test.835

ISA*00*          *00*          *ZZ*SENDERID      *ZZ*RECEIVERID    *240101*1200*^*00501*000000001*1*T*:~
GS*HP*SENDERID*RECEIVERID*20240101*1200*1*X*005010X221A1~

ST*835*0001~
BPR*I*1500.00*C*CHK*PPD*01*123456789*DA*987654321*1234567890**01*111222333*DA*555666777*20240101~
TRN*1*1234567890*123456789*999999999~
N1*PR*INSURANCE COMPANY A*FI*999999999~
N3*123 MAIN STREET~
N4*NEW YORK*NY*10001~
N1*PE*HEALTHCARE PROVIDER A*XX*1234567890~
N3*456 MEDICAL PLAZA~
N4*LOS ANGELES*CA*90001~

CLP*PATIENTID123*1*2000.00*1500.00**MC*555555555~
CAS*CO*45*500.00~
NM1*QC*1*DOE*JOHN****MI*PATIENT12345~
DTM*472*20231205~
SVC*HC:99213*200.00*1*150.00**1~
CAS*CO*45*50.00~

SE*12*0001~

ST*835*0002~
BPR*I*2500.00*C*CHK*PPD*01*223344556*DA*667788990*1234567890**01*444555666*DA*888999000*20240101~
TRN*1*9876543210*223344556*888888888~
N1*PR*INSURANCE COMPANY B*FI*888888888~
N1*PE*HEALTHCARE PROVIDER B*XX*9876543210~

CLP*PATIENTID456*1*1800.00*1400.00**MC*666777888~
CAS*CO*45*400.00~
NM1*QC*1*SMITH*JANE****MI*PATIENT67890~
DTM*472*20231206~
SVC*HC:99214*250.00*1*200.00**1~
CAS*CO*45*50.00~

SE*10*0002~

GE*2*1~
IEA*1*000000001~