ISA*00*          *00*          *ZZ*COMEDICAID     *ZZ*DZINESCO       *240620*1200*^*00501*000000123*0*P*:~
GS*HN*COMEDICAID*DZINESCO*20240620*1200*1*X*005010X214~
ST*277CA*0001*005010X214~
BHT*0085*08*REFNUM001*20240620*1200*TH~
HL*1**20*1~
NM1*PR*2*COLORADO MEDICAL ASSIST*****PI*COMEDICAID~
TRN*2*REFNUM001~
DTP*050*RD8*20240601-20240630~
DTP*009*RD8*20240601-20240630~
HL*2*1*21*1~
NM1*41*2*DZINESCO*****46*11525703~
TRN*2*REFNUM001~
HL*3*2*19*1~
NM1*IL*1*DOE*JOHN****MI*MEMBERID001~
TRN*2*TRACE001~
HL*4*3*PT~
NM1*QC*1*DOE*JANE~
REF*1K*CLAIM001~
REF*EJ*721587149~
STC*A3:19:PR*20240620*WQ*100.00~
QTY*90*1~
AMT*YU*100.00~
DTP*472*RD8*20240615-20240615~
HL*5*3*PT~
NM1*QC*1*SMITH*ROBERT~
REF*1K*CLAIM002~
REF*EJ*721587149~
STC*A6:19:PR*20240620*U*250.00~
QTY*90*1~
AMT*YU*250.00~
DTP*472*D8*20240610~
HL*6*3*PT~
NM1*QC*1*GARCIA*MARIA~
REF*1K*CLAIM003~
REF*EJ*721587149~
STC*A8:19:PR*20240620*U*175.50~
QTY*90*1~
AMT*YU*175.50~
DTP*472*RD8*20240612-20240612~
SE*40*0001~
GE*1*1~
IEA*1*000000123~