Sample 824 004050X166 (4010 format) from Production Header Segments: ISA*00*00 *00* *ZZ*ID_MMIS_4MOLINA*ZZ*IDTPID000020 GS*AG*ID_MMIS_4MOLINA*IDTPID000020*20140528*2128*1*X*004050X166~ ST*824*0001*004050X166~ BGN*11*999999999*20140528*212858**999999999**U~ N1*40*XYZ Physicians*46*IDTPID000020$$Upload$$XYZ Services$$-5010~ N1*41*STATE OF IDAHO DHW*46*ID_MMIS_4MOLINA~ *140528*2128*^*00405*999999999*0*P*:~ Receiver Submitter Detail Segments: OTI*BR*BT*Provider***20140528*160555*999999999*999999999*837*005010X222A1~ REF*IX*1~ TED*024*00 Invalid Billing Provider. Billing Provider ID not found o*NM1*8*9**9999999999~ NTE*DEP*Invalid Billing Provider. Billing Provider ID not found on file.~ TED*024*00 Invalid Rendering Provider. Rendering Provider ID not fou*NM1*31*9**9999999999~ NTE*DEP*Invalid Rendering Provider. Rendering Provider ID not found on file.~ TED*024*00 Pay To Affiliation Error| No Pay To Provider Found.*NM1*31*9**9999999999~ NTE*DEP*Pay To Affiliation Error| No Pay To Provider Found.~ Trans Batch Rejects Item # Error Desc/location Error Desc Error Desc/location Error Desc Error Desc/location Error Desc OTI*IR*IX*Claim***20140528*160555*999999999*999999999*837*005010X222A1~ REF*X1*99999999999999~ REF*D9*06659-2026841419~ AMT*GW*247~ TED*024*00 Invalid Rendering Provider. Rendering Provider ID not fou*NM1*81*9**9999999999~ NTE*DEP*Invalid Rendering Provider. Rendering Provider ID not found on file.~ TED*024*00 Pay To Affiliation Error| No Pay To Provider Found.*NM1*81*9**9999999999~ NTE*DEP*Pay To Affiliation Error| No Pay To Provider Found.~ Trans Item Rejects Claim # Date Total charges Error Desc/location Error Desc Error Desc/location Error Desc Trailer Segments: SE*21*0001~ GE*1*1~ IEA*1*999999999~ Page 1 of 2 Sample 824 005010X186 (5010 format) will be sending effective 8-15-14 with differences highlighted Header Segments: ISA*00* *00* *ZZ*ID_MMIS_4MOLINA*ZZ*IDTPID000020 GS*AG*ID_MMIS_4MOLINA*IDTPID000020*20140529*1338*1*X*005010X186~ ST*824*0001*005010X186~ BGN*11*999999999*20140529*133841**999999999**U~ N1*41*STATE OF IDAHO DHW*46*ID_MMIS_4MOLINA~ N1*40*XYZ Physicians*46*IDTPID000020$$Upload$$Test CH$$-5010~ *140529*1338*^*00501*999999999*0*P*:~ Submitter (now 1st) Receiver (now 2nd) Detail Segments: OTI*BR*BT*NA***20140528*160555*999999999*999999999*837*005010X222A1~ REF*IX*1~ NM1*85*2*XYZ Billing Provider*****XX*9999999999~ TED*024**NM1*8*9**9999999999~ RED*NA**94**IBP*E012~ TED*024**NM1*31*9**9999999999~ RED*NA**94**IBP*E014~ TED*024**NM1*51*9**9999999999~ RED*NA**94**IBP*E013~ Trans Batch Rejects (OTI03 always NA) Item # Individual or Organization Name Error location (no description in TED02) Error code (no description/no NTE) Error location (no description in TED02) Error code (no description/no NTE) Error location (no description in TED02) Error code (no description/no NTE) OTI*IR*IX*NA***20140528*160555*999999999*999999999*837*005010X222A1~ REF*EJ*99999999999999~ DTM*232*20140417~ AMT*T3*247~ TED*024**NM1*81*9**9999999999~ RED*NA**94**IBP*E014~ TED*024**NM1*81*9**9999999999~ RED*NA**94**IBP*E013~ Trans Item Rejects (OTI03 always NA) Claim # Date Total submitted charges Error location (no description in TED02) Error code (no description/no NTE) Error location (no description in TED02) Error code (no description/no NTE) Trailer Segments: SE*21*0001~ GE*1*1~ IEA*1*999999999~ Page 2 of 2
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