ISA*00*          *00*          *01*030240928      *30*421406317      *180807*1202*^*00501*000001507*0*T*:~
GS*HC*030240928*421406317*20180807*12022605*150700*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*421400001*20180807*12022607*CH~
NM1*41*2*Centene Corporation*****46*421406317~
PER*IC*Sambit*TE*3143202264*EX*8099264~
NM1*40*2*Centene Corporation*****46*CENTENE001~
HL*1**20*1~
PRV*BI*PXC*261QM0801X~
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-R192ICE00094*600***11:B:1*Y*A*Y*Y~
DTP*435*D8*20180625~
HI*ABK:F341*ABF:F4310~
LX*1~
SV1*HC:H0004:HO:HQ*300*UN*12*11**1:2~
DTP*472*RD8*20180625-20180625~
LX*2~
SV1*HC:H0004:HO:HQ*300*UN*12*11**1:2~
DTP*472*RD8*20180629-20180629~
SE*30*0001~
GE*1*150700~
IEA*1*000001507~