Tyler
22 lines
733 B
Plaintext
22 lines
733 B
Plaintext
ISA*00* *00* *ZZ*COMEDASSISTPROG*ZZ*TPID001 *260617*1937*^*00501*991102984*1*P*:~ST*835*991102984*005010X221A1~
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BPR*C*85.00*C*ACH*CCP*01*021000021*DA*123456789*81-1725341******20260617~
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TRN*1*TPID001*81-1725341~
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DTM*405*20260617~
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N1*PR*2*CO_TXIX*****XV*7912900843~
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N3*PO BOX 11000~
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N4*DENVER*CO*802110000~
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PER*BL*Customer Service*TE*8001234567*UR*hcpf.colorado.gov~
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N1*PE*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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LX*1~
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CLP*CLM001*1*100.00*85.00*15.00*MC*CLM001*12*1~
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CAS*CO*45*15.00~
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SVC*HC:S5130:U2*60.00*50.00*7.73*UN*20260602~
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DTM*472*20260602~
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SVC*HC:S5130:U2*40.00*35.00*7.73*UN*20260603~
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DTM*472*20260603~
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SE*22*991102984~
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GE*1*991102984~
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IEA*1*991102984~
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