ISA*00*          *00*          *ZZ*TESTSENDER     *ZZ*TESTRECEIVER   *220608*1246*^*00501*000001023*1*P*:
GS*HC*TESTSENDER*TESTRECEIVER*20220608*1246*1023*X*005010X223A2
ST*837*0001*005010X223A2
BHT*0019*00*CLAIMBATCHID1023*20220608*1246*CH
NM1*41*2*AGILE BILLING SOLUTIONS*****46*TESTSENDER
PER*IC*Zoe Barns*TE*8182457850*EM*zoebarns@agile.com
NM1*40*2*CA Medicaid*****46*TESTRECEIVER
HL*1**20*1
PRV*BI*PXC*282NC0060X
NM1*85*2*PERFECT CARE MEDICAL CENTER*****XX*1063449361
N3*420 CENTURY BLVD
N4*LOS ANGELES*CA*921200009
REF*EI*576999115
PER*IC*PERFECT CARE MEDICAL CENTER*TE*8182457850
HL*2*1*22*0
SBR*P*18*9140461101******CI
NM1*IL*1*SUMMER*DONA****MI*858453784
N3*104 MORSE AVE
N4*LOS ANGELES*CA*921200009
DMG*D8*19270121*F
NM1*PR*2*LAX Health Plan*****PI*LAXPLAN
CLM*130030C*954***21:A:1**A*Y*Y
DTP*096*TM*1300
DTP*434*RD8*20220514-20220517
DTP*435*DT*202205141000
CL1*3*5*01
HI*ABK:N186
HI*ABJ:N186
NM1*71*1*ROBERTS*ANDRE****XX*1699712752
PRV*AT*PXC*314000000X
LX*1
SV2*0191**954*DA*3
REF*6R*161987715
SE*32*0001
GE*1*1023
IEA*1*000001023