ISA*00*          *00*          *ZZ*77027          *ZZ*999999999      *110711*1201*^*00501*247360022*0*T*:~
GS*HP*77027*999999999*20110711*1201*247360022*X*005010X221A1~
ST*835*0001~
BPR*I*200*C*ACH*CCP*01*999999999*DA*1234567890-*9876543210**01*8765432109*DA*2345678901*20110720~
TRN*1*222222222*112345678~
REF*EV*1111111111~
DTM*405*20110711~
N1*PR*STATE OF FLORIDA MEDICAID~
N3*P.O. BOX 7060*-~
N4*TALLAHASSEE*FL*323147060~
PER*BL*FL Medicaid Help Desk*TE*8002897799~
N1*PE*REMITTANCE RECEIVER*XX*1111111111~
N3*ADDRESS LINE~
N4*CITY*FL*334106463~
REF*PQ*999999999~
REF*TJ*591111111~
LX*1~
TS3*1111111111*99*20111231*7*900.00~
CLP*12345600*1*100*100**MC*2001190000000*12~
NM1*QC*1*LAST*FIRST****MR*9496718779~
NM1*82*2******MC*1111111111~
DTM*232*20110714~
DTM*233*20110714~
SVC*HC:G9012:U3*100*100**1~
DTM*472*20110714~
REF*1D*987654321~
AMT*B6*100~
CLP*12345601*1*200*100**MC*2001190000001*12~
NM1*QC*1*LAST*FIRST****MR*9491051083~
NM1*82*2******MC*1111111111~
DTM*232*20110714~
DTM*233*20110714~
SVC*HC:G9012:U3*200*100**1**2~
DTM*472*20110714~
CAS*CO*147*100~
REF*1D*987654321~
AMT*B6*100~
LQ*HE*N59~
LQ*HE*N59~
CLP*12345602*1*100*100**MC*2001190000002*12~
NM1*QC*1*LAST*FIRST****MR*7718122743~
NM1*82*2******MC*1111111111~
DTM*232*20110713~
DTM*233*20110713~
SVC*HC:G9012:U3*100*100**1~
DTM*472*20110713~
REF*1D*987654321~
AMT*B6*100~
CLP*12345603*4*100*0**MC*2001190000003*12~
NM1*QC*1*LAST*FIRST****MR*9496718779~
NM1*82*2******MC*1111111111~
DTM*232*20110714~
DTM*233*20110714~
SVC*HC:G9012:U3*100*0**0**1~
DTM*472*20110714~
CAS*CO*18*100~
REF*1D*987654321~
LQ*HE*N59~
LQ*HE*N59~
CLP*12345604*4*200*0**MC*2001190000004*12~
NM1*QC*1*LAST*FIRST****MR*9491051083~
NM1*82*2******MC*1111111111~
DTM*232*20110714~
DTM*233*20110714~
SVC*HC:G9012:U3*200*0**0**2~
DTM*472*20110714~
CAS*CO*18*200~
REF*1D*987654321~
LQ*HE*N59~
LQ*HE*N59~
LQ*HE*N59~
LQ*HE*N59~
LQ*HE*N192~
LQ*HE*N59~
CLP*12345605*4*100*0**MC*2001190000005*12~
NM1*QC*1*LAST*FIRST****MR*7718122743~
NM1*82*2******MC*1111111111~
DTM*232*20110713~
DTM*233*20110713~
SVC*HC:G9012:U3*100*0**0**1~
DTM*472*20110713~
CAS*CO*18*100~
REF*1D*987654321~
LQ*HE*N59~
LQ*HE*N59~
LQ*HE*N59~
LQ*HE*N59~
CLP*12345606*4*100*0**MC*2001190000006*12~
NM1*QC*1*LAST*FIRST****MR*7718122743~
NM1*82*2******MC*1111111111~
DTM*232*20110713~
DTM*233*20110713~
SVC*HC:G9012:U3*100*0**0**1~
DTM*472*20110713~
CAS*CO*18*100~
REF*1D*987654321~
LQ*HE*N59~
LQ*HE*N59~
LQ*HE*N59~
LQ*HE*N59~
PLB*1111111111*20111231*WO:053319331*100~
SE*100*0001~
GE*1*247360022~
IEA*1*247360022~