Segment | Entire Segment |
View | ST*276*0001*Implementation Convention Reference |
View | BHT*0010*13*500*20200304*1349*31 |
View | NM1*PR*1*ABC INSURANCE*X*T***PI*9012345918341 |
View | PER*IC*ARTHUR JONES*TE*6145551212*EX*1212*FX*6145551212 |
View | NM1*41*2*SMITH*****46*111222333 |
View | HL*1**20*1 |
View | PRV*BI*1K*3920394930203 |
View | CUR*1P*004 |
View | NM1*IL*1*SMITH*BARBARA*M**M.D.*SV*43202 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | REF*BLT*12345678900987654321768958473 |
View | REF*EA*500 |
View | PER*IC*ARTHUR JONES*TE*1212*EX*6145551212*FX*1212 |
View | NM1*QC*1 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | NM1*PR*2*SMITH*****MI*123456789 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | REF*FJ*3920394930203 |
View | REF*1K*12345678900987654321768958473 |
View | HL*2*1*22*0 |
View | SBR*A*18*500*ARTHUR JONES*12****11 |
View | PAT*****D8*20030204*01*19991267*Y |
View | NM1*41*1*ABC INSURANCE*X*F**PH.D*PI*9012345918341 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | DMG*RD8*20030201-20030204*M |
View | REF*BLT*3920394930203 |
View | REF*EA*12345678900987654321768958473 |
View | PER*IC*ARTHUR JONES*TE*6145551212*EX*1212 |
View | NM1*1P*2*ABC INSURANCE*****46*111222333 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | REF*FJ*500 |
View | REF*1K*3920394930203 |
View | REF*BLT*12345678900987654321768958473 |
View | CLM*Claim Submitter's Identifier*665.75***01+B+0*N*A*N*I*P*AA+AA++AA+004*02********1 |
View | DTP*431*D8*20030204 |
View | DTP*454*RD8*20030201-20030204 |
View | DTP*304*D8*20030204 |
View | DTP*453*RD8*20030201-20030204 |
View | DTP*439*D8*20030204 |
View | DTP*484*RD8*20030201-20030204 |
View | DTP*455*D8*20030204 |
View | DTP*471*RD8*20030201-20030204 |
View | DTP*314*D8*20030204 |
View | DTP*297*RD8*20030201-20030204 |
View | DTP*296*D8*20030204 |
View | DTP*435*RD8*20030201-20030204 |
View | DTP*096*D8*20030204 |
View | DTP*090*RD8*20030201-20030204 |
View | DTP*090*D8*20030204 |
View | DTP*444*RD8*20030201-20030204 |
View | DTP*050*D8*20030204 |
View | PWK*03*AA***SV*43202 |
View | CN1*01*75*15665*500*268768*Version Identifier |
View | AMT*T3*665.75 |
View | REF*EA*3920394930203 |
View | REF*FJ*12345678900987654321768958473 |
View | REF*1K*500 |
View | REF*BLT*3920394930203 |
View | REF*EA*12345678900987654321768958473 |
View | REF*FJ*500 |
View | REF*1K*3920394930203 |
View | REF*BLT*12345678900987654321768958473 |
View | REF*EA*500 |
View | REF*FJ*3920394930203 |
View | REF*1K*12345678900987654321768958473 |
View | REF*BLT*500 |
View | REF*EA*3920394930203 |
View | REF*FJ*12345678900987654321768958473 |
View | K3*Fixed Format Information |
View | NTE*ADD*Description |
View | CR1*LB*4112753**A*DH*1***Description*Description |
View | CR2********A**Description*Description |
View | CRC*07*N*01*01*01*01*01 |
View | CRC*E1*N*L1*L1*L1*L1*L1 |
View | CRC*E1*N*L1*L1*L1*L1*L1 |
View | CRC*75*Y*IH |
View | CRC*ZZ*N*AV*AV*AV |
View | HI*BK+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000*BF+A000 |
View | HI*BP+0001F*BO+0001F |
View | HI*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001*BG+0001 |
View | HCP*00*75*665.75*500*2284*3920394930203*75******T1*1*1 |
View | NM1*IL*1*ABC INSURANCE*X*T**M.D.*MI*123456789 |
View | REF*1K*12345678900987654321768958473 |
View | NM1*QC*1*ABC INSURANCE*X*M**PH.D*PI*9012345918341 |
View | PRV*PE*BLT*500 |
View | REF*EA*3920394930203 |
View | NM1*PR*2*JONES*****46*111222333 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | REF*FJ*12345678900987654321768958473 |
View | PER*IC*ARTHUR JONES*FX*6145551212*TE*1212 |
View | NM1*41*1*SMITH*BARBARA*F**M.D.*SV*43202 |
View | REF*1K*500 |
View | NM1*1P*2 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | NM1*IL*2*SMITH |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | SBR*A*01*3920394930203*ARTHUR JONES*12****11 |
View | CAS*CO*1*665.75*1*1*75*1*1*665.75*1*1*75*1*1*665.75*1*1*75*1 |
View | AMT*T3*665.75 |
View | AMT*T3*75 |
View | AMT*T3*665.75 |
View | OI***N*P**I |
View | MOA*7*75*12345678900987654321768958473*500*3920394930203*12345678900987654321768958473*500*665.75*75 |
View | NM1*QC*1*SMITH*BARBARA*T**PH.D*MI*123456789 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | REF*BLT*3920394930203 |
View | NM1*PR*2*ABC INSURANCE*****PI*9012345918341 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | DTP*573*RD8*20030201-20030204 |
View | REF*EA*12345678900987654321768958473 |
View | REF*FJ*500 |
View | REF*1K*3920394930203 |
View | REF*BLT*12345678900987654321768958473 |
View | REF*EA*500 |
View | NM1*41*1 |
View | REF*FJ*3920394930203 |
View | REF*1K*12345678900987654321768958473 |
View | REF*BLT*500 |
View | NM1*1P*1 |
View | REF*EA*3920394930203 |
View | NM1*IL*2 |
View | REF*FJ*12345678900987654321768958473 |
View | NM1*QC*1 |
View | REF*1K*500 |
View | REF*BLT*3920394930203 |
View | REF*EA*12345678900987654321768958473 |
View | NM1*PR*1 |
View | REF*FJ*500 |
View | LX*229732 |
View | SV1*HC+0446T+99566+99566+99566+99566+Description*665.75*MJ*1*01**19+8+2+18**Y**Y*Y***0 |
View | SV5*HC+0447T*DA*1*75*665.75*1 |
View | PWK*03*AA***46*111222333 |
View | PWK*CT*AB |
View | CR1*LB*19**A*DH*1***Description*Description |
View | CR3*I*MO*1 |
View | CRC*07*N*01*01*01*01*01 |
View | CRC*70*N*65 |
View | CRC*09*N*38*38 |
View | DTP*472*D8*20030204 |
View | DTP*471*RD8*20030201-20030204 |
View | DTP*607*D8*20030204 |
View | DTP*463*RD8*20030201-20030204 |
View | DTP*461*D8*20030204 |
View | DTP*304*RD8*20030201-20030204 |
View | DTP*738*D8*20030204 |
View | DTP*011*RD8*20030201-20030204 |
View | DTP*455*D8*20030204 |
View | DTP*454*RD8*20030201-20030204 |
View | QTY*PT*1 |
View | QTY*FL*1 |
View | MEA*OG*HT*282 |
View | CN1*01*75*32432*3920394930203*84*Version Identifier |
View | REF*1K*12345678900987654321768958473 |
View | REF*BLT*500 |
View | REF*EA*3920394930203**FJ+12345678900987654321768958473 |
View | REF*1K*500 |
View | REF*BLT*3920394930203 |
View | REF*EA*12345678900987654321768958473 |
View | REF*FJ*500 |
View | REF*1K*3920394930203 |
View | REF*BLT*12345678900987654321768958473**EA+500 |
View | AMT*T3*665.75 |
View | AMT*T3*75 |
View | K3*Fixed Format Information |
View | NTE*ADD*Description |
View | NTE*TPO*Description |
View | PS1*3920394930203*665.75 |
View | HCP*00*75*665.75*12345678900987654321768958473*40754*500*75**HC*0001F*MJ*1*T1*1*1 |
View | LIN**HC*00002060440 |
View | CTP****1*F2 |
View | REF*FJ*3920394930203 |
View | NM1*41*1*SMITH*BARBARA*M**M.D.*SV*43202 |
View | PRV*PE*1K*12345678900987654321768958473 |
View | REF*BLT*500**EA+3920394930203 |
View | NM1*1P*1******MI*123456789 |
View | REF*FJ*12345678900987654321768958473**1K+500 |
View | NM1*IL*2*JONES*****PI*9012345918341 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | REF*BLT*3920394930203**EA+12345678900987654321768958473 |
View | NM1*QC*1*ABC INSURANCE*X*F**PH.D*46*111222333 |
View | REF*FJ*500**1K+3920394930203 |
View | NM1*PR*1*ABC INSURANCE*X*T**M.D.*SV*43202 |
View | N3*Address Information*Address Information |
View | N4*City Name*AA*00501*004 |
View | REF*BLT*12345678900987654321768958473**EA+500 |
View | PER*IC*ARTHUR JONES*EX*6145551212*FX*1212*TE*6145551212 |
View | NM1*41*1*SMITH*BARBARA*M**PH.D*MI*123456789 |
View | REF*FJ*3920394930203**1K+12345678900987654321768958473 |