{
  "schemaVersion": "2.0",
  "transaction": {
    "controlNumber": "0002",
    "submitterTransactionIdentifier": "SYNTHETIC-BATCH-0001",
    "creationDate": "2026-09-15",
    "creationTime": "14:30:15",
    "purposeCode": "00"
  },
  "submitter": {
    "organizationName": "Example Billing Platform",
    "identifier": "EXAMPLEBILLING",
    "contact": {
      "name": "EDI Operations",
      "phone": "14165550100",
      "email": "edi@example.test"
    }
  },
  "receiver": {
    "organizationName": "Example Health Plan",
    "identifier": "842610001"
  },
  "claims": [
    {
      "billingProvider": {
        "entityType": "organization",
        "organizationName": "Example Health Clinic",
        "npi": "1234567893",
        "taxonomyCode": "207Q00000X",
        "taxId": "123456789",
        "address": {
          "address1": "100 Main Street",
          "address2": "Suite 200",
          "city": "Miami",
          "state": "FL",
          "postalCode": "33111"
        }
      },
      "subscriber": {
        "firstName": "Jane",
        "middleName": "Q",
        "lastName": "Doe",
        "memberId": "SYNTHETIC123",
        "groupNumber": "SYNTHETIC42",
        "dateOfBirth": "1980-04-23",
        "gender": "F",
        "relationshipCode": "18",
        "address": {
          "address1": "45 Lake Shore Road",
          "city": "Miami",
          "state": "FL",
          "postalCode": "33133"
        }
      },
      "patient": {
        "firstName": "John",
        "lastName": "Doe",
        "dateOfBirth": "2015-06-12",
        "gender": "M",
        "relationshipCode": "19",
        "address": {
          "address1": "45 Lake Shore Road",
          "city": "Miami",
          "state": "FL",
          "postalCode": "33133"
        }
      },
      "payer": {
        "organizationName": "Example Health Plan",
        "identifier": "842610001"
      },
      "claim": {
        "patientControlNumber": "SYNTHETIC-DEPENDENT-0001",
        "totalChargeAmount": "125.50",
        "placeOfServiceCode": "11",
        "frequencyCode": "1",
        "claimFilingIndicatorCode": "CI",
        "diagnoses": ["M5450"],
        "priorAuthorizationNumber": "SYNTHETIC-AUTH-0001",
        "attachments": [
          {
            "reportTypeCode": "OZ",
            "transmissionCode": "BM",
            "controlNumber": "SYNTHETIC-ATTACHMENT-0001"
          }
        ],
        "providers": {
          "referring": {
            "firstName": "Robert",
            "lastName": "Smith",
            "npi": "1245319599"
          },
          "serviceFacility": {
            "organizationName": "Example Health Facility",
            "npi": "1234567893",
            "address": {
              "address1": "100 Main Street",
              "address2": "Suite 200",
              "city": "Miami",
              "state": "FL",
              "postalCode": "33111"
            }
          }
        },
        "coordinationOfBenefits": [
          {
            "sequenceCode": "S",
            "claimFilingIndicatorCode": "CI",
            "paidAmount": "75.00",
            "payerClaimControlNumber": "SYNTHETIC-OTHER-0001",
            "subscriber": {
              "firstName": "Jane",
              "lastName": "Doe",
              "memberId": "SYNTHETIC-SECONDARY",
              "relationshipCode": "18"
            },
            "payer": {
              "organizationName": "Example Secondary Plan",
              "identifier": "SECONDARY1"
            }
          }
        ],
        "serviceLines": [
          {
            "procedureCode": "99213",
            "modifiers": ["25"],
            "chargeAmount": "125.50",
            "unitCount": "1",
            "serviceDate": "2026-09-14",
            "diagnosisPointers": [1],
            "lineControlNumber": "SYNTHETIC-LINE-0001",
            "drug": {
              "nationalDrugCode": "00026063512",
              "quantity": "10",
              "unitCode": "ML"
            }
          }
        ]
      }
    }
  ]
}