Tyler
30 lines
871 B
Plaintext
30 lines
871 B
Plaintext
ISA*00* *00* *ZZ*11525703 *ZZ*COMEDASSISTPROG*260611*0814*^*00501*991102977*1*P*:~
|
|
GS*HC*11525703*COMEDASSISTPROG*20260611*081417*991102977*X*005010X222A1~
|
|
ST*837*991102977*005010X222A1~
|
|
BHT*0019*00*ref-001*20260611*081417*CH~
|
|
NM1*41*2*Test Submitter*****46*11525703~
|
|
PER*IC*Test Contact*EM*test@example.com~
|
|
NM1*40*2*COLORADO MEDICAL ASSISTANCE PROGRAM*****46*COMEDASSISTPROG~
|
|
HL*1**20*1~
|
|
PRV*BI*PXC*251E00000X~
|
|
NM1*85*2*Test Provider Inc*****XX*1234567890~
|
|
N3*123 Test St~
|
|
N4*Denver*CO*80202~
|
|
REF*EI*123456789~
|
|
HL*2*1*22*0~
|
|
SBR*P*18*******MC~
|
|
NM1*IL*1*Doe*John****MI*ABC123~
|
|
N3*456 Member St~
|
|
N4*Denver*CO*80203~
|
|
DMG*D8*19800101*M~
|
|
NM1*PR*2*COHCPF*****PI*SKCO0~
|
|
CLM*CLM001*100.00***12:B:1*Y*A*Y*Y~
|
|
REF*G1*PA123~
|
|
HI*ABK:Z00~
|
|
LX*1~
|
|
SV1*HC:99213*100.00*UN*1***1~
|
|
DTP*472*D8*20260611~
|
|
REF*6R*REF001~
|
|
SE*26*991102977~
|
|
GE*1*991102977~
|
|
IEA*1*991102977~ |