ISA*00*..........*01*..........*ZZ*SAMPL_SENDRID..*ZZ*SAMPL_RECVRID..*191116*1439*^*00501*100000086*0*P*>~
GS*HP*SENDR_ID*RECVR_ID*20191116*1439*1*X*005010X221A1~
ST*835*100000001~
BPR*I*9724.18*C*CHK************20191116~
TRN*1*CHK00001*150001342 ~
N1*PR*LOWEST BIDDER HMO~
N3*400 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*2U*150001342~
PER*BL*TECH CONTACT*TE*4155550001~
N1*PE*CHEAPEST EVER HMO*XX*1234567893~
N3*200 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*TJ*150000676~
LX*1~
CLP*PAT00012983*1*800.8*400.4*11.12*HM*CLM0000000010*13~
NM1*QC*1*BREAD*SHANNON****MI*SUB000000093~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180830~
DTM*233*20180902~
AMT*AU*800.8~
SVC*HC>99202*129.7*64.85**1~
DTM*472*20180830~
CAS*CO*45*64.85~
AMT*B6*129.7~
SVC*HC>99202>RT*86.14*43.07**1~
DTM*472*20180831~
CAS*PR*2*8.62~
CAS*CO*45*34.45~
AMT*B6*86.14~
SVC*HC>99202>RT*90.3*45.15**1~
DTM*472*20180901~
CAS*CO*45*45.15~
AMT*B6*90.3~
SVC*HC>99202*494.66*247.33**1~
DTM*472*20180902~
CAS*PR*3*2.5~
CAS*CO*45*244.83~
xxxxxAMT*B6*494.66~
CLP*PAT00063069*1*270*135**HM*CLM0000000011*13~
NM1*QC*1*BREAD*SHANNON****MI*SUB000000093~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180430~
DTM*233*20180430~
AMT*AU*270~
SVC*HC>99213*270*135**1~
DTM*472*20180430~
CAS*CO*45*135~
AMT*B6*270~
CLP*PAT00050841*1*276.04*138.02*13.2*HM*CLM0000000022*13~
NM1*QC*1*CHIPOTLE*ALICIA****MI*SUB000000020~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180826~
DTM*233*20180829~
AMT*AU*276.04~
SVC*HC>93880*132*66**1~
DTM*472*20180826~
CAS*PR*2*13.2~
CAS*CO*45*52.8~
AMT*B6*132~
SVC*HC>93880*144*72**1~
DTM*472*20180827~
CAS*CO*45*72~
AMT*B6*144~
SVC*HC>93880*.02*.01**1~
DTM*472*20180828~
CAS*CO*45*.01~
AMT*B6*.02~
SVC*HC>93880*.02*.01**1~
DTM*472*20180829~
CAS*CO*45*.01~
AMT*B6*.02~
CLP*PAT00048966*1*565*282.5*20.5*HM*CLM0000000023*13~
NM1*QC*1*CHIPOTLE*ALICIA****MI*SUB000000020~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180426~
DTM*233*20180428~
AMT*AU*565~
SVC*HC>85027>25*205*102.5**1~
DTM*472*20180426~
CAS*CO*45*102.5~
AMT*B6*205~
SVC*HC>J2250>59*180*90**2~
DTM*472*20180427~
CAS*CO*45*90~
AMT*B6*180~
SVC*HC>85027>26*180*90**1~
DTM*472*20180428~
CAS*PR*2*18**3*2.5~
CAS*CO*45*69.5~
AMT*B6*180~
CLP*PAT00024026*1*120*60**HM*CLM0000000034*13~
NM1*QC*1*DUMPLING*ZACHARY****MI*SUB000000183~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180822~
DTM*233*20180822~
AMT*AU*120~
SVC*HC>97530*120*60**1~
DTM*472*20180822~
CAS*CO*45*60~
AMT*B6*120~
CLP*PAT00050370*1*198.84*99.42**HM*CLM0000000035*13~
NM1*QC*1*DUMPLING*ZACHARY****MI*SUB000000183~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180422~
DTM*233*20180422~
AMT*AU*198.84~
SVC*HC>86592*198.84*99.42**1~
DTM*472*20180422~
CAS*CO*45*99.42~
AMT*B6*198.84~
CLP*PAT00050755*1*90*45**HM*CLM0000000046*13~
NM1*QC*1*HAM*GERMAN****MI*SUB000000022~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180818~
DTM*233*20180818~
AMT*AU*90~
SVC*HC>86803*90*45**1~
DTM*472*20180818~
CAS*CO*45*45~
AMT*B6*90~
CLP*PAT00018070*1*170*85**HM*CLM0000000047*13~
NM1*QC*1*HAM*GERMAN****MI*SUB000000022~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180418~
DTM*233*20180418~
AMT*AU*170~
SVC*HC>86901*170*85**1~
DTM*472*20180418~
CAS*CO*45*85~
AMT*B6*170~
CLP*PAT00052447*1*214*107*2.5*HM*CLM0000000058*13~
NM1*QC*1*MAIZE*SAMON****MI*SUB000000162~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180814~
DTM*233*20180816~
AMT*AU*214~
SVC*HC>80048*160*80**1~
DTM*472*20180814~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>80048*27*13.5**1~
DTM*472*20180815~
CAS*PR*3*2.5~
CAS*CO*45*11~
AMT*B6*27~
SVC*HC>80048*27*13.5**1~
DTM*472*20180816~
CAS*CO*45*13.5~
AMT*B6*27~
CLP*PAT00065066*1*301*150.5*30.1*HM*CLM0000000059*13~
NM1*QC*1*MAIZE*SAMON****MI*SUB000000162~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180414~
DTM*233*20180415~
AMT*AU*301~
SVC*HC>72128*286*143**1~
DTM*472*20180414~
CAS*PR*2*28.6~
CAS*CO*45*114.4~
AMT*B6*286~
SVC*HC>99285*15*7.5**1~
DTM*472*20180415~
CAS*PR*1*1.5~
CAS*CO*45*6~
AMT*B6*15~
CLP*PAT00057589*1*270*135*8.5*HM*CLM0000000070*13~
NM1*QC*1*PEAS*FRANCISCO****MI*SUB000000042~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180810~
DTM*233*20180811~
AMT*AU*270~
SVC*HC>G0463>25*85*42.5**1~
DTM*472*20180810~
CAS*PR*2*8.5~
CAS*CO*104*25**45*9~
AMT*B6*85~
SVC*HC>82570*185*92.5**1~
DTM*472*20180811~
CAS*CO*45*92.5~
AMT*B6*185~
CLP*PAT00037733*1*295.14*147.57**HM*CLM0000000071*13~
NM1*QC*1*PEAS*FRANCISCO****MI*SUB000000042~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180410~
DTM*233*20180411~
AMT*AU*295.14~
SVC*HC>99285*178.16*89.08**1~
DTM*472*20180410~
CAS*CO*45*89.08~
AMT*B6*178.16~
SVC*HC>99285*116.98*58.49**1~
DTM*472*20180411~
CAS*CO*45*58.49~
AMT*B6*116.98~
CLP*PAT00033513*1*335*167.5**HM*CLM0000000082*13~
NM1*QC*1*SALMON*SERGIO****MI*SUB000000006~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180806~
DTM*233*20180807~
AMT*AU*335~
SVC*HC>73590*250*125**1~
DTM*472*20180806~
CAS*CO*45*125~
AMT*B6*250~
SVC*HC>94760*85*42.5**1~
DTM*472*20180807~
CAS*CO*104*25**45*17.5~
AMT*B6*85~
CLP*PAT00029657*1*248*124*5.2*HM*CLM0000000083*13~
NM1*QC*1*SALMON*SERGIO****MI*SUB000000006~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180406~
DTM*233*20180408~
AMT*AU*248~
SVC*HC>97799>25*160*80**1~
DTM*472*20180406~
CAS*PR*3*2.5~
CAS*CO*45*77.5~
AMT*B6*160~
SVC*HC>97799*61*30.5**1~
DTM*472*20180407~
CAS*CO*45*30.5~
AMT*B6*61~
SVC*HC>97799*27*13.5**1~
DTM*472*20180408~
CAS*PR*2*2.7~
CAS*CO*45*10.8~
AMT*B6*27~
CLP*PAT00037214*1*522.7*261.35*8.09*HM*CLM0000000094*13~
NM1*QC*1*TEA*STELLA****MI*SUB000000033~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180802~
DTM*233*20180806~
AMT*AU*522.7~
SVC*HC>81002*80.9*40.45**1~
DTM*472*20180802~
CAS*CO*45*40.45~
AMT*B6*80.9~
SVC*HC>82948*140*70**1~
DTM*472*20180803~
CAS*CO*45*70~
AMT*B6*140~
SVC*HC>81002*140*70**1~
DTM*472*20180804~
CAS*CO*45*70~
AMT*B6*140~
SVC*HC>82948*80.9*40.45**1~
DTM*472*20180805~
CAS*CO*45*40.45~
AMT*B6*80.9~
SVC*HC>81002*80.9*40.45**1~
DTM*472*20180806~
CAS*PR*2*8.09~
CAS*CO*45*32.36~
AMT*B6*80.9~
CLP*PAT00034535*1*677*338.5*6.2*HM*CLM0000000095*13~
NM1*QC*1*TEA*STELLA****MI*SUB000000033~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180402~
DTM*233*20180404~
AMT*AU*677~
SVC*HC>86336*605*302.5**1~
DTM*472*20180402~
CAS*CO*45*302.5~
AMT*B6*605~
SVC*HC>86336>26*37*18.5**1~
DTM*472*20180403~
CAS*PR*1*3.7**3*2.5~
CAS*CO*45*12.3~
AMT*B6*37~
SVC*HC>86336*35*17.5**1~
DTM*472*20180404~
CAS*CO*104*12.5**45*5~
AMT*B6*35~
CLP*PAT00023497*1*125*62.5**HM*CLM0000000104*13~
NM1*QC*1*PEAS*TIFFANY****MI*MEM000000079~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180330~
DTM*233*20180330~
AMT*AU*125~
SVC*HC>S9129*125*62.5**1~
DTM*472*20180330~
CAS*CO*45*62.5~
AMT*B6*125~
CLP*PAT00005907*1*250*125**HM*CLM0000000105*13~
NM1*QC*1*PEAS*TIFFANY****MI*MEM000000079~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181128~
DTM*233*20181128~
AMT*AU*250~
SVC*HC>36415*250*125**1~
DTM*472*20181128~
CAS*CO*45*125~
AMT*B6*250~
CLP*PAT00029210*1*133*66.5*10.8*HM*CLM0000000112*13~
NM1*QC*1*PEAS*LEE****MI*MEM000000075~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180727~
DTM*233*20180728~
AMT*AU*133~
SVC*HC>86787*108*54**1~
DTM*472*20180727~
CAS*PR*2*10.8~
CAS*CO*45*43.2~
AMT*B6*108~
SVC*HC>90471>QW*25*12.5**1~
DTM*472*20180728~
CAS*CO*45*12.5~
AMT*B6*25~
CLP*PAT00036157*1*90*45*2.5*HM*CLM0000000113*13~
NM1*QC*1*PEAS*LEE****MI*MEM000000075~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180327~
DTM*233*20180327~
AMT*AU*90~
SVC*HC>36415*90*45**1~
DTM*472*20180327~
CAS*PR*3*2.5~
CAS*CO*45*42.5~
AMT*B6*90~
CLP*PAT00049182*1*88.28*44.14*2.5*HM*CLM0000000146*13~
NM1*QC*1*PEAS*MARCIA****MI*MEM000000076~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180316~
DTM*233*20180317~
AMT*AU*88.28~
SVC*HC>H1002*44.14*22.07**1~
DTM*472*20180316~
CAS*CO*104*12.5**45*9.57~
AMT*B6*44.14~
SVC*HC>H1002*44.14*22.07**1~
DTM*472*20180317~
CAS*PR*3*2.5~
CAS*CO*45*19.57~
AMT*B6*44.14~
CLP*PAT00052561*1*75*37.5**HM*CLM0000000147*22~
NM1*QC*1*PEAS*MARCIA****MI*MEM000000076~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181114~
DTM*233*20181114~
AMT*AU*75~
SVC*HC>J3490*75*37.5**4~
DTM*472*20181114~
CAS*CO*45*37.5~
AMT*B6*75~
CLP*PAT00009624*1*167*83.5**HM*CLM0000000240*13~
NM1*QC*1*PEAS*SCOTT****MI*MEM000000077~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181014~
DTM*233*20181015~
AMT*AU*167~
SVC*HC>84165*100*50**1~
DTM*472*20181014~
CAS*CO*45*50~
AMT*B6*100~
SVC*HC>84165*67*33.5**1~
DTM*472*20181015~
CAS*CO*45*33.5~
AMT*B6*67~
CLP*PAT00010882*1*7491.2*3745.6**HM*CLM0000000241*13~
NM1*QC*1*PEAS*SCOTT****MI*MEM000000077~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180614~
DTM*233*20180616~
AMT*AU*7491.2~
SVC*HC>J1885*7302.8*3651.4**4~
DTM*472*20180614~
CAS*CO*45*3651.4~
AMT*B6*7302.8~
SVC*HC>99283>59*57.04*28.52**1~
DTM*472*20180615~
CAS*CO*45*28.52~
AMT*B6*57.04~
SVC*HC>J1885*131.36*65.68**4~
DTM*472*20180616~
CAS*CO*45*65.68~
AMT*B6*131.36~
CLP*PAT00021392*1*153*76.5**HM*CLM0000000246*13~
NM1*QC*1*DUMPLING*DANIEL****MI*MEM000000022~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181012~
DTM*233*20181013~
AMT*AU*153~
SVC*HC>T2033>26*140*70**1~
DTM*472*20181012~
CAS*CO*45*70~
AMT*B6*140~
SVC*HC>T2033>26*13*6.5**1~
DTM*472*20181013~
CAS*CO*45*6.5~
AMT*B6*13~
CLP*PAT00028168*1*327.9*163.95*10.28*HM*CLM0000000247*13~
NM1*QC*1*DUMPLING*DANIEL****MI*MEM000000022~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180612~
DTM*233*20180616~
AMT*AU*327.9~
SVC*HC>96361*57.46*28.73**5~
DTM*472*20180612~
CAS*CO*45*28.73~
AMT*B6*57.46~
SVC*HC>96361*77.76*38.88**5~
DTM*472*20180613~
CAS*PR*3*2.5~
CAS*CO*45*36.38~
AMT*B6*77.76~
SVC*HC>96361*57.46*28.73**5~
DTM*472*20180614~
CAS*CO*45*28.73~
AMT*B6*57.46~
SVC*HC>96361*77.76*38.88**5~
DTM*472*20180615~
CAS*PR*2*7.78~
CAS*CO*45*31.1~
AMT*B6*77.76~
SVC*HC>96361*57.46*28.73**5~
DTM*472*20180616~
CAS*CO*45*28.73~
AMT*B6*57.46~
CLP*PAT00020038*1*228*114*2.7*HM*CLM0000000258*13~
NM1*QC*1*TEA*YESENIA****MI*MEM000000116~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181008~
DTM*233*20181012~
AMT*AU*228~
SVC*HC>81003*77*38.5**1~
DTM*472*20181008~
CAS*CO*45*38.5~
AMT*B6*77~
SVC*HC>81003*51*25.5**1~
DTM*472*20181009~
CAS*CO*45*25.5~
AMT*B6*51~
SVC*HC>81003*46*23**1~
DTM*472*20181010~
CAS*CO*45*23~
AMT*B6*46~
SVC*HC>81003*27*13.5**1~
DTM*472*20181011~
CAS*PR*2*2.7~
CAS*CO*45*10.8~
AMT*B6*27~
SVC*HC>81003*27*13.5**1~
DTM*472*20181012~
CAS*CO*45*13.5~
AMT*B6*27~
CLP*PAT00021844*1*502*251*29.5*HM*CLM0000000259*13~
NM1*QC*1*TEA*YESENIA****MI*MEM000000116~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180608~
DTM*233*20180610~
AMT*AU*502~
SVC*HC>87220*270*135**1~
DTM*472*20180608~
CAS*PR*1*27**3*2.5~
CAS*CO*45*105.5~
AMT*B6*270~
SVC*HC>87220>25*209*104.5**1~
DTM*472*20180609~
CAS*CO*45*104.5~
AMT*B6*209~
SVC*HC>87220*23*11.5**1~
DTM*472*20180610~
CAS*CO*45*11.5~
AMT*B6*23~
CLP*PAT00025439*1*475*237.5*20*HM*CLM0000000304*13~
NM1*QC*1*MAIZE*MONICA****MI*MEM000000055~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180524~
DTM*233*20180526~
AMT*AU*475~
SVC*HC>87798*175*87.5**1~
DTM*472*20180524~
CAS*PR*1*17.5~
CAS*CO*45*70~
AMT*B6*175~
SVC*HC>87220*175*87.5**1~
DTM*472*20180525~
CAS*PR*3*2.5~
CAS*CO*45*85~
AMT*B6*175~
SVC*HC>87798*125*62.5**1~
DTM*472*20180526~
CAS*CO*45*62.5~
AMT*B6*125~
CLP*PAT00028864*1*172*86*2.5*HM*CLM0000000305*13~
NM1*QC*1*MAIZE*MONICA****MI*MEM000000055~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180122~
DTM*233*20180124~
AMT*AU*172~
SVC*HC>J1170*42*21**1~
DTM*472*20180122~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>J1170*105*52.5**1~
DTM*472*20180123~
CAS*CO*45*52.5~
AMT*B6*105~
SVC*HC>J1170*25*12.5**1~
DTM*472*20180124~
CAS*PR*2*2.5~
CAS*CO*45*10~
AMT*B6*25~
CLP*PAT00047916*1*36*18**HM*CLM0000000310*13~
NM1*QC*1*TEA*GERMAN****MI*MEM000000114~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180522~
DTM*233*20180522~
AMT*AU*36~
SVC*HC>62270>26*36*18**1~
DTM*472*20180522~
CAS*CO*45*18~
AMT*B6*36~
CLP*PAT00051936*1*130*65*12.5*HM*CLM0000000311*13~
NM1*QC*1*TEA*GERMAN****MI*MEM000000114~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180120~
DTM*233*20180121~
AMT*AU*130~
SVC*HC>36415*80*40**1~
DTM*472*20180120~
CAS*CO*45*40~
AMT*B6*80~
SVC*HC>36415>59*50*25**1~
DTM*472*20180121~
CAS*PR*1*5**2*5**3*2.5~
CAS*CO*45*12.5~
AMT*B6*50~
CLP*PAT00030542*1*162*81*16.2*HM*CLM0000000320*13~
NM1*QC*1*DUMPLING*TIFFANY****MI*MEM000000024~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180117~
DTM*233*20180118~
AMT*AU*162~
SVC*HC>86308*81*40.5**1~
DTM*472*20180117~
CAS*PR*1*8.1~
CAS*CO*45*32.4~
AMT*B6*81~
SVC*HC>80048*81*40.5**1~
DTM*472*20180118~
CAS*PR*2*8.1~
CAS*CO*45*32.4~
AMT*B6*81~
CLP*PAT00031363*1*780*390**HM*CLM0000000321*13~
NM1*QC*1*DUMPLING*TIFFANY****MI*MEM000000024~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180917~
DTM*233*20180920~
AMT*AU*780~
SVC*HC>76801*150*75**1~
DTM*472*20180917~
CAS*CO*45*75~
AMT*B6*150~
SVC*HC>76801*420*210**1~
DTM*472*20180918~
CAS*CO*45*210~
AMT*B6*420~
SVC*HC>76801*120*60**1~
DTM*472*20180919~
CAS*CO*45*60~
AMT*B6*120~
SVC*HC>76801*90*45**1~
DTM*472*20180920~
CAS*CO*45*45~
AMT*B6*90~
CLP*PAT00036345*1*868*434*12.5*HM*CLM0000000322*13~
NM1*QC*1*TEA*MATTHEW****MI*MEM000000115~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180518~
DTM*233*20180524~
AMT*AU*868~
SVC*HC>86705*24*12**1~
DTM*472*20180518~
CAS*CO*45*12~
AMT*B6*24~
SVC*HC>86705*100*50**1~
DTM*472*20180519~
CAS*PR*2*10**3*2.5~
CAS*CO*104*25**45*12.5~
AMT*B6*100~
SVC*HC>86705*187*93.5**1~
DTM*472*20180520~
CAS*CO*45*93.5~
AMT*B6*187~
SVC*HC>86705*188*94**1~
DTM*472*20180521~
CAS*CO*45*94~
AMT*B6*188~
SVC*HC>86705*30*15**1~
DTM*472*20180522~
CAS*CO*45*15~
AMT*B6*30~
SVC*HC>86705*162*81**1~
DTM*472*20180523~
CAS*CO*45*81~
AMT*B6*162~
SVC*HC>86705*177*88.5**1~
DTM*472*20180524~
CAS*CO*45*88.5~
AMT*B6*177~
CLP*PAT00037939*1*113*56.5*11.3*HM*CLM0000000323*13~
NM1*QC*1*TEA*MATTHEW****MI*MEM000000115~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180116~
DTM*233*20180116~
AMT*AU*113~
SVC*HC>Q9967*113*56.5**1~
DTM*472*20180116~
CAS*PR*2*11.3~
CAS*CO*45*45.2~
AMT*B6*113~
CLP*PAT00030093*1*211*105.5**HM*CLM0000000330*13~
NM1*QC*1*DUMPLING*SANDRA****MI*MEM000000023~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180914~
DTM*233*20180916~
AMT*AU*211~
SVC*HC>87591>25*81*40.5**1~
DTM*472*20180914~
CAS*CO*104*25**45*15.5~
AMT*B6*81~
SVC*HC>87491>51>59*75*37.5**1~
DTM*472*20180915~
CAS*CO*45*37.5~
AMT*B6*75~
SVC*HC>87591*55*27.5**1~
DTM*472*20180916~
CAS*CO*45*27.5~
AMT*B6*55~
CLP*PAT00030483*1*196*98*13.7*HM*CLM0000000331*13~
NM1*QC*1*DUMPLING*SANDRA****MI*MEM000000023~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180515~
DTM*233*20180518~
AMT*AU*196~
SVC*HC>90853*42*21**7~
DTM*472*20180515~
CAS*PR*2*4.2**3*2.5~
CAS*CO*45*14.3~
AMT*B6*42~
SVC*HC>90853*42*21**7~
DTM*472*20180516~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>90853*42*21**7~
DTM*472*20180517~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>90853*70*35**7~
DTM*472*20180518~
CAS*PR*1*7~
CAS*CO*45*28~
AMT*B6*70~
CLP*PAT00046994*1*188*94**HM*CLM0000000334*13~
NM1*QC*1*PEAS*SONIA****MI*MEM000000078~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180514~
DTM*233*20180514~
AMT*AU*188~
SVC*HC>96360*188*94**1~
DTM*472*20180514~
CAS*CO*45*94~
AMT*B6*188~
CLP*PAT00049552*1*1133.46*566.73*38.3*HM*CLM0000000335*13~
NM1*QC*1*PEAS*SONIA****MI*MEM000000078~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180112~
DTM*233*20180115~
AMT*AU*1133.46~
SVC*HC>87591>25*111.12*55.56**1~
DTM*472*20180112~
CAS*CO*45*55.56~
AMT*B6*111.12~
SVC*HC>87491>51*164.98*82.49**1~
DTM*472*20180113~
CAS*CO*45*82.49~
AMT*B6*164.98~
SVC*HC>87591>51>59*383*191.5**1~
DTM*472*20180114~
CAS*PR*2*38.3~
CAS*CO*45*153.2~
AMT*B6*383~
SVC*HC>87491>59*474.36*237.18**1~
DTM*472*20180115~
CAS*CO*45*237.18~
AMT*B6*474.36~
SE*728*100000001~
ST*835*100000002~
BPR*I*12867.8*C*CHK************20191116~
TRN*1*CHK00001*150001009 ~
N1*PR*BUY 1 GET 1 FREE HEALTHCARE~
N3*300 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*2U*150001009~
PER*BL*TECH CONTACT*TE*4155550002~
N1*PE*LOWEST BIDDER HMO*XX*1234568917~
N3*400 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*TJ*150001342~
LX*1~
CLP*PAT0000000*1*260*130**HM*CLM0000000001*13~
NM1*QC*1*BACON*SUSAN****MI*SUB000000037~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180902~
DTM*233*20180903~
AMT*AU*260~
SVC*HC>86900*211*105.5**1~
DTM*472*20180902~
CAS*CO*45*105.5~
AMT*B6*211~
SVC*HC>86900*49*24.5**1~
DTM*472*20180903~
CAS*CO*45*24.5~
AMT*B6*49~
CLP*PAT00023114*1*93.32*46.66*3.37*HM*CLM0000000012*13~
NM1*QC*1*BURGER*DEVIN****MI*SUB000000011~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181229~
DTM*233*20190109~
AMT*AU*93.32~
SVC*HC>73610*3*1.5**1~
DTM*472*20181229~
CAS*PR*1*.3~
CAS*CO*45*1.2~
AMT*B6*3~
SVC*HC>73610*14.24*7.12**1~
DTM*472*20181230~
CAS*CO*45*7.12~
AMT*B6*14.24~
SVC*HC>73610*4.26*2.13**1~
DTM*472*20181231~
CAS*PR*2*.43~
CAS*CO*45*1.7~
AMT*B6*4.26~
SVC*HC>73610*6.76*3.38**1~
DTM*472*20190101~
CAS*CO*45*3.38~
AMT*B6*6.76~
SVC*HC>73610*6.98*3.49**1~
DTM*472*20190102~
CAS*CO*45*3.49~
AMT*B6*6.98~
SVC*HC>73610*9.7*4.85**1~
DTM*472*20190103~
CAS*CO*45*4.85~
AMT*B6*9.7~
SVC*HC>73610*16.94*8.47**1~
DTM*472*20190104~
CAS*PR*3*2.5~
CAS*CO*45*5.97~
AMT*B6*16.94~
SVC*HC>73610*4.94*2.47**1~
DTM*472*20190105~
CAS*CO*45*2.47~
AMT*B6*4.94~
SVC*HC>73610*10.48*5.24**1~
DTM*472*20190106~
CAS*PR*2*.14~
CAS*CO*104*3.13**45*1.97~
AMT*B6*10.48~
SVC*HC>73610*5.4*2.7**1~
DTM*472*20190107~
CAS*CO*45*2.7~
AMT*B6*5.4~
SVC*HC>73610*3.64*1.82**1~
DTM*472*20190108~
CAS*CO*45*1.82~
AMT*B6*3.64~
SVC*HC>73610*6.98*3.49**1~
DTM*472*20190109~
CAS*CO*45*3.49~
AMT*B6*6.98~
CLP*PAT00008571*1*1180*590*37*HM*CLM0000000013*13~
NM1*QC*1*BURGER*DEVIN****MI*SUB000000011~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180829~
DTM*233*20180907~
AMT*AU*1180~
SVC*HC>99211*30*15**1~
DTM*472*20180829~
CAS*CO*45*15~
AMT*B6*30~
SVC*HC>99211*200*100**1~
DTM*472*20180830~
CAS*CO*45*100~
AMT*B6*200~
SVC*HC>99211*10*5**1~
DTM*472*20180831~
CAS*PR*2*1**3*2.5~
CAS*CO*45*1.5~
AMT*B6*10~
SVC*HC>99211*25*12.5**1~
DTM*472*20180901~
CAS*CO*45*12.5~
AMT*B6*25~
SVC*HC>99211*325*162.5**1~
DTM*472*20180902~
CAS*CO*45*162.5~
AMT*B6*325~
SVC*HC>99211*325*162.5**1~
DTM*472*20180903~
CAS*PR*1*32.5~
CAS*CO*45*130~
AMT*B6*325~
SVC*HC>99211*30*15**1~
DTM*472*20180904~
CAS*CO*45*15~
AMT*B6*30~
SVC*HC>99211*200*100**1~
DTM*472*20180905~
CAS*CO*45*100~
AMT*B6*200~
SVC*HC>99211*10*5**1~
DTM*472*20180906~
CAS*PR*2*1~
CAS*CO*45*4~
AMT*B6*10~
SVC*HC>99211*25*12.5**1~
DTM*472*20180907~
CAS*CO*45*12.5~
AMT*B6*25~
CLP*PAT00036662*1*170*85**HM*CLM0000000024*13~
NM1*QC*1*CHOCOLATE*CLAUDIA****MI*SUB000000005~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181225~
DTM*233*20181225~
AMT*AU*170~
SVC*HC>83036*170*85**1~
DTM*472*20181225~
CAS*CO*45*85~
AMT*B6*170~
CLP*PAT00056001*1*187*93.5**HM*CLM0000000025*13~
NM1*QC*1*CHOCOLATE*CLAUDIA****MI*SUB000000005~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180825~
DTM*233*20180825~
AMT*AU*187~
SVC*HC>92134*187*93.5**1~
DTM*472*20180825~
CAS*CO*45*93.5~
AMT*B6*187~
CLP*PAT00060845*1*1222*611**HM*CLM0000000036*13~
NM1*QC*1*EGG*KRIS****MI*SUB000000009~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181221~
DTM*233*20181222~
AMT*AU*1222~
SVC*HC>81002*994*497**1~
DTM*472*20181221~
CAS*CO*45*497~
AMT*B6*994~
SVC*HC>81002>51*228*114**1~
DTM*472*20181222~
CAS*CO*45*114~
AMT*B6*228~
CLP*PAT00048105*1*12*6*2.4*HM*CLM0000000037*13~
NM1*QC*1*EGG*KRIS****MI*SUB000000009~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180821~
DTM*233*20180821~
AMT*AU*12~
SVC*HC>L3908*12*6**1~
DTM*472*20180821~
CAS*PR*1*1.2**2*1.2~
CAS*CO*45*3.6~
AMT*B6*12~
CLP*PAT00001503*1*791*395.5**HM*CLM0000000048*13~
NM1*QC*1*HASHBROWNS*ZACHARY****MI*SUB000000003~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181217~
DTM*233*20181218~
AMT*AU*791~
SVC*HC>73610*293*146.5**1~
DTM*472*20181217~
CAS*CO*104*25**45*121.5~
AMT*B6*293~
SVC*HC>99283*498*249**1~
DTM*472*20181218~
CAS*CO*45*249~
AMT*B6*498~
CLP*PAT00034087*1*37*18.5**HM*CLM0000000049*13~
NM1*QC*1*HASHBROWNS*ZACHARY****MI*SUB000000003~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180817~
DTM*233*20180817~
AMT*AU*37~
SVC*HC>80061>26*37*18.5**1~
DTM*472*20180817~
CAS*CO*45*18.5~
AMT*B6*37~
CLP*PAT00040239*1*680*340**HM*CLM0000000060*13~
NM1*QC*1*MATCHA*LEYLA****MI*SUB000000087~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181213~
DTM*233*20181216~
AMT*AU*680~
SVC*HC>86880*160*80**1~
DTM*472*20181213~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>86880*160*80**1~
DTM*472*20181214~
CAS*CO*104*25**45*55~
AMT*B6*160~
SVC*HC>81001>26*200*100**1~
DTM*472*20181215~
CAS*CO*45*100~
AMT*B6*200~
SVC*HC>86880*160*80**1~
DTM*472*20181216~
CAS*CO*45*80~
AMT*B6*160~
CLP*PAT00032502*1*145*72.5*6.1*HM*CLM0000000061*13~
NM1*QC*1*MATCHA*LEYLA****MI*SUB000000087~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180813~
DTM*233*20180814~
AMT*AU*145~
SVC*HC>64447>26>59*36*18**1~
DTM*472*20180813~
CAS*PR*2*3.6**3*2.5~
CAS*CO*45*11.9~
AMT*B6*36~
SVC*HC>64447>26*109*54.5**1~
DTM*472*20180814~
CAS*CO*45*54.5~
AMT*B6*109~
CLP*PAT00054388*1*73*36.5**HM*CLM0000000072*13~
NM1*QC*1*PICKLES*YESENIA****MI*SUB000000027~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181209~
DTM*233*20181210~
AMT*AU*73~
SVC*HC>87591*35*17.5**1~
DTM*472*20181209~
CAS*CO*45*17.5~
AMT*B6*35~
SVC*HC>87591*38*19**1~
DTM*472*20181210~
CAS*CO*45*19~
AMT*B6*38~
CLP*PAT00007379*1*209*104.5*23.4*HM*CLM0000000073*13~
NM1*QC*1*PICKLES*YESENIA****MI*SUB000000027~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180809~
DTM*233*20180809~
AMT*AU*209~
SVC*HC>83520*209*104.5**1~
DTM*472*20180809~
CAS*PR*2*20.9**3*2.5~
CAS*CO*45*81.1~
AMT*B6*209~
CLP*PAT00029033*1*230*115**HM*CLM0000000084*13~
NM1*QC*1*SANDWICH*NELSON****MI*SUB000000019~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181205~
DTM*233*20181206~
AMT*AU*230~
SVC*HC>87210*222*111**1~
DTM*472*20181205~
CAS*CO*45*111~
AMT*B6*222~
SVC*HC>87210*8*4**1~
DTM*472*20181206~
CAS*CO*45*4~
AMT*B6*8~
CLP*PAT00032832*1*724*362*49.4*HM*CLM0000000085*13~
NM1*QC*1*SANDWICH*NELSON****MI*SUB000000019~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180805~
DTM*233*20180807~
AMT*AU*724~
SVC*HC>T2033>25*222*111**1~
DTM*472*20180805~
CAS*CO*45*111~
AMT*B6*222~
SVC*HC>T2033*494*247**1~
DTM*472*20180806~
CAS*PR*1*49.4~
CAS*CO*45*197.6~
AMT*B6*494~
SVC*HC>T2033*8*4**1~
DTM*472*20180807~
CAS*CO*45*4~
AMT*B6*8~
CLP*PAT00049875*1*41*20.5**HM*CLM0000000096*13~
NM1*QC*1*WHEAT*NELSON****MI*SUB000000017~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181201~
DTM*233*20181201~
AMT*AU*41~
SVC*HC>J2250>26>RT*41*20.5**2~
DTM*472*20181201~
CAS*CO*45*20.5~
AMT*B6*41~
CLP*PAT00023399*1*764*382*19.1*HM*CLM0000000097*13~
NM1*QC*1*WHEAT*NELSON****MI*SUB000000017~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180801~
DTM*233*20180804~
AMT*AU*764~
SVC*HC>J0461*191*95.5**25~
DTM*472*20180801~
CAS*CO*45*95.5~
AMT*B6*191~
SVC*HC>J0461*191*95.5**25~
DTM*472*20180802~
CAS*PR*2*19.1~
CAS*CO*45*76.4~
AMT*B6*191~
SVC*HC>J0461*191*95.5**25~
DTM*472*20180803~
CAS*CO*45*95.5~
AMT*B6*191~
SVC*HC>J0461*191*95.5**25~
DTM*472*20180804~
CAS*CO*45*95.5~
AMT*B6*191~
CLP*PAT00012469*1*1183*591.5*14.9*HM*CLM0000000110*13~
NM1*QC*1*HASHBROWNS*MICHAEL****MI*MEM000000042~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180328~
DTM*233*20180403~
AMT*AU*1183~
SVC*HC>11900*439*219.5**1~
DTM*472*20180328~
CAS*CO*45*219.5~
AMT*B6*439~
SVC*HC>11900*124*62**1~
DTM*472*20180329~
CAS*CO*45*62~
AMT*B6*124~
SVC*HC>11900*124*62**1~
DTM*472*20180330~
CAS*PR*2*12.4**3*2.5~
CAS*CO*45*47.1~
AMT*B6*124~
SVC*HC>11900*124*62**1~
DTM*472*20180331~
CAS*CO*45*62~
AMT*B6*124~
SVC*HC>11900*124*62**1~
DTM*472*20180401~
CAS*CO*45*62~
AMT*B6*124~
SVC*HC>11900*124*62**1~
DTM*472*20180402~
CAS*CO*104*25**45*37~
AMT*B6*124~
SVC*HC>11900*124*62**1~
DTM*472*20180403~
CAS*CO*45*62~
AMT*B6*124~
CLP*PAT00062965*1*582*291**HM*CLM0000000111*13~
NM1*QC*1*HASHBROWNS*MICHAEL****MI*MEM000000042~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181126~
DTM*233*20181126~
AMT*AU*582~
SVC*HC>J7613*582*291**9~
DTM*472*20181126~
CAS*CO*45*291~
AMT*B6*582~
CLP*PAT00060612*1*284*142**HM*CLM0000000114*13~
NM1*QC*1*HASHBROWNS*JORGE****MI*MEM000000041~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181125~
DTM*233*20181126~
AMT*AU*284~
SVC*HC>93005>25*254*127**1~
DTM*472*20181125~
CAS*CO*45*127~
AMT*B6*254~
SVC*HC>93005*30*15**1~
DTM*472*20181126~
CAS*CO*45*15~
AMT*B6*30~
CLP*PAT00028398*1*801*400.5*53.9*HM*CLM0000000115*13~
NM1*QC*1*HASHBROWNS*JORGE****MI*MEM000000041~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180726~
DTM*233*20180729~
AMT*AU*801~
SVC*HC>85610>25*333*166.5**1~
DTM*472*20180726~
CAS*PR*1*33.3~
CAS*CO*45*133.2~
AMT*B6*333~
SVC*HC>78226>LT*206*103**1~
DTM*472*20180727~
CAS*PR*2*20.6~
CAS*CO*45*82.4~
AMT*B6*206~
SVC*HC>85610>RT*206*103**1~
DTM*472*20180728~
CAS*CO*45*103~
AMT*B6*206~
SVC*HC>78226*56*28**1~
DTM*472*20180729~
CAS*CO*45*28~
AMT*B6*56~
CLP*PAT00063630*1*449*224.5*6*HM*CLM0000000138*13~
NM1*QC*1*PICKLES*CARLOS****MI*MEM000000080~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181117~
DTM*233*20181119~
AMT*AU*449~
SVC*HC>73130*388*194**1~
DTM*472*20181117~
CAS*CO*45*194~
AMT*B6*388~
SVC*HC>73130>26*35*17.5**1~
DTM*472*20181118~
CAS*PR*2*3.5**3*2.5~
CAS*CO*45*11.5~
AMT*B6*35~
SVC*HC>73130>26*26*13**1~
DTM*472*20181119~
CAS*CO*45*13~
AMT*B6*26~
CLP*PAT00000169*1*598*299**HM*CLM0000000139*13~
NM1*QC*1*PICKLES*CARLOS****MI*MEM000000080~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180718~
DTM*233*20180718~
AMT*AU*598~
SVC*HC>73630>26*598*299**1~
DTM*472*20180718~
CAS*CO*45*299~
AMT*B6*598~
CLP*PAT00013601*1*634*317*13.8*HM*CLM0000000140*13~
NM1*QC*1*PICKLES*VIRGIL****MI*MEM000000084~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180318~
DTM*233*20180322~
AMT*AU*634~
SVC*HC>82947>25*282*141**1~
DTM*472*20180318~
CAS*CO*45*141~
AMT*B6*282~
SVC*HC>82947*122*61**1~
DTM*472*20180319~
CAS*CO*45*61~
AMT*B6*122~
SVC*HC>82947*92*46**1~
DTM*472*20180320~
CAS*CO*45*46~
AMT*B6*92~
SVC*HC>82947*76*38**1~
DTM*472*20180321~
CAS*PR*2*7.6~
CAS*CO*45*30.4~
AMT*B6*76~
SVC*HC>82947*62*31**1~
DTM*472*20180322~
CAS*PR*1*6.2~
CAS*CO*45*24.8~
AMT*B6*62~
CLP*PAT00016052*1*85*42.5*2.5*HM*CLM0000000141*13~
NM1*QC*1*PICKLES*VIRGIL****MI*MEM000000084~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181116~
DTM*233*20181116~
AMT*AU*85~
SVC*HC>92012*85*42.5**1~
DTM*472*20181116~
CAS*PR*3*2.5~
CAS*CO*45*40~
AMT*B6*85~
CLP*PAT00030252*1*60*30*6*HM*CLM0000000144*13~
NM1*QC*1*MATCHA*MICHELLE****MI*MEM000000059~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181115~
DTM*233*20181115~
AMT*AU*60~
SVC*HC>87081*60*30**1~
DTM*472*20181115~
CAS*PR*2*6~
CAS*CO*45*24~
AMT*B6*60~
CLP*PAT00043623*1*212*106**HM*CLM0000000145*13~
NM1*QC*1*MATCHA*MICHELLE****MI*MEM000000059~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180716~
DTM*233*20180717~
AMT*AU*212~
SVC*HC>87210*36*18**1~
DTM*472*20180716~
CAS*CO*45*18~
AMT*B6*36~
SVC*HC>87210*176*88**1~
DTM*472*20180717~
CAS*CO*45*88~
AMT*B6*176~
CLP*PAT00055572*1*4830*2415*52.5*HM*CLM0000000150*13~
NM1*QC*1*BACON*SAMON****MI*MEM000000003~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181113~
DTM*233*20181115~
AMT*AU*4830~
SVC*HC>83036*1980*990**1~
DTM*472*20181113~
CAS*CO*45*990~
AMT*B6*1980~
SVC*HC>83036*2600*1300**1~
DTM*472*20181114~
CAS*CO*45*1300~
AMT*B6*2600~
SVC*HC>83036*250*125**1~
DTM*472*20181115~
CAS*PR*1*25**2*25**3*2.5~
CAS*CO*45*72.5~
AMT*B6*250~
CLP*PAT00058444*1*153*76.5**HM*CLM0000000151*13~
NM1*QC*1*BACON*SAMON****MI*MEM000000003~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180714~
DTM*233*20180715~
AMT*AU*153~
SVC*HC>90649>26*140*70**1~
DTM*472*20180714~
CAS*CO*45*70~
AMT*B6*140~
SVC*HC>90649>26*13*6.5**1~
DTM*472*20180715~
CAS*CO*45*6.5~
AMT*B6*13~
CLP*PAT00002279*1*328*164**HM*CLM0000000154*13~
NM1*QC*1*PICKLES*MARTA****MI*MEM000000082~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180713~
DTM*233*20180713~
AMT*AU*328~
SVC*HC>87210*328*164**2~
DTM*472*20180713~
CAS*CO*45*164~
AMT*B6*328~
CLP*PAT00008552*1*135*67.5**HM*CLM0000000155*13~
NM1*QC*1*PICKLES*MARTA****MI*MEM000000082~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180313~
DTM*233*20180313~
AMT*AU*135~
SVC*HC>87210*135*67.5**2~
DTM*472*20180313~
CAS*CO*45*67.5~
AMT*B6*135~
CLP*PAT00005969*1*181*90.5*4*HM*CLM0000000174*13~
NM1*QC*1*MATCHA*JOSEPH****MI*MEM000000058~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181105~
DTM*233*20181110~
AMT*AU*181~
SVC*HC>99213*10*5**1~
DTM*472*20181105~
CAS*CO*45*5~
AMT*B6*10~
SVC*HC>99213*20*10**1~
DTM*472*20181106~
CAS*CO*45*10~
AMT*B6*20~
SVC*HC>99213*6*3**1~
DTM*472*20181107~
CAS*CO*45*3~
AMT*B6*6~
SVC*HC>99213*15*7.5**1~
DTM*472*20181108~
CAS*PR*2*1.5**3*2.5~
CAS*CO*45*3.5~
AMT*B6*15~
SVC*HC>99213*10*5**1~
DTM*472*20181109~
CAS*CO*45*5~
AMT*B6*10~
SVC*HC>99213*120*60**1~
DTM*472*20181110~
CAS*CO*45*60~
AMT*B6*120~
CLP*PAT00010465*1*276*138*9.7*HM*CLM0000000175*13~
NM1*QC*1*MATCHA*JOSEPH****MI*MEM000000058~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180706~
DTM*233*20180711~
AMT*AU*276~
SVC*HC>36415*48*24**1~
DTM*472*20180706~
CAS*PR*1*4.8~
CAS*CO*45*19.2~
AMT*B6*48~
SVC*HC>36415>59*45*22.5**1~
DTM*472*20180707~
CAS*CO*45*22.5~
AMT*B6*45~
SVC*HC>36415>59*45*22.5**1~
DTM*472*20180708~
CAS*CO*45*22.5~
AMT*B6*45~
SVC*HC>36415*48*24**1~
DTM*472*20180709~
CAS*PR*2*2.4~
CAS*CO*104*12.5**45*9.1~
AMT*B6*48~
SVC*HC>36415>59*45*22.5**1~
DTM*472*20180710~
CAS*CO*45*22.5~
AMT*B6*45~
SVC*HC>36415>59*45*22.5**1~
DTM*472*20180711~
CAS*PR*3*2.5~
CAS*CO*45*20~
AMT*B6*45~
CLP*PAT00019858*1*279*139.5*27.9*HM*CLM0000000180*13~
NM1*QC*1*PICKLES*DELIA****MI*MEM000000081~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181103~
DTM*233*20181103~
AMT*AU*279~
SVC*HC>99218*279*139.5**1~
DTM*472*20181103~
CAS*PR*2*27.9~
CAS*CO*45*111.6~
AMT*B6*279~
CLP*PAT00025856*1*755*377.5*37.5*HM*CLM0000000181*13~
NM1*QC*1*PICKLES*DELIA****MI*MEM000000081~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180704~
DTM*233*20180709~
AMT*AU*755~
SVC*HC>76815*125*62.5**1~
DTM*472*20180704~
CAS*CO*45*62.5~
AMT*B6*125~
SVC*HC>76815*150*75**1~
DTM*472*20180705~
CAS*PR*1*15~
CAS*CO*45*60~
AMT*B6*150~
SVC*HC>76815*50*25**1~
DTM*472*20180706~
CAS*CO*45*25~
AMT*B6*50~
SVC*HC>76815*180*90**1~
DTM*472*20180707~
CAS*CO*45*90~
AMT*B6*180~
SVC*HC>76815*50*25**1~
DTM*472*20180708~
CAS*CO*45*25~
AMT*B6*50~
SVC*HC>76815*200*100**1~
DTM*472*20180709~
CAS*PR*2*20**3*2.5~
CAS*CO*45*77.5~
AMT*B6*200~
CLP*PAT00052685*1*1059*529.5**HM*CLM0000000220*13~
NM1*QC*1*PICKLES*SUSAN****MI*MEM000000083~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180621~
DTM*233*20180623~
AMT*AU*1059~
SVC*HC>99213>59*105*52.5**1~
DTM*472*20180621~
CAS*CO*45*52.5~
AMT*B6*105~
SVC*HC>99213*685*342.5**1~
DTM*472*20180622~
CAS*CO*45*342.5~
AMT*B6*685~
SVC*HC>99213>59*269*134.5**1~
DTM*472*20180623~
CAS*CO*45*134.5~
AMT*B6*269~
CLP*PAT00058761*1*175*87.5*10.5*HM*CLM0000000221*13~
NM1*QC*1*PICKLES*SUSAN****MI*MEM000000083~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180219~
DTM*233*20180220~
AMT*AU*175~
SVC*HC>96374*80*40**1~
DTM*472*20180219~
CAS*PR*2*8**3*2.5~
CAS*CO*45*29.5~
AMT*B6*80~
SVC*HC>96374*95*47.5**1~
DTM*472*20180220~
CAS*CO*45*47.5~
AMT*B6*95~
CLP*PAT00022773*1*349*174.5*2.5*HM*CLM0000000224*13~
NM1*QC*1*MATCHA*GERMAN****MI*MEM000000057~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180218~
DTM*233*20180220~
AMT*AU*349~
SVC*HC>84466>25*180*90**1~
DTM*472*20180218~
CAS*CO*45*90~
AMT*B6*180~
SVC*HC>84466*45*22.5**1~
DTM*472*20180219~
CAS*PR*3*2.5~
CAS*CO*45*20~
AMT*B6*45~
SVC*HC>84466*124*62**1~
DTM*472*20180220~
CAS*CO*45*62~
AMT*B6*124~
CLP*PAT00023361*1*258*129*.68*HM*CLM0000000225*13~
NM1*QC*1*MATCHA*GERMAN****MI*MEM000000057~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181019~
DTM*233*20181021~
AMT*AU*258~
SVC*HC>99213*61*30.5**1~
DTM*472*20181019~
CAS*CO*45*30.5~
AMT*B6*61~
SVC*HC>99213>25*170*85**1~
DTM*472*20181020~
CAS*CO*45*85~
AMT*B6*170~
SVC*HC>99213*27*13.5**1~
DTM*472*20181021~
CAS*PR*2*.68~
CAS*CO*104*6.25**45*6.57~
AMT*B6*27~
CLP*PAT00038723*1*125*62.5*12.5*HM*CLM0000000230*13~
NM1*QC*1*BACON*MARIO****MI*MEM000000002~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180216~
DTM*233*20180217~
AMT*AU*125~
SVC*HC>99285>59*90*45**1~
DTM*472*20180216~
CAS*PR*2*9~
CAS*CO*45*36~
AMT*B6*90~
SVC*HC>99285*35*17.5**1~
DTM*472*20180217~
CAS*PR*1*3.5~
CAS*CO*45*14~
AMT*B6*35~
CLP*PAT00041871*1*660*330**HM*CLM0000000231*13~
NM1*QC*1*BACON*MARIO****MI*MEM000000002~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181017~
DTM*233*20181017~
AMT*AU*660~
SVC*HC>78226*660*330**9~
DTM*472*20181017~
CAS*CO*45*330~
AMT*B6*660~
CLP*PAT00036161*1*502*251**HM*CLM0000000250*13~
NM1*QC*1*HASHBROWNS*ELISE****MI*MEM000000040~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180611~
DTM*233*20180612~
AMT*AU*502~
SVC*HC>J1170*295*147.5**4~
DTM*472*20180611~
CAS*CO*45*147.5~
AMT*B6*295~
SVC*HC>J1170*207*103.5**4~
DTM*472*20180612~
CAS*CO*104*25**45*78.5~
AMT*B6*207~
CLP*PAT00037690*1*2355*1177.5*26.5*HM*CLM0000000251*13~
NM1*QC*1*HASHBROWNS*ELISE****MI*MEM000000040~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180209~
DTM*233*20180214~
AMT*AU*2355~
SVC*HC>86762>59*600*300**1~
DTM*472*20180209~
CAS*CO*45*300~
AMT*B6*600~
SVC*HC>86850>59*1120*560**1~
DTM*472*20180210~
CAS*CO*45*560~
AMT*B6*1120~
SVC*HC>86762*240*120**1~
DTM*472*20180211~
CAS*PR*2*24~
CAS*CO*45*96~
AMT*B6*240~
SVC*HC>86850*115*57.5**1~
DTM*472*20180212~
CAS*CO*45*57.5~
AMT*B6*115~
SVC*HC>86762*240*120**1~
DTM*472*20180213~
CAS*PR*3*2.5~
CAS*CO*45*117.5~
AMT*B6*240~
SVC*HC>86850*40*20**1~
DTM*472*20180214~
CAS*CO*45*20~
AMT*B6*40~
CLP*PAT00010834*1*88.28*44.14*2.5*HM*CLM0000000296*13~
NM1*QC*1*BACON*CECILIA****MI*MEM000000001~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180125~
DTM*233*20180126~
AMT*AU*88.28~
SVC*HC>87491*44.14*22.07**1~
DTM*472*20180125~
CAS*PR*3*2.5~
CAS*CO*45*19.57~
AMT*B6*44.14~
SVC*HC>87491*44.14*22.07**1~
DTM*472*20180126~
CAS*CO*45*22.07~
AMT*B6*44.14~
CLP*PAT00012104*1*619*309.5*32.8*HM*CLM0000000297*13~
NM1*QC*1*BACON*CECILIA****MI*MEM000000001~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180925~
DTM*233*20180926~
AMT*AU*619~
SVC*HC>88304>25*328*164**1~
DTM*472*20180925~
CAS*PR*2*32.8~
CAS*CO*45*131.2~
AMT*B6*328~
SVC*HC>00790*291*145.5**9~
DTM*472*20180926~
CAS*CO*45*145.5~
AMT*B6*291~
CLP*PAT00013482*1*170*85**HM*CLM0000000314*13~
NM1*QC*1*HASHBROWNS*SERGIO****MI*MEM000000043~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180119~
DTM*233*20180119~
AMT*AU*170~
SVC*HC>81001*170*85**1~
DTM*472*20180119~
CAS*CO*45*85~
AMT*B6*170~
CLP*PAT00014734*1*194*97*7.4*HM*CLM0000000315*13~
NM1*QC*1*HASHBROWNS*SERGIO****MI*MEM000000043~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180919~
DTM*233*20180922~
AMT*AU*194~
SVC*HC>J3010*48*24**2~
DTM*472*20180919~
CAS*CO*45*24~
AMT*B6*48~
SVC*HC>12011>59*49*24.5**1~
DTM*472*20180920~
CAS*PR*2*4.9~
CAS*CO*45*19.6~
AMT*B6*49~
SVC*HC>J3010*48*24**2~
DTM*472*20180921~
CAS*CO*45*24~
AMT*B6*48~
SVC*HC>12011>59*49*24.5**1~
DTM*472*20180922~
CAS*PR*3*2.5~
CAS*CO*45*22~
AMT*B6*49~
CLP*PAT00037830*1*182*91*7*HM*CLM0000000332*13~
NM1*QC*1*MATCHA*CELIA****MI*MEM000000056~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180113~
DTM*233*20180115~
AMT*AU*182~
SVC*HC>87086>59*70*35**1~
DTM*472*20180113~
CAS*CO*45*35~
AMT*B6*70~
SVC*HC>87591*42*21**1~
DTM*472*20180114~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>87086*70*35**1~
DTM*472*20180115~
CAS*PR*2*7~
CAS*CO*45*28~
AMT*B6*70~
CLP*PAT00039920*1*356*178*2.5*HM*CLM0000000333*13~
NM1*QC*1*MATCHA*CELIA****MI*MEM000000056~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180913~
DTM*233*20180914~
AMT*AU*356~
SVC*HC>86703*265*132.5**1~
DTM*472*20180913~
CAS*CO*45*132.5~
AMT*B6*265~
SVC*HC>86703>RT*91*45.5**1~
DTM*472*20180914~
CAS*PR*3*2.5~
CAS*CO*45*43~
AMT*B6*91~
SE*958*100000002~
ST*835*100000003~
BPR*I*21704.81*C*CHK************20191116~
TRN*1*CHK00001*150001675 ~
N1*PR*CARING COSTS EXTRA HMO~
N3*500 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*2U*150001675~
PER*BL*TECH CONTACT*TE*4155550003~
N1*PE*BUY 1 GET 1 FREE HEALTHCARE*XX*1234567885~
N3*300 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*TJ*150001009~
LX*1~
CLP*PAT00019757*1*144*72**HM*CLM0000000002*13~
NM1*QC*1*BARLEY*NELSON****MI*SUB000000054~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180503~
DTM*233*20180503~
AMT*AU*144~
SVC*HC>84403*144*72**1~
DTM*472*20180503~
CAS*CO*45*72~
AMT*B6*144~
CLP*PAT00057330*1*230*115**HM*CLM0000000003*13~
NM1*QC*1*BARLEY*NELSON****MI*SUB000000054~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20190101~
DTM*233*20190101~
AMT*AU*230~
SVC*HC>85027*230*115**1~
DTM*472*20190101~
CAS*CO*45*115~
AMT*B6*230~
CLP*PAT00044250*1*55*27.5*2.5*HM*CLM0000000014*13~
NM1*QC*1*CAKE*MANUEL****MI*SUB000000035~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180429~
DTM*233*20180430~
AMT*AU*55~
SVC*HC>36415*25*12.5**1~
DTM*472*20180429~
CAS*PR*3*2.5~
CAS*CO*45*10~
AMT*B6*25~
SVC*HC>36415*30*15**1~
DTM*472*20180430~
CAS*CO*45*15~
AMT*B6*30~
CLP*PAT00020845*1*90*45**HM*CLM0000000015*22~
NM1*QC*1*CAKE*MANUEL****MI*SUB000000035~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181228~
DTM*233*20181228~
AMT*AU*90~
SVC*HC>97110*90*45**3~
DTM*472*20181228~
CAS*CO*45*45~
AMT*B6*90~
CLP*PAT00001893*1*41*20.5**HM*CLM0000000026*13~
NM1*QC*1*COD*HEIDI****MI*SUB000000146~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180425~
DTM*233*20180425~
AMT*AU*41~
SVC*HC>J0690>26>RT*41*20.5**4~
DTM*472*20180425~
CAS*CO*45*20.5~
AMT*B6*41~
CLP*PAT00053113*1*24.1*12.05**HM*CLM0000000027*13~
NM1*QC*1*COD*HEIDI****MI*SUB000000146~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181224~
DTM*233*20181224~
AMT*AU*24.1~
SVC*HC>36415>26*24.1*12.05**1~
DTM*472*20181224~
CAS*CO*45*12.05~
AMT*B6*24.1~
CLP*PAT00060790*1*112.58*56.29*4.45*HM*CLM0000000038*13~
NM1*QC*1*FILET*SYLVIA****MI*SUB000000028~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180421~
DTM*233*20180501~
AMT*AU*112.58~
SVC*HC>81025*3*1.5**1~
DTM*472*20180421~
CAS*CO*45*1.5~
AMT*B6*3~
SVC*HC>81025*14.24*7.12**1~
DTM*472*20180422~
CAS*PR*3*2.5~
CAS*CO*45*4.62~
AMT*B6*14.24~
SVC*HC>81025*18.06*9.03**1~
DTM*472*20180423~
CAS*CO*104*6.25**45*2.78~
AMT*B6*18.06~
SVC*HC>81025*7.8*3.9**1~
DTM*472*20180424~
CAS*CO*45*3.9~
AMT*B6*7.8~
SVC*HC>81025*39.9*19.95**1~
DTM*472*20180425~
CAS*CO*45*19.95~
AMT*B6*39.9~
SVC*HC>81025*6.98*3.49**1~
DTM*472*20180426~
CAS*PR*2*.7~
CAS*CO*45*2.79~
AMT*B6*6.98~
SVC*HC>81025*8.72*4.36**1~
DTM*472*20180427~
CAS*CO*45*4.36~
AMT*B6*8.72~
SVC*HC>81025*3.2*1.6**1~
DTM*472*20180428~
CAS*CO*45*1.6~
AMT*B6*3.2~
SVC*HC>81025*3.2*1.6**1~
DTM*472*20180429~
CAS*CO*45*1.6~
AMT*B6*3.2~
SVC*HC>81025*4.06*2.03**1~
DTM*472*20180430~
CAS*PR*3*1.25~
CAS*CO*45*.78~
AMT*B6*4.06~
SVC*HC>81025*3.42*1.71**1~
DTM*472*20180501~
CAS*CO*45*1.71~
AMT*B6*3.42~
CLP*PAT00040956*1*132*66*1.2*HM*CLM0000000039*13~
NM1*QC*1*FILET*SYLVIA****MI*SUB000000028~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181220~
DTM*233*20181221~
AMT*AU*132~
SVC*HC>99214*12*6**1~
DTM*472*20181220~
CAS*PR*2*1.2~
CAS*CO*45*4.8~
AMT*B6*12~
SVC*HC>99214*120*60**1~
DTM*472*20181221~
CAS*CO*45*60~
AMT*B6*120~
CLP*PAT00054721*1*950*475*34.5*HM*CLM0000000050*13~
NM1*QC*1*HERRING*CECILIA****MI*SUB000000004~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180417~
DTM*233*20180422~
AMT*AU*950~
SVC*HC>51702>25*160*80**1~
DTM*472*20180417~
CAS*PR*2*16~
CAS*CO*45*64~
AMT*B6*160~
SVC*HC>51702*280*140**1~
DTM*472*20180418~
CAS*CO*45*140~
AMT*B6*280~
SVC*HC>51702*35*17.5**1~
DTM*472*20180419~
CAS*PR*3*2.5~
CAS*CO*45*15~
AMT*B6*35~
SVC*HC>51702>25*160*80**1~
DTM*472*20180420~
CAS*PR*1*16~
CAS*CO*45*64~
AMT*B6*160~
SVC*HC>51702*280*140**1~
DTM*472*20180421~
CAS*CO*45*140~
AMT*B6*280~
SVC*HC>51702*35*17.5**1~
DTM*472*20180422~
CAS*CO*45*17.5~
AMT*B6*35~
CLP*PAT00054580*1*715*357.5*47.5*HM*CLM0000000051*13~
NM1*QC*1*HERRING*CECILIA****MI*SUB000000004~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181216~
DTM*233*20181221~
AMT*AU*715~
SVC*HC>99213*450*225**1~
DTM*472*20181216~
CAS*PR*2*45~
CAS*CO*45*180~
AMT*B6*450~
SVC*HC>99213*35*17.5**1~
DTM*472*20181217~
CAS*CO*45*17.5~
AMT*B6*35~
SVC*HC>99213*62*31**1~
DTM*472*20181218~
CAS*CO*45*31~
AMT*B6*62~
SVC*HC>99213*48*24**1~
DTM*472*20181219~
CAS*CO*45*24~
AMT*B6*48~
SVC*HC>99213*40*20**1~
DTM*472*20181220~
CAS*PR*3*2.5~
CAS*CO*45*17.5~
AMT*B6*40~
SVC*HC>99213*80*40**1~
DTM*472*20181221~
CAS*CO*45*40~
AMT*B6*80~
CLP*PAT00039703*1*1065*532.5**HM*CLM0000000062*13~
NM1*QC*1*MUNSTER*DAVID****MI*SUB000000055~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180413~
DTM*233*20180415~
AMT*AU*1065~
SVC*HC>36415>26*288*144**1~
DTM*472*20180413~
CAS*CO*45*144~
AMT*B6*288~
SVC*HC>36415*173*86.5**1~
DTM*472*20180414~
CAS*CO*45*86.5~
AMT*B6*173~
SVC*HC>36415*604*302**1~
DTM*472*20180415~
CAS*CO*45*302~
AMT*B6*604~
CLP*PAT00038028*1*95*47.5**HM*CLM0000000063*13~
NM1*QC*1*MUNSTER*DAVID****MI*SUB000000055~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181212~
DTM*233*20181212~
AMT*AU*95~
SVC*HC>36415>26*95*47.5**1~
DTM*472*20181212~
CAS*CO*45*47.5~
AMT*B6*95~
CLP*PAT00036780*1*215*107.5**HM*CLM0000000074*13~
NM1*QC*1*PIE*EDDY****MI*SUB000000043~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180409~
DTM*233*20180412~
AMT*AU*215~
SVC*HC>J3010*60*30**1~
DTM*472*20180409~
CAS*CO*45*30~
AMT*B6*60~
SVC*HC>J3010*55*27.5**1~
DTM*472*20180410~
CAS*CO*45*27.5~
AMT*B6*55~
SVC*HC>J3010*40*20**1~
DTM*472*20180411~
CAS*CO*45*20~
AMT*B6*40~
SVC*HC>J3010*60*30**1~
DTM*472*20180412~
CAS*CO*45*30~
AMT*B6*60~
CLP*PAT00010148*1*36*18*3.6*HM*CLM0000000075*13~
NM1*QC*1*PIE*EDDY****MI*SUB000000043~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181208~
DTM*233*20181208~
AMT*AU*36~
SVC*HC>96360>26*36*18**1~
DTM*472*20181208~
CAS*PR*1*3.6~
CAS*CO*45*14.4~
AMT*B6*36~
CLP*PAT00011530*1*302*151*32.7*HM*CLM0000000086*13~
NM1*QC*1*SAUSAGE*ANA****MI*SUB000000016~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180405~
DTM*233*20180405~
AMT*AU*302~
SVC*HC>70450*302*151**1~
DTM*472*20180405~
CAS*PR*2*30.2**3*2.5~
CAS*CO*45*118.3~
AMT*B6*302~
CLP*PAT00002587*1*305*152.5**HM*CLM0000000087*13~
NM1*QC*1*SAUSAGE*ANA****MI*SUB000000016~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181204~
DTM*233*20181208~
AMT*AU*305~
SVC*HC>83721>59*65*32.5**1~
DTM*472*20181204~
CAS*CO*45*32.5~
AMT*B6*65~
SVC*HC>82306*110*55**1~
DTM*472*20181205~
CAS*CO*45*55~
AMT*B6*110~
SVC*HC>83721*80*40**1~
DTM*472*20181206~
CAS*CO*45*40~
AMT*B6*80~
SVC*HC>82306>59*25*12.5**1~
DTM*472*20181207~
CAS*CO*45*12.5~
AMT*B6*25~
SVC*HC>83721*25*12.5**1~
DTM*472*20181208~
CAS*CO*45*12.5~
AMT*B6*25~
CLP*PAT00055293*1*140*70**HM*CLM0000000098*13~
NM1*QC*1*WINE*HONG****MI*SUB000000048~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180401~
DTM*233*20180401~
AMT*AU*140~
SVC*HC>36415*140*70**1~
DTM*472*20180401~
CAS*CO*45*70~
AMT*B6*140~
CLP*PAT00046210*1*125*62.5*6.78*HM*CLM0000000099*13~
NM1*QC*1*WINE*HONG****MI*SUB000000048~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181130~
DTM*233*20181202~
AMT*AU*125~
SVC*HC>99213*35.02*17.51**1~
DTM*472*20181130~
CAS*PR*3*2.5~
CAS*CO*45*15.01~
AMT*B6*35.02~
SVC*HC>99213*47.22*23.61**1~
DTM*472*20181201~
CAS*CO*45*23.61~
AMT*B6*47.22~
SVC*HC>99213*42.76*21.38**1~
DTM*472*20181202~
CAS*PR*2*4.28~
CAS*CO*45*17.1~
AMT*B6*42.76~
CLP*PAT00013262*1*395.84*197.92*10*HM*CLM0000000106*13~
NM1*QC*1*FILET*LEE****MI*MEM000000028~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180729~
DTM*233*20180801~
AMT*AU*395.84~
SVC*HC>36415*200*100**1~
DTM*472*20180729~
CAS*CO*45*100~
AMT*B6*200~
SVC*HC>36415*100*50**1~
DTM*472*20180730~
CAS*PR*2*10~
CAS*CO*45*40~
AMT*B6*100~
SVC*HC>36415*95.82*47.91**1~
DTM*472*20180731~
CAS*CO*45*47.91~
AMT*B6*95.82~
SVC*HC>36415*.02*.01**1~
DTM*472*20180801~
CAS*CO*45*.01~
AMT*B6*.02~
CLP*PAT00065395*1*650*325*2.5*HM*CLM0000000107*13~
NM1*QC*1*FILET*LEE****MI*MEM000000028~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180329~
DTM*233*20180330~
AMT*AU*650~
SVC*HC>84466*275*137.5**1~
DTM*472*20180329~
CAS*CO*45*137.5~
AMT*B6*275~
SVC*HC>84466*375*187.5**1~
DTM*472*20180330~
CAS*PR*3*2.5~
CAS*CO*45*185~
AMT*B6*375~
CLP*PAT00002444*1*745*372.5*47.4*HM*CLM0000000108*13~
NM1*QC*1*WINE*VIRGIL****MI*MEM000000120~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181127~
DTM*233*20181130~
AMT*AU*745~
SVC*HC>83002>25*122*61**1~
DTM*472*20181127~
CAS*CO*45*61~
AMT*B6*122~
SVC*HC>83002>59*237*118.5**1~
DTM*472*20181128~
CAS*PR*1*23.7**2*23.7~
CAS*CO*45*71.1~
AMT*B6*237~
SVC*HC>83002>59*187*93.5**1~
DTM*472*20181129~
CAS*CO*45*93.5~
AMT*B6*187~
SVC*HC>83002*199*99.5**1~
DTM*472*20181130~
CAS*CO*45*99.5~
AMT*B6*199~
CLP*PAT00036241*1*114*57**HM*CLM0000000109*13~
NM1*QC*1*WINE*VIRGIL****MI*MEM000000120~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180728~
DTM*233*20180728~
AMT*AU*114~
SVC*HC>99214*114*57**1~
DTM*472*20180728~
CAS*CO*45*57~
AMT*B6*114~
CLP*PAT00012662*1*145*72.5*2.5*HM*CLM0000000116*13~
NM1*QC*1*FILET*KRISTEN****MI*MEM000000026~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180326~
DTM*233*20180328~
AMT*AU*145~
SVC*HC>J2270*70*35**1~
DTM*472*20180326~
CAS*CO*45*35~
AMT*B6*70~
SVC*HC>J2270*50*25**1~
DTM*472*20180327~
CAS*PR*3*2.5~
CAS*CO*45*22.5~
AMT*B6*50~
SVC*HC>J2270*25*12.5**1~
DTM*472*20180328~
CAS*CO*45*12.5~
AMT*B6*25~
CLP*PAT00007062*1*170*85*17*HM*CLM0000000117*13~
NM1*QC*1*FILET*KRISTEN****MI*MEM000000026~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181124~
DTM*233*20181124~
AMT*AU*170~
SVC*HC>81003*170*85**1~
DTM*472*20181124~
CAS*PR*2*17~
CAS*CO*45*68~
AMT*B6*170~
CLP*PAT00014854*1*363*181.5**HM*CLM0000000120*13~
NM1*QC*1*HERRING*SYLVIA****MI*MEM000000045~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181123~
DTM*233*20181124~
AMT*AU*363~
SVC*HC>J2405*302*151**4~
DTM*472*20181123~
CAS*CO*45*151~
AMT*B6*302~
SVC*HC>J2405*61*30.5**4~
DTM*472*20181124~
CAS*CO*45*30.5~
AMT*B6*61~
CLP*PAT00013030*1*307*153.5*6.3*HM*CLM0000000121*13~
NM1*QC*1*HERRING*SYLVIA****MI*MEM000000045~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180724~
DTM*233*20180727~
AMT*AU*307~
SVC*HC>87798*215*107.5**1~
DTM*472*20180724~
CAS*CO*45*107.5~
AMT*B6*215~
SVC*HC>87491*50*25**1~
DTM*472*20180725~
CAS*PR*1*5~
CAS*CO*45*20~
AMT*B6*50~
SVC*HC>87798*29*14.5**1~
DTM*472*20180726~
CAS*CO*45*14.5~
AMT*B6*29~
SVC*HC>87491*13*6.5**1~
DTM*472*20180727~
CAS*PR*2*1.3~
CAS*CO*45*5.2~
AMT*B6*13~
CLP*PAT00050909*1*1720*860*38*HM*CLM0000000124*13~
NM1*QC*1*SAUSAGE*TIFFANY****MI*MEM000000099~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180723~
DTM*233*20180727~
AMT*AU*1720~
SVC*HC>87220>25*360*180**1~
DTM*472*20180723~
CAS*CO*45*180~
AMT*B6*360~
SVC*HC>87798>25*280*140**1~
DTM*472*20180724~
CAS*CO*45*140~
AMT*B6*280~
SVC*HC>87220*380*190**1~
DTM*472*20180725~
CAS*PR*2*38~
CAS*CO*45*152~
AMT*B6*380~
SVC*HC>87798*380*190**1~
DTM*472*20180726~
CAS*CO*45*190~
AMT*B6*380~
SVC*HC>87220*320*160**1~
DTM*472*20180727~
CAS*CO*45*160~
AMT*B6*320~
CLP*PAT00057458*1*1100*550*2.5*HM*CLM0000000125*22~
NM1*QC*1*SAUSAGE*TIFFANY****MI*MEM000000099~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180323~
DTM*233*20180325~
AMT*AU*1100~
SVC*HC>99211>25*150*75**1~
DTM*472*20180323~
CAS*CO*45*75~
AMT*B6*150~
SVC*HC>99211*800*400**1~
DTM*472*20180324~
CAS*PR*3*2.5~
CAS*CO*45*397.5~
AMT*B6*800~
SVC*HC>99211*150*75**1~
DTM*472*20180325~
CAS*CO*45*75~
AMT*B6*150~
CLP*PAT00015067*1*186.88*93.44*21.19*HM*CLM0000000130*13~
NM1*QC*1*BARLEY*STEVEN****MI*MEM000000007~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180721~
DTM*233*20180721~
AMT*AU*186.88~
SVC*HC>82570*186.88*93.44**1~
DTM*472*20180721~
CAS*PR*2*18.69**3*2.5~
CAS*CO*45*72.25~
AMT*B6*186.88~
CLP*PAT00020489*1*137*68.5**HM*CLM0000000131*13~
NM1*QC*1*BARLEY*STEVEN****MI*MEM000000007~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180321~
DTM*233*20180323~
AMT*AU*137~
SVC*HC>86359*70*35**1~
DTM*472*20180321~
CAS*CO*45*35~
AMT*B6*70~
SVC*HC>86359*42*21**1~
DTM*472*20180322~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>86359*25*12.5**1~
DTM*472*20180323~
CAS*CO*45*12.5~
AMT*B6*25~
CLP*PAT00045841*1*270*135*2.5*HM*CLM0000000132*13~
NM1*QC*1*PIE*WEI****MI*MEM000000087~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181119~
DTM*233*20181122~
AMT*AU*270~
SVC*HC>96366*70*35**4~
DTM*472*20181119~
CAS*CO*45*35~
AMT*B6*70~
SVC*HC>87086*50*25**1~
DTM*472*20181120~
CAS*CO*45*25~
AMT*B6*50~
SVC*HC>96366*25*12.5**4~
DTM*472*20181121~
CAS*PR*2*2.5~
CAS*CO*45*10~
AMT*B6*25~
SVC*HC>87086*125*62.5**1~
DTM*472*20181122~
CAS*CO*45*62.5~
AMT*B6*125~
CLP*PAT00053064*1*185*92.5*2.5*HM*CLM0000000133*13~
NM1*QC*1*PIE*WEI****MI*MEM000000087~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180720~
DTM*233*20180720~
AMT*AU*185~
SVC*HC>87077*185*92.5**1~
DTM*472*20180720~
CAS*PR*3*2.5~
CAS*CO*45*90~
AMT*B6*185~
CLP*PAT00018356*1*509*254.5**HM*CLM0000000142*13~
NM1*QC*1*FILET*LAUREN****MI*MEM000000027~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180717~
DTM*233*20180718~
AMT*AU*509~
SVC*HC>99212*350*175**1~
DTM*472*20180717~
CAS*CO*45*175~
AMT*B6*350~
SVC*HC>99212>25*159*79.5**1~
DTM*472*20180718~
CAS*CO*45*79.5~
AMT*B6*159~
CLP*PAT00022864*1*110*55**HM*CLM0000000143*13~
NM1*QC*1*FILET*LAUREN****MI*MEM000000027~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180317~
DTM*233*20180317~
AMT*AU*110~
SVC*HC>90715*110*55**1~
DTM*472*20180317~
CAS*CO*45*55~
AMT*B6*110~
CLP*PAT00038464*1*590*295**HM*CLM0000000164*13~
NM1*QC*1*MUNSTER*FRANK****MI*MEM000000061~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180310~
DTM*233*20180310~
AMT*AU*590~
SVC*HC>97535*590*295**1~
DTM*472*20180310~
CAS*CO*45*295~
AMT*B6*590~
CLP*PAT00038546*1*384*192**HM*CLM0000000165*13~
NM1*QC*1*MUNSTER*FRANK****MI*MEM000000061~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181108~
DTM*233*20181109~
AMT*AU*384~
SVC*HC>80048*324*162**1~
DTM*472*20181108~
CAS*CO*45*162~
AMT*B6*324~
SVC*HC>80076*60*30**1~
DTM*472*20181109~
CAS*CO*45*30~
AMT*B6*60~
CLP*PAT00042243*1*189*94.5*14*HM*CLM0000000166*13~
NM1*QC*1*BARLEY*LEYLA****MI*MEM000000005~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180709~
DTM*233*20180710~
AMT*AU*189~
SVC*HC>80076*140*70**1~
DTM*472*20180709~
CAS*PR*2*14~
CAS*CO*45*56~
AMT*B6*140~
SVC*HC>80061*49*24.5**1~
DTM*472*20180710~
CAS*CO*45*24.5~
AMT*B6*49~
CLP*PAT00049862*1*415*207.5*13*HM*CLM0000000167*13~
NM1*QC*1*BARLEY*LEYLA****MI*MEM000000005~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180309~
DTM*233*20180311~
AMT*AU*415~
SVC*HC>81025>TC*100*50**1~
DTM*472*20180309~
CAS*PR*3*2.5~
CAS*CO*45*47.5~
AMT*B6*100~
SVC*HC>81025>TC*210*105**1~
DTM*472*20180310~
CAS*CO*104*25**45*80~
AMT*B6*210~
SVC*HC>81025>TC*105*52.5**1~
DTM*472*20180311~
CAS*PR*1*10.5~
CAS*CO*45*42~
AMT*B6*105~
CLP*PAT00061994*1*160*80**HM*CLM0000000172*13~
NM1*QC*1*PIE*SALLY****MI*MEM000000086~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180707~
DTM*233*20180707~
AMT*AU*160~
SVC*HC>86336*160*80**1~
DTM*472*20180707~
CAS*CO*45*80~
AMT*B6*160~
CLP*PAT00064966*1*2365*1182.5**HM*CLM0000000173*13~
NM1*QC*1*PIE*SALLY****MI*MEM000000086~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180307~
DTM*233*20180307~
AMT*AU*2365~
SVC*HC>73130>RT*2365*1182.5**1~
DTM*472*20180307~
CAS*CO*45*1182.5~
AMT*B6*2365~
CLP*PAT00036541*1*90*45*9*HM*CLM0000000184*13~
NM1*QC*1*MUNSTER*VALENTINA****MI*MEM000000064~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180703~
DTM*233*20180703~
AMT*AU*90~
SVC*HC>99211*90*45**1~
DTM*472*20180703~
CAS*PR*2*9~
CAS*CO*45*36~
AMT*B6*90~
CLP*PAT00039160*1*31.64*15.82*2.5*HM*CLM0000000185*13~
NM1*QC*1*MUNSTER*VALENTINA****MI*MEM000000064~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180303~
DTM*233*20180307~
AMT*AU*31.64~
SVC*HC>81025*3*1.5**1~
DTM*472*20180303~
CAS*CO*45*1.5~
AMT*B6*3~
SVC*HC>99285*8.74*4.37**1~
DTM*472*20180304~
CAS*PR*3*2.5~
CAS*CO*45*1.87~
AMT*B6*8.74~
SVC*HC>81025*9.28*4.64**1~
DTM*472*20180305~
CAS*CO*45*4.64~
AMT*B6*9.28~
SVC*HC>99285*3.64*1.82**1~
DTM*472*20180306~
CAS*CO*45*1.82~
AMT*B6*3.64~
SVC*HC>81025*6.98*3.49**1~
DTM*472*20180307~
CAS*CO*45*3.49~
AMT*B6*6.98~
CLP*PAT00053400*1*260*130**HM*CLM0000000188*13~
NM1*QC*1*SAUSAGE*KARLA****MI*MEM000000097~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180302~
DTM*233*20180303~
AMT*AU*260~
SVC*HC>36415*211*105.5**1~
DTM*472*20180302~
CAS*CO*45*105.5~
AMT*B6*211~
SVC*HC>87081*49*24.5**1~
DTM*472*20180303~
CAS*CO*45*24.5~
AMT*B6*49~
CLP*PAT00057969*1*1019.52*509.76*17.32*HM*CLM0000000189*13~
NM1*QC*1*SAUSAGE*KARLA****MI*MEM000000097~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181031~
DTM*233*20181105~
AMT*AU*1019.52~
SVC*HC>81001>25*111.18*55.59**1~
DTM*472*20181031~
CAS*CO*45*55.59~
AMT*B6*111.18~
SVC*HC>81001>RT*276.62*138.31**1~
DTM*472*20181101~
CAS*CO*45*138.31~
AMT*B6*276.62~
SVC*HC>81001>LT*276.62*138.31**1~
DTM*472*20181102~
CAS*CO*45*138.31~
AMT*B6*276.62~
SVC*HC>81001>RT*148.22*74.11**1~
DTM*472*20181103~
CAS*PR*2*14.82**3*2.5~
CAS*CO*104*25**45*31.79~
AMT*B6*148.22~
SVC*HC>81001>LT*148.22*74.11**1~
DTM*472*20181104~
CAS*CO*45*74.11~
AMT*B6*148.22~
SVC*HC>81001*58.66*29.33**1~
DTM*472*20181105~
CAS*CO*45*29.33~
AMT*B6*58.66~
CLP*PAT00003987*1*37*18.5*7.4*HM*CLM0000000192*13~
NM1*QC*1*FILET*VIRGIL****MI*MEM000000029~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181030~
DTM*233*20181030~
AMT*AU*37~
SVC*HC>73130>26*37*18.5**1~
DTM*472*20181030~
CAS*PR*1*3.7**2*3.7~
CAS*CO*45*11.1~
AMT*B6*37~
CLP*PAT00014783*1*176*88*2.5*HM*CLM0000000193*13~
NM1*QC*1*FILET*VIRGIL****MI*MEM000000029~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180630~
DTM*233*20180701~
AMT*AU*176~
SVC*HC>96361*101*50.5**7~
DTM*472*20180630~
CAS*CO*45*50.5~
AMT*B6*101~
SVC*HC>96361>59*75*37.5**7~
DTM*472*20180701~
CAS*PR*3*2.5~
CAS*CO*45*35~
AMT*B6*75~
CLP*PAT00060395*1*100*50**HM*CLM0000000200*13~
NM1*QC*1*WINE*CHARLES****MI*MEM000000117~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180226~
DTM*233*20180226~
AMT*AU*100~
SVC*HC>J3010*100*50**2~
DTM*472*20180226~
CAS*CO*45*50~
AMT*B6*100~
CLP*PAT00063344*1*440*220*6.1*HM*CLM0000000201*13~
NM1*QC*1*WINE*CHARLES****MI*MEM000000117~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181027~
DTM*233*20181030~
AMT*AU*440~
SVC*HC>99283*61*30.5**1~
DTM*472*20181027~
CAS*PR*2*6.1~
CAS*CO*45*24.4~
AMT*B6*61~
SVC*HC>99283>25*254*127**1~
DTM*472*20181028~
CAS*CO*45*127~
AMT*B6*254~
SVC*HC>99283*98*49**1~
DTM*472*20181029~
CAS*CO*45*49~
AMT*B6*98~
SVC*HC>99283*27*13.5**1~
DTM*472*20181030~
CAS*CO*104*12.5**45*1~
AMT*B6*27~
CLP*PAT00003512*1*37*18.5**HM*CLM0000000204*13~
NM1*QC*1*WINE*HARIS****MI*MEM000000118~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181026~
DTM*233*20181026~
AMT*AU*37~
SVC*HC>85025*37*18.5**1~
DTM*472*20181026~
CAS*CO*45*18.5~
AMT*B6*37~
CLP*PAT00003905*1*129*64.5**HM*CLM0000000205*13~
NM1*QC*1*WINE*HARIS****MI*MEM000000118~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180626~
DTM*233*20180626~
AMT*AU*129~
SVC*HC>84466*129*64.5**1~
DTM*472*20180626~
CAS*CO*45*64.5~
AMT*B6*129~
CLP*PAT00009010*1*90*45**HM*CLM0000000208*13~
NM1*QC*1*MUNSTER*LESTER****MI*MEM000000062~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180625~
DTM*233*20180626~
AMT*AU*90~
SVC*HC>86355*75*37.5**1~
DTM*472*20180625~
CAS*CO*45*37.5~
AMT*B6*75~
SVC*HC>86357*15*7.5**1~
DTM*472*20180626~
CAS*CO*45*7.5~
AMT*B6*15~
CLP*PAT00010161*1*171*85.5*.1*HM*CLM0000000209*13~
NM1*QC*1*MUNSTER*LESTER****MI*MEM000000062~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180223~
DTM*233*20180224~
AMT*AU*171~
SVC*HC>81003*170*85**1~
DTM*472*20180223~
CAS*CO*45*85~
AMT*B6*170~
SVC*HC>81003*1*.5**1~
DTM*472*20180224~
CAS*PR*2*.1~
CAS*CO*45*.4~
AMT*B6*1~
CLP*PAT00014451*1*10321.98*5160.99*1026.1*HM*CLM0000000210*13~
NM1*QC*1*BARLEY*DEVIN****MI*MEM000000004~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181024~
DTM*233*20181029~
AMT*AU*10321.98~
SVC*HC>01922*5.2*2.6**9~
DTM*472*20181024~
CAS*CO*45*2.6~
AMT*B6*5.2~
SVC*HC>72146*4.18*2.09**1~
DTM*472*20181025~
CAS*CO*45*2.09~
AMT*B6*4.18~
SVC*HC>01922*5.84*2.92**9~
DTM*472*20181026~
CAS*CO*45*2.92~
AMT*B6*5.84~
SVC*HC>72146*9911.64*4955.82**1~
DTM*472*20181027~
CAS*PR*1*991.17**3*2.5~
CAS*CO*45*3962.15~
AMT*B6*9911.64~
SVC*HC>01922*70.88*35.44**9~
DTM*472*20181028~
CAS*CO*45*35.44~
AMT*B6*70.88~
SVC*HC>72146*324.24*162.12**1~
DTM*472*20181029~
CAS*PR*2*32.43~
CAS*CO*104*25**45*104.69~
AMT*B6*324.24~
CLP*PAT00021944*1*144*72**HM*CLM0000000211*13~
NM1*QC*1*BARLEY*DEVIN****MI*MEM000000004~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180624~
DTM*233*20180625~
AMT*AU*144~
SVC*HC>86705>26*133*66.5**1~
DTM*472*20180624~
CAS*CO*45*66.5~
AMT*B6*133~
SVC*HC>72202>26*11*5.5**1~
DTM*472*20180625~
CAS*CO*45*5.5~
AMT*B6*11~
CLP*PAT00033880*1*50*25**HM*CLM0000000216*13~
NM1*QC*1*FILET*FRANCISCO****MI*MEM000000025~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181022~
DTM*233*20181023~
AMT*AU*50~
SVC*HC>J3010*25*12.5**1~
DTM*472*20181022~
CAS*CO*45*12.5~
AMT*B6*25~
SVC*HC>J3010*25*12.5**1~
DTM*472*20181023~
CAS*CO*45*12.5~
AMT*B6*25~
CLP*PAT00040595*1*444*222*23.4*HM*CLM0000000217*13~
NM1*QC*1*FILET*FRANCISCO****MI*MEM000000025~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180622~
DTM*233*20180625~
AMT*AU*444~
SVC*HC>82306>25*234*117**1~
DTM*472*20180622~
CAS*PR*2*23.4~
CAS*CO*45*93.6~
AMT*B6*234~
SVC*HC>82306*154*77**1~
DTM*472*20180623~
CAS*CO*45*77~
AMT*B6*154~
SVC*HC>82306>26*26*13**1~
DTM*472*20180624~
CAS*CO*45*13~
AMT*B6*26~
SVC*HC>82306*30*15**1~
DTM*472*20180625~
CAS*CO*104*12.5**45*2.5~
AMT*B6*30~
CLP*PAT00061366*1*320*160*2.5*HM*CLM0000000238*13~
NM1*QC*1*SAUSAGE*MARCIA****MI*MEM000000098~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180615~
DTM*233*20180616~
AMT*AU*320~
SVC*HC>84439*180*90**1~
DTM*472*20180615~
CAS*PR*3*2.5~
CAS*CO*45*87.5~
AMT*B6*180~
SVC*HC>84439*140*70**1~
DTM*472*20180616~
CAS*CO*45*70~
AMT*B6*140~
CLP*PAT00064236*1*459.64*229.82*45.97*HM*CLM0000000239*13~
NM1*QC*1*SAUSAGE*MARCIA****MI*MEM000000098~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180213~
DTM*233*20180213~
AMT*AU*459.64~
SVC*HC>84443*459.64*229.82**1~
DTM*472*20180213~
CAS*PR*2*45.97~
CAS*CO*45*183.85~
AMT*B6*459.64~
CLP*PAT00029674*1*47*23.5**HM*CLM0000000248*22~
NM1*QC*1*MUNSTER*EDDY****MI*MEM000000060~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180210~
DTM*233*20180210~
AMT*AU*47~
SVC*HC>99385>26*47*23.5**1~
DTM*472*20180210~
CAS*CO*45*23.5~
AMT*B6*47~
CLP*PAT00031160*1*271*135.5*10.7*HM*CLM0000000249*13~
NM1*QC*1*MUNSTER*EDDY****MI*MEM000000060~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181011~
DTM*233*20181015~
AMT*AU*271~
SVC*HC>99212*100*50**1~
DTM*472*20181011~
CAS*CO*45*50~
AMT*B6*100~
SVC*HC>99212*50*25**1~
DTM*472*20181012~
CAS*PR*1*5~
CAS*CO*45*20~
AMT*B6*50~
SVC*HC>99212*50*25**1~
DTM*472*20181013~
CAS*CO*45*25~
AMT*B6*50~
SVC*HC>99212*32*16**1~
DTM*472*20181014~
CAS*PR*2*3.2**3*2.5~
CAS*CO*45*10.3~
AMT*B6*32~
SVC*HC>99212*39*19.5**1~
DTM*472*20181015~
CAS*CO*45*19.5~
AMT*B6*39~
CLP*PAT00000159*1*435*217.5*30.5*HM*CLM0000000256*22~
NM1*QC*1*BARLEY*OSCAR****MI*MEM000000006~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180609~
DTM*233*20180611~
AMT*AU*435~
SVC*HC>G0381>25*280*140**1~
DTM*472*20180609~
CAS*PR*1*28~
CAS*CO*45*112~
AMT*B6*280~
SVC*HC>90471>LT*145*72.5**1~
DTM*472*20180610~
CAS*PR*3*2.5~
CAS*CO*45*70~
AMT*B6*145~
SVC*HC>G0381*10*5**1~
DTM*472*20180611~
CAS*CO*45*5~
AMT*B6*10~
CLP*PAT00018330*1*2809.36*1404.68*33.2*HM*CLM0000000257*13~
NM1*QC*1*BARLEY*OSCAR****MI*MEM000000006~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180207~
DTM*233*20180215~
AMT*AU*2809.36~
SVC*HC>86003*237*118.5**1~
DTM*472*20180207~
CAS*PR*2*23.7~
CAS*CO*45*94.8~
AMT*B6*237~
SVC*HC>86003*554*277**1~
DTM*472*20180208~
CAS*CO*45*277~
AMT*B6*554~
SVC*HC>86003*115*57.5**1~
DTM*472*20180209~
CAS*CO*45*57.5~
AMT*B6*115~
SVC*HC>86003*612*306**1~
DTM*472*20180210~
CAS*CO*45*306~
AMT*B6*612~
SVC*HC>86003*272*136**1~
DTM*472*20180211~
CAS*CO*45*136~
AMT*B6*272~
SVC*HC>86003*488*244**1~
DTM*472*20180212~
CAS*CO*45*244~
AMT*B6*488~
SVC*HC>86003*70*35**1~
DTM*472*20180213~
CAS*PR*2*7**3*2.5~
CAS*CO*104*25**45*.5~
AMT*B6*70~
SVC*HC>86003*97*48.5**1~
DTM*472*20180214~
CAS*CO*45*48.5~
AMT*B6*97~
SVC*HC>86003*364.36*182.18**1~
DTM*472*20180215~
CAS*CO*45*182.18~
AMT*B6*364.36~
CLP*PAT00049216*1*735*367.5*17.5*HM*CLM0000000268*13~
NM1*QC*1*COD*ZHANG****MI*MEM000000017~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180605~
DTM*233*20180608~
AMT*AU*735~
SVC*HC>71275>25*175*87.5**1~
DTM*472*20180605~
CAS*CO*45*87.5~
AMT*B6*175~
SVC*HC>71275>59*150*75**1~
DTM*472*20180606~
CAS*PR*2*15~
CAS*CO*45*60~
AMT*B6*150~
SVC*HC>71275>59*160*80**1~
DTM*472*20180607~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>71275>59*250*125**1~
DTM*472*20180608~
CAS*PR*3*2.5~
CAS*CO*45*122.5~
AMT*B6*250~
CLP*PAT00050500*1*170*85**HM*CLM0000000269*13~
NM1*QC*1*COD*ZHANG****MI*MEM000000017~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180203~
DTM*233*20180203~
AMT*AU*170~
SVC*HC>87798*170*85**1~
DTM*472*20180203~
CAS*CO*45*85~
AMT*B6*170~
CLP*PAT00058701*1*174*87**HM*CLM0000000274*13~
NM1*QC*1*COD*JOHN****MI*MEM000000015~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180603~
DTM*233*20180603~
AMT*AU*174~
SVC*HC>73620*174*87**1~
DTM*472*20180603~
CAS*CO*45*87~
AMT*B6*174~
CLP*PAT00062454*1*88.28*44.14*4.42*HM*CLM0000000275*13~
NM1*QC*1*COD*JOHN****MI*MEM000000015~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180201~
DTM*233*20180202~
AMT*AU*88.28~
SVC*HC>73600*44.14*22.07**1~
DTM*472*20180201~
CAS*PR*1*2.21**2*2.21~
CAS*CO*104*12.5**45*5.15~
AMT*B6*44.14~
SVC*HC>73600*44.14*22.07**1~
DTM*472*20180202~
CAS*CO*45*22.07~
AMT*B6*44.14~
CLP*PAT00015870*1*585*292.5**HM*CLM0000000278*22~
NM1*QC*1*HERRING*DAWN****MI*MEM000000044~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180131~
DTM*233*20180201~
AMT*AU*585~
SVC*HC>97035*85*42.5**1~
DTM*472*20180131~
CAS*CO*45*42.5~
AMT*B6*85~
SVC*HC>97124*500*250**1~
DTM*472*20180201~
CAS*CO*45*250~
AMT*B6*500~
CLP*PAT00016167*1*162*81**HM*CLM0000000279*13~
NM1*QC*1*HERRING*DAWN****MI*MEM000000044~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181001~
DTM*233*20181002~
AMT*AU*162~
SVC*HC>99213*81*40.5**1~
DTM*472*20181001~
CAS*CO*45*40.5~
AMT*B6*81~
SVC*HC>99213*81*40.5**1~
DTM*472*20181002~
CAS*CO*45*40.5~
AMT*B6*81~
CLP*PAT00035329*1*675*337.5*20*HM*CLM0000000286*13~
NM1*QC*1*SAUSAGE*GEORGE****MI*MEM000000096~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180530~
DTM*233*20180601~
AMT*AU*675~
SVC*HC>86705>25*320*160**1~
DTM*472*20180530~
CAS*CO*45*160~
AMT*B6*320~
SVC*HC>86705*175*87.5**1~
DTM*472*20180531~
CAS*PR*2*17.5**3*2.5~
CAS*CO*45*67.5~
AMT*B6*175~
SVC*HC>86705*180*90**1~
DTM*472*20180601~
CAS*CO*45*90~
AMT*B6*180~
CLP*PAT00047612*1*258*129*6.8*HM*CLM0000000287*13~
NM1*QC*1*SAUSAGE*GEORGE****MI*MEM000000096~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180128~
DTM*233*20180202~
AMT*AU*258~
SVC*HC>86696*89*44.5**1~
DTM*472*20180128~
CAS*CO*45*44.5~
AMT*B6*89~
SVC*HC>86696*56*28**1~
DTM*472*20180129~
CAS*CO*45*28~
AMT*B6*56~
SVC*HC>86696*41*20.5**1~
DTM*472*20180130~
CAS*PR*1*4.1~
CAS*CO*45*16.4~
AMT*B6*41~
SVC*HC>86696*27*13.5**1~
DTM*472*20180131~
CAS*CO*45*13.5~
AMT*B6*27~
SVC*HC>86696*27*13.5**1~
DTM*472*20180201~
CAS*PR*2*2.7~
CAS*CO*45*10.8~
AMT*B6*27~
SVC*HC>86696*18*9**1~
DTM*472*20180202~
CAS*CO*45*9~
AMT*B6*18~
CLP*PAT00051403*1*560*280*2.5*HM*CLM0000000288*22~
NM1*QC*1*PIE*JORGE****MI*MEM000000085~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180928~
DTM*233*20181001~
AMT*AU*560~
SVC*HC>70543*210*105**1~
DTM*472*20180928~
CAS*PR*3*2.5~
CAS*CO*45*102.5~
AMT*B6*210~
SVC*HC>70543*160*80**1~
DTM*472*20180929~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>70543*150*75**1~
DTM*472*20180930~
CAS*CO*45*75~
AMT*B6*150~
SVC*HC>70543*40*20**1~
DTM*472*20181001~
CAS*CO*45*20~
AMT*B6*40~
CLP*PAT00052210*1*524*262*23.1*HM*CLM0000000289*13~
NM1*QC*1*PIE*JORGE****MI*MEM000000085~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180529~
DTM*233*20180530~
AMT*AU*524~
SVC*HC>99214>25*231*115.5**1~
DTM*472*20180529~
CAS*PR*2*23.1~
CAS*CO*104*25**45*67.4~
AMT*B6*231~
SVC*HC>99214*293*146.5**1~
DTM*472*20180530~
CAS*CO*45*146.5~
AMT*B6*293~
CLP*PAT00003754*1*362*181**HM*CLM0000000312*13~
NM1*QC*1*COD*STELLA****MI*MEM000000016~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180920~
DTM*233*20180921~
AMT*AU*362~
SVC*HC>99285>25*208*104**1~
DTM*472*20180920~
CAS*CO*45*104~
AMT*B6*208~
SVC*HC>99285>26*154*77**1~
DTM*472*20180921~
CAS*CO*45*77~
AMT*B6*154~
CLP*PAT00006710*1*85*42.5**HM*CLM0000000313*13~
NM1*QC*1*COD*STELLA****MI*MEM000000016~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180521~
DTM*233*20180521~
AMT*AU*85~
SVC*HC>87086*85*42.5**1~
DTM*472*20180521~
CAS*CO*104*25**45*17.5~
AMT*B6*85~
CLP*PAT00060598*1*263.8*131.9*2.5*HM*CLM0000000336*13~
NM1*QC*1*MUNSTER*PHAN****MI*MEM000000063~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180912~
DTM*233*20180914~
AMT*AU*263.8~
SVC*HC>87253*81.4*40.7**1~
DTM*472*20180912~
CAS*CO*45*40.7~
AMT*B6*81.4~
SVC*HC>81003*11.34*5.67**1~
DTM*472*20180913~
CAS*CO*45*5.67~
AMT*B6*11.34~
SVC*HC>87253*171.06*85.53**1~
DTM*472*20180914~
CAS*PR*3*2.5~
CAS*CO*45*83.03~
AMT*B6*171.06~
CLP*PAT00062180*1*4897*2448.5*111.5*HM*CLM0000000337*13~
NM1*QC*1*MUNSTER*PHAN****MI*MEM000000063~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180513~
DTM*233*20180521~
AMT*AU*4897~
SVC*HC>96360*930*465**1~
DTM*472*20180513~
CAS*CO*45*465~
AMT*B6*930~
SVC*HC>83605>26*460*230**1~
DTM*472*20180514~
CAS*PR*2*46~
CAS*CO*104*25**45*159~
AMT*B6*460~
SVC*HC>96360>26*320*160**1~
DTM*472*20180515~
CAS*CO*45*160~
AMT*B6*320~
SVC*HC>83605>26*400*200**1~
DTM*472*20180516~
CAS*PR*1*40~
CAS*CO*45*160~
AMT*B6*400~
SVC*HC>96360>26*940*470**1~
DTM*472*20180517~
CAS*CO*45*470~
AMT*B6*940~
SVC*HC>83605>26*501*250.5**1~
DTM*472*20180518~
CAS*CO*45*250.5~
AMT*B6*501~
SVC*HC>96360>26*960*480**1~
DTM*472*20180519~
CAS*CO*45*480~
AMT*B6*960~
SVC*HC>83605>26*230*115**1~
DTM*472*20180520~
CAS*PR*2*23**3*2.5~
CAS*CO*45*89.5~
AMT*B6*230~
SVC*HC>96360>26*156*78**1~
DTM*472*20180521~
CAS*CO*45*78~
AMT*B6*156~
SE*1433*100000003~
ST*835*100000004~
BPR*I*20847.61*C*CHK************20191116~
TRN*1*CHK00001*150002008 ~
N1*PR*STITCH-YOU-UP HEALTH~
N3*600 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*2U*150002008~
PER*BL*TECH CONTACT*TE*4155550004~
N1*PE*CARING COSTS EXTRA HMO*XX*1234568925~
N3*500 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*TJ*150001675~
LX*1~
CLP*PAT00024932*1*289*144.5*5*HM*CLM0000000004*13~
NM1*QC*1*BEEF*CECILIA****MI*SUB000000058~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180901~
DTM*233*20180905~
AMT*AU*289~
SVC*HC>87070*180*90**1~
DTM*472*20180901~
CAS*CO*45*90~
AMT*B6*180~
SVC*HC>87070*25*12.5**1~
DTM*472*20180902~
CAS*PR*2*2.5~
CAS*CO*45*10~
AMT*B6*25~
SVC*HC>87070*14*7**1~
DTM*472*20180903~
CAS*CO*45*7~
AMT*B6*14~
SVC*HC>87070*30*15**1~
DTM*472*20180904~
CAS*PR*3*2.5~
CAS*CO*45*12.5~
AMT*B6*30~
SVC*HC>87070*40*20**1~
DTM*472*20180905~
CAS*CO*45*20~
AMT*B6*40~
CLP*PAT00043187*1*5130*2565*12*HM*CLM0000000005*13~
NM1*QC*1*BEEF*CECILIA****MI*SUB000000058~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180502~
DTM*233*20180508~
AMT*AU*5130~
SVC*HC>99285>AA>P3*3040*1520**1~
DTM*472*20180502~
CAS*CO*45*1520~
AMT*B6*3040~
SVC*HC>99285*950*475**1~
DTM*472*20180503~
CAS*CO*45*475~
AMT*B6*950~
SVC*HC>99285>26*95*47.5**1~
DTM*472*20180504~
CAS*PR*2*9.5~
CAS*CO*45*38~
AMT*B6*95~
SVC*HC>99285*285*142.5**1~
DTM*472*20180505~
CAS*CO*45*142.5~
AMT*B6*285~
SVC*HC>99285>26>59*570*285**1~
DTM*472*20180506~
CAS*CO*45*285~
AMT*B6*570~
SVC*HC>99285>26*95*47.5**1~
DTM*472*20180507~
CAS*CO*45*47.5~
AMT*B6*95~
SVC*HC>99285>26*95*47.5**1~
DTM*472*20180508~
CAS*PR*3*2.5~
CAS*CO*45*45~
AMT*B6*95~
CLP*PAT00016201*1*85*42.5**HM*CLM0000000016*13~
NM1*QC*1*CEREAL*MATTHEW****MI*SUB000000064~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180828~
DTM*233*20180828~
AMT*AU*85~
SVC*HC>97110*85*42.5**3~
DTM*472*20180828~
CAS*CO*45*42.5~
AMT*B6*85~
CLP*PAT00064578*1*25*12.5*2.5*HM*CLM0000000017*13~
NM1*QC*1*CEREAL*MATTHEW****MI*SUB000000064~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180428~
DTM*233*20180428~
AMT*AU*25~
SVC*HC>99214>QW*25*12.5**1~
DTM*472*20180428~
CAS*PR*2*2.5~
CAS*CO*45*10~
AMT*B6*25~
CLP*PAT00039725*1*438.2*219.1*2*HM*CLM0000000028*13~
NM1*QC*1*COFFEE*SOLOMAN****MI*SUB000000025~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180824~
DTM*233*20180825~
AMT*AU*438.2~
SVC*HC>12011>25*418.2*209.1**8~
DTM*472*20180824~
CAS*CO*45*209.1~
AMT*B6*418.2~
SVC*HC>97530*20*10**1~
DTM*472*20180825~
CAS*PR*2*2~
CAS*CO*45*8~
AMT*B6*20~
CLP*PAT00053982*1*945*472.5*5.5*HM*CLM0000000029*13~
NM1*QC*1*COFFEE*SOLOMAN****MI*SUB000000025~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180424~
DTM*233*20180429~
AMT*AU*945~
SVC*HC>64708*175*87.5**1~
DTM*472*20180424~
CAS*CO*45*87.5~
AMT*B6*175~
SVC*HC>J2250>RT*250*125**2~
DTM*472*20180425~
CAS*PR*3*2.5~
CAS*CO*45*122.5~
AMT*B6*250~
SVC*HC>64708>LT*250*125**1~
DTM*472*20180426~
CAS*CO*45*125~
AMT*B6*250~
SVC*HC>J2250*150*75**2~
DTM*472*20180427~
CAS*CO*45*75~
AMT*B6*150~
SVC*HC>64708>RT*60*30**1~
DTM*472*20180428~
CAS*CO*45*30~
AMT*B6*60~
SVC*HC>J2250>LT*60*30**2~
DTM*472*20180429~
CAS*PR*2*3~
CAS*CO*104*12.5**45*14.5~
AMT*B6*60~
CLP*PAT00011042*1*253*126.5**HM*CLM0000000040*13~
NM1*QC*1*GRUYERE*WALTER****MI*SUB000000124~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180820~
DTM*233*20180820~
AMT*AU*253~
SVC*HC>78226>26*253*126.5**9~
DTM*472*20180820~
CAS*CO*45*126.5~
AMT*B6*253~
CLP*PAT00029105*1*200*100**HM*CLM0000000041*13~
NM1*QC*1*GRUYERE*WALTER****MI*SUB000000124~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180420~
DTM*233*20180421~
AMT*AU*200~
SVC*HC>85025*40*20**1~
DTM*472*20180420~
CAS*CO*45*20~
AMT*B6*40~
SVC*HC>J2270*160*80**1~
DTM*472*20180421~
CAS*CO*45*80~
AMT*B6*160~
CLP*PAT00058884*1*170*85*10*HM*CLM0000000052*13~
NM1*QC*1*HOAGIE*GARY****MI*SUB000000001~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180816~
DTM*233*20180818~
AMT*AU*170~
SVC*HC>94760*100*50**1~
DTM*472*20180816~
CAS*PR*2*10~
CAS*CO*45*40~
AMT*B6*100~
SVC*HC>94760*30*15**1~
DTM*472*20180817~
CAS*CO*45*15~
AMT*B6*30~
SVC*HC>94760*40*20**1~
DTM*472*20180818~
CAS*CO*45*20~
AMT*B6*40~
CLP*PAT00042894*1*435*217.5*3*HM*CLM0000000053*13~
NM1*QC*1*HOAGIE*GARY****MI*SUB000000001~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180416~
DTM*233*20180420~
AMT*AU*435~
SVC*HC>70450*125*62.5**1~
DTM*472*20180416~
CAS*CO*45*62.5~
AMT*B6*125~
SVC*HC>70450*115*57.5**1~
DTM*472*20180417~
CAS*CO*45*57.5~
AMT*B6*115~
SVC*HC>70450*35*17.5**1~
DTM*472*20180418~
CAS*CO*45*17.5~
AMT*B6*35~
SVC*HC>70450*35*17.5**1~
DTM*472*20180419~
CAS*PR*2*1.75**3*1.25~
CAS*CO*104*12.5**45*2~
AMT*B6*35~
SVC*HC>70450*125*62.5**1~
DTM*472*20180420~
CAS*CO*45*62.5~
AMT*B6*125~
CLP*PAT00032963*1*174.94*87.47*11.77*HM*CLM0000000064*13~
NM1*QC*1*NOODLES*CHARLES****MI*SUB000000083~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180812~
DTM*233*20180814~
AMT*AU*174.94~
SVC*HC>86900*92.7*46.35**1~
DTM*472*20180812~
CAS*PR*2*9.27~
CAS*CO*45*37.08~
AMT*B6*92.7~
SVC*HC>86900*35.02*17.51**1~
DTM*472*20180813~
CAS*CO*45*17.51~
AMT*B6*35.02~
SVC*HC>86900*47.22*23.61**1~
DTM*472*20180814~
CAS*PR*3*2.5~
CAS*CO*45*21.11~
AMT*B6*47.22~
CLP*PAT00035842*1*3732*1866**HM*CLM0000000065*13~
NM1*QC*1*NOODLES*CHARLES****MI*SUB000000083~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180412~
DTM*233*20180414~
AMT*AU*3732~
SVC*HC>85025*20*10**1~
DTM*472*20180412~
CAS*CO*45*10~
AMT*B6*20~
SVC*HC>86592*3500*1750**1~
DTM*472*20180413~
CAS*CO*45*1750~
AMT*B6*3500~
SVC*HC>85025*212*106**1~
DTM*472*20180414~
CAS*CO*45*106~
AMT*B6*212~
CLP*PAT00049262*1*25.5*12.75*2.55*HM*CLM0000000076*13~
NM1*QC*1*PORRIDGE*NELSON****MI*SUB000000128~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180808~
DTM*233*20180808~
AMT*AU*25.5~
SVC*HC>83036*25.5*12.75**1~
DTM*472*20180808~
CAS*PR*2*2.55~
CAS*CO*45*10.2~
AMT*B6*25.5~
CLP*PAT00012581*1*57.76*28.88*2.5*HM*CLM0000000077*13~
NM1*QC*1*PORRIDGE*NELSON****MI*SUB000000128~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180408~
DTM*233*20180409~
AMT*AU*57.76~
SVC*HC>88304*7.5*3.75**1~
DTM*472*20180408~
CAS*CO*45*3.75~
AMT*B6*7.5~
SVC*HC>88304>LR*50.26*25.13**1~
DTM*472*20180409~
CAS*PR*3*2.5~
CAS*CO*45*22.63~
AMT*B6*50.26~
CLP*PAT00037702*1*135*67.5*13.5*HM*CLM0000000088*13~
NM1*QC*1*STEW*EDWIN****MI*SUB000000060~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180804~
DTM*233*20180804~
AMT*AU*135~
SVC*HC>82948*135*67.5**1~
DTM*472*20180804~
CAS*PR*2*13.5~
CAS*CO*45*54~
AMT*B6*135~
CLP*PAT00006853*1*385*192.5*2.5*HM*CLM0000000089*13~
NM1*QC*1*STEW*EDWIN****MI*SUB000000060~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180404~
DTM*233*20180407~
AMT*AU*385~
SVC*HC>87206>25*170*85**1~
DTM*472*20180404~
CAS*CO*45*85~
AMT*B6*170~
SVC*HC>87116>RT*145*72.5**1~
DTM*472*20180405~
CAS*PR*3*2.5~
CAS*CO*45*70~
AMT*B6*145~
SVC*HC>87206*60*30**1~
DTM*472*20180406~
CAS*CO*45*30~
AMT*B6*60~
SVC*HC>87116*10*5**1~
DTM*472*20180407~
CAS*CO*45*5~
AMT*B6*10~
CLP*PAT00031552*1*88*44*2.5*HM*CLM0000000122*13~
NM1*QC*1*BEEF*DELIA****MI*MEM000000009~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180324~
DTM*233*20180325~
AMT*AU*88~
SVC*HC>36415*61*30.5**1~
DTM*472*20180324~
CAS*CO*45*30.5~
AMT*B6*61~
SVC*HC>36415*27*13.5**1~
DTM*472*20180325~
CAS*PR*3*2.5~
CAS*CO*45*11~
AMT*B6*27~
CLP*PAT00012065*1*120*60**HM*CLM0000000123*13~
NM1*QC*1*BEEF*DELIA****MI*MEM000000009~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181122~
DTM*233*20181122~
AMT*AU*120~
SVC*HC>87220>25*120*60**1~
DTM*472*20181122~
CAS*CO*45*60~
AMT*B6*120~
CLP*PAT00003579*1*171*85.5*17.1*HM*CLM0000000126*13~
NM1*QC*1*BEEF*EDWIN****MI*MEM000000010~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181121~
DTM*233*20181121~
AMT*AU*171~
SVC*HC>80048*171*85.5**1~
DTM*472*20181121~
CAS*PR*2*17.1~
CAS*CO*45*68.4~
AMT*B6*171~
CLP*PAT00009960*1*165*82.5**HM*CLM0000000127*13~
NM1*QC*1*BEEF*EDWIN****MI*MEM000000010~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180722~
DTM*233*20180722~
AMT*AU*165~
SVC*HC>36415*165*82.5**1~
DTM*472*20180722~
CAS*CO*45*82.5~
AMT*B6*165~
CLP*PAT00050264*1*53*26.5*.5*HM*CLM0000000128*13~
NM1*QC*1*BEEF*KATERYNA****MI*MEM000000011~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180322~
DTM*233*20180323~
AMT*AU*53~
SVC*HC>99213*33*16.5**1~
DTM*472*20180322~
CAS*CO*45*16.5~
AMT*B6*33~
SVC*HC>99213*20*10**1~
DTM*472*20180323~
CAS*PR*1*.5~
CAS*CO*104*6.25**45*3.25~
AMT*B6*20~
CLP*PAT00023634*1*334*167**HM*CLM0000000129*13~
NM1*QC*1*BEEF*KATERYNA****MI*MEM000000011~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181120~
DTM*233*20181121~
AMT*AU*334~
SVC*HC>94762*124*62**1~
DTM*472*20181120~
CAS*CO*45*62~
AMT*B6*124~
SVC*HC>94762*210*105**1~
DTM*472*20181121~
CAS*CO*45*105~
AMT*B6*210~
CLP*PAT00057854*1*254*127**HM*CLM0000000134*13~
NM1*QC*1*NOODLES*KRISTEN****MI*MEM000000067~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180320~
DTM*233*20180320~
AMT*AU*254~
SVC*HC>76801*254*127**1~
DTM*472*20180320~
CAS*CO*45*127~
AMT*B6*254~
CLP*PAT00055776*1*367*183.5**HM*CLM0000000135*13~
NM1*QC*1*NOODLES*KRISTEN****MI*MEM000000067~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181118~
DTM*233*20181119~
AMT*AU*367~
SVC*HC>87798>25*318*159**1~
DTM*472*20181118~
CAS*CO*45*159~
AMT*B6*318~
SVC*HC>86705*49*24.5**1~
DTM*472*20181119~
CAS*CO*45*24.5~
AMT*B6*49~
CLP*PAT00006363*1*428.02*214.01*30*HM*CLM0000000136*13~
NM1*QC*1*BEEF*CHERYL****MI*MEM000000008~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180719~
DTM*233*20180725~
AMT*AU*428.02~
SVC*HC>86706>25*235*117.5**1~
DTM*472*20180719~
CAS*PR*2*23.5~
CAS*CO*45*94~
AMT*B6*235~
SVC*HC>86706*50*25**1~
DTM*472*20180720~
CAS*CO*45*25~
AMT*B6*50~
SVC*HC>86706*25*12.5**1~
DTM*472*20180721~
CAS*PR*1*2.5~
CAS*CO*45*10~
AMT*B6*25~
SVC*HC>86706*18*9**1~
DTM*472*20180722~
CAS*CO*45*9~
AMT*B6*18~
SVC*HC>86706*60.02*30.01**1~
DTM*472*20180723~
CAS*PR*3*2.5~
CAS*CO*45*27.51~
AMT*B6*60.02~
SVC*HC>86706*10*5**1~
DTM*472*20180724~
CAS*CO*45*5~
AMT*B6*10~
SVC*HC>86706*30*15**1~
DTM*472*20180725~
CAS*PR*2*1.5~
CAS*CO*104*12.5**45*1~
AMT*B6*30~
CLP*PAT00040820*1*431*215.5**HM*CLM0000000137*13~
NM1*QC*1*BEEF*CHERYL****MI*MEM000000008~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180319~
DTM*233*20180322~
AMT*AU*431~
SVC*HC>J1885>26*160*80**4~
DTM*472*20180319~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>J1885>26*180*90**4~
DTM*472*20180320~
CAS*CO*45*90~
AMT*B6*180~
SVC*HC>J1885*55*27.5**4~
DTM*472*20180321~
CAS*CO*45*27.5~
AMT*B6*55~
SVC*HC>J1885*36*18**4~
DTM*472*20180322~
CAS*CO*45*18~
AMT*B6*36~
CLP*PAT00054512*1*71.76*35.88*.75*HM*CLM0000000148*13~
NM1*QC*1*COFFEE*SCOTT****MI*MEM000000021~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180715~
DTM*233*20180717~
AMT*AU*71.76~
SVC*HC>97110*7.5*3.75**2~
DTM*472*20180715~
CAS*PR*2*.75~
CAS*CO*45*3~
AMT*B6*7.5~
SVC*HC>97110*13.5*6.75**2~
DTM*472*20180716~
CAS*CO*45*6.75~
AMT*B6*13.5~
SVC*HC>97110>LR*50.76*25.38**2~
DTM*472*20180717~
CAS*CO*45*25.38~
AMT*B6*50.76~
CLP*PAT00055245*1*75*37.5**HM*CLM0000000149*13~
NM1*QC*1*COFFEE*SCOTT****MI*MEM000000021~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180315~
DTM*233*20180315~
AMT*AU*75~
SVC*HC>84443>TC*75*37.5**1~
DTM*472*20180315~
CAS*CO*45*37.5~
AMT*B6*75~
CLP*PAT00061039*1*500*250**HM*CLM0000000152*13~
NM1*QC*1*PORRIDGE*SAMON****MI*MEM000000090~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180314~
DTM*233*20180314~
AMT*AU*500~
SVC*HC>80076*500*250**1~
DTM*472*20180314~
CAS*CO*45*250~
AMT*B6*500~
CLP*PAT00000208*1*272*136*6*HM*CLM0000000153*13~
NM1*QC*1*PORRIDGE*SAMON****MI*MEM000000090~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181112~
DTM*233*20181116~
AMT*AU*272~
SVC*HC>J2405*145*72.5**4~
DTM*472*20181112~
CAS*CO*45*72.5~
AMT*B6*145~
SVC*HC>96375*42*21**1~
DTM*472*20181113~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>J2405*35*17.5**4~
DTM*472*20181114~
CAS*PR*2*3.5~
CAS*CO*45*14~
AMT*B6*35~
SVC*HC>96375*25*12.5**1~
DTM*472*20181115~
CAS*CO*45*12.5~
AMT*B6*25~
SVC*HC>J2405*25*12.5**4~
DTM*472*20181116~
CAS*PR*3*2.5~
CAS*CO*45*10~
AMT*B6*25~
CLP*PAT00035531*1*65*32.5**HM*CLM0000000162*13~
NM1*QC*1*STEW*RANDOLPH****MI*MEM000000102~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181109~
DTM*233*20181109~
AMT*AU*65~
SVC*HC>84156*65*32.5**1~
DTM*472*20181109~
CAS*CO*45*32.5~
AMT*B6*65~
CLP*PAT00037685*1*85*42.5**HM*CLM0000000163*13~
NM1*QC*1*STEW*RANDOLPH****MI*MEM000000102~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180710~
DTM*233*20180710~
AMT*AU*85~
SVC*HC>93306*85*42.5**1~
DTM*472*20180710~
CAS*CO*45*42.5~
AMT*B6*85~
CLP*PAT00012121*1*36*18*2.5*HM*CLM0000000178*13~
NM1*QC*1*PORRIDGE*SHANNON****MI*MEM000000091~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180705~
DTM*233*20180705~
AMT*AU*36~
SVC*HC>73564>26>RT*36*18**1~
DTM*472*20180705~
CAS*PR*3*2.5~
CAS*CO*45*15.5~
AMT*B6*36~
CLP*PAT00014431*1*164*82**HM*CLM0000000179*13~
NM1*QC*1*PORRIDGE*SHANNON****MI*MEM000000091~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180305~
DTM*233*20180305~
AMT*AU*164~
SVC*HC>80076>Q6*164*82**1~
DTM*472*20180305~
CAS*CO*45*82~
AMT*B6*164~
CLP*PAT00032699*1*310*155**HM*CLM0000000182*13~
NM1*QC*1*GRUYERE*SCOTT****MI*MEM000000032~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180304~
DTM*233*20180305~
AMT*AU*310~
SVC*HC>80164*180*90**1~
DTM*472*20180304~
CAS*CO*45*90~
AMT*B6*180~
SVC*HC>80164>GY*130*65**1~
DTM*472*20180305~
CAS*CO*45*65~
AMT*B6*130~
CLP*PAT00035171*1*260*130**HM*CLM0000000183*13~
NM1*QC*1*GRUYERE*SCOTT****MI*MEM000000032~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181102~
DTM*233*20181104~
AMT*AU*260~
SVC*HC>J2001>Q8*123*61.5**1~
DTM*472*20181102~
CAS*CO*104*25**45*36.5~
AMT*B6*123~
SVC*HC>J2001>59>Q8*79*39.5**1~
DTM*472*20181103~
CAS*CO*45*39.5~
AMT*B6*79~
SVC*HC>J2001>Q8*58*29**1~
DTM*472*20181104~
CAS*CO*45*29~
AMT*B6*58~
CLP*PAT00058776*1*130*65**HM*CLM0000000190*13~
NM1*QC*1*STEW*HEIDI****MI*MEM000000101~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180701~
DTM*233*20180701~
AMT*AU*130~
SVC*HC>J2405>25*130*65**4~
DTM*472*20180701~
CAS*CO*45*65~
AMT*B6*130~
CLP*PAT00065192*1*102*51**HM*CLM0000000191*13~
NM1*QC*1*STEW*HEIDI****MI*MEM000000101~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180301~
DTM*233*20180302~
AMT*AU*102~
SVC*HC>90837*61*30.5**1~
DTM*472*20180301~
CAS*CO*45*30.5~
AMT*B6*61~
SVC*HC>90837*41*20.5**1~
DTM*472*20180302~
CAS*CO*45*20.5~
AMT*B6*41~
CLP*PAT00039067*1*348*174**HM*CLM0000000198*13~
NM1*QC*1*PORRIDGE*ADELA****MI*MEM000000088~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181028~
DTM*233*20181029~
AMT*AU*348~
SVC*HC>81025*174*87**1~
DTM*472*20181028~
CAS*CO*45*87~
AMT*B6*174~
SVC*HC>81025*174*87**1~
DTM*472*20181029~
CAS*CO*45*87~
AMT*B6*174~
CLP*PAT00044536*1*25*12.5*2.5*HM*CLM0000000199*13~
NM1*QC*1*PORRIDGE*ADELA****MI*MEM000000088~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180628~
DTM*233*20180628~
AMT*AU*25~
SVC*HC>81003*25*12.5**1~
DTM*472*20180628~
CAS*PR*3*2.5~
CAS*CO*45*10~
AMT*B6*25~
CLP*PAT00002745*1*44*22**HM*CLM0000000202*13~
NM1*QC*1*GRUYERE*CORINA****MI*MEM000000030~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180627~
DTM*233*20180627~
AMT*AU*44~
SVC*HC>36415>26*44*22**1~
DTM*472*20180627~
CAS*CO*45*22~
AMT*B6*44~
CLP*PAT00002792*1*330*165*26.5*HM*CLM0000000203*13~
NM1*QC*1*GRUYERE*CORINA****MI*MEM000000030~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180225~
DTM*233*20180228~
AMT*AU*330~
SVC*HC>86705*200*100**1~
DTM*472*20180225~
CAS*PR*1*20~
CAS*CO*45*80~
AMT*B6*200~
SVC*HC>86705*40*20**1~
DTM*472*20180226~
CAS*PR*2*4**3*2.5~
CAS*CO*45*13.5~
AMT*B6*40~
SVC*HC>86705*60*30**1~
DTM*472*20180227~
CAS*CO*45*30~
AMT*B6*60~
SVC*HC>86705*30*15**1~
DTM*472*20180228~
CAS*CO*45*15~
AMT*B6*30~
CLP*PAT00044713*1*126*63*2.5*HM*CLM0000000218*13~
NM1*QC*1*NOODLES*FRANCISCA****MI*MEM000000066~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180220~
DTM*233*20180220~
AMT*AU*126~
SVC*HC>81003*126*63**1~
DTM*472*20180220~
CAS*PR*3*2.5~
CAS*CO*45*60.5~
AMT*B6*126~
CLP*PAT00052483*1*652*326*.1*HM*CLM0000000219*13~
NM1*QC*1*NOODLES*FRANCISCA****MI*MEM000000066~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181021~
DTM*233*20181024~
AMT*AU*652~
SVC*HC>76816*582*291**1~
DTM*472*20181021~
CAS*CO*45*291~
AMT*B6*582~
SVC*HC>76816*1*.5**1~
DTM*472*20181022~
CAS*PR*2*.1~
CAS*CO*45*.4~
AMT*B6*1~
SVC*HC>76816>26*35*17.5**1~
DTM*472*20181023~
CAS*CO*45*17.5~
AMT*B6*35~
SVC*HC>76816*34*17**1~
DTM*472*20181024~
CAS*CO*45*17~
AMT*B6*34~
CLP*PAT00013809*1*29.46*14.73*2.95*HM*CLM0000000222*13~
NM1*QC*1*NOODLES*LESTER****MI*MEM000000068~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181020~
DTM*233*20181020~
AMT*AU*29.46~
SVC*HC>96413>90*29.46*14.73**1~
DTM*472*20181020~
CAS*PR*1*2.95~
CAS*CO*45*11.78~
AMT*B6*29.46~
CLP*PAT00019766*1*414.38*207.19*14.95*HM*CLM0000000223*13~
NM1*QC*1*NOODLES*LESTER****MI*MEM000000068~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180620~
DTM*233*20180623~
AMT*AU*414.38~
SVC*HC>85730*80*40**1~
DTM*472*20180620~
CAS*CO*45*40~
AMT*B6*80~
SVC*HC>85025*20*10**1~
DTM*472*20180621~
CAS*CO*45*10~
AMT*B6*20~
SVC*HC>85730*164.88*82.44**1~
DTM*472*20180622~
CAS*CO*45*82.44~
AMT*B6*164.88~
SVC*HC>85025>25*149.5*74.75**1~
DTM*472*20180623~
CAS*PR*2*14.95~
CAS*CO*45*59.8~
AMT*B6*149.5~
CLP*PAT00042556*1*338*169**HM*CLM0000000232*13~
NM1*QC*1*STEW*EMMA****MI*MEM000000100~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180617~
DTM*233*20180617~
AMT*AU*338~
SVC*HC>J0690*338*169**4~
DTM*472*20180617~
CAS*CO*45*169~
AMT*B6*338~
CLP*PAT00044718*1*106.18*53.09*.34*HM*CLM0000000233*13~
NM1*QC*1*STEW*EMMA****MI*MEM000000100~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180215~
DTM*233*20180219~
AMT*AU*106.18~
SVC*HC>87491*102.18*51.09**1~
DTM*472*20180215~
CAS*CO*45*51.09~
AMT*B6*102.18~
SVC*HC>87798*1*.5**1~
DTM*472*20180216~
CAS*CO*45*.5~
AMT*B6*1~
SVC*HC>87491*1*.5**1~
DTM*472*20180217~
CAS*PR*2*.02**3*.32~
CAS*CO*45*.16~
AMT*B6*1~
SVC*HC>87798*1*.5**1~
DTM*472*20180218~
CAS*CO*45*.5~
AMT*B6*1~
SVC*HC>87491*1*.5**1~
DTM*472*20180219~
CAS*CO*45*.5~
AMT*B6*1~
CLP*PAT00052235*1*270*135*22*HM*CLM0000000236*13~
NM1*QC*1*STEW*SCOTT****MI*MEM000000103~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180214~
DTM*233*20180215~
AMT*AU*270~
SVC*HC>73620*160*80**1~
DTM*472*20180214~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>73620*110*55**1~
DTM*472*20180215~
CAS*PR*1*11**2*11~
CAS*CO*45*33~
AMT*B6*110~
CLP*PAT00052439*1*125*62.5**HM*CLM0000000237*13~
NM1*QC*1*STEW*SCOTT****MI*MEM000000103~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181015~
DTM*233*20181017~
AMT*AU*125~
SVC*HC>J1644>26*43*21.5**1~
DTM*472*20181015~
CAS*CO*45*21.5~
AMT*B6*43~
SVC*HC>J1644>26*45*22.5**1~
DTM*472*20181016~
CAS*CO*45*22.5~
AMT*B6*45~
SVC*HC>J1644>26*37*18.5**1~
DTM*472*20181017~
CAS*CO*45*18.5~
AMT*B6*37~
CLP*PAT00032350*1*105*52.5**HM*CLM0000000262*13~
NM1*QC*1*COFFEE*GERTRUDE****MI*MEM000000020~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180607~
DTM*233*20180607~
AMT*AU*105~
SVC*HC>80048*105*52.5**1~
DTM*472*20180607~
CAS*CO*45*52.5~
AMT*B6*105~
CLP*PAT00037282*1*55*27.5**HM*CLM0000000263*13~
NM1*QC*1*COFFEE*GERTRUDE****MI*MEM000000020~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180205~
DTM*233*20180206~
AMT*AU*55~
SVC*HC>96374*25*12.5**1~
DTM*472*20180205~
CAS*CO*104*12.5~
AMT*B6*25~
SVC*HC>96374*30*15**1~
DTM*472*20180206~
CAS*CO*45*15~
AMT*B6*30~
CLP*PAT00040088*1*130*65**HM*CLM0000000264*13~
NM1*QC*1*NOODLES*DEVIN****MI*MEM000000065~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181006~
DTM*233*20181006~
AMT*AU*130~
SVC*HC>36415*130*65**1~
DTM*472*20181006~
CAS*CO*45*65~
AMT*B6*130~
CLP*PAT00040917*1*375*187.5*40*HM*CLM0000000265*13~
NM1*QC*1*NOODLES*DEVIN****MI*MEM000000065~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180606~
DTM*233*20180606~
AMT*AU*375~
SVC*HC>87591*375*187.5**1~
DTM*472*20180606~
CAS*PR*2*37.5**3*2.5~
CAS*CO*45*147.5~
AMT*B6*375~
CLP*PAT00018023*1*15124.02*7562.01*1.84*HM*CLM0000000280*13~
NM1*QC*1*PORRIDGE*WEI****MI*MEM000000092~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180601~
DTM*233*20180606~
AMT*AU*15124.02~
SVC*HC>76942*3160*1580**1~
DTM*472*20180601~
CAS*CO*45*1580~
AMT*B6*3160~
SVC*HC>76942*5.84*2.92**1~
DTM*472*20180602~
CAS*PR*2*.59~
CAS*CO*45*2.33~
AMT*B6*5.84~
SVC*HC>76942*11563.58*5781.79**1~
DTM*472*20180603~
CAS*CO*45*5781.79~
AMT*B6*11563.58~
SVC*HC>76942*2.6*1.3**1~
DTM*472*20180604~
CAS*PR*3*1.25~
CAS*CO*45*.05~
AMT*B6*2.6~
SVC*HC>76942*324.24*162.12**1~
DTM*472*20180605~
CAS*CO*45*162.12~
AMT*B6*324.24~
SVC*HC>76942*67.76*33.88**1~
DTM*472*20180606~
CAS*CO*45*33.88~
AMT*B6*67.76~
CLP*PAT00020798*1*1095*547.5*105.9*HM*CLM0000000281*13~
NM1*QC*1*PORRIDGE*WEI****MI*MEM000000092~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180130~
DTM*233*20180201~
AMT*AU*1095~
SVC*HC>96361*929*464.5**2~
DTM*472*20180130~
CAS*PR*1*92.9~
CAS*CO*45*371.6~
AMT*B6*929~
SVC*HC>85025*130*65**1~
DTM*472*20180131~
CAS*PR*2*13~
CAS*CO*45*52~
AMT*B6*130~
SVC*HC>96361*36*18**2~
DTM*472*20180201~
CAS*CO*45*18~
AMT*B6*36~
CLP*PAT00022020*1*88*44*2.5*HM*CLM0000000282*13~
NM1*QC*1*COFFEE*DAVID****MI*MEM000000018~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180930~
DTM*233*20181002~
AMT*AU*88~
SVC*HC>87491*40*20**1~
DTM*472*20180930~
CAS*CO*45*20~
AMT*B6*40~
SVC*HC>87491*30*15**1~
DTM*472*20181001~
CAS*CO*104*12.5**45*2.5~
AMT*B6*30~
SVC*HC>87491*18*9**1~
DTM*472*20181002~
CAS*PR*3*2.5~
CAS*CO*45*6.5~
AMT*B6*18~
CLP*PAT00026106*1*160*80*7*HM*CLM0000000283*13~
NM1*QC*1*COFFEE*DAVID****MI*MEM000000018~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180531~
DTM*233*20180601~
AMT*AU*160~
SVC*HC>J9040*90*45**2~
DTM*472*20180531~
CAS*CO*45*45~
AMT*B6*90~
SVC*HC>J9040*70*35**2~
DTM*472*20180601~
CAS*PR*2*7~
CAS*CO*45*28~
AMT*B6*70~
CLP*PAT00028628*1*98*49**HM*CLM0000000284*13~
NM1*QC*1*STEW*YESENIA****MI*MEM000000104~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180129~
DTM*233*20180130~
AMT*AU*98~
SVC*HC>J2405*68*34**8~
DTM*472*20180129~
CAS*CO*45*34~
AMT*B6*68~
SVC*HC>J2405*30*15**8~
DTM*472*20180130~
CAS*CO*45*15~
AMT*B6*30~
CLP*PAT00031662*1*55*27.5**HM*CLM0000000285*13~
NM1*QC*1*STEW*YESENIA****MI*MEM000000104~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180929~
DTM*233*20180930~
AMT*AU*55~
SVC*HC>J2405*25*12.5**4~
DTM*472*20180929~
CAS*CO*45*12.5~
AMT*B6*25~
SVC*HC>J2250*30*15**2~
DTM*472*20180930~
CAS*CO*45*15~
AMT*B6*30~
CLP*PAT00012379*1*700*350**HM*CLM0000000298*13~
NM1*QC*1*GRUYERE*MANUEL****MI*MEM000000031~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180526~
DTM*233*20180527~
AMT*AU*700~
SVC*HC>86705>59*350*175**1~
DTM*472*20180526~
CAS*CO*45*175~
AMT*B6*350~
SVC*HC>90471>59*350*175**1~
DTM*472*20180527~
CAS*CO*45*175~
AMT*B6*350~
CLP*PAT00012639*1*279*139.5**HM*CLM0000000299*13~
NM1*QC*1*GRUYERE*MANUEL****MI*MEM000000031~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180124~
DTM*233*20180124~
AMT*AU*279~
SVC*HC>36415*279*139.5**1~
DTM*472*20180124~
CAS*CO*45*139.5~
AMT*B6*279~
CLP*PAT00014858*1*34*17*4*HM*CLM0000000300*13~
NM1*QC*1*COFFEE*ERNESTO****MI*MEM000000019~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180924~
DTM*233*20180925~
AMT*AU*34~
SVC*HC>87070*19*9.5**1~
DTM*472*20180924~
CAS*CO*45*9.5~
AMT*B6*19~
SVC*HC>87070*15*7.5**1~
DTM*472*20180925~
CAS*PR*2*1.5**3*2.5~
CAS*CO*45*3.5~
AMT*B6*15~
CLP*PAT00016502*1*140*70**HM*CLM0000000301*13~
NM1*QC*1*COFFEE*ERNESTO****MI*MEM000000019~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180525~
DTM*233*20180527~
AMT*AU*140~
SVC*HC>80164*85*42.5**1~
DTM*472*20180525~
CAS*CO*45*42.5~
AMT*B6*85~
SVC*HC>36415*25*12.5**1~
DTM*472*20180526~
CAS*CO*45*12.5~
AMT*B6*25~
SVC*HC>80164*30*15**1~
DTM*472*20180527~
CAS*CO*45*15~
AMT*B6*30~
CLP*PAT00020049*1*88*44**HM*CLM0000000302*13~
NM1*QC*1*PORRIDGE*ERICA****MI*MEM000000089~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180123~
DTM*233*20180124~
AMT*AU*88~
SVC*HC>83721*61*30.5**1~
DTM*472*20180123~
CAS*CO*45*30.5~
AMT*B6*61~
SVC*HC>36415*27*13.5**1~
DTM*472*20180124~
CAS*CO*45*13.5~
AMT*B6*27~
CLP*PAT00022110*1*2600*1300*260*HM*CLM0000000303*13~
NM1*QC*1*PORRIDGE*ERICA****MI*MEM000000089~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180923~
DTM*233*20180923~
AMT*AU*2600~
SVC*HC>85027>P4>AA*2600*1300**1~
DTM*472*20180923~
CAS*PR*2*260~
CAS*CO*104*25**45*1015~
AMT*B6*2600~
CLP*PAT00021573*1*725*362.5*13.5*HM*CLM0000000328*13~
NM1*QC*1*NOODLES*MARCIA****MI*MEM000000069~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180516~
DTM*233*20180519~
AMT*AU*725~
SVC*HC>81002*215*107.5**1~
DTM*472*20180516~
CAS*CO*45*107.5~
AMT*B6*215~
SVC*HC>85027>RT*200*100**1~
DTM*472*20180517~
CAS*PR*3*2.5~
CAS*CO*45*97.5~
AMT*B6*200~
SVC*HC>81002>LT*200*100**1~
DTM*472*20180518~
CAS*CO*45*100~
AMT*B6*200~
SVC*HC>85027*110*55**1~
DTM*472*20180519~
CAS*PR*2*11~
CAS*CO*45*44~
AMT*B6*110~
CLP*PAT00023954*1*74*37**HM*CLM0000000329*13~
NM1*QC*1*NOODLES*MARCIA****MI*MEM000000069~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180114~
DTM*233*20180115~
AMT*AU*74~
SVC*HC>84443*56*28**1~
DTM*472*20180114~
CAS*CO*45*28~
AMT*B6*56~
SVC*HC>84443*18*9**1~
DTM*472*20180115~
CAS*CO*45*9~
AMT*B6*18~
SE*1181*100000004~
ST*835*100000005~
BPR*I*14162.01*C*CHK************20191116~
TRN*1*CHK00001*150000343 ~
N1*PR*FLY BY NIGHT HEALTHCARE~
N3*100 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*2U*150000343~
PER*BL*TECH CONTACT*TE*4155550005~
N1*PE*STITCH-YOU-UP HEALTH*XX*1234568933~
N3*600 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*TJ*150002008~
LX*1~
CLP*PAT00027505*1*638*319*63.8*HM*CLM0000000006*13~
NM1*QC*1*BEER*HONG****MI*SUB000000008~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181231~
DTM*233*20190101~
AMT*AU*638~
SVC*HC>77003>26>59*322*161**1~
DTM*472*20181231~
CAS*PR*1*32.2~
CAS*CO*45*128.8~
AMT*B6*322~
SVC*HC>77003>26*316*158**1~
DTM*472*20190101~
CAS*PR*2*31.6~
CAS*CO*45*126.4~
AMT*B6*316~
CLP*PAT00004613*1*44*22**HM*CLM0000000007*13~
NM1*QC*1*BEER*HONG****MI*SUB000000008~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180831~
DTM*233*20180831~
AMT*AU*44~
SVC*HC>94760>26*44*22**1~
DTM*472*20180831~
CAS*CO*45*22~
AMT*B6*44~
CLP*PAT00039715*1*221*110.5**HM*CLM0000000018*13~
NM1*QC*1*CHEESE*SANDY****MI*SUB000000044~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181227~
DTM*233*20181227~
AMT*AU*221~
SVC*HC>86003*221*110.5**1~
DTM*472*20181227~
CAS*CO*45*110.5~
AMT*B6*221~
CLP*PAT00047250*1*582*291**HM*CLM0000000019*13~
NM1*QC*1*CHEESE*SANDY****MI*SUB000000044~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180827~
DTM*233*20180827~
AMT*AU*582~
SVC*HC>36415*582*291**1~
DTM*472*20180827~
CAS*CO*45*291~
AMT*B6*582~
CLP*PAT00050820*1*175*87.5*17.5*HM*CLM0000000030*13~
NM1*QC*1*COOKIE*HENRIETTA****MI*SUB000000337~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181223~
DTM*233*20181223~
AMT*AU*175~
SVC*HC>76816*175*87.5**1~
DTM*472*20181223~
CAS*PR*1*17.5~
CAS*CO*45*70~
AMT*B6*175~
CLP*PAT00020357*1*696*348*2.5*HM*CLM0000000031*13~
NM1*QC*1*COOKIE*HENRIETTA****MI*SUB000000337~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180823~
DTM*233*20180826~
AMT*AU*696~
SVC*HC>87591>26*300*150**1~
DTM*472*20180823~
CAS*CO*45*150~
AMT*B6*300~
SVC*HC>88142>26*129*64.5**1~
DTM*472*20180824~
CAS*CO*45*64.5~
AMT*B6*129~
SVC*HC>87591>26*172*86**1~
DTM*472*20180825~
CAS*PR*3*2.5~
CAS*CO*45*83.5~
AMT*B6*172~
SVC*HC>88142>26*95*47.5**1~
DTM*472*20180826~
CAS*CO*45*47.5~
AMT*B6*95~
CLP*PAT00029418*1*170*85*17*HM*CLM0000000042*13~
NM1*QC*1*GYRO*ELISE****MI*SUB000000039~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181219~
DTM*233*20181219~
AMT*AU*170~
SVC*HC>87210*170*85**2~
DTM*472*20181219~
CAS*PR*1*17~
CAS*CO*45*68~
AMT*B6*170~
CLP*PAT00004412*1*493.3*246.65*13.65*HM*CLM0000000043*13~
NM1*QC*1*GYRO*ELISE****MI*SUB000000039~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180819~
DTM*233*20180909~
AMT*AU*493.3~
SVC*HC>76801>26*52*26**1~
DTM*472*20180819~
CAS*PR*2*5.2**3*2.5~
CAS*CO*45*18.3~
AMT*B6*52~
SVC*HC>76801>26*4*2**1~
DTM*472*20180820~
CAS*CO*45*2~
AMT*B6*4~
SVC*HC>76801>26*40*20**1~
DTM*472*20180821~
CAS*CO*45*20~
AMT*B6*40~
SVC*HC>76801>26*22*11**1~
DTM*472*20180822~
CAS*CO*45*11~
AMT*B6*22~
SVC*HC>76801>26*14.5*7.25**1~
DTM*472*20180823~
CAS*CO*45*7.25~
AMT*B6*14.5~
SVC*HC>76801>26*22.5*11.25**1~
DTM*472*20180824~
CAS*CO*45*11.25~
AMT*B6*22.5~
SVC*HC>76801>26*15.5*7.75**1~
DTM*472*20180825~
CAS*PR*2*.39~
CAS*CO*104*6.25**45*1.11~
AMT*B6*15.5~
SVC*HC>76801>26*45.5*22.75**1~
DTM*472*20180826~
CAS*CO*45*22.75~
AMT*B6*45.5~
SVC*HC>76801>26*8*4**1~
DTM*472*20180827~
CAS*PR*3*2.5~
CAS*CO*45*1.5~
AMT*B6*8~
SVC*HC>76801>26*29*14.5**1~
DTM*472*20180828~
CAS*CO*45*14.5~
AMT*B6*29~
SVC*HC>76801>26*28*14**1~
DTM*472*20180829~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>76801>26*1.76*.88**1~
DTM*472*20180830~
CAS*CO*45*.88~
AMT*B6*1.76~
SVC*HC>76801>26*1.76*.88**1~
DTM*472*20180831~
CAS*PR*2*.18~
CAS*CO*45*.7~
AMT*B6*1.76~
SVC*HC>76801>26*22*11**1~
DTM*472*20180901~
CAS*CO*45*11~
AMT*B6*22~
SVC*HC>76801>26*12.26*6.13**1~
DTM*472*20180902~
CAS*CO*45*6.13~
AMT*B6*12.26~
SVC*HC>76801>26*28*14**1~
DTM*472*20180903~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>76801>26*1.76*.88**1~
DTM*472*20180904~
CAS*PR*1*.05**3*.63~
CAS*CO*45*.2~
AMT*B6*1.76~
SVC*HC>76801>26*1.76*.88**1~
DTM*472*20180905~
CAS*CO*45*.88~
AMT*B6*1.76~
SVC*HC>76801>26*22*11**1~
DTM*472*20180906~
CAS*PR*2*2.2~
CAS*CO*45*8.8~
AMT*B6*22~
SVC*HC>76801>26*71*35.5**1~
DTM*472*20180907~
CAS*CO*45*35.5~
AMT*B6*71~
SVC*HC>76801>26*28*14**1~
DTM*472*20180908~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>76801>26*22*11**1~
DTM*472*20180909~
CAS*CO*45*11~
AMT*B6*22~
CLP*PAT00010482*1*235*117.5*17.5*HM*CLM0000000054*13~
NM1*QC*1*JELLO*FRANCISCA****MI*SUB000000080~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181215~
DTM*233*20181216~
AMT*AU*235~
SVC*HC>82570*175*87.5**1~
DTM*472*20181215~
CAS*PR*1*17.5~
CAS*CO*45*70~
AMT*B6*175~
SVC*HC>82570>RT*60*30**1~
DTM*472*20181216~
CAS*CO*45*30~
AMT*B6*60~
CLP*PAT00036626*1*352*176**HM*CLM0000000055*13~
NM1*QC*1*JELLO*FRANCISCA****MI*SUB000000080~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180815~
DTM*233*20180816~
AMT*AU*352~
SVC*HC>86762*254*127**1~
DTM*472*20180815~
CAS*CO*45*127~
AMT*B6*254~
SVC*HC>86762*98*49**1~
DTM*472*20180816~
CAS*CO*45*49~
AMT*B6*98~
CLP*PAT00019874*1*209*104.5*41.8*HM*CLM0000000066*13~
NM1*QC*1*PASTA*CLAUDIA****MI*SUB000000032~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181211~
DTM*233*20181211~
AMT*AU*209~
SVC*HC>70450*209*104.5**1~
DTM*472*20181211~
CAS*PR*1*20.9**2*20.9~
CAS*CO*45*62.7~
AMT*B6*209~
CLP*PAT00013515*1*104*52**HM*CLM0000000067*13~
NM1*QC*1*PASTA*CLAUDIA****MI*SUB000000032~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180811~
DTM*233*20180812~
AMT*AU*104~
SVC*HC>99203*69*34.5**1~
DTM*472*20180811~
CAS*CO*45*34.5~
AMT*B6*69~
SVC*HC>99203*35*17.5**1~
DTM*472*20180812~
CAS*CO*45*17.5~
AMT*B6*35~
CLP*PAT00037115*1*410*205**HM*CLM0000000078*13~
NM1*QC*1*RAMEN*THOMAS****MI*SUB000000056~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181207~
DTM*233*20181208~
AMT*AU*410~
SVC*HC>99213>25*160*80**1~
DTM*472*20181207~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>99213>59*250*125**1~
DTM*472*20181208~
CAS*CO*45*125~
AMT*B6*250~
CLP*PAT00027391*1*92*46**HM*CLM0000000079*13~
NM1*QC*1*RAMEN*THOMAS****MI*SUB000000056~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180807~
DTM*233*20180807~
AMT*AU*92~
SVC*HC>85025*92*46**1~
DTM*472*20180807~
CAS*CO*45*46~
AMT*B6*92~
CLP*PAT00029098*1*380*190*3*HM*CLM0000000090*13~
NM1*QC*1*STROGANOFF*MATTHEW****MI*SUB000000092~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181203~
DTM*233*20181205~
AMT*AU*380~
SVC*HC>87081>25*300*150**1~
DTM*472*20181203~
CAS*CO*45*150~
AMT*B6*300~
SVC*HC>87081*60*30**1~
DTM*472*20181204~
CAS*PR*2*3~
CAS*CO*104*12.5**45*14.5~
AMT*B6*60~
SVC*HC>87081*20*10**1~
DTM*472*20181205~
CAS*CO*45*10~
AMT*B6*20~
CLP*PAT00001882*1*914*457*28.7*HM*CLM0000000091*13~
NM1*QC*1*STROGANOFF*MATTHEW****MI*SUB000000092~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180803~
DTM*233*20180808~
AMT*AU*914~
SVC*HC>73130*259*129.5**1~
DTM*472*20180803~
CAS*CO*45*129.5~
AMT*B6*259~
SVC*HC>73130*131*65.5**1~
DTM*472*20180804~
CAS*PR*1*13.1~
CAS*CO*45*52.4~
AMT*B6*131~
SVC*HC>73130*131*65.5**1~
DTM*472*20180805~
CAS*PR*3*2.5~
CAS*CO*45*63~
AMT*B6*131~
SVC*HC>73130*131*65.5**1~
DTM*472*20180806~
CAS*CO*45*65.5~
AMT*B6*131~
SVC*HC>73130*131*65.5**1~
DTM*472*20180807~
CAS*PR*2*13.1~
CAS*CO*45*52.4~
AMT*B6*131~
SVC*HC>73130*131*65.5**1~
DTM*472*20180808~
CAS*CO*45*65.5~
AMT*B6*131~
CLP*PAT00014184*1*761.12*380.56*17.41*HM*CLM0000000156*13~
NM1*QC*1*PASTA*NELSON****MI*MEM000000072~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181111~
DTM*233*20181113~
AMT*AU*761.12~
SVC*HC>99203*382.6*191.3**1~
DTM*472*20181111~
CAS*CO*45*191.3~
AMT*B6*382.6~
SVC*HC>J0561*174.1*87.05**12~
DTM*472*20181112~
CAS*PR*2*17.41~
CAS*CO*104*25**45*44.64~
AMT*B6*174.1~
SVC*HC>99203*204.42*102.21**1~
DTM*472*20181113~
CAS*CO*45*102.21~
AMT*B6*204.42~
CLP*PAT00024683*1*292*146**HM*CLM0000000157*13~
NM1*QC*1*PASTA*NELSON****MI*MEM000000072~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180712~
DTM*233*20180713~
AMT*AU*292~
SVC*HC>80048>26*146*73**1~
DTM*472*20180712~
CAS*CO*45*73~
AMT*B6*146~
SVC*HC>80076>26*146*73**1~
DTM*472*20180713~
CAS*CO*45*73~
AMT*B6*146~
CLP*PAT00019099*1*101*50.5**HM*CLM0000000194*13~
NM1*QC*1*STROGANOFF*ELI****MI*MEM000000106~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180228~
DTM*233*20180228~
AMT*AU*101~
SVC*HC>99283*101*50.5**1~
DTM*472*20180228~
CAS*CO*45*50.5~
AMT*B6*101~
CLP*PAT00026252*1*350*175**HM*CLM0000000195*13~
NM1*QC*1*STROGANOFF*ELI****MI*MEM000000106~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181029~
DTM*233*20181030~
AMT*AU*350~
SVC*HC>85025*200*100**1~
DTM*472*20181029~
CAS*CO*45*100~
AMT*B6*200~
SVC*HC>85025*150*75**1~
DTM*472*20181030~
CAS*CO*45*75~
AMT*B6*150~
CLP*PAT00033045*1*816*408*81.6*HM*CLM0000000196*13~
NM1*QC*1*GYRO*DAVID****MI*MEM000000034~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180629~
DTM*233*20180629~
AMT*AU*816~
SVC*HC>86901*816*408**1~
DTM*472*20180629~
CAS*PR*2*81.6~
CAS*CO*45*326.4~
AMT*B6*816~
CLP*PAT00038490*1*345*172.5**HM*CLM0000000197*13~
NM1*QC*1*GYRO*DAVID****MI*MEM000000034~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180227~
DTM*233*20180227~
AMT*AU*345~
SVC*HC>86359*345*172.5**1~
DTM*472*20180227~
CAS*CO*45*172.5~
AMT*B6*345~
CLP*PAT00029431*1*168.5*84.25**HM*CLM0000000214*13~
NM1*QC*1*GYRO*STELLA****MI*MEM000000036~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180623~
DTM*233*20180624~
AMT*AU*168.5~
SVC*HC>87210>25*118.5*59.25**1~
DTM*472*20180623~
CAS*CO*45*59.25~
AMT*B6*118.5~
SVC*HC>81025*50*25**1~
DTM*472*20180624~
CAS*CO*45*25~
AMT*B6*50~
CLP*PAT00029567*1*162*81*12*HM*CLM0000000215*13~
NM1*QC*1*GYRO*STELLA****MI*MEM000000036~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180221~
DTM*233*20180224~
AMT*AU*162~
SVC*HC>85025*70*35**1~
DTM*472*20180221~
CAS*PR*2*7~
CAS*CO*45*28~
AMT*B6*70~
SVC*HC>85025*42*21**1~
DTM*472*20180222~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>85025*25*12.5**1~
DTM*472*20180223~
CAS*PR*3*2.5~
CAS*CO*45*10~
AMT*B6*25~
SVC*HC>85025*25*12.5**1~
DTM*472*20180224~
CAS*PR*1*2.5~
CAS*CO*45*10~
AMT*B6*25~
CLP*PAT00031487*1*490*245*2.5*HM*CLM0000000228*13~
NM1*QC*1*PASTA*RICHARD****MI*MEM000000074~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181018~
DTM*233*20181019~
AMT*AU*490~
SVC*HC>78226*314*157**1~
DTM*472*20181018~
CAS*CO*45*157~
AMT*B6*314~
SVC*HC>82570>25*176*88**1~
DTM*472*20181019~
CAS*PR*3*2.5~
CAS*CO*45*85.5~
AMT*B6*176~
CLP*PAT00033240*1*36*18**HM*CLM0000000229*13~
NM1*QC*1*PASTA*RICHARD****MI*MEM000000074~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180618~
DTM*233*20180618~
AMT*AU*36~
SVC*HC>80076>26*36*18**1~
DTM*472*20180618~
CAS*CO*45*18~
AMT*B6*36~
CLP*PAT00050491*1*241*120.5**HM*CLM0000000234*13~
NM1*QC*1*GYRO*ADELA****MI*MEM000000033~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181016~
DTM*233*20181017~
AMT*AU*241~
SVC*HC>58353>25*166*83**1~
DTM*472*20181016~
CAS*CO*45*83~
AMT*B6*166~
SVC*HC>58353*75*37.5**1~
DTM*472*20181017~
CAS*CO*45*37.5~
AMT*B6*75~
CLP*PAT00051207*1*63.16*31.58*3.93*HM*CLM0000000235*13~
NM1*QC*1*GYRO*ADELA****MI*MEM000000033~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180616~
DTM*233*20180621~
AMT*AU*63.16~
SVC*HC>87206*3*1.5**1~
DTM*472*20180616~
CAS*CO*45*1.5~
AMT*B6*3~
SVC*HC>87206*14.24*7.12**1~
DTM*472*20180617~
CAS*PR*2*1.43~
CAS*CO*45*5.69~
AMT*B6*14.24~
SVC*HC>87206*18.06*9.03**1~
DTM*472*20180618~
CAS*CO*45*9.03~
AMT*B6*18.06~
SVC*HC>87206*7.8*3.9**1~
DTM*472*20180619~
CAS*PR*3*2.5~
CAS*CO*45*1.4~
AMT*B6*7.8~
SVC*HC>87206*6.98*3.49**1~
DTM*472*20180620~
CAS*CO*104*3.13**45*.36~
AMT*B6*6.98~
SVC*HC>87206*13.08*6.54**1~
DTM*472*20180621~
CAS*CO*45*6.54~
AMT*B6*13.08~
CLP*PAT00010912*1*485*242.5*51*HM*CLM0000000242*13~
NM1*QC*1*JELLO*KARLA****MI*MEM000000046~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180212~
DTM*233*20180212~
AMT*AU*485~
SVC*HC>87081*485*242.5**1~
DTM*472*20180212~
CAS*PR*2*48.5**3*2.5~
CAS*CO*45*191.5~
AMT*B6*485~
CLP*PAT00014208*1*9524*4762**HM*CLM0000000243*13~
NM1*QC*1*JELLO*KARLA****MI*MEM000000046~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181013~
DTM*233*20181016~
AMT*AU*9524~
SVC*HC>87491*2883*1441.5**1~
DTM*472*20181013~
CAS*CO*45*1441.5~
AMT*B6*2883~
SVC*HC>87491>59*3441*1720.5**1~
DTM*472*20181014~
CAS*CO*45*1720.5~
AMT*B6*3441~
SVC*HC>87491>51*3076*1538**1~
DTM*472*20181015~
CAS*CO*45*1538~
AMT*B6*3076~
SVC*HC>87491>59*124*62**1~
DTM*472*20181016~
CAS*CO*45*62~
AMT*B6*124~
CLP*PAT00016441*1*326*163*28.1*HM*CLM0000000244*13~
NM1*QC*1*STROGANOFF*CELIA****MI*MEM000000105~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180613~
DTM*233*20180616~
AMT*AU*326~
SVC*HC>85025>RT*145*72.5**1~
DTM*472*20180613~
CAS*PR*1*14.5~
CAS*CO*45*58~
AMT*B6*145~
SVC*HC>85025>25*111*55.5**1~
DTM*472*20180614~
CAS*PR*2*11.1~
CAS*CO*104*25**45*19.4~
AMT*B6*111~
SVC*HC>85025*60*30**1~
DTM*472*20180615~
CAS*CO*45*30~
AMT*B6*60~
SVC*HC>85025*10*5**1~
DTM*472*20180616~
CAS*PR*3*2.5~
CAS*CO*45*2.5~
AMT*B6*10~
CLP*PAT00018181*1*335.02*167.51*6*HM*CLM0000000245*13~
NM1*QC*1*STROGANOFF*CELIA****MI*MEM000000105~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180211~
DTM*233*20180214~
AMT*AU*335.02~
SVC*HC>J2550>25*175*87.5**1~
DTM*472*20180211~
CAS*CO*45*87.5~
AMT*B6*175~
SVC*HC>J2550*18*9**1~
DTM*472*20180212~
CAS*CO*45*9~
AMT*B6*18~
SVC*HC>J2550*82*41**1~
DTM*472*20180213~
CAS*CO*45*41~
AMT*B6*82~
SVC*HC>J2550*60.02*30.01**1~
DTM*472*20180214~
CAS*PR*2*6~
CAS*CO*45*24.01~
AMT*B6*60.02~
CLP*PAT00048234*1*254*127*25.4*HM*CLM0000000254*13~
NM1*QC*1*PASTA*DELIA****MI*MEM000000070~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180208~
DTM*233*20180208~
AMT*AU*254~
SVC*HC>85025*254*127**1~
DTM*472*20180208~
CAS*PR*2*25.4~
CAS*CO*45*101.6~
AMT*B6*254~
CLP*PAT00050800*1*130*65**HM*CLM0000000255*13~
NM1*QC*1*PASTA*DELIA****MI*MEM000000070~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181009~
DTM*233*20181010~
AMT*AU*130~
SVC*HC>86900*105*52.5**1~
DTM*472*20181009~
CAS*CO*45*52.5~
AMT*B6*105~
SVC*HC>86900*25*12.5**1~
DTM*472*20181010~
CAS*CO*45*12.5~
AMT*B6*25~
CLP*PAT00030488*1*1153*576.5*42.4*HM*CLM0000000260*13~
NM1*QC*1*PASTA*MARIO****MI*MEM000000071~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180206~
DTM*233*20180209~
AMT*AU*1153~
SVC*HC>93306>25*120*60**1~
DTM*472*20180206~
CAS*CO*45*60~
AMT*B6*120~
SVC*HC>73700*424*212**1~
DTM*472*20180207~
CAS*PR*2*42.4~
CAS*CO*45*169.6~
AMT*B6*424~
SVC*HC>93306*418*209**1~
DTM*472*20180208~
CAS*CO*45*209~
AMT*B6*418~
SVC*HC>73700*191*95.5**1~
DTM*472*20180209~
CAS*CO*45*95.5~
AMT*B6*191~
CLP*PAT00031180*1*1130*565*18.5*HM*CLM0000000261*13~
NM1*QC*1*PASTA*MARIO****MI*MEM000000071~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181007~
DTM*233*20181011~
AMT*AU*1130~
SVC*HC>G0463*430*215**1~
DTM*472*20181007~
CAS*CO*45*215~
AMT*B6*430~
SVC*HC>G0463*220*110**1~
DTM*472*20181008~
CAS*PR*3*2.5~
CAS*CO*45*107.5~
AMT*B6*220~
SVC*HC>G0463*160*80**1~
DTM*472*20181009~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>G0463*160*80**1~
DTM*472*20181010~
CAS*PR*2*16~
CAS*CO*45*64~
AMT*B6*160~
SVC*HC>G0463*160*80**1~
DTM*472*20181011~
CAS*CO*45*80~
AMT*B6*160~
CLP*PAT00041277*1*330*165*11*HM*CLM0000000266*13~
NM1*QC*1*PASTA*RANDOLPH****MI*MEM000000073~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180204~
DTM*233*20180206~
AMT*AU*330~
SVC*HC>99283*110*55**1~
DTM*472*20180204~
CAS*PR*1*11~
CAS*CO*45*44~
AMT*B6*110~
SVC*HC>99283*110*55**1~
DTM*472*20180205~
CAS*CO*45*55~
AMT*B6*110~
SVC*HC>99283*110*55**1~
DTM*472*20180206~
CAS*CO*45*55~
AMT*B6*110~
CLP*PAT00048945*1*187*93.5**HM*CLM0000000267*13~
NM1*QC*1*PASTA*RANDOLPH****MI*MEM000000073~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181005~
DTM*233*20181005~
AMT*AU*187~
SVC*HC>83036*187*93.5**1~
DTM*472*20181005~
CAS*CO*45*93.5~
AMT*B6*187~
CLP*PAT00052130*1*274.86*137.43*9.2*HM*CLM0000000272*13~
NM1*QC*1*GYRO*KRISTEN****MI*MEM000000035~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180202~
DTM*233*20180204~
AMT*AU*274.86~
SVC*HC>H1002*92*46**1~
DTM*472*20180202~
CAS*PR*2*9.2~
CAS*CO*45*36.8~
AMT*B6*92~
SVC*HC>87591*92*46**1~
DTM*472*20180203~
CAS*CO*45*46~
AMT*B6*92~
SVC*HC>H1002*90.86*45.43**1~
DTM*472*20180204~
CAS*CO*45*45.43~
AMT*B6*90.86~
CLP*PAT00057017*1*54*27*2.5*HM*CLM0000000273*13~
NM1*QC*1*GYRO*KRISTEN****MI*MEM000000035~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181003~
DTM*233*20181004~
AMT*AU*54~
SVC*HC>36415*27*13.5**1~
DTM*472*20181003~
CAS*CO*45*13.5~
AMT*B6*27~
SVC*HC>36415*27*13.5**1~
DTM*472*20181004~
CAS*PR*3*2.5~
CAS*CO*45*11~
AMT*B6*27~
CLP*PAT00053882*1*290*145**HM*CLM0000000290*13~
NM1*QC*1*STROGANOFF*HELENE****MI*MEM000000107~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180127~
DTM*233*20180128~
AMT*AU*290~
SVC*HC>81002*145*72.5**1~
DTM*472*20180127~
CAS*CO*45*72.5~
AMT*B6*145~
SVC*HC>81002*145*72.5**1~
DTM*472*20180128~
CAS*CO*45*72.5~
AMT*B6*145~
CLP*PAT00055565*1*177*88.5*2.5*HM*CLM0000000291*13~
NM1*QC*1*STROGANOFF*HELENE****MI*MEM000000107~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180927~
DTM*233*20180928~
AMT*AU*177~
SVC*HC>96372>26*166*83**1~
DTM*472*20180927~
CAS*PR*3*2.5~
CAS*CO*45*80.5~
AMT*B6*166~
SVC*HC>96372>26*11*5.5**1~
DTM*472*20180928~
CAS*CO*45*5.5~
AMT*B6*11~
CLP*PAT00058604*1*598*299*29.5*HM*CLM0000000292*13~
NM1*QC*1*JELLO*STEVEN****MI*MEM000000050~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180528~
DTM*233*20180608~
AMT*AU*598~
SVC*HC>Q9967>59*90*45**1~
DTM*472*20180528~
CAS*PR*2*9~
CAS*CO*45*36~
AMT*B6*90~
SVC*HC>Q9967*35*17.5**1~
DTM*472*20180529~
CAS*CO*45*17.5~
AMT*B6*35~
SVC*HC>Q9967*28*14**1~
DTM*472*20180530~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>Q9967>59*90*45**1~
DTM*472*20180531~
CAS*PR*1*9~
CAS*CO*45*36~
AMT*B6*90~
SVC*HC>Q9967*28*14**1~
DTM*472*20180601~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>Q9967*28*14**1~
DTM*472*20180602~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>Q9967>59*90*45**1~
DTM*472*20180603~
CAS*PR*2*9**3*2.5~
CAS*CO*45*33.5~
AMT*B6*90~
SVC*HC>Q9967*28*14**1~
DTM*472*20180604~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>Q9967*28*14**1~
DTM*472*20180605~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>Q9967>59*90*45**1~
DTM*472*20180606~
CAS*CO*45*45~
AMT*B6*90~
SVC*HC>Q9967*35*17.5**1~
DTM*472*20180607~
CAS*CO*45*17.5~
AMT*B6*35~
SVC*HC>Q9967*28*14**1~
DTM*472*20180608~
CAS*CO*45*14~
AMT*B6*28~
CLP*PAT00005006*1*284.06*142.03*28.41*HM*CLM0000000293*13~
NM1*QC*1*JELLO*STEVEN****MI*MEM000000050~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180126~
DTM*233*20180126~
AMT*AU*284.06~
SVC*HC>80164>90*284.06*142.03**1~
DTM*472*20180126~
CAS*PR*2*28.41~
CAS*CO*45*113.62~
AMT*B6*284.06~
CLP*PAT00032645*1*387*193.5**HM*CLM0000000306*13~
NM1*QC*1*JELLO*LEE****MI*MEM000000047~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180922~
DTM*233*20180924~
AMT*AU*387~
SVC*HC>T2033>59*161*80.5**1~
DTM*472*20180922~
CAS*CO*45*80.5~
AMT*B6*161~
SVC*HC>T2033>59*113*56.5**1~
DTM*472*20180923~
CAS*CO*45*56.5~
AMT*B6*113~
SVC*HC>T2033>59*113*56.5**1~
DTM*472*20180924~
CAS*CO*45*56.5~
AMT*B6*113~
CLP*PAT00034819*1*54*27*2.5*HM*CLM0000000307*13~
NM1*QC*1*JELLO*LEE****MI*MEM000000047~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180523~
DTM*233*20180524~
AMT*AU*54~
SVC*HC>62270*27*13.5**1~
DTM*472*20180523~
CAS*PR*3*2.5~
CAS*CO*45*11~
AMT*B6*27~
SVC*HC>62270*27*13.5**1~
DTM*472*20180524~
CAS*CO*45*13.5~
AMT*B6*27~
CLP*PAT00020835*1*267*133.5*25.4*HM*CLM0000000318*13~
NM1*QC*1*STROGANOFF*JULIO****MI*MEM000000108~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180918~
DTM*233*20180919~
AMT*AU*267~
SVC*HC>64490*254*127**1~
DTM*472*20180918~
CAS*PR*2*25.4~
CAS*CO*45*101.6~
AMT*B6*254~
SVC*HC>64490*13*6.5**1~
DTM*472*20180919~
CAS*CO*45*6.5~
AMT*B6*13~
CLP*PAT00030514*1*1202*601*2.5*HM*CLM0000000319*13~
NM1*QC*1*STROGANOFF*JULIO****MI*MEM000000108~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180519~
DTM*233*20180521~
AMT*AU*1202~
SVC*HC>83036>RT*312*156**1~
DTM*472*20180519~
CAS*CO*45*156~
AMT*B6*312~
SVC*HC>83036>LT*312*156**1~
DTM*472*20180520~
CAS*CO*45*156~
AMT*B6*312~
SVC*HC>83036*578*289**1~
DTM*472*20180521~
CAS*PR*3*2.5~
CAS*CO*45*286.5~
AMT*B6*578~
CLP*PAT00041303*1*235*117.5*2.5*HM*CLM0000000324*13~
NM1*QC*1*JELLO*SCOTT****MI*MEM000000049~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180916~
DTM*233*20180917~
AMT*AU*235~
SVC*HC>31240*160*80**1~
DTM*472*20180916~
CAS*CO*45*80~
AMT*B6*160~
SVC*HC>31240*75*37.5**1~
DTM*472*20180917~
CAS*PR*3*2.5~
CAS*CO*45*35~
AMT*B6*75~
CLP*PAT00043841*1*639*319.5*13.3*HM*CLM0000000325*13~
NM1*QC*1*JELLO*SCOTT****MI*MEM000000049~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180517~
DTM*233*20180518~
AMT*AU*639~
SVC*HC>96374*506*253**1~
DTM*472*20180517~
CAS*CO*45*253~
AMT*B6*506~
SVC*HC>81003>26*133*66.5**2~
DTM*472*20180518~
CAS*PR*1*13.3~
CAS*CO*45*53.2~
AMT*B6*133~
CLP*PAT00047574*1*355*177.5*29*HM*CLM0000000326*13~
NM1*QC*1*JELLO*MICHAEL****MI*MEM000000048~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180115~
DTM*233*20180116~
AMT*AU*355~
SVC*HC>94660>25*65*32.5**1~
DTM*472*20180115~
CAS*CO*45*32.5~
AMT*B6*65~
SVC*HC>94660*290*145**1~
DTM*472*20180116~
CAS*PR*2*29~
CAS*CO*45*116~
AMT*B6*290~
CLP*PAT00012518*1*112*56**HM*CLM0000000327*13~
NM1*QC*1*JELLO*MICHAEL****MI*MEM000000048~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180915~
DTM*233*20180916~
AMT*AU*112~
SVC*HC>96413*42*21**1~
DTM*472*20180915~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>J3490*70*35**1~
DTM*472*20180916~
CAS*CO*45*35~
AMT*B6*70~
SE*1018*100000005~
ST*835*100000006~
BPR*I*13712.58*C*CHK************20191116~
TRN*1*CHK00001*150000676 ~
N1*PR*CHEAPEST EVER HMO~
N3*200 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*2U*150000676~
PER*BL*TECH CONTACT*TE*4155550006~
N1*PE*FLY BY NIGHT HEALTHCARE*XX*2345678918~
N3*100 FICTION ST~
N4*SAN FRANCISCO*CA*94117~
REF*TJ*150000343~
LX*1~
CLP*PAT00007353*1*677*338.5**HM*CLM0000000008*13~
NM1*QC*1*BORSCHT*DANIEL****MI*SUB000000018~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180501~
DTM*233*20180504~
AMT*AU*677~
SVC*HC>80048*582*291**1~
DTM*472*20180501~
CAS*CO*45*291~
AMT*B6*582~
SVC*HC>80048*34*17**1~
DTM*472*20180502~
CAS*CO*104*12.5**45*4.5~
AMT*B6*34~
SVC*HC>80048>26*35*17.5**1~
DTM*472*20180503~
CAS*CO*45*17.5~
AMT*B6*35~
SVC*HC>80048>26*26*13**1~
DTM*472*20180504~
CAS*CO*45*13~
AMT*B6*26~
CLP*PAT00046995*1*2431.06*1215.53*157.6*HM*CLM0000000009*13~
NM1*QC*1*BORSCHT*DANIEL****MI*SUB000000018~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181230~
DTM*233*20190103~
AMT*AU*2431.06~
SVC*HC>10060>AA*1551*775.5**1~
DTM*472*20181230~
CAS*PR*2*155.1**3*2.5~
CAS*CO*45*617.9~
AMT*B6*1551~
SVC*HC>10060*.02*.01**1~
DTM*472*20181231~
CAS*CO*45*.01~
AMT*B6*.02~
SVC*HC>10060*.02*.01**1~
DTM*472*20190101~
CAS*CO*45*.01~
AMT*B6*.02~
SVC*HC>10060*.02*.01**1~
DTM*472*20190102~
CAS*CO*45*.01~
AMT*B6*.02~
SVC*HC>10060>59*880*440**1~
DTM*472*20190103~
CAS*CO*45*440~
AMT*B6*880~
CLP*PAT00062457*1*137.72*68.86**HM*CLM0000000020*13~
NM1*QC*1*CHICKEN*SUSAN****MI*SUB000000023~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180427~
DTM*233*20180427~
AMT*AU*137.72~
SVC*HC>87210>90*137.72*68.86**1~
DTM*472*20180427~
CAS*CO*104*25**45*43.86~
AMT*B6*137.72~
CLP*PAT00055539*1*26*13*2.5*HM*CLM0000000021*13~
NM1*QC*1*CHICKEN*SUSAN****MI*SUB000000023~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181226~
DTM*233*20181227~
AMT*AU*26~
SVC*HC>76815*6*3**1~
DTM*472*20181226~
CAS*PR*3*2.5~
CAS*CO*45*.5~
AMT*B6*6~
SVC*HC>59025*20*10**1~
DTM*472*20181227~
CAS*CO*45*10~
AMT*B6*20~
CLP*PAT00040756*1*742.02*371.01*23.5*HM*CLM0000000032*13~
NM1*QC*1*CORN*SUSAN****MI*SUB000000002~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180423~
DTM*233*20180427~
AMT*AU*742.02~
SVC*HC>93017>25*235*117.5**1~
DTM*472*20180423~
CAS*PR*2*23.5~
CAS*CO*45*94~
AMT*B6*235~
SVC*HC>93017*350*175**1~
DTM*472*20180424~
CAS*CO*45*175~
AMT*B6*350~
SVC*HC>93017*75.02*37.51**1~
DTM*472*20180425~
CAS*CO*45*37.51~
AMT*B6*75.02~
SVC*HC>93017*42*21**1~
DTM*472*20180426~
CAS*CO*45*21~
AMT*B6*42~
SVC*HC>93017*40*20**1~
DTM*472*20180427~
CAS*CO*45*20~
AMT*B6*40~
CLP*PAT00028868*1*145*72.5*11.5*HM*CLM0000000033*13~
NM1*QC*1*CORN*SUSAN****MI*SUB000000002~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181222~
DTM*233*20181224~
AMT*AU*145~
SVC*HC>97140*10*5**2~
DTM*472*20181222~
CAS*CO*45*5~
AMT*B6*10~
SVC*HC>97140*90*45**2~
DTM*472*20181223~
CAS*PR*2*9**3*2.5~
CAS*CO*45*33.5~
AMT*B6*90~
SVC*HC>97140*45*22.5**2~
DTM*472*20181224~
CAS*CO*45*22.5~
AMT*B6*45~
CLP*PAT00040331*1*21.42*10.71**HM*CLM0000000044*13~
NM1*QC*1*HAGGIS*SOLOMAN****MI*SUB000000114~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180419~
DTM*233*20180419~
AMT*AU*21.42~
SVC*HC>37224*21.42*10.71**1~
DTM*472*20180419~
CAS*CO*45*10.71~
AMT*B6*21.42~
CLP*PAT00021766*1*500*250*27.1*HM*CLM0000000045*14~
NM1*QC*1*HAGGIS*SOLOMAN****MI*SUB000000114~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181218~
DTM*233*20181219~
AMT*AU*500~
SVC*HC>36415>25*254*127**1~
DTM*472*20181218~
CAS*CO*45*127~
AMT*B6*254~
SVC*HC>36415*246*123**1~
DTM*472*20181219~
CAS*PR*2*24.6**3*2.5~
CAS*CO*45*95.9~
AMT*B6*246~
CLP*PAT00026172*1*255.74*127.87*15*HM*CLM0000000056*13~
NM1*QC*1*KEBAB*HARIS****MI*SUB000000010~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180415~
DTM*233*20180420~
AMT*AU*255.74~
SVC*HC>97116*125*62.5**1~
DTM*472*20180415~
CAS*PR*2*12.5~
CAS*CO*45*50~
AMT*B6*125~
SVC*HC>97116*25*12.5**1~
DTM*472*20180416~
CAS*CO*45*12.5~
AMT*B6*25~
SVC*HC>97116*30*15**1~
DTM*472*20180417~
CAS*PR*3*2.5~
CAS*CO*45*12.5~
AMT*B6*30~
SVC*HC>97116*49.74*24.87**1~
DTM*472*20180418~
CAS*CO*45*24.87~
AMT*B6*49.74~
SVC*HC>97116*25*12.5**1~
DTM*472*20180419~
CAS*CO*45*12.5~
AMT*B6*25~
SVC*HC>97116*1*.5**1~
DTM*472*20180420~
CAS*CO*45*.5~
AMT*B6*1~
CLP*PAT00055895*1*231*115.5*12.9*HM*CLM0000000057*13~
NM1*QC*1*KEBAB*HARIS****MI*SUB000000010~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181214~
DTM*233*20181216~
AMT*AU*231~
SVC*HC>97112>25*129*64.5**1~
DTM*472*20181214~
CAS*PR*2*12.9~
CAS*CO*45*51.6~
AMT*B6*129~
SVC*HC>97110*61*30.5**1~
DTM*472*20181215~
CAS*CO*45*30.5~
AMT*B6*61~
SVC*HC>97112*41*20.5**1~
DTM*472*20181216~
CAS*CO*45*20.5~
AMT*B6*41~
CLP*PAT00039070*1*388*194**HM*CLM0000000068*13~
NM1*QC*1*PEACH*SOLOMAN****MI*SUB000000007~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180411~
DTM*233*20180411~
AMT*AU*388~
SVC*HC>86592*388*194**1~
DTM*472*20180411~
CAS*CO*45*194~
AMT*B6*388~
CLP*PAT00022839*1*230*115*2.5*HM*CLM0000000069*13~
NM1*QC*1*PEACH*SOLOMAN****MI*SUB000000007~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181210~
DTM*233*20181211~
AMT*AU*230~
SVC*HC>J1644*222*111**1~
DTM*472*20181210~
CAS*PR*3*2.5~
CAS*CO*45*108.5~
AMT*B6*222~
SVC*HC>J1644*8*4**1~
DTM*472*20181211~
CAS*CO*45*4~
AMT*B6*8~
CLP*PAT00031215*1*125*62.5*12.5*HM*CLM0000000080*13~
NM1*QC*1*ROLL*SAMON****MI*SUB000000107~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180407~
DTM*233*20180407~
AMT*AU*125~
SVC*HC>80048*125*62.5**1~
DTM*472*20180407~
CAS*PR*2*12.5~
CAS*CO*45*50~
AMT*B6*125~
CLP*PAT00062970*1*1*.5**HM*CLM0000000081*13~
NM1*QC*1*ROLL*SAMON****MI*SUB000000107~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181206~
DTM*233*20181206~
AMT*AU*1~
SVC*HC>36415*1*.5**1~
DTM*472*20181206~
CAS*CO*45*.5~
AMT*B6*1~
CLP*PAT00017136*1*152*76**HM*CLM0000000092*13~
NM1*QC*1*SUSHI*JOSIAH****MI*SUB000000123~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180403~
DTM*233*20180403~
AMT*AU*152~
SVC*HC>10060*152*76**1~
DTM*472*20180403~
CAS*CO*45*76~
AMT*B6*152~
CLP*PAT00044127*1*1458*729*30.1*HM*CLM0000000093*13~
NM1*QC*1*SUSHI*JOSIAH****MI*SUB000000123~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181202~
DTM*233*20181206~
AMT*AU*1458~
SVC*HC>96367*378*189**1~
DTM*472*20181202~
CAS*CO*45*189~
AMT*B6*378~
SVC*HC>J7030*264*132**1~
DTM*472*20181203~
CAS*CO*45*132~
AMT*B6*264~
SVC*HC>96367*264*132**1~
DTM*472*20181204~
CAS*CO*45*132~
AMT*B6*264~
SVC*HC>J7030*276*138**1~
DTM*472*20181205~
CAS*PR*2*27.6**3*2.5~
CAS*CO*45*107.9~
AMT*B6*276~
SVC*HC>96367*276*138**1~
DTM*472*20181206~
CAS*CO*45*138~
AMT*B6*276~
CLP*PAT00020656*1*165.6*82.8**HM*CLM0000000100*13~
NM1*QC*1*CHICKEN*KARLA****MI*MEM000000012~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180731~
DTM*233*20180801~
AMT*AU*165.6~
SVC*HC>99214>90*82.8*41.4**1~
DTM*472*20180731~
CAS*CO*45*41.4~
AMT*B6*82.8~
SVC*HC>99214>90*82.8*41.4**1~
DTM*472*20180801~
CAS*CO*45*41.4~
AMT*B6*82.8~
CLP*PAT00041004*1*282.56*141.28*12.9*HM*CLM0000000101*13~
NM1*QC*1*CHICKEN*KARLA****MI*MEM000000012~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180331~
DTM*233*20180403~
AMT*AU*282.56~
SVC*HC>81003*44*22**1~
DTM*472*20180331~
CAS*CO*45*22~
AMT*B6*44~
SVC*HC>81003*51*25.5**1~
DTM*472*20180401~
CAS*CO*45*25.5~
AMT*B6*51~
SVC*HC>81003*83.56*41.78**1~
DTM*472*20180402~
CAS*CO*45*41.78~
AMT*B6*83.56~
SVC*HC>81003*104*52**1~
DTM*472*20180403~
CAS*PR*2*10.4**3*2.5~
CAS*CO*45*39.1~
AMT*B6*104~
CLP*PAT00059025*1*7117*3558.5*38.4*HM*CLM0000000102*13~
NM1*QC*1*CHICKEN*NELSON****MI*MEM000000014~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181129~
DTM*233*20181205~
AMT*AU*7117~
SVC*HC>97802*140*70**2~
DTM*472*20181129~
CAS*PR*1*14~
CAS*CO*45*56~
AMT*B6*140~
SVC*HC>97802*240*120**2~
DTM*472*20181130~
CAS*CO*45*120~
AMT*B6*240~
SVC*HC>97802*5915*2957.5**2~
DTM*472*20181201~
CAS*CO*45*2957.5~
AMT*B6*5915~
SVC*HC>97802*9*4.5**2~
DTM*472*20181202~
CAS*CO*45*4.5~
AMT*B6*9~
SVC*HC>97802*554*277**2~
DTM*472*20181203~
CAS*CO*45*277~
AMT*B6*554~
SVC*HC>97802*244*122**2~
DTM*472*20181204~
CAS*PR*2*24.4~
CAS*CO*104*25**45*72.6~
AMT*B6*244~
SVC*HC>97802*15*7.5**2~
DTM*472*20181205~
CAS*CO*45*7.5~
AMT*B6*15~
CLP*PAT00065398*1*131*65.5*2.5*HM*CLM0000000103*13~
NM1*QC*1*CHICKEN*NELSON****MI*MEM000000014~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180730~
DTM*233*20180730~
AMT*AU*131~
SVC*HC>95810>26*131*65.5**1~
DTM*472*20180730~
CAS*PR*3*2.5~
CAS*CO*45*63~
AMT*B6*131~
CLP*PAT00019626*1*1435*717.5**HM*CLM0000000118*13~
NM1*QC*1*KEBAB*ZHANG****MI*MEM000000054~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180725~
DTM*233*20180729~
AMT*AU*1435~
SVC*HC>90471*650*325**1~
DTM*472*20180725~
CAS*CO*45*325~
AMT*B6*650~
SVC*HC>90471*325*162.5**1~
DTM*472*20180726~
CAS*CO*45*162.5~
AMT*B6*325~
SVC*HC>90471>26>59*250*125**1~
DTM*472*20180727~
CAS*CO*45*125~
AMT*B6*250~
SVC*HC>90471>26*130*65**1~
DTM*472*20180728~
CAS*CO*45*65~
AMT*B6*130~
SVC*HC>90471*80*40**1~
DTM*472*20180729~
CAS*CO*45*40~
AMT*B6*80~
CLP*PAT00027592*1*14*7*.5*HM*CLM0000000119*13~
NM1*QC*1*KEBAB*ZHANG****MI*MEM000000054~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180325~
DTM*233*20180325~
AMT*AU*14~
SVC*HC>99214*14*7**1~
DTM*472*20180325~
CAS*PR*2*.18**3*.32~
CAS*CO*104*3.13**45*3.37~
AMT*B6*14~
CLP*PAT00027819*1*1185*592.5*27*HM*CLM0000000158*13~
NM1*QC*1*KEBAB*VALERIA****MI*MEM000000053~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180312~
DTM*233*20180315~
AMT*AU*1185~
SVC*HC>87340>59*855*427.5**1~
DTM*472*20180312~
CAS*PR*3*2.5~
CAS*CO*45*425~
AMT*B6*855~
SVC*HC>87340*133*66.5**1~
DTM*472*20180313~
CAS*PR*1*13.3~
CAS*CO*45*53.2~
AMT*B6*133~
SVC*HC>87340*112*56**1~
DTM*472*20180314~
CAS*PR*2*11.2~
CAS*CO*45*44.8~
AMT*B6*112~
SVC*HC>87340*85*42.5**1~
DTM*472*20180315~
CAS*CO*45*42.5~
AMT*B6*85~
CLP*PAT00029365*1*40*20**HM*CLM0000000159*22~
NM1*QC*1*KEBAB*VALERIA****MI*MEM000000053~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181110~
DTM*233*20181111~
AMT*AU*40~
SVC*HC>73600*20*10**1~
DTM*472*20181110~
CAS*CO*45*10~
AMT*B6*20~
SVC*HC>73600*20*10**1~
DTM*472*20181111~
CAS*CO*45*10~
AMT*B6*20~
CLP*PAT00032571*1*400*200**HM*CLM0000000160*13~
NM1*QC*1*SUSHI*JAMES****MI*MEM000000112~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180711~
DTM*233*20180712~
AMT*AU*400~
SVC*HC>99284*225*112.5**1~
DTM*472*20180711~
CAS*CO*45*112.5~
AMT*B6*225~
SVC*HC>99284>25*175*87.5**1~
DTM*472*20180712~
CAS*CO*45*87.5~
AMT*B6*175~
CLP*PAT00033315*1*26*13*5.1*HM*CLM0000000161*13~
NM1*QC*1*SUSHI*JAMES****MI*MEM000000112~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180311~
DTM*233*20180311~
AMT*AU*26~
SVC*HC>82948*26*13**1~
DTM*472*20180311~
CAS*PR*2*2.6**3*2.5~
CAS*CO*45*7.9~
AMT*B6*26~
CLP*PAT00052001*1*142*71*3.5*HM*CLM0000000168*22~
NM1*QC*1*HAGGIS*ERNESTO****MI*MEM000000038~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181107~
DTM*233*20181110~
AMT*AU*142~
SVC*HC>77338*36*18**1~
DTM*472*20181107~
CAS*CO*45*18~
AMT*B6*36~
SVC*HC>84403*35*17.5**1~
DTM*472*20181108~
CAS*PR*2*3.5~
CAS*CO*45*14~
AMT*B6*35~
SVC*HC>77338*36*18**1~
DTM*472*20181109~
CAS*CO*45*18~
AMT*B6*36~
SVC*HC>84403*35*17.5**1~
DTM*472*20181110~
CAS*CO*45*17.5~
AMT*B6*35~
CLP*PAT00056932*1*316*158**HM*CLM0000000169*13~
NM1*QC*1*HAGGIS*ERNESTO****MI*MEM000000038~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180708~
DTM*233*20180708~
AMT*AU*316~
SVC*HC>84403>26*316*158**1~
DTM*472*20180708~
CAS*CO*45*158~
AMT*B6*316~
CLP*PAT00060248*1*2000*1000*2.5*HM*CLM0000000170*13~
NM1*QC*1*SUSHI*ALICIA****MI*MEM000000109~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180308~
DTM*233*20180309~
AMT*AU*2000~
SVC*HC>36000*1000*500**1~
DTM*472*20180308~
CAS*PR*3*2.5~
CAS*CO*45*497.5~
AMT*B6*1000~
SVC*HC>36000*1000*500**1~
DTM*472*20180309~
CAS*CO*45*500~
AMT*B6*1000~
CLP*PAT00060302*1*200*100*20*HM*CLM0000000171*13~
NM1*QC*1*SUSHI*ALICIA****MI*MEM000000109~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181106~
DTM*233*20181106~
AMT*AU*200~
SVC*HC>96372>26*200*100**1~
DTM*472*20181106~
CAS*PR*2*20~
CAS*CO*45*80~
AMT*B6*200~
CLP*PAT00010807*1*891.72*445.86**HM*CLM0000000176*13~
NM1*QC*1*SUSHI*KARLA****MI*MEM000000113~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180306~
DTM*233*20180307~
AMT*AU*891.72~
SVC*HC>87591*445.86*222.93**1~
DTM*472*20180306~
CAS*CO*45*222.93~
AMT*B6*445.86~
SVC*HC>87591*445.86*222.93**1~
DTM*472*20180307~
CAS*CO*45*222.93~
AMT*B6*445.86~
CLP*PAT00011118*1*58.86*29.43*1.43*HM*CLM0000000177*13~
NM1*QC*1*SUSHI*KARLA****MI*MEM000000113~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181104~
DTM*233*20181108~
AMT*AU*58.86~
SVC*HC>87491*3*1.5**1~
DTM*472*20181104~
CAS*CO*45*1.5~
AMT*B6*3~
SVC*HC>87491*14.24*7.12**1~
DTM*472*20181105~
CAS*PR*2*1.43~
CAS*CO*45*5.69~
AMT*B6*14.24~
SVC*HC>87491*18.06*9.03**1~
DTM*472*20181106~
CAS*CO*45*9.03~
AMT*B6*18.06~
SVC*HC>87491*13.08*6.54**1~
DTM*472*20181107~
CAS*CO*45*6.54~
AMT*B6*13.08~
SVC*HC>87491*10.48*5.24**1~
DTM*472*20181108~
CAS*CO*45*5.24~
AMT*B6*10.48~
CLP*PAT00041903*1*167*83.5*16.7*HM*CLM0000000186*13~
NM1*QC*1*KEBAB*RICHARD****MI*MEM000000052~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181101~
DTM*233*20181102~
AMT*AU*167~
SVC*HC>88304*137*68.5**3~
DTM*472*20181101~
CAS*PR*2*13.7~
CAS*CO*45*54.8~
AMT*B6*137~
SVC*HC>88304*30*15**3~
DTM*472*20181102~
CAS*PR*1*3~
CAS*CO*45*12~
AMT*B6*30~
CLP*PAT00048525*1*597*298.5*10*HM*CLM0000000187*13~
NM1*QC*1*KEBAB*RICHARD****MI*MEM000000052~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180702~
DTM*233*20180706~
AMT*AU*597~
SVC*HC>99214*248*124**1~
DTM*472*20180702~
CAS*CO*45*124~
AMT*B6*248~
SVC*HC>99214*51*25.5**1~
DTM*472*20180703~
CAS*CO*45*25.5~
AMT*B6*51~
SVC*HC>99214*163*81.5**1~
DTM*472*20180704~
CAS*PR*3*2.5~
CAS*CO*45*79~
AMT*B6*163~
SVC*HC>99214*60*30**1~
DTM*472*20180705~
CAS*CO*45*30~
AMT*B6*60~
SVC*HC>99214*75*37.5**1~
DTM*472*20180706~
CAS*PR*2*7.5~
CAS*CO*45*30~
AMT*B6*75~
CLP*PAT00004720*1*88.28*44.14*4.42*HM*CLM0000000206*13~
NM1*QC*1*ROLL*LEYLA****MI*MEM000000094~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180224~
DTM*233*20180225~
AMT*AU*88.28~
SVC*HC>78226*44.14*22.07**1~
DTM*472*20180224~
CAS*CO*45*22.07~
AMT*B6*44.14~
SVC*HC>85027*44.14*22.07**1~
DTM*472*20180225~
CAS*PR*2*4.42~
CAS*CO*45*17.65~
AMT*B6*44.14~
CLP*PAT00005540*1*556*278*2.5*HM*CLM0000000207*13~
NM1*QC*1*ROLL*LEYLA****MI*MEM000000094~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181025~
DTM*233*20181026~
AMT*AU*556~
SVC*HC>J3010*529*264.5**1~
DTM*472*20181025~
CAS*CO*45*264.5~
AMT*B6*529~
SVC*HC>J3010*27*13.5**1~
DTM*472*20181026~
CAS*PR*3*2.5~
CAS*CO*45*11~
AMT*B6*27~
CLP*PAT00025707*1*472.18*236.09*7.25*HM*CLM0000000212*13~
NM1*QC*1*ROLL*STEVEN****MI*MEM000000095~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180222~
DTM*233*20180226~
AMT*AU*472.18~
SVC*HC>86705>25*222.34*111.17**1~
DTM*472*20180222~
CAS*CO*45*111.17~
AMT*B6*222.34~
SVC*HC>99385*20*10**1~
DTM*472*20180223~
CAS*CO*45*10~
AMT*B6*20~
SVC*HC>86705*141.76*70.88**1~
DTM*472*20180224~
CAS*CO*45*70.88~
AMT*B6*141.76~
SVC*HC>99385*47.5*23.75**1~
DTM*472*20180225~
CAS*PR*2*4.75**3*2.5~
CAS*CO*45*16.5~
AMT*B6*47.5~
SVC*HC>86705*40.58*20.29**1~
DTM*472*20180226~
CAS*CO*45*20.29~
AMT*B6*40.58~
CLP*PAT00026258*1*360*180**HM*CLM0000000213*13~
NM1*QC*1*ROLL*STEVEN****MI*MEM000000095~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181023~
DTM*233*20181024~
AMT*AU*360~
SVC*HC>99203*210*105**1~
DTM*472*20181023~
CAS*CO*45*105~
AMT*B6*210~
SVC*HC>99203*150*75**1~
DTM*472*20181024~
CAS*CO*45*75~
AMT*B6*150~
CLP*PAT00025218*1*70*35**HM*CLM0000000226*13~
NM1*QC*1*ROLL*HELENE****MI*MEM000000093~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180619~
DTM*233*20180619~
AMT*AU*70~
SVC*HC>87491*70*35**1~
DTM*472*20180619~
CAS*CO*45*35~
AMT*B6*70~
CLP*PAT00026506*1*422*211**HM*CLM0000000227*13~
NM1*QC*1*ROLL*HELENE****MI*MEM000000093~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180217~
DTM*233*20180217~
AMT*AU*422~
SVC*HC>99212*422*211**1~
DTM*472*20180217~
CAS*CO*45*211~
AMT*B6*422~
CLP*PAT00038953*1*37*18.5**HM*CLM0000000252*13~
NM1*QC*1*HAGGIS*ADELA****MI*MEM000000037~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181010~
DTM*233*20181010~
AMT*AU*37~
SVC*HC>85025>26*37*18.5**1~
DTM*472*20181010~
CAS*CO*45*18.5~
AMT*B6*37~
CLP*PAT00039345*1*75*37.5**HM*CLM0000000253*13~
NM1*QC*1*HAGGIS*ADELA****MI*MEM000000037~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180610~
DTM*233*20180610~
AMT*AU*75~
SVC*HC>99284*75*37.5**1~
DTM*472*20180610~
CAS*CO*45*37.5~
AMT*B6*75~
CLP*PAT00050660*1*142*71**HM*CLM0000000270*13~
NM1*QC*1*KEBAB*DANIELLE****MI*MEM000000051~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181004~
DTM*233*20181004~
AMT*AU*142~
SVC*HC>88304*142*71**2~
DTM*472*20181004~
CAS*CO*45*71~
AMT*B6*142~
CLP*PAT00051785*1*830*415**HM*CLM0000000271*13~
NM1*QC*1*KEBAB*DANIELLE****MI*MEM000000051~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180604~
DTM*233*20180604~
AMT*AU*830~
SVC*HC>81025*830*415**1~
DTM*472*20180604~
CAS*CO*45*415~
AMT*B6*830~
CLP*PAT00002887*1*78*39**HM*CLM0000000276*13~
NM1*QC*1*HAGGIS*RICHARD****MI*MEM000000039~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20181002~
DTM*233*20181003~
AMT*AU*78~
SVC*HC>87491*39*19.5**1~
DTM*472*20181002~
CAS*CO*45*19.5~
AMT*B6*39~
SVC*HC>87491*39*19.5**1~
DTM*472*20181003~
CAS*CO*45*19.5~
AMT*B6*39~
CLP*PAT00006168*1*338*169*5.2*HM*CLM0000000277*13~
NM1*QC*1*HAGGIS*RICHARD****MI*MEM000000039~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180602~
DTM*233*20180604~
AMT*AU*338~
SVC*HC>99203>25*250*125**1~
DTM*472*20180602~
CAS*CO*45*125~
AMT*B6*250~
SVC*HC>99203*61*30.5**1~
DTM*472*20180603~
CAS*CO*45*30.5~
AMT*B6*61~
SVC*HC>99203*27*13.5**1~
DTM*472*20180604~
CAS*PR*2*2.7**3*2.5~
CAS*CO*45*8.3~
AMT*B6*27~
CLP*PAT00008342*1*292*146*9.3*HM*CLM0000000294*13~
NM1*QC*1*SUSHI*CECILIA****MI*MEM000000110~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180926~
DTM*233*20181003~
AMT*AU*292~
SVC*HC>96376>59*50*25**2~
DTM*472*20180926~
CAS*CO*45*25~
AMT*B6*50~
SVC*HC>81015*40*20**1~
DTM*472*20180927~
CAS*PR*3*2.5~
CAS*CO*45*17.5~
AMT*B6*40~
SVC*HC>96376*28*14**2~
DTM*472*20180928~
CAS*CO*104*12.5**45*1.5~
AMT*B6*28~
SVC*HC>81015*28*14**1~
DTM*472*20180929~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>96376>59*50*25**2~
DTM*472*20180930~
CAS*CO*45*25~
AMT*B6*50~
SVC*HC>81015*40*20**1~
DTM*472*20181001~
CAS*PR*2*4~
CAS*CO*45*16~
AMT*B6*40~
SVC*HC>96376*28*14**2~
DTM*472*20181002~
CAS*CO*45*14~
AMT*B6*28~
SVC*HC>81015*28*14**1~
DTM*472*20181003~
CAS*PR*1*2.8~
CAS*CO*45*11.2~
AMT*B6*28~
CLP*PAT00010762*1*225*112.5**HM*CLM0000000295*13~
NM1*QC*1*SUSHI*CECILIA****MI*MEM000000110~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180527~
DTM*233*20180527~
AMT*AU*225~
SVC*HC>82948*225*112.5**1~
DTM*472*20180527~
CAS*CO*45*112.5~
AMT*B6*225~
CLP*PAT00038986*1*160*80*16*HM*CLM0000000308*13~
NM1*QC*1*CHICKEN*MANUEL****MI*MEM000000013~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180121~
DTM*233*20180121~
AMT*AU*160~
SVC*HC>80061*160*80**1~
DTM*472*20180121~
CAS*PR*2*16~
CAS*CO*45*64~
AMT*B6*160~
CLP*PAT00043416*1*271*135.5**HM*CLM0000000309*13~
NM1*QC*1*CHICKEN*MANUEL****MI*MEM000000013~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180921~
DTM*233*20180923~
AMT*AU*271~
SVC*HC>99212>26*180*90**1~
DTM*472*20180921~
CAS*CO*45*90~
AMT*B6*180~
SVC*HC>99212*55*27.5**1~
DTM*472*20180922~
CAS*CO*45*27.5~
AMT*B6*55~
SVC*HC>99212*36*18**1~
DTM*472*20180923~
CAS*CO*45*18~
AMT*B6*36~
CLP*PAT00014922*1*166*83**HM*CLM0000000316*13~
NM1*QC*1*SUSHI*EMMA****MI*MEM000000111~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180520~
DTM*233*20180520~
AMT*AU*166~
SVC*HC>84443*166*83**1~
DTM*472*20180520~
CAS*CO*45*83~
AMT*B6*166~
CLP*PAT00018278*1*153*76.5**HM*CLM0000000317*13~
NM1*QC*1*SUSHI*EMMA****MI*MEM000000111~
REF*1L*POLCY0001~
REF*CE*C001~
DTM*232*20180118~
DTM*233*20180119~
AMT*AU*153~
SVC*HC>86787>26*13*6.5**1~
DTM*472*20180118~
CAS*CO*45*6.5~
AMT*B6*13~
SVC*HC>86592>26*140*70**1~
DTM*472*20180119~
CAS*CO*45*70~
AMT*B6*140~
SE*942*100000006~
GE*6*1~
IEA*1*100000086~
