ISA*00*          *00*          *ZZ*100000         *ZZ*106191         *030911*0800*U*00401*000000001*0*T*:~
GS*HP*77032*106191*20030911*0800*000000001*X*004010X091A1~
ST*835*TEST~
BPR*I*4500*C*ACH*CTX*01*122000496*DA*0123456789*1234567890*012345678*01*061100473*DA*98765*20030911~
TRN*1*0001*1234567890*012345678~
DTM*405*20030909~
N1*PR*Mississippi Division of Medicaid*XV*77032~
N3*123 Road~
N4*City*MS*38862~
PER*CX*MS Partner*TE*1800000000~
N1*PE*XYZ*FI*582625964~
N3*10 MAIN~
N4*JACKSONVILLE*FL*32211~
LX*1~
CLP*000000001*1*4500*4500**MC*12345678~
NM1*QC*1*Patientslastname*Firstname****HN*7722337~
SE*15*TEST~
GE*1*000000001~
IEA*1*000000001~