Tyler
43 lines
1.2 KiB
Plaintext
43 lines
1.2 KiB
Plaintext
ISA*00* *00* *ZZ*COMEDASSISTPROG*ZZ*TPID001 *260617*1937*^*00501*991102986*1*P*:~ST*835*991102986*005010X221A1~
|
|
BPR*C*241.16*C*ACH*CCP*01*021000021*DA*123456789*81-1725341******20260617~
|
|
TRN*1*TPID001*81-1725341~
|
|
DTM*405*20260617~
|
|
N1*PR*2*CO_TXIX*****XV*7912900843~
|
|
N3*PO BOX 11000~
|
|
N4*DENVER*CO*802110000~
|
|
PER*BL*Customer Service*TE*8001234567*UR*hcpf.colorado.gov~
|
|
N1*PE*2*TOC, Inc.*****XX*1881068062~
|
|
N3*1100 East Main St*Suite A~
|
|
N4*Montrose*CO*814014063~
|
|
REF*TJ*123456789~
|
|
LX*1~
|
|
CLP*t991102986o1c1d*1*85.40*85.40*0.00*MC*t991102986o1c1d*12*1~
|
|
CAS*CO*45*0.00~
|
|
REF*CE*PLAN_A~
|
|
NM1*QC*1*Balliache*Marianela~
|
|
SVC*HC:T1019:U2*42.70*42.70*UN*6.00*20260602~
|
|
DTM*472*20260602~
|
|
SVC*HC:T1019:U2*42.70*42.70*UN*6.00*20260603~
|
|
DTM*472*20260603~
|
|
LX*2~
|
|
CLP*t991102986o1c2d*1*155.76*155.76*0.00*MC*t991102986o1c2d*12*1~
|
|
CAS*CO*45*0.00~
|
|
REF*CE*PLAN_A~
|
|
QTY*CA*4~
|
|
NM1*QC*1*Barella*Victoria~
|
|
SVC*HC:S5130:U2*38.94*38.94*UN*6.00*20260602~
|
|
DTM*472*20260602~
|
|
REF*0K*PLAN_A~
|
|
SVC*HC:S5130:U2*38.94*38.94*UN*6.00*20260603~
|
|
DTM*472*20260603~
|
|
REF*0K*PLAN_A~
|
|
SVC*HC:S5130:U2*38.94*38.94*UN*6.00*20260604~
|
|
DTM*472*20260604~
|
|
REF*0K*PLAN_A~
|
|
SVC*HC:S5130:U2*38.94*38.94*UN*6.00*20260605~
|
|
DTM*472*20260605~
|
|
REF*0K*PLAN_A~
|
|
SE*45*991102986~
|
|
GE*1*991102986~
|
|
IEA*1*991102986~
|