Sample EDI 274 Data for the Healthcare Provider Information Transaction Set


AgencySet IDFGTransaction DescriptionSubcommittee
ANSI274PWHealthcare Provider Information Insurance


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Below is a sample EDI 274 transaction set. The Jobisez.com site has an online translation tool that converts the EDI 274 (Healthcare Provider Information) document into a CSV file. You can also gain knowledge by researching all EDI Document Types. Jobisez LLC can also provide assistance if you need additional help.

Sample of an EDI 274 Transaction Set

Entire Segment
ST*274*0001*004050X109
BHT*0028*27*1*20201209*054102
DTM*507*20201204
PER*BJ*Michael Chaffee*TE*2094612311*EM*mchaffee@hpsj.com
HL*1**20*1
NM1*ACV*2*Health Plan of San Joaquin*****FI*680355833
NM1*NN*2*VSP
HL*2*1*21*1
NM1*40*2*DHCS Managed Care
HL*3*2*4*1
NM1*QV*2*William C Henshaw OD*****XX*1205940889
N2*020347879
DTP*092*D8*19860901
LQ*68*193400000X
REF*N5*X120001003740
HL*4*3*N*1
NM1*77*2*William C Henshaw OD*****XX*1205940889
N2*020347879;10;;39;;;;0;;;N;N*;N;OTO;Eye & Vision Services;;N
PER*AJ**TE*2093342020*EM*billfcovd@gmail.com*FX*2093332015
DTP*092*D8*19860901
WS*D*0900*0600
WS*E*0900*0600
WS*F*0900*0600
WS*G*0800*0500
WS*H*0800*0500
WS*J*0800*1200
CRC*C4*Y*P8
CRC*DJ*Y*1U
NX1*77
N3*801 S Fairmont Ave
N4*Lodi*CA*95240
LQ*68*193400000X
REF*N5*;X120001004926;1205940889
NM1*30*2*Bill Henshaw*****EQ*020347879
HL*5*4*19*0
NM1*1P*1*Henshaw*Bill****XX*1205940889
N2*FIRST;050;M;19441127;N;;N;;02;;;B;N*5036;OTH;CA;3;;;
DEG*3.1***Doctor of Optometry
LUI*LE*spa***B
DTP*092*D8*20090301
LQ*68*152W00000X
YNQ*YR*Y
REF*N5*;13133;
HL*6*2*4*1
NM1*QV*2*Freda Chin OD Inc*****XX*1538246715
N2*200216626
DTP*092*D8*20031001
LQ*68*193400000X
REF*N5*X120001003778
HL*7*6*N*1
NM1*77*2*Freda Chin OD Inc*****XX*1538246715
N2*200216626;10;;50;;;;0;;;N;B*;N;OTO;Eye & Vision Services;;N
PER*AJ**TE*2098922161*EM*cindy@fredachinod.com*FX*2098925512
LUI*LE*mya***B
LUI*LE*spa***B
DTP*092*D8*20110516
WS*D*0800*0500
WS*E*0800*0600
WS*F*0800*0500
WS*G*0800*0500
WS*H*0800*0500
CRC*C4*Y*P8
CRC*DJ*Y*1U
NX1*77
N3*46 S Del Puerto Ave Ste A
N4*Patterson*CA*95363
LQ*68*193400000X
REF*N5*;X120001004972;1538246715
NM1*30*2*Freda Chin*****EQ*200216626
HL*8*7*19*0
NM1*1P*1*Chin*Freda****XX*1982645420
N2*FIRST;050;F;19700710;N;;B;;02;;;B;N*10755;OTH;CA;3;;;
DEG*3.1***Doctor of Optometry
LUI*LE*mya***B
DTP*092*D8*20110516
LQ*68*152W00000X
YNQ*YR*Y
REF*N5*;21185;
HL*9*2*4*1
NM1*QV*2*Lien Thi Kim Nguyen*****XX*1124066931
N2*203350876
DTP*092*D8*20051026
LQ*68*193400000X
REF*N5*X120001003820
HL*10*9*N*1
NM1*77*2*Modern Optometric Eyecare*****XX*1124066931
N2*203350876;10;;39;;;;0;;;N;B*;N;OTO;Eye & Vision Services;;N
PER*AJ**TE*2093332221*EM*modernoptometric@gmail.com*FX*2093337771
LUI*LE*spa***B
LUI*LE*vie***B
DTP*092*D8*20051026
WS*D*0900*0100
WS*E*1000*0600
WS*F*0800*0500
WS*G*1000*0600
WS*H*0800*0500
CRC*C4*Y*P8
CRC*DJ*Y*1U
NX1*77
N3*400 E Kettleman Ln Ste 18
N4*Lodi*CA*95240
LQ*68*193400000X
REF*N5*;X120001005023;1124066931
NM1*30*2*Lien Nguyen*****EQ*203350876
HL*11*10*19*0
NM1*1P*1*Nguyen*Lien*T***XX*1124066931
N2*FIRST;050;F;19760613;N;;B;;02;;;B;N*12471;OTH;CA;3;;;
DEG*3.1***Doctor of Optometry
LUI*LE*spa***B
LUI*LE*vie***B
DTP*092*D8*20090301
LQ*68*152W00000X
YNQ*YR*Y
REF*N5*;23174;
HL*12*2*4*1
NM1*QV*2*Kathryn Larsson OD*****XX*1750375440
N2*204078019
DTP*092*D8*20120401
LQ*68*193400000X
REF*N5*X120001003829
HL*13*12*N*1
NM1*77*2*Visionary Optometry of Modesto*****XX*1750375440
N2*204078019;10;;50;;;;0;;;N;N*;N;OTO;Eye & Vision Services;;N
PER*AJ**TE*2095269883*EM*klarssonod@123mail.org*FX*2095268681
LUI*LE*spa***B
DTP*092*D8*20180511
WS*D*0900*0500
WS*E*0900*0500
WS*F*0900*0500
WS*G*0900*0500
WS*H*0900*0400
CRC*C4*Y*P8
CRC*DJ*Y*1T
NX1*77
N3*1150 W Orangeburg Ave
N4*Modesto*CA*95350
LQ*68*193400000X
REF*N5*;X120001005034;1750375440
NM1*30*2*Kathryn Larsson*****EQ*204078019
HL*14*13*19*0
NM1*1P*1*Larsson*Kathryn*L***XX*1750375440
N2*FIRST;037;F;19620820;N;;N;;02;;;B;N*9225;OTH;CA;3;;;
DEG*3.1***Doctor of Optometry
LUI*LE*spa***B
DTP*092*D8*20180511
LQ*68*152W00000X
YNQ*YR*Y
REF*N5*;116042;
HL*15*2*4*1
NM1*QV*2*Quinn Q Nguyen Optometry Inc*****XX*1528038486
N2*300484984
DTP*092*D8*20080701
LQ*68*193400000X
REF*N5*X120001003995
HL*16*15*N*1
NM1*77*2*Quinn Q Nguyen OD*****XX*1528038486
N2*300484984;10;;39;;;;0;;;N;N*;N;OTO;Eye & Vision Services;;N
PER*AJ**TE*2094767040*EM*quinnod@sbcglobal.net*FX*2094767041
LUI*LE*vie***B
DTP*092*D8*20190801
WS*D*0800*0200
WS*E*0800*0500
WS*F*0800*0500
WS*G*0800*0500
WS*H*0800*0500
CRC*C4*Y*P8
CRC*DJ*Y*1U
NX1*77
N3*1111 W Robinhood Dr Ste E
N4*Stockton*CA*95207
LQ*68*193400000X
REF*N5*;X120001005502;1528038486
NM1*30*2*Quinn Nguyen*****EQ*300484984
HL*17*16*19*0
NM1*1P*1*Nguyen*Quinn*Q***XX*1528038486
N2*FIRST;012;M;19720610;N;;N;;02;;;B;N*11194;OTH;CA;3;;;
DEG*3.1***Doctor of Optometry
LUI*LE*vie***B
DTP*092*D8*20190801
LQ*68*152W00000X
YNQ*YR*Y
REF*N5*;121321;
HL*18*2*4*1
NM1*QV*2*Modesto Eye Center Inc*****XX*1942501952
N2*364555253
DTP*092*D8*20101222
LQ*68*193400000X
REF*N5*X120001004100
HL*19*18*N*1
NM1*77*2*Modesto Eye Center Inc*****XX*1942501952
N2*364555253;10;;50;;;;0;;;N;B*;N;OTO;Eye & Vision Services;;N
PER*AJ**TE*2095242020*EM*christine@moodestoeyecenter.com*FX*2095492004
LUI*LE*por***B
LUI*LE*spa***B
DTP*092*D8*20101222
WS*D*0800*0500
WS*E*0800*0500
WS*F*0800*0500
WS*G*0800*0500

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