ISA*00*          *00*          *ZZ*EMEDNYBAT      *ZZ*ETIN           *140101*0929*^*00501*111111123*0*P*:~
GS*HP*EMEDNYBAT*ETIN*20140101*09304100*111111123*X*005010X221A1~
ST*835*123456789~
BPR*H*0*C*NON************20140101~
TRN*1*12345678901*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*EXAMPLE PROVIDER*FI*111222333~
N4*A CITY IN*NY*10001~
REF*PQ*12345678~
LX*1~
CLP*987654321*22*-7151.17*-7151.17**MC*1400000000000020*34*7~
NM1*QC*1*ANGELA*APPLE****MI*AA11111A~
MOA***N689~
REF*9A*1234~
DTM*232*20140201~
DTM*233*20140201~
AMT*AU*7131.01~
CLP*987654321*1*7151.17*7131.01**MC*1400000000000020*34*7~
CAS*CO*45*20.16~
NM1*QC*1*ANGELA*APPLE****MI*AA11111A~
MOA***N419~
REF*9A*1234~
DTM*232*20140101~
DTM*233*20140211~
AMT*AU*7131.01~
PLB*02245834*20141231*FB:FCN#201401011010200*-20.16~
SE*30*123456789~
GE*1*111111123~
IEA*1*111111123~