Health Care Service Corp (BCBS IL/TX/OK/NM/MT) · Health Care Claim — Professional

Envelope defaults

{
  "isaSenderQualifier": "ZZ",
  "isaReceiverQualifier": "ZZ",
  "receiverId": "00621",
  "versionId": "005010X222A1",
  "gsCode": "HC",
  "usageIndicator": "P"
}

Required fields

• NM1/NM109 — Payer ID varies by state — 00621 IL / 84980 TX/NM / 84105 OK / 00751 MT
• REF/REF02 — Provider commercial ID (REF*G2) at 2010BB

Fixed values

None.