ISA*00* *00* *ZZ*100000 *ZZ*12345 *111207*1119*^*00501*000197351*1*T*:~ GS*HP*77032*12345*20111207*1119*197351*X*005010X221A1~ ST*835*000000001~ BPR*I*78*C*ACH*CCP*01*111111111*DA*2222222222*1640476393**01*999999999*DA*8888888888*20111208~ TRN*1*456789012*1640476393~ DTM*405*20111208~ N1*PR*MISSISSIPPI DIVISION OF MEDICAID*XV*640476393~ N3*P.O.BOX 23078~ N4*JACKSON*MS*392253078~ PER*BL*CONDUENT*TE*8008843222~ N1*PE*PayeeName*XX*1234567890~ N3*10 Main*SUITE M~ N4*CITY*MS*39402~ REF*TJ*777777777~ REF*PQ*12345678~ LX*1~ TS3*1234567890*11*20111231*2*145~ CLP*00000001*1*100*49.31*3*MC*12345678901234567*11~ NM1*QC*1*Patientslastname*Firstname*D***MI*00000123456789~ DTM*232*20111111~ DTM*233*20111111~ SVC*HC:12345*65*31.6**1~ DTM*472*20111111~ CAS*PI*45*31.74*1*137*1.66*1~ REF*HPI*1234567890~ SVC*HC:12345*35*17.71**1~ DTM*472*20111111~ CAS*PI*45*13.2*1*137*1.09*1~ CAS*PR*3*3*1~ REF*HPI*1234567890~ CLP*00000003*1*45*28.69**MC*12345678901234577*11~ NM1*QC*1*Patientslastname*Firstname*M***MI*00000123456788~ DTM*232*20111109~ DTM*233*20111109~ SVC*HC:12345*45*28.69**1~ DTM*472*20111109~ CAS*PI*45*14.8*1*137*1.51*1~ REF*HPI*1234567890~ SE*37*000000001~ GE*1*197351~ IEA*1*000197351~