ISA*00* *00* *ZZ*EMEDNYBAT *ZZ*ETIN *140101*0730*^*00501*123456789*0*T*:~GS*HP*EMEDNYBAT*ETIN*20140101*07294900*123456789*X*005010X221A1~ST*835*123456789~BPR*I*1.57*C*ACH*CCP*01*123456789*DA*123456789123*1141797357**01*987654321*DA*9876543210*20140101~TRN*1*123456789012345*1141797357~REF*EV*ETIN~DTM*405*20140101~N1*PR*NYSDOH~N3*OFFICE OF HEALTH INSURANCE PROGRAMS*CORNING TOWER, EMPIRE STATE PLAZA~N4*ALBANY*NY*122370080~PER*BL*PROVIDER SERVICES*TE*8003439000*UR*WWW.EMEDNY.ORG~N1*PE*FACILITY NAME*XX*0123456789~N4*A CITY IN*NY*100011234~REF*TJ*987654321~LX*1~CLP*9876543210ABC*22*-37617.33*-627.97**MC*1300000000000020*11*1**7753*1.1919~CAS*CO*45*-36989.36~NM1*QC*1*PATIENTLNAME*PATIENTFNAME****MI*AA11111A~NM1*82*1******XX*1234567890~MIA*0***-19.37*N689~REF*EA*098765432109876~REF*9A*2946~DTM*232*20130121~DTM*233*20130125~QTY*CA*4~CLP*9876543210ABC*1*37617.33*629.54**MC*1400000000000020*11*7**7753*1.2317~CAS*CO*45*36987.79~NM1*QC*1*PATIENTLNAME*PATIENTFNAME****MI*AA11111A~NM1*82*1******XX*1234567890~MIA*0***19.37*N419~REF*EA*987654321XYZ123~REF*9A*3130~DTM*232*20130121~DTM*233*20130125~AMT*AU*629.54~QTY*CA*4~SE*35*123456789~GE*1*123456789~IEA*1*123456789~