{

"ediSubmitterDTO": {
"submitterID": "111134 ",
"receiverID": "53589",
"authorizationQualifier": "00",
"ediControlNumber": "796000000",
"usageIndicator": "P",
"acknowledgementRequested": "0",
"contactName": "S Martinez",
"contactPhone": "2025550170",
"entityType": "2",
"lastName": "Demo Practice",
"contactFax": "2025550179"
},
"claimsList": [
{
"claimNo": "124304",
"billedAmount": 60.00,
"icd1": "A05",
"providerSignIndicator": "Y",
"claimType": "1",
"providerAcceptAssCode": "A",
"benefitAssIndicator": "Y",
"releaseInfoCode": "Y",
"pos": "11",
"facilityDTO": {
"name": "NY Office",
"npi": "1821689787",
"address1": "30,Tonto Apache Reservation",
"city": "Payson",
"state": "AZ",
"zip": "855415556"
},
"renderingProviderDTO": {
"entityType": "1",
"lastName": "Borak",
"firstName": "Steve",
"npi": "1821689787"
},
"subscriberDTO": {
"entityType": "1",
"lastName": "Doe",
"firstName": "John",
"address1": "30, Tonto Apache Reservation",
"address2": "Payson",
"city": "Payson",
"state": "AZ",
"zip": "855415556",
"dob": "11/23/1945",
"gender": "M",
"groupNumber": "TAT102",
"groupName": "GFAMPLAN",
"payerRespon": "P",
"claimFillingIndicator": "BL",
"policyNo": "Y333RF3333",
"insuredRelation": "18"
},
"payerDTO": {
"name": "Blue Choice",
 "address1": "4787 BLUFF STREET",
"city": "Blue bell",
"state": "TX",
"zip": "74102",
"payerID": "53589"
},
"lineItems": [
{
"procedureCode": "99214",
"chargesPerUnit": 60,
"serviceFromDate": "05/17/2019",
"serviceToDate": "05/17/2019",
"units": 1.00,
"icdPointers": "1",
"lineItemId": "75965",
"pos": "11"
}
],
"billingProviderDTO": {
"entityType": "2",
"lastName": "Tonto Apache Healthcare LLC",
"npi": "1447843651",
"address1": "30, tonto Apache Reservation",
"address2": "",
"city": "Payson",
"state": "AZ",
"zip": "855415556",
"taxNo": "222222222"
}
}
]
}

==========================================================

ISA*00* *00* *ZZ*111134 *ZZ*53589

*210816*0431*^*00501*796000000*0*P*:
GS*HC*111134*53589*20210816*0431*796000000*X*005010X222A1
ST*837*0001*005010X222A1
BHT*0019*00*0001*20210816*0431*CH
NM1*41*2*Demo Practice*****46*111134
PER*IC*S Martinez*TE*2025550170*FX*2025550179
NM1*40*2*53589*****46*53589
HL*1**20*1
NM1*85*2*Tonto Apache Healthcare LLC*****XX*1447843651
N3*30, tonto Apache Reservation
N4*Payson*AZ*855415556
REF*EI*222222222
HL*2*1*22*0
SBR*P*18*TAT102*GFAMPLAN*****BL
NM1*IL*1*Doe*John****MI*Y333RF3333
N3*30, Tonto Apache Reservation*Payson
N4*Payson*AZ*855415556
DMG*D8*19451122*M
NM1*PR*2*Blue Choice*****PI*53589
N3*4787 BLUFF STREET
N4*Blue bell*TX*74102
CLM*124304*60***11:B:1*Y*A*Y*Y*P
HI*ABK:A05
NM1*82*1*Borak*Steve****XX*1821689787
NM1*77*2*NY Office*****XX*1821689787
N3*30,Tonto Apache Reservation
N4*Payson*AZ*855415556
LX*1
SV1*HC:99214*60*UN*1*11**1
DTP*472*D8*20190516
REF*6R*75965
SE*30*0001
GE*1*796000000
IEA*1*796000000

==========================================================

https://demo.nagatabilling.com/NagataEDITool/zk/main/main.zul

bhavesh.dalal@mednetlabs.com

dee11741

-----------------------------------------------------------------------------------
-----
Insurance verification
EDI 270
EDI 271

Preauth
EDI

Claim
EDI 837P
EDI 837I

Remittance
EDI 835