ISA*00*          *00*          *30*133052274      *ZZ*421406317      *180807*1202*^*00501*000001508*0*T*:~
GS*HC*133052274*421406317*20180807*12022761*150800*X*005010X223A2~
ST*837*0001*005010X223A2~
BHT*0019*00*0008B7D46*20180807*12022762*CH~
NM1*41*2*TALEND*****46*133052274~
PER*IC*SAMBIT*TE*3143202264*EX*8099264~
NM1*40*2*CENTENE CORP*****46*421406317~
HL*1**20*1~
PRV*BI*PXC*273R00000X~
NM1*85*2*Test Provider*****XX*9999999999~
N3*123 MAIN STREET~
N4*WOODSTOCK*IL*600980000~
REF*EI*999999999~
HL*2*1*22*0~
SBR*P*18**MEDICAID*****MC~
NM1*IL*1*TEST*MEMBER****MI*U0000000001~
N3*123 MAIN STREET~
N4*Elgin*IL*601200001~
DMG*D8*19960215*F~
NM1*PR*2*CENTENE*****PI*421406317~
N3*123 MAIN STREET~
N4*CITYNAME*NA*000000000~
CLM*TD-R192ICE00087*17166.7***11:A:1**A*Y*Y~
DTP*096*TM*0900~
DTP*434*RD8*20180628-20180702~
DTP*435*DT*201806280800~
CL1*1*1*01~
REF*D9*TD-R192ICE00087~
HI*ABK:F39:::::::Y~
HI*ABJ:F39~
HI*DR:885~
HI*ABF:F1319:::::::Y*ABF:F419:::::::Y*ABF:F17210:::::::Y*ABF:E876:::::::N~
HI*BE:01:::1563*BE:80:::4~
NM1*77*2*BETHANY HOMES AND METHODIST HOSPITAL~
N3*240 WILSON RD~
N4*CHICAGO*IL*606400000~
LX*1~
SV2*0124**9148*UN*4~
DTP*472*RD8*20180628-20180702~
LX*2~
SV2*0250**48.1*UN*28~
DTP*472*RD8*20180628-20180702~
LX*3~
SV2*0260**133*UN*1~
DTP*472*RD8*20180628-20180702~
LX*4~
SV2*0300**32.9*UN*1~
DTP*472*RD8*20180628-20180702~
LX*5~
SV2*0301**798.5*UN*4~
DTP*472*RD8*20180628-20180702~
LX*6~
SV2*0305**200.6*UN*2~
DTP*472*RD8*20180628-20180702~
LX*7~
SV2*0306**175*UN*1~
DTP*472*RD8*20180628-20180702~
LX*8~
SV2*0307**113.6*UN*2~
DTP*472*RD8*20180628-20180702~
LX*9~
SV2*0351**6517*UN*2~
DTP*472*RD8*20180628-20180702~
SE*62*0001~
GE*1*150800~
IEA*1*000001508~