ISA*00*          *00*          *ZZ*77027          *ZZ*PLAN ID        *110707*1854*^*00501*104096382*0*T*:~
GS*RA*77027*PLAN ID*20110707*1854*104096382*X*005010X218~
ST*820*0001*005010X218~
BPR*I*1081.58*C*NON******1593452939******20110704~
TRN*3*NO PAYMNT~
REF*14*PLAN ID~
DTM*582****RD8*20110601-20110630~
N1*PE**FI*PLAN TAX ID~
N1*PR**FI*593452939~
ENT*1*2J*EI*MEMBER MEDICAID ID~
NM1*QE*1*LAST NAME*FIRST NAME****N*MEMBER MEDICAID ID~
RMR*AZ*0123456789**372.58*372.58~
REF*ZZ*03Z5B~
DTM*582****RD8*20110601-20110630~
ENT*2*2J*EI*MEMBER MEDICAID ID~
NM1*QE*1*LAST NAME*FIRST NAME****N*MEMBER MEDICAID ID~
RMR*AZ*0234567891**55.75*55.75~
REF*ZZ*03Z3B~
DTM*582****RD8*20110601-20110630~
ENT*3*2J*EI*MEMBER MEDICAID ID~
NM1*QE*1*LAST NAME*FIRST NAME****N*MEMBER MEDICAID ID~
RMR*AZ*0345678912**55.75*55.75~
REF*ZZ*03Z3B~
DTM*582****RD8*20110601-20110630~
ENT*4*2J*EI*MEMBER MEDICAID ID~
NM1*QE*1*LAST NAME*FIRST NAME****N*MEMBER MEDICAID ID~
RMR*AZ*0456789123**298.75*298.75~
REF*ZZ*03Z4B~
DTM*582****RD8*20110601-20110630~
ENT*5*2J*EI*MEMBER MEDICAID ID~
NM1*QE*1*LAST NAME*FIRST NAME****N*MEMBER MEDICAID ID~
RMR*AZ*0567891234**298.75*298.75~
REF*ZZ*03Z4B~
DTM*582****RD8*20110601-20110630~
SE*33*0001~
GE*1*104096382~
IEA*1*104096382~