ISA*00*          *00*          *ZZ*11525703       *ZZ*COMEDASSISTPROG*260617*1937*^*00501*991102984*1*P*:~
GS*HC*11525703*COMEDASSISTPROG*20260617*193715*991102984*X*005010X222A1~
ST*837*991102984*005010X222A1~
BHT*0019*00*co-fixture-001*20260617*193715*CH~
NM1*41*2*Dzinesco*****46*11525703~
PER*IC*Tester*EM*tester@example.com~
NM1*40*2*COLORADO MEDICAL ASSISTANCE PROGRAM*****46*COMEDASSISTPROG~
HL*1**20*1~
PRV*BI*PXC*251E00000X~
NM1*85*2*TOC, Inc.*****XX*1881068062~
N3*1100 East Main St*Suite A~
N4*Montrose*CO*814014063~
REF*EI*721587149~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*Balliache*Marianela****MI*P060946~
N3*1811 PAVILION DR APT 303~
N4*Montrose*CO*814016072~
DMG*D8*19590223*F~
NM1*PR*2*COHCPF*****PI*SKCO0~
CLM*t991102984o1c1d*85.40***12:B:1*Y*A*Y*Y~
REF*G1*3173~
HI*ABK:R69~
LX*1~
SV1*HC:T1019:U2*42.70*UN*6.00***1~
DTP*472*D8*20260602~
REF*6R*t991102984v769804d~
LX*2~
SV1*HC:T1019:U2*42.70*UN*6.00***1~
DTP*472*D8*20260603~
REF*6R*t991102984v770058d~
HL*3*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*Barella*Victoria****MI*H582447~
N3*1900 Kellie DR~
N4*Montrose*CO*814019524~
DMG*D8*19570727*F~
NM1*PR*2*COHCPF*****PI*SKCO0~
CLM*t991102984o1c2d*155.76***12:B:1*Y*A*Y*Y~
REF*G1*3173~
HI*ABK:R69~
LX*1~
SV1*HC:S5130:U2*38.94*UN*6.00***1~
DTP*472*D8*20260602~
REF*6R*t991102984v769805d~
LX*2~
SV1*HC:S5130:U2*38.94*UN*6.00***1~
DTP*472*D8*20260603~
REF*6R*t991102984v770059d~
LX*3~
SV1*HC:S5130:U2*38.94*UN*6.00***1~
DTP*472*D8*20260604~
REF*6R*t991102984v770308d~
LX*4~
SV1*HC:S5130:U2*38.94*UN*6.00***1~
DTP*472*D8*20260605~
REF*6R*t991102984v770668d~
SE*44*991102984~
GE*1*991102984~
IEA*1*991102984~