM*050*20160112~
SVC*HC:99213*40*30**1~ Service 1
DTM*472*20101116~ Service Date
CAS*PR*3*10~ Adjustment
REF*6R*20001~ Provider Line Item number
AMT*B6*40~ Allowed Amount
SVC*HC:95010*15*9.75**1~ Service 2
DTM*472*20101116~
CAS*CO*45*5.25~
REF*6R*20002~
AMT*B6*15~
SVC*HC:87072*35*0**1~ Service 3
DTM*472*20101116~
CAS*PI*15*35~
REF*6R*20003~
AMT*B6*35~
SVC*HC:86663*10*6**1~ Service 4
DTM*472*20101116~
CAS*CO*45*4~
REF*6R*20004~
AMT*B6*40~
LX*2~
CLP*A126462960*4*15*0**HM*BCBS_CLAIM11~2nd Claim (denied)
NM1*QC*1*DUCK*DAISY****MI*DDD0221111-02~
NM1*IL*1*DUCK*DONALD*D***MI*DDD0221111-01~
NM1*82*1*KILDARE*BEN****XX*1122333344~
REF*9A*REPRICED_CLAIM11~
DTM*050*20160107~
SVC*HC:T1013*15*0**1~ Service 1
DTM*472*20101107~
CAS*CO*B7*15~
REF*6R*19006~
LX*3~
CLP*A126462910*1*45.5*35.5*10*HM*BCBS_CLAIM08~3rd Claim
NM1*QC*1*DUCK*DAISY****MI*DDD0221111-02~
NM1*IL*1*DUCK*DONALD*D***MI*DDD0221111-01~
NM1*82*1*KILDARE*BEN****XX*1122333344~
REF*9A*REPRICED_CLAIM08~
DTM*050*20160106~
SVC*HC:99213*45.5*35.5**1~ Service 1
DTM*472*20101101~
CAS*PR*3*10~
REF*6R*19002~
AMT*B6*45.5~
SE*63*0001~
GE*1*1~
IEA*1*000000001~