Example EDI X12 837

ST*837*0001*005010X222~BHT*0019*00*565743*20110523*154959*CH~NM1*41*2*SAMPLE INC*****46*496103~PER*IC*EDI DEPT*EM*FEEDBACK@1edisource.com*TE*3305551212~NM1*40*2*PPO BLUE*****46*54771~HL*1**20*1~PRV*BI*PXC*333600000X~NM1*85*2*EDI SPECIALTY SAMPLE*****XX*123456789~N3*1212 DEPOT DRIVE~N4*CHICAGO*IL*606930159~REF*EI*300123456~HL*2*1*22*1~SBR*P********BL~NM1*IL*1*CUSTOMER*KAREN****MI*YYX123456789~N3*228 PINEAPPLE CIRCLE~N4*CORA*PA*15108~DMG*D8*19630625*M~NM1*PR*2*PPO BLUE*****PI*54771~N3*PO BOX 12345~N4*CAMP HILL*PA*17089~HL*3*2*23*0~PAT*19~NM1*QC*1*CUSTOMER*COLE~N3*228 PINEAPPLE CIRCLE~N4*CORA*PA*15108~DMG*D8*19940921*M~CLM*945405*5332.54***12>B>1*Y*A*Y*Y*P~HI*BK>2533~LX*1~SV1*HC>J2941*5332.54*UN*84***1~DTP*472*RD8*20110511-20110511~REF*6R*1099999731~NTE*ADD*GENERIC 12MG CARTRIDGE~LIN**N4*00013264681~CTP****7*UN~NM1*DK*1*PATIENT*DEBORAH****XX*12345679030~N3*123 MAIN ST*APT B~N4*PITTSBURGH*PA*152181871~SE*39*0001~