The following is a sample HIPAA document in Electronic Data Interchange (EDI) format. Shown in the next two topics are the acknowledgement and XML file that are generated from this HIPAA document on a channel configured for inbound processing.
The interchange (ISA) is 106 characters fixed length, but it has been reformatted here to fit on the page.
ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID.. *ZZ*RECEIVERS.ID...*030101*1253*^*00501*000000905*0*T*:~ GS*HR*SENDER CODE*RECEIVER CODE*19991231*0802*1*X*005010X212~ ST*276*0001*005010X212~ BHT*0010*13*ABC276XXX*20050915*1425~ HL*1**20*1~ NM1*PR*2*ABC INSURANCE*****PI*12345~ HL*2*1*21*1~ NM1*41*2*XYZ SERVICE*****46*X67E~ HL*3*2*19*1~ NM1*1P*2*HOME HOSPITAL*****XX*1666666668~ HL*4*3*22*0~ DMG*D8*19301210*M~ NM1*IL*1*SMITH*FRED****MI*123456789A~ TRN*1*ABCXYZ1~ REF*BLT*111~ REF*EJ*SM123456~ AMT*T3*8513.88~ DTP*472*RD8*20050831-20050906~ HL*5*3*22*0~ DMG*D8*19301115*F~ NM1*IL*1*JONES*MARY****MI*234567890A~ TRN*1*ABCXYZ2~ REF*BLT*111~ REF*EJ*JO234567~ AMT*T3*7599~ DTP*472*RD8*20050731-20050809~ HL*6*2*19*1~ NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666668~ HL*7*6*22*1~ NM1*IL*1*MANN*JOHN****MI*345678901~ HL*8*7*23~ DMG*D8*19951101*M~ NM1*QC*1*MANN*JOSEPH~
TRN*1*ABCXYZ3~ REF*EJ*MA345678~ SVC*HC:99203*150*****1~ DTP*472*D8*20050501~ SE*36*0001~ GE*1*1~ IEA*1*000000905~
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