ISA*00*          *00*          *ZZ*M00044SC1      *ZZ*SCMEDICAID     *110209*1327*U*00401*100000880*1*P*:~
GS*HC*M00044SC1*SCMEDICAID*20110209*1327*1070*X*004010X098A1~
ST*837*0001~
BHT*0019*00*1615*20110209*1327*CH~
REF*87*004010X098A1~
NM1*41*2*ANDERSON SCHOOL DISTRICT THREE*****46*M00044SC1~
PER*IC*CHARLENE POWELL*TE*8643486196*EX*10*EM*POWELLC@ANDERSON3.K12.SC.US~
NM1*40*2*SCMEDICAID*****46*SCMEDICAID~
HL*1**20*1~
NM1*85*2*ANDERSON SCHOOL DISTRICT THREE*****XX*1467406462~
N3*P. O. BOX 118~
N4*IVA*SC*29655~
REF*1D*SD0403~
REF*EI*576001050~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*BARNES*KILLIAN*J***MI*0781241340~
N3*201 BROADWELL MILL ROAD~
N4*ANDERSON*SC*29626~
DMG*D8*20041209*M~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22664*38.10***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:31401~
LX*1~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101207~
REF*6R*98575~
LX*2~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101208~
REF*6R*98576~
LX*3~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101209~
REF*6R*98577~
LX*4~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101210~
REF*6R*98578~
LX*5~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101213~
REF*6R*98579~
LX*6~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101215~
REF*6R*98580~
NM1*82*1*HUGHES*BETH****24*576001050~
HL*3*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*BLACK*DEBRA*J***MI*0046782902~
N3*401 ANTREVILLE HWY~
N4*IVA*SC*29655~
DMG*D8*19970312*F~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22660*6.25***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:78096~
LX*1~
SV1*HC:T1003*6.25*UN*1*03**1~
DTP*472*D8*20101201~
REF*6R*98556~
NM1*82*1*MCGUFFIN*RHONDA****24*576001050~
HL*4*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*BURGOS*TANE'VIA*I***MI*5780016142~
N3*103 CHRISTOPHER DRIVE~
N4*ANDERSON*SC*29626~
DMG*D8*20021107*F~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22658*8.25***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:7840*BF:9309~
LX*1~
SV1*HC:T1002*8.25*UN*1*03**1~
DTP*472*D8*20101213~
REF*6R*98567~
NM1*82*1*HUGHES*BETH****24*576001050~
HL*5*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*GROVER*CARMEN*G***MI*1780358736~
N3*1806 FLATROCK RD.~
N4*STARR*SC*29684~
DMG*D8*20030926*F~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22661*38.10***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:31401~
LX*1~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101206~
REF*6R*98560~
LX*2~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101209~
REF*6R*98561~
LX*3~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101210~
REF*6R*98566~
LX*4~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101213~
REF*6R*98568~
LX*5~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101215~
REF*6R*98570~
LX*6~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101216~
REF*6R*98571~
NM1*82*1*HUGHES*BETH****24*576001050~
CLM*22663*51.44***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:31532*BF:31539~
LX*1~
SV1*HC:92508*25.72*UN*2*03**1~
DTP*472*D8*20101214~
REF*6R*98572~
LX*2~
SV1*HC:92508*25.72*UN*2*03**1~
DTP*472*D8*20101216~
REF*6R*98573~
NM1*82*1*WARD*CRYSTAL****24*576001050~
HL*6*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*GROVER*KIRA*C***MI*1780358730~
N3*1806 FLATROCK RD.~
N4*STARR*SC*29684~
DMG*D8*20020619*F~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22662*31.75***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:31401~
LX*1~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101206~
REF*6R*98562~
LX*2~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101208~
REF*6R*98563~
LX*3~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101209~
REF*6R*98564~
LX*4~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101210~
REF*6R*98565~
LX*5~
SV1*HC:T1015:TD*6.35*UN*1*03**1~
DTP*472*D8*20101215~
REF*6R*98569~
NM1*82*1*HUGHES*BETH****24*576001050~
HL*7*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*TUCKER*KASEY*E***MI*2832489102~
N3*211 HAMBY RD~
N4*STARR*SC*29684~
DMG*D8*19960910*F~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22659*13.05***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:78096~
LX*1~
SV1*HC:T1015:TE*4.35*UN*1*03**1~
DTP*472*D8*20101201~
REF*6R*98557~
LX*2~
SV1*HC:T1015:TE*4.35*UN*1*03**1~
DTP*472*D8*20101202~
REF*6R*98558~
LX*3~
SV1*HC:T1015:TE*4.35*UN*1*03**1~
DTP*472*D8*20101214~
REF*6R*98574~
NM1*82*1*MCGUFFIN*RHONDA****24*576001050~
HL*8*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*TUCKER*KERI*M***MI*4555349301~
N3*211 HAMBY RD.~
N4*STARR*SC*29684~
DMG*D8*19991217*F~
NM1*PR*2*SCMEDICAID*****PI*SCXIX~
CLM*22657*6.35***99::1*Y*C*Y*N***05~
REF*G1*1467406462~
HI*BK:7840*BF:7841~
LX*1~
SV1*HC:T1015:TD*6.35*UN*1*03**2~
DTP*472*D8*20101206~
REF*6R*98559~
NM1*82*1*HUGHES*BETH****24*576001050~
SE*194*0001~
GE*1*1070~
IEA*1*100000880~
