Sample EDI 837 Data for the Health Care Claim Transaction Set


AgencySet IDFGTransaction DescriptionSubcommittee
ANSI837HCHealth Care Claim Insurance


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Below is a sample EDI 837 transaction set. The Jobisez.com site has an online translation tool that converts the EDI 837 (Health Care Claim) 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 837 Transaction Set

Entire Segment
ST*837*1
BHT*0019*00*868-0-0-1*20030722*114945*CH
REF*87*004010X098
NM1*41*2*Social Provider*****46*445566778
PER*IC*Administrator*TE*6106876080*EX*111
NM1*40*2*Institution of Welfare*****46*998877665
HL*1**20*1
PRV*BI*ZZ*101YM0800X
NM1*85*2*Social Provider*****24*199999999
N3*1234 Good Street
N4*Philadelphia*PA*59128
REF*1C*ZZ908008
HL*2*1*22*1
SBR*P********MB
NM1*IL*1*Doesubscrib*John****MI*3000000003
N3*Subscribe Drive
N4*Philadelphia*PA*49125
DMG*D8*19400303*M
NM1*PR*2*Community Social Health*****PI*ZZ432678
N3*714 Market Street
N4*Philadelphia*PA*49106
HL*3*2*23*0
PAT*01
NM1*QC*1*Doedepend*Joe
N3*307 Dependant Street
N4*Philadelphia*PA*49125
DMG*D8*3/3/1950*M
REF*SY*333333333
CLM*62672*22.5***11::1*Y*A*Y*Y*C
HI*BK:V7389
LX*1
SV1*HC:87073*22.5*UN*3***1**N
DTP*472*D8*20030328
REF*G1*1968342
CLM*63325*147***11::1*Y*A*Y*Y*C
HI*BK:V7389
LX*1
SV1*HC:87073*147*UN*12***1**N
DTP*472*D8*20030404
REF*G1*1968341
CLM*63593*15***11::1*Y*A*Y*Y*C
HI*BK:V7389
LX*1
SV1*HC:87073*15*UN*2***1**N
DTP*472*D8*20030401
REF*G1*1968342
CLM*65119*147***11::1*Y*A*Y*Y*C
HI*BK:V7389
LX*1
SV1*HC:87073*147*UN*12***1**N
DTP*472*D8*20030408
REF*G1*1968341
CLM*65411*60***11::1*Y*A*Y*Y*C
HI*BK:V7389
LX*1
SV1*HC:87073*60*UN*8***1**N
DTP*472*D8*20030409
REF*G1*1968342
CLM*65901*147***11::1*Y*A*Y*Y*C
HI*BK:V7389
LX*1
SV1*HC:87073*147*UN*12***1**N
DTP*472*D8*20030415
REF*G1*1968341
CLM*62437*147***11::1*Y*A*Y*Y*C
HI*BK:V7389
LX*1
SV1*HC:87073*147*UN*12***1**N
DTP*472*D8*20030324
REF*G1*1968341
SE*71*1

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