Nora
61 lines
1.6 KiB
Plaintext
61 lines
1.6 KiB
Plaintext
ISA*00* *00* *ZZ*11525703 *ZZ*COMEDASSISTPROG*260617*1937*^*00501*991102984*1*P*:~
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GS*HC*11525703*COMEDASSISTPROG*20260617*193715*991102984*X*005010X222A1~
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ST*837*991102984*005010X222A1~
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BHT*0019*00*co-fixture-001*20260617*193715*CH~
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NM1*41*2*Dzinesco*****46*11525703~
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PER*IC*Tester*EM*tester@example.com~
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NM1*40*2*COLORADO MEDICAL ASSISTANCE PROGRAM*****46*COMEDASSISTPROG~
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HL*1**20*1~
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PRV*BI*PXC*251E00000X~
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NM1*85*2*TOC, Inc.*****XX*1881068062~
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N3*1100 East Main St*Suite A~
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N4*Montrose*CO*814014063~
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REF*EI*721587149~
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HL*2*1*22*0~
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SBR*P*18*******MC~
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NM1*IL*1*Balliache*Marianela****MI*P060946~
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N3*1811 PAVILION DR APT 303~
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N4*Montrose*CO*814016072~
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DMG*D8*19590223*F~
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NM1*PR*2*COHCPF*****PI*SKCO0~
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CLM*t991102984o1c1d*85.40***12:B:1*Y*A*Y*Y~
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REF*G1*3173~
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HI*ABK:R69~
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LX*1~
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SV1*HC:T1019:U2*42.70*UN*6.00***1~
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DTP*472*D8*20260602~
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REF*6R*t991102984v769804d~
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LX*2~
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SV1*HC:T1019:U2*42.70*UN*6.00***1~
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DTP*472*D8*20260603~
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REF*6R*t991102984v770058d~
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NM1*82*2*RENDERING PROVIDER*****XX*1234567893~
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HL*3*1*22*0~
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SBR*P*18*******MC~
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NM1*IL*1*Barella*Victoria****MI*H582447~
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N3*1900 Kellie DR~
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N4*Montrose*CO*814019524~
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DMG*D8*19570727*F~
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NM1*PR*2*COHCPF*****PI*SKCO0~
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CLM*t991102984o1c2d*155.76***12:B:1*Y*A*Y*Y~
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REF*G1*3173~
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HI*ABK:R69~
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LX*1~
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SV1*HC:S5130:U2*38.94*UN*6.00***1~
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DTP*472*D8*20260602~
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REF*6R*t991102984v769805d~
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LX*2~
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SV1*HC:S5130:U2*38.94*UN*6.00***1~
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DTP*472*D8*20260603~
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REF*6R*t991102984v770059d~
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LX*3~
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SV1*HC:S5130:U2*38.94*UN*6.00***1~
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DTP*472*D8*20260604~
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REF*6R*t991102984v770308d~
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LX*4~
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SV1*HC:S5130:U2*38.94*UN*6.00***1~
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DTP*472*D8*20260605~
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REF*6R*t991102984v770668d~
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SE*45*991102984~
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GE*1*991102984~
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IEA*1*991102984~ |