{
  "schemaVersion": "1.0",
  "transaction": {
    "controlNumber": "0001",
    "submitterTransactionIdentifier": "SYNTHETIC0001",
    "creationDate": "2026-09-07",
    "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"
  },
  "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"
    }
  },
  "payer": {
    "organizationName": "Example Health Plan",
    "identifier": "842610001"
  },
  "claim": {
    "patientControlNumber": "SYNTHETIC0001",
    "totalChargeAmount": "175.50",
    "placeOfServiceCode": "11",
    "frequencyCode": "1",
    "claimFilingIndicatorCode": "CI",
    "diagnoses": ["M5450", "I10"],
    "renderingProvider": {
      "firstName": "Robert",
      "lastName": "Smith",
      "npi": "1245319599",
      "taxonomyCode": "207Q00000X"
    },
    "serviceLines": [
      {
        "procedureCode": "99213",
        "modifiers": ["25"],
        "chargeAmount": "125.50",
        "unitCount": "1.000",
        "serviceDate": "2026-09-06",
        "diagnosisPointers": [1, 2]
      },
      {
        "procedureCode": "36415",
        "chargeAmount": "50.00",
        "unitCount": "1",
        "serviceDate": "2026-09-06",
        "diagnosisPointers": [2],
        "placeOfServiceCode": "22"
      }
    ]
  }
}