ISA*00*Authorizat*00*Security I*ZZ*InterchangeSen *ZZ*Interchange Rec*141001*1037*^*00501*000031033*0*T*:~
GS*HS*Sample Sen*Sample Rec*20141001*1037*123456*X*005010X279A1~
ST*271*000000001*005010X279A1~
BHT*0022*11*7237581e2e400890ee96a51bc62ed0*20200308*1901~
HL*1**20*1~
NM1*PR*2*CMS*****PI*CMS~
HL*2*1*21*1~
NM1*1P*2*SINAI HADASSAH MEDICAL ASSOCIATES*****XX*1508165317~
HL*3*2*22*0~
TRN*1*2223255592*99Trizetto~
NM1*IL*1*BELMAR*ALBERT*R***MI*9UY4R33KV83~
N3*1029 SALEM AVE~
N4*WOODBURY*NJ*080966062~
DMG*D8*19500722*M~
DTP*307*RD8*20191230-20191230~
EB*1**88~
EB*1**30^42^45^48^49^69^76^83^A5^A7^AG^BT^BU^BV*MA~
DTP*291*D8*20150701~
EB*1**30^2^23^24^25^26^27^28^3^33^36^37^38^39^40^42^50^51^52^53^67^69^73^76^83^86^98^A4^A6^A8^AI^AJ^AK^AL^BT^BU^BV^DM^UC*MB~
DTP*291*D8*20150701~
EB*A**30*QM*Medicare Part B*27**0~
DTP*291*RD8*20190101-20191231~
EB*C**30*QM*Medicare Part A*26*0~
DTP*291*RD8*20190101-20191231~
EB*C**30*QM*Medicare Part B*23*0~
DTP*291*RD8*20190101-20191231~
EB*I**41^54~
EB*R***QM*NJ QMB Plan~
DTP*290*D8*20170201~
EB*R**88*OT~
REF*18*S5601~
REF*N6*008*SilverScript Choice~
DTP*292*D8*20170101~
LS*2120~
NM1*PR*2*SILVERSCRIPT INSURANCE COMPANY~
N3*445 Great Circle Road~
N4*Nashville*TN*37228~
PER*IC**TE*8664430934*UR*www.silverscript.com~
LE*2120~
SE*38*000000001~