Submission Request Body

{
    "senderId": "201985AAS",
    "submitterTransactionIdentifier": "1234567890",
    "payerId": "BCBSSC",
    "payerName": "South Carolina Blue Cross Blue",
    "umClearingHouseId": "INQNIA",
    "portalUsername": "portalUsername",
    "portalPassword": "portalPassword",
    "requester": {
        "requesterType": "1P",
        "organizationName": "Regional Medical Center",
        "lastName": "Regional Medical Center",
        "requesterIdentification": {
            "employerIdentificationNumber": "123456789"
        },
        "city": "Orangeburg",
        "state": "SC",
        "postalCode": "12345",
        "npi": "1234567890",
        "contactTelephone": "803-395-2200"
    },
    "subscriber": {
        "lastName": "TEST",
        "firstName": "BRITTANY",
        "memberId": "ZCS12345678",
        "dateOfBirth": "19701231",
        "supplementalIdentification": {
            "groupNumber": "123456789",
            "ssn": "111223333"
        }
    },
    "patientEventDetail": {
        "requestCategoryCode": "HS",
        "certificationTypeCode": "I",
        "serviceTypeCode": "1",
        "facilityTypeCode": "11",
        "facilityCodeQualifier": "B",
        "eventDateBegin": "20231017",
        "eventDateEnd": "20231017",
        "patientEventProviderName": [
            {
                "entityIdentifierCode": "SJ",
                "lastName": "TEST",
                "firstName": "STEVEN",
                "identificationCodeQualifier": "XX",
                "identifier": "1234567890"
            },
            {
                "entityIdentifierCode": "DN",
                "lastName": "TEST",
                "firstName": "STEVEN",
                "identificationCodeQualifier": "XX",
                "identifier": "1234567890"
            }
        ],
        "serviceLevel": [
            {
                "requestCategoryCode": "HS",
                "facilityTypeCode": "11",
                "facilityCodeQualifier": "B",
                "serviceDateBegin": "20231017",
                "serviceDateEnd": "20231017",
                "professionalService": {
                    "productOrServiceIDQualifier": "HC",
                    "procedureCode": "71260"
                }
            },
            {
                "requestCategoryCode": "HS",
                "facilityTypeCode": "11",
                "facilityCodeQualifier": "B",
                "serviceDateBegin": "20231017",
                "serviceDateEnd": "20231017",
                "professionalService": {
                    "productOrServiceIDQualifier": "HC",
                    "procedureCode": "74177"
                }
            }
        ]
    }
}

{
    "portalUsername": "string",
    "portalPassword": "string",
    "x12": "ISA*00*4444      *00*5555      *ZZ*6546564        *ZZ*278R_2000E_A1  *0623  *1301*^*00501*000000001*0*T*:~GS*HI*FL0738*PERSEPVS*20090601*040612*1*X*005010X217~ST*278*0001*005010X217~BHT*0007*13*A12345*20050502*1101~HL*1**20*1~NM1*X3*2*MARYLAND CAPITAL INSURANCE COMPANY*****46*789312~HL*2*1*21*1~NM1*1P*1*GARDENER*JAMES****46*8189991234~HL*3*2*22*1~NM1*IL*1*SMITH*JOE****MI*12345678901~HL*4*3*EV*0~TRN*1*111099*9012345678~UM*SC*I*3*11:B*****Y~HI*BF:41090:D8:20050430~HSD*VS*1~NM1*SJ*1*WATSON*SUSAN****34*987654321~PER*IC**TE*4029993456~SE*16*0001~GE*1*1~IEA*1*000000001~"
}