Example 5b

Example 5b X12 Admin Tue, 08/04/2026 - 08:42 Example shows additional line payment amount: Provider Performance bonus paid at the service line level. Transmission ISA 00 * *00 * *ZZ *ABCPAYER *ZZ *ABCPROVIDER *250827 *0212 *^ *00806 *191511902 *0 *P *:~ GSHPABCDABCD202508271234567812345678X008060X322~ ST83510060875~ BPRI12.00CCHK****20250827~ TRN*1*CK002*1234567890~ REF*EV*FAC~ DTM*405*20250827~ N1*PR*ANY PLAN USA~ N3*1 WALK THIS WAY~ N4*ANYCITY*OH*45209~ PER*CXTE8661112222~ PERBLEDITE8002223333EMEDI.SUPPORT@ANYPAYER.COM~ PERIC**URWWW.ANYPAYER.COM~ N1PEPROVI