ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *990914*0244*U*00401*100007098*0*P*@~
GS*SS*147754931*065873374*19990914*0244*1*X*004010~
ST*837*987654~
BHT*0019*00*A12345*20010801*1800~

NM1*41*2*TOO GOOD HOSPITAL*****46*999008888~

NM1*40*2*MY STATE DATA AGENCY*****46*12000~

HL*1**20*1~

NM1*85*2*TOO GOOD HOSPITAL*****24*999008888~
REF*1J*898989~

HL*2*1*22*1~
SBR*P********BL~

NM1*IL*1*GREENE*SCOTT*A**MI*GRNESSC1234~
N3*1313 MOCKINGBIRD LANE~
N4*ANYTOWN*NY*09090~
DMG*D8*19760706*M**::RET:3::RET:2~
REF*SY*130281234~

NM1*PR*2*EMPIRE BLUE CROSS*****PI*00303~

CLM*ABH123456*5015***11:A:1~
DTP*096*TM*1200~
DTP*434*RD8*20010610-20010611~
DTP*435*DT*200106100900~
CL1*2*1*01~
REF*EA*ABHMEDRECMOM~
NTE*UPI*STATE SPECIFIC REQUIREMENTS~
HI*BK:66411*BJ:66411~
HI*BF:66331:::::::Y*BF:66111:::::::N*BF:V270:::::::N~
HI*BR:7569:D8:20010610~
HI*BQ:7309:D8:20010610~

NM1*71*1*DOCTOR*JOE****XX*F88888~
REF*1G*JDUPIN~
REF*0B*JDSTAATE~

NM1*72*1*SURGEON*REALGOOD****XX*F99999~
REF*0B*RSUPIN~
REF*1G*RSSTA

SBR*S********CI~

NM1*IL*1*Greene*Beth*P~

LX*1~
SV2*001**5015-
LX*2~
SV2*122**2754*DA*2*1377~
LX*3~
SV2*258**15~
LX*4~
SV2*259**68~
LX*5~
SV2*279**59~
LX*6~
SV2*305**38~
LX*7~
SV2*309**39~
LX*8~
SV2*729**2034~
LX*9~
SV2*999**8~

HL*3*1*22*0~
PAT*********Y~

NM1*QC*1*BEST*NANCY*E**MI*BESTNA9999~
N3*1313 MOCKINGBIRD LANE~
N4*ANYTOWN*NJ*0*09090~
DMG*D8*20010610*F**::RET:3::RET:2~
REF*SY*999999999~

CLM*ABH1234567*2343***11:A:1~
DTP*096*TM*1600~
DTP*434*RD8*20010610-20010611~
DTP*435*DT*200106100900~
CL1*4*1*01~
REF*EA*ABHMEDRECKID~
REF*MRN*ABHMEDRECMOM~
NTE*UPI*STATE SPECIFIC REQUIREMENTS~
HI*BK:V3000*BJ:V3000~
HI*BF:7625:::::::N*BF:V053:::::::N~
HI*BR:9604:D8:20010610~
HI*BQ:9955:D8:20010610~
HI*BE:54:::3610~

NM1*71*1*DOCTOR*JOE****XX*F88888~
REF*1G*JDUPIN~
REF*0B*JDSTAATE~

NM1*72*1*SURGEON*REALGOOD****XX*F99999~
REF*0B*RSUPIN~
REF*1G*RSSTATE~

SBR*S********CI~

NM1*IL*1*SAMPLE*TIMOTHY*O~

LX*1~
SV2*001**2343~
LX*2~
SV2*171**2232*DA*2*1116~
LX*3~
SV2*279**37~
LX*4~
SV2*309**63~
LX*5~
SV2*729**11~

HL*4**20*1~

NM1*85*2*ALL RIGHT HOSPITAL*****24*999008888~
REF*1J*898989~

HL*5*4*22*1~
SBR*P********BL~

NM1*IL*1*DUNNET*BILL*A**MI*DUETBI1234~
N3*1313 MOCKINGBIRD LANE~
N4*ANYTOWN*NY*09090~
DMG*D8*19760706*M**::RET:3::RET:2~
REF*SY*130281234~

NM1*PR*2*EMPIRE BLUE CROSS*****PI*00303~

CLM*ABH123456*5015***11:A:1~
DTP*096*TM*1200~
DTP*434*RD8*20010610-20010611~
DTP*435*DT*200106100900~
CL1*2*1*01~
REF*EA*ABHMEDRECMOM~
NTE*UPI*STATE SPECIFIC REQUIREMENTS~
HI*BK:66411*BJ:66411~
HI*BF:66331:::::::Y*BF:66111:::::::N*BF:V270:::::::N~
HI*BR:7569:D8:20010610~
HI*BQ:7309:D8:20010610~

NM1*71*1*DOCTOR*JOE****XX*F88888~
REF*1G*JDUPIN~
REF*0B*JDSTAATE~

NM1*72*1*SURGEON*REALGOOD****XX*F99999~
REF*0B*RSUPIN~
REF*1G*RSSTA

SBR*S********CI~

NM1*IL*1*Dunnet*Sue*O~

LX*1~

SV2*001**5015-
LX*2~
SV2*122**2754*DA*2*1377~
LX*3~
SV2*258**15~
LX*4~
SV2*259**68~
LX*5~
SV2*279**59~
LX*6~
SV2*305**38~
LX*7~
SV2*309**39~
LX*8~
SV2*729**2034~
LX*9~
SV2*999**8~

SE*135*987654~
GE*1*1~
IEA*1*100007098~