ISA*00*          *00*          *ZZ*100000         *ZZ*106191         *030911*1253*U*00401*000000905*1*T*:~
GS*RA*106191*77032*20030911*1524*1*X*004010X061A1~
ST*820*Test~
BPR*I*2150.00*C*ACH*CTX*01*021200339*DA*1234587*1231555555*987898789*01*031207607*DA*99887766*19970620~
TRN*1*0002*1231555555*987898789~
REF*14*12345678~
DTM*582****RD8*20030501-20030530~
N1*PE*YOUR INSURANCE*FI*123456789~
N1*PR*MS Medicaid*FI*770320000~
PER*IC*ACS Provider Inquiry Unit*TE*8662252502~
ENT*1*2L*FI*123456789~
RMR*IK*123456789**1150~
IT1*1~
SLN*1**O*100*IE~
ADX*1150*20~
ENT*2*2J*34*030668776~
NM1*QE*1*ABC*XYZ****N*12345789~
RMR*AZ*123456789**1000~
DTM*582****RD8*20030505-20040520~
SE*18*Test~
GE*1*1~
IEA*1*000000905~