ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *080319*2327*U*00401*002721171*0*P*:~
GS*HC*SENDER*RECEIVER*20080319*2327*27211711*X*004010X096A1~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
ST*837*987654~
BHT*0019*00*0123*19960918*0932*CH~
REF*87*004010X096~
NM1*40*2*MEDICARE*****46*00120~
PER*IC*JANE DOE*TE*9005555555~
NM1*41*2*JONES HOSPITAL*****46*12345~
HL*1**20*1~
PRV*BI*ZZ*203BA0200N~
NM1*85*2*JONES HOSPITAL*****XX*330127~
PRV*AT*ZZ*363LP0200N~
N3*225 MAIN STREET BARKLEY BUILDING~
N4*CENTERVILLE*PA*17111~
REF*G2*987654080~
HL*2*1*22*0~
SBR*P*18*******MB~
NM1*IL*1*DOE*JOHN*T***MI*030005074A~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
DMG*D8*19261111*M~
NM1*PR*2*MEDICARE B*****PI*00435~
CLM*756048Q*89.93***14:A:1**Y*Y*Y~
DTP*434*D8*19960911~
CL1*3*1~
HI*BK:366.9~
HI*BF:401.9*BF:794.31~
HI*BQ:15.3:D8:19960911~
HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~
HI*BE:A2:::15.31~
HI*BG:09~
NM1*71*1*JONES*JOHN*J***XX*B99937~
PRV*AT*ZZ*363LP0200N~
SBR*S*01*351630*STATE TEACHERS*GP****CI~
DMG***F~
OI***Y***Y~
NM1*IL*1*DOE*JANE*S***MI*222004433~
N3*125 CITY AVENUE~
N4*CENTERVILLE*PA*17111~
NM1*PR*2*STATE TEACHERS*****PI*1135~
LX*1~
SV2*305*HC:85025*13.39*UN*1~
DTP*472*D8*19960911~
LX*2~
SV2*730*HC:93005*76.54*UN*3~
DTP*472*D8*19960911~
SE*44*987654~
GE*1*27211711~
IEA*1*002721171~
