ISA*00*          *00*          *33*87726          *ZZ*TSTSUB1        *110603*1252*!*00501*154125236*1*T*:~GS*HP*87726*TSTSUB1*20110603*12523790*154125236*X*005010X221A1~ST*835*24  ~BPR*H*0*C*NON************20110503~TRN*1*RZ00333615*1987654321*PE0087726~REF*EV*TSTSUB1~DTM*405*20110428~N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~N3*P O BOX 740800~N4*ATLANTA*GA*303740800~REF*2U*87726~PER*CX*OLDSMAR SERVICE CENTER*TE*8775553210~PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1876543210~N3*PO BOX 12345~N4*ANYTOWN*OH*451110000~REF*TJ*999911134~LX*1~TS3*1123456789*81*20111231*4*1026.25~CLP*PATIENT26*1*266.4*0*266.4*13*0004102425 0002190625*81~NM1*QC*1*SMITH*JAMES****MI*999111222~NM1*74*1*JONES*JOHN~MOA***MA15~REF*1L*126997~REF*G1*1073691440~REF*CE*CHOYC+~DTM*232*20101005~DTM*050*20110420~SVC*HC:80061*121.4*0**1~DTM*472*20101005~CAS*PR*100*97.12**2*24.28~REF*6R*01~AMT*B6*121.4~SVC*HC:36415*18.45*0**1~DTM*472*20101005~CAS*PR*100*14.76**2*3.69~REF*6R*02~AMT*B6*18.45~SVC*HC:81001*45.3*0**1~DTM*472*20101005~CAS*PR*100*36.24**2*9.06~REF*6R*03~AMT*B6*45.3~SVC*HC:85025*35.95*0**1~DTM*472*20101005~CAS*PR*100*28.76**2*7.19~REF*6R*04~AMT*B6*35.95~SVC*HC:82248*17.7*0**1~DTM*472*20101005~CAS*PR*100*14.16**2*3.54~REF*6R*05~AMT*B6*17.7~SVC*HC:80053*27.6*0**1~DTM*472*20101005~CAS*PR*100*22.08**2*5.52~REF*6R*06~AMT*B6*27.6~CLP*PATIENT27*1*191.9*0*191.9*13*0004102429 0000004409*81~NM1*QC*1*SMITH*BILL~NM1*IL*1*JONES*WILLIAM****MI*999111222~NM1*74*1*JONES*JANET~REF*G1*1043261316~REF*1L*715014~REF*CE*CHOYC+~DTM*232*20101004~DTM*050*20110420~SVC*HC:87046*59.05*0**1~DTM*472*20101004~CAS*PR*1*59.05~REF*6R*01~AMT*B6*59.05~SVC*HC:87045*40.45*0**1~DTM*472*20101004~CAS*PR*1*40.45~REF*6R*02~AMT*B6*40.45~SVC*HC:87427*92.4*0**1~DTM*472*20101004~CAS*PR*1*92.4~REF*6R*03~AMT*B6*92.4~CLP*PATIENT28*1*357*0*357*13*0004102431 0000004410*81~NM1*QC*1*SMITH*JANET~NM1*IL*1*JONES*JAMES****MI*999111222~NM1*74*1*JONES*JIMMY~REF*G1*1073607909~REF*CE*CHOYC+~REF*1L*715014~DTM*232*20100917~DTM*050*20110420~SVC*HC:87209*114.3*0**1~DTM*472*20100917~CAS*PR*1*114.3~REF*6R*01~AMT*B6*114.3~SVC*HC:87177*22.7*0**1~DTM*472*20100917~CAS*PR*1*22.7~REF*6R*02~AMT*B6*22.7~SVC*HC:82489*129.84*0**1~DTM*472*20100917~CAS*PR*1*129.84~REF*6R*03~AMT*B6*129.84~SVC*HC:83735*45.08*0**1~DTM*472*20100917~CAS*PR*1*45.08~REF*6R*04~AMT*B6*45.08~SVC*HC:84100*45.08*0**1~DTM*472*20100917~CAS*PR*1*45.08~REF*6R*05~AMT*B6*45.08~CLP*PATIENT29*1*210.95*0*210.95*13*0004102423 0000004687*81~NM1*QC*1*SMITH*JANE****MI*999111222~NM1*74*1*JONES*JANET~REF*G1*1174586143~REF*CE*CHOYC+~REF*1L*704419~DTM*232*20100929~DTM*050*20110420~SVC*HC:87205*28.56*0**1~DTM*472*20100929~CAS*PR*1*28.56~REF*6R*01~AMT*B6*28.56~SVC*HC:87075*119.46*0**1~DTM*472*20100929~CAS*PR*1*119.46~REF*6R*02~AMT*B6*119.46~SVC*HC:87070*62.93*0**1~DTM*472*20100929~CAS*PR*1*62.93~REF*6R*03~AMT*B6*62.93~SE*138*24  ~ST*835*25  ~BPR*H*0*C*NON************20110503~TRN*1*RZ00333614*1987654321*PE0087726~REF*EV*TSTSUB1~DTM*405*20110428~N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~N3*OLDSMAR SERVICE CENTER*PO BOX 740800~N4*ATLANTA*GA*303740800~REF*2U*87726~PER*CX*OLDSMAR SERVICE CENTER*TE*8775553210~PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1876543210~N3*PO BOX 12345~N4*ANYTOWN*TN*381110000~REF*TJ*999911135~LX*1~TS3*1123456789*81*20111231*1*103.74~CLP*PATIENT30*1*103.74*0*24*13*0004102408 0000000129*81~NM1*QC*1*SMITH*JANICE~NM1*IL*1*JONES*JANET****MI*999111222~NM1*74*1*JONES*JOHN~NM1*82*2*UHC   DIAGNOSTICS CLINICAL LA*****XX*1122333341~REF*G1*1265516488~REF*1L*229614~REF*CE*CHOYC+~DTM*232*20100929~DTM*050*20110420~SVC*HC:85025*34.2*0**1~DTM*472*20100929~CAS*PI*45*20.2~CAS*PR*100*11.2**2*2.8~REF*6R*01~AMT*B6*14~SVC*HC:85610*29.9*0**1~DTM*472*20100929~CAS*PI*45*19.9~CAS*PR*100*8**2*2~REF*6R*02~AMT*B6*10~SVC*HC:80048*39.64*0**1~DTM*472*20100929~CAS*PI*45*39.64~REF*6R*03~SE*44*25  ~ST*835*26  ~BPR*H*0*C*NON************20110503~TRN*1*RZ00333618*1987654321*PE0087726~REF*EV*TSTSUB1~DTM*405*20110428~N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~N3*P O BOX 740800~N4*ATLANTA*GA*303740800~REF*2U*87726~PER*CX*SPRINGFIELD SERVICE CENTER*TE*8775553210~PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1876543210~N3*PO BOX 12345~N4*ANYTOWN*OH*451110000~REF*TJ*999911136~LX*1~TS3*1123456789*81*20111231*6*1564.72~CLP*PATIENT31*1*571.66*0*100*13*0004102422 0002190627*81~NM1*QC*1*SMITH*JOHN~NM1*IL*1*JONES*JAMES****MI*999111222~MOA***MA15~REF*1L*126997~REF*CE*CHOYC+~REF*G1*1780698779~DTM*232*20100928~DTM*050*20110420~SVC*HC:36415*18.45*0**1~DTM*472*20100928~CAS*PI*45*8.45~CAS*PR*100*8**2*2~REF*6R*01~AMT*B6*10~SVC*HC:84702*110*0**1~DTM*472*20100928~CAS*PI*45*60~CAS*PR*100*35**2*15~REF*6R*02~AMT*B6*50~SVC*HC:86703*85*0**1~DTM*472*20100928~CAS*PI*45*45~CAS*PR*100*36**2*4~REF*6R*03~AMT*B6*40~SVC*HC:80055*344.65*0**1~DTM*472*20100928~CAS*PI*45*344.65~REF*6R*04~SVC*HC:83891*1.84*0**1~DTM*472*20100928~CAS*PI*45*1.84~REF*6R*05~SVC*HC:83909*11.72*0**1~DTM*472*20100928~CAS*PI*45*11.72~REF*6R*06~CLP*PATIENT32*1*358.8*0*358.8*12*0004102426 0002190626*81~NM1*QC*1*SMITH*JANE****MI*999111222~REF*G1*1194799676~REF*1L*126997~REF*CE*OPT/PPO~DTM*232*20100930~DTM*050*20110420~SVC*HC:36415*18.45*0**1~DTM*472*20100930~CAS*PR*1*18.45~REF*6R*01~AMT*B6*18.45~SVC*HC:85025*35.95*0**1~DTM*472*20100930~CAS*PR*1*35.95~REF*6R*02~AMT*B6*35.95~SVC*HC:86710*304.4*0**2~DTM*472*20100930~CAS*PR*1*268**45*36.4~REF*6R*03~AMT*B6*268~CLP*PATIENT33*1*166.45*0*166.45*13*0004102424 0000004407*81~NM1*QC*1*SMITH*JANET~NM1*IL*1*JONES*JAMES****MI*999111222~REF*1L*715014~REF*CE*CHOYC+~REF*G1*1710929864~DTM*232*20101001~DTM*050*20110420~SVC*HC:36415*18.45*0**1~DTM*472*20101001~CAS*PR*1*18.45~REF*6R*01~AMT*B6*18.45~SVC*HC:86304*148*0**1~DTM*472*20101001~CAS*PR*1*148~REF*6R*02~AMT*B6*148~CLP*PATIENT34*1*128.45*0*128.45*13*0004102428 0000004408*81~NM1*QC*1*SMITH*JANEY~NM1*IL*1*JONES*JAYNE****MI*999111222~REF*G1*1922290188~REF*CE*CHOYC+~REF*1L*715014~DTM*232*20101005~DTM*050*20110420~SVC*HC:36415*18.45*0**1~DTM*472*20101005~CAS*PR*1*18.45~REF*6R*01~AMT*B6*18.45~SVC*HC:84702*110*0**1~DTM*472*20101005~CAS*PR*1*110~REF*6R*02~AMT*B6*110~CLP*PATIENT35*1*110.71*0*110.71*14*0004102427 0000016068*81~NM1*QC*1*SMITH*JANICE~NM1*IL*1*JONES*JAMES****MI*999111222~REF*G1*1083679880~REF*1L*184109~REF*CE*CHOYC~DTM*232*20100929~DTM*050*20110420~SVC*HC:85025*35.95*0**1~DTM*472*20100929~CAS*PR*100*32.36**2*3.59~REF*6R*01~AMT*B6*35.95~SVC*HC:81001*21.25*0**1~DTM*472*20100929~CAS*PR*100*19.12**2*2.13~REF*6R*02~AMT*B6*21.25~SVC*HC:80053*53.51*0**1~DTM*472*20100929~CAS*PR*100*48.16**2*5.35~REF*6R*03~AMT*B6*53.51~CLP*PATIENT36*1*228.65*0*228.65*13*0004102430 0000030493*81~NM1*QC*1*SMITH*JAMES****MI*999111222~REF*G1*1912987512~REF*CE*CHOYC+~REF*1L*704077~DTM*232*20101004~DTM*050*20110420~SVC*HC:83036*57*0**1~DTM*472*20101004~CAS*PR*100*45.6**2*11.4~REF*6R*01~AMT*B6*57~SVC*HC:84153*115*0**1~DTM*472*20101004~CAS*PR*100*92**2*23~REF*6R*02~AMT*B6*115~SVC*HC:82570*13.81*0**1~DTM*472*20101004~CAS*PR*100*11.05**2*2.76~REF*6R*03~AMT*B6*13.81~SVC*HC:82043*42.84*0**1~DTM*472*20101004~CAS*PR*100*34.27**2*8.57~REF*6R*04~AMT*B6*42.84~SE*165*26  ~ST*835*27  ~BPR*H*0*C*NON************20110503~TRN*1*RZ00333617*1987654321*PE0087726~REF*EV*TSTSUB1~DTM*405*20110428~N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~N3*GREENSBORO SERVICE CENTER*P O BOX 740800~N4*ATLANTA*GA*303740800~REF*2U*87726~PER*CX*GREENSBORO SERVICE CENTER*TE*8775553210~PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1876543210~N3*PO BOX 12345~N4*ANYTOWN*OH*451110000~REF*TJ*999911137~LX*1~TS3*1123456789*81*20111231*1*60.4~CLP*PATIENT37*1*60.4*0*60.4*12*0004102404 0000021053*81~NM1*QC*1*SMITH*JANE~NM1*IL*1*JONES*JAMES****MI*999111222~NM1*74*1*JONES*JIMMY~NM1*82*2*UHC*****XX*1122333341~REF*1L*196484~REF*CE*OPT/PPO~REF*G1*1326269440~DTM*232*20100927~DTM*050*20110420~SVC*HC:87070*60.4*0**1~DTM*472*20100927~CAS*PR*1*60.4~REF*6R*01~AMT*B6*60.4~SE*33*27  ~ST*835*28  ~BPR*H*0*C*NON************20110503~TRN*1*RZ00333616*1987654321*PE0087726~REF*EV*TSTSUB1~DTM*405*20110428~N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~N3*P O BOX 740800~N4*ATLANTA*GA*303740800~REF*2U*87726~PER*CX*OLDSMAR SERVICE CENTER*TE*8775553210~PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1876543210~N3*PO BOX 12345~N4*ANYTOWN*TN*381110000~REF*TJ*999911138~LX*1~TS3*1123456789*81*20111231*4*755.4~CLP*PATIENT38*1*60.4*0*60.4*12*0004102405 0000021054*81~NM1*QC*1*SMITH*JOHN~NM1*IL*1*JONES*JANET****MI*999111222~NM1*82*2*UHC   DIAGNOSTICS CLINICAL LA*****XX*1122333341~REF*1L*196484~REF*G1*1467665554~REF*CE*OPT/PPO~DTM*232*20100930~DTM*050*20110420~SVC*HC:87070*60.4*0**1~DTM*472*20100930~CAS*PR*1*60.4~REF*6R*01~AMT*B6*60.4~CLP*PATIENT39*1*335.75*0*335.75*13*0004102406 0000004611*81~NM1*QC*1*SMITH*JAN~NM1*IL*1*JONES*JAMES****MI*999111222~NM1*82*2*UHC   DIAGNOSTICS CLINICAL LA*****XX*1122333341~REF*G1*1235107301~REF*1L*228763~REF*CE*CHOYC+~DTM*232*20100927~DTM*050*20110420~SVC*HC:86038*65*0**1~DTM*472*20100927~CAS*PR*1*65~REF*6R*01~AMT*B6*65~SVC*HC:85652*28.45*0**1~DTM*472*20100927~CAS*PR*1*28.45~REF*6R*02~AMT*B6*28.45~SVC*HC:36415*15.9*0**1~DTM*472*20100927~CAS*PR*1*15.9~REF*6R*03~AMT*B6*15.9~SVC*HC:86431*45*0**1~DTM*472*20100927~CAS*PR*1*40.65**100*3.92**2*.43~REF*6R*04~AMT*B6*45~SVC*HC:86039*71.4*0**1~DTM*472*20100927~CAS*PR*100*64.26**2*7.14~REF*6R*05~AMT*B6*71.4~SVC*HC:86021*110*0**1~DTM*472*20100927~CAS*PR*100*99**2*11~REF*6R*06~AMT*B6*110~CLP*PATIENT40*1*201.7*0*8*13*0004102407 0000031769*81~NM1*QC*1*SMITH*JANICE~NM1*IL*1*JONES*JANET****MI*999111222~NM1*74*1*JONSES*JANE~NM1*82*2*UHC   DIAGNOSTICS CLINICAL LA*****XX*1122333341~REF*G1*1740243187~REF*CE*CHOYC+~REF*1L*185002~DTM*232*20100927~DTM*050*20110420~SVC*HC:87088*28.15*0**1~DTM*472*20100927~CAS*PI*45*20.15~CAS*PR*1*8~REF*6R*01~AMT*B6*8~SVC*HC:87086*49*0**1~DTM*472*20100927~CAS*PI*45*49~REF*6R*02~SVC*HC:81001*41.4*0**1~DTM*472*20100927~CAS*PI*45*41.4~REF*6R*03~SVC*HC:87077*28.15*0**1~DTM*472*20100927~CAS*PI*45*28.15~REF*6R*04~SVC*HC:87186*55*0**1~DTM*472*20100927~CAS*PI*45*55~REF*6R*05~CLP*PATIENT41*1*157.55*0*157.55*13*0004102409 0000016067*81~NM1*QC*1*SMITH*JAMES****MI*999111222~NM1*82*2*UHC   DIAGNOSTICS CLINICAL LA*****XX*1122333341~REF*1L*182019~REF*CE*CHOYC+~REF*G1*1346311073~DTM*232*20101005~DTM*050*20110420~SVC*HC:82728*96.05*0**1~DTM*472*20101005~CAS*PR*1*96.05~REF*6R*01~AMT*B6*96.05~SVC*HC:83540*30.01*0**1~DTM*472*20101005~CAS*PR*1*30.01~REF*6R*02~AMT*B6*30.01~SVC*HC:83550*31.49*0**1~DTM*472*20101005~CAS*PR*1*31.49~REF*6R*03~AMT*B6*31.49~SE*126*28  ~GE*5*154125236~IEA*1*154125236~