Example 02: Multiple Claims Single Check

Example 02: Multiple Claims Single Check X12 Admin Tue, 07/28/2026 - 07:34 This 835 scenario shows multiple claims (9 claims) on a single check where the amount submitted for all claims was $2,819.00 and the payer paid amount was $810.80 total. Transmission ISA 00 * *00 * *ZZ *ABCPAYER *ZZ *ABCPROVIDER *250827 *0212 *^ *00806 *191511902 *0 *P *:~ GSHPABCDABCD202508271234567812345678X008060X322~ ST83535681~ BPRI810.8CCHK******20250827~ TRN1123451512345678~ REFEVXYZ CLEARINGHOUSE~ DTM405202590827~ N1PRDENTAL OF ABC~ N3225 MAIN STREET~ N4CENTERVILLEPA17111~ PER*B