ISA*00* *00* *33*87726 *ZZ*TSTSUB1 *110302*1501*¬*00501*061145958*1*T*:~ GS*HP*87726*TSTSUB1*20110302*15010830*61145958*X*005010X221~ ST*835*1 ~ BPR*H*0*C*NON************20110202~ TRN*1*RZ90000310*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110202~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*OLDSMAR SERVICE CENTER*PO BOX 30555~ N4*SALT LAKE CITY*UT*841300555~ 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*1122333341~ N3*PO BOX 12345~ N4*LOS ANGELES*CA*900840000~ REF*TJ*999111111~ LX*1~ TS3*111222333*11*20111231*2*0~ CLP*TP-TESTCLAIM1*22*-4531*-800**13*0000756395 0000006113*11*1**639~ NM1*QC*1*SMITH*JOHN****MI*111222333~ NM1*74*1*SMITH*JAMES****C*986555673~ REF*1L*708302~ REF*CE*CHOYC+~ REF*BB*4394939870~ DTM*232*20101208~ DTM*050*20110104~ SVC*NU:0120*-1000*-250**1*NU:0121~ DTM*472*20101208~ CAS*CO*45*-500~ CAS*PR*2*-250~ SVC*NU:0300*-1000*-400**1~ DTM*472*20101208~ CAS*CO*45*-200~ CAS*PR*2*-400~ SVC*NU:0250*-1200*-100**0~ DTM*472*20101208~ CAS*CO*45*-1000~ CAS*PR*2*-100~ SVC*NU:0300*-1231*0**0*NU:0360~ DTM*472*20101208~ CAS*CO*97*-1231~ SVC*NU:0121*-100*-50**1*NU:0120~ DTM*472*20101208~ CAS*PR*2*-50~ CLP*TP-TESTCLAIM2*1*4531*800*800*13*0000756395 0000006394*11*1**639~ NM1*QC*1*SMITH*JOHN****MI*111222333~ NM1*74*1*SMITH*JAMES****C*986555673~ REF*1L*708302~ REF*F8*0000756395 0000006113~ REF*CE*CHOYC+~ DTM*232*20101208~ DTM*050*20110104~ AMT*AU*5531~ SVC*NU:0121*1000*250**1~ DTM*472*20101208~ CAS*CO*45*500~ CAS*PR*2*250~ REF*6R*000005~ AMT*B6*500~ SVC*NU:0300*1000*400**1~ DTM*472*20101208~ CAS*CO*45*200~ CAS*PR*2*400~ REF*6R*000002~ AMT*B6*800~ SVC*NU:0250*1200*100**0~ DTM*472*20101208~ CAS*CO*45*1000~ CAS*PR*2*100~ REF*6R*000003~ AMT*B6*200~ SVC*NU:0300*1231*0**0*NU:0360~ DTM*472*20101208~ CAS*CO*97*1231~ REF*6R*000004~ SVC*NU:0120*100*50**1~ DTM*472*20101208~ CAS*PR*2*50~ REF*6R*000001~ AMT*B6*100~ SE*80*1 ~ ST*835*2 ~ BPR*I*929.6*C*CHK************20110201~ TRN*1*RZ30007299*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*P O BOX 740800~ N4*ATLANTA*GA*303740800~ REF*2U*87726~ PER*CX*TAMPA SERVICE CENTER*TE*8775553210~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*CHICAGO*IL*606940000~ REF*TJ*999111123~ LX*1~ TS3*111333666*13*20111231*2*3526.45~ CLP*TP-TESTCLAIM17*1*1500*472*100*14*0000762568 0000002977*13*1~ NM1*QC*1*SMITH*JUNE~ NM1*IL*1*JONES*JAMES****MI*999251110~ REF*1L*705789~ REF*CE*SEL/EPO~ DTM*232*20110117~ DTM*050*20110124~ AMT*AU*1500~ SVC*HC:99282*500*472*0450*1~ DTM*472*20110117~ CAS*CO*94*-72~ CAS*PR*3*100~ REF*6R*0001~ AMT*B6*572~ SVC*HC:99282*500*0*0450*0*NU:0320~ DTM*472*20110117~ CAS*CO*97*500~ REF*6R*0002~ SVC*HC:99282*500*0*0450*0*NU:0250~ DTM*472*20110117~ CAS*CO*97*500~ REF*6R*0003~ CLP*TP-TESTCLAIM18*1*2026.45*457.6*114.4*13*0000762672 0000000328*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251110~ NM1*74*1*JONES*JAMES****C*995555303~ REF*1L*717292~ REF*CE*CHOYC+~ DTM*232*20110111~ DTM*050*20110124~ AMT*AU*2026.45~ SVC*HC:12011*850.43*457.6*0450*1~ DTM*472*20110111~ CAS*CO*45*278.43~ CAS*PR*2*114.4~ REF*6R*000001~ AMT*B6*572~ SVC*HC:12011*850.44*0*0450*0~ DTM*472*20110111~ CAS*CO*97*850.44~ REF*6R*000002~ SVC*HC:12011*56.56*0*0450*0*NU:0250~ DTM*472*20110111~ CAS*CO*97*56.56~ REF*6R*000003~ SVC*HC:12011*17.5*0*0450*0*NU:0258~ DTM*472*20110111~ CAS*CO*97*17.5~ REF*6R*000004~ SVC*HC:12011*251.52*0*0450*1*NU:0272~ DTM*472*20110111~ CAS*CO*97*251.52~ REF*6R*000005~ SE*70*2 ~ ST*835*3 ~ BPR*I*2934*C*CHK************20110201~ TRN*1*RZ30007298*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*OLDSMAR SERVICE CENTER*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*1122333341~ N3*PO BOX 12345~ N4*PITTSBURGH*PA*152640000~ REF*TJ*999111124~ LX*1~ TS3*111333777*11*20111231*1*125859.2~ CLP*TP-TESTCLAIM19*1*125859.2*2934*2738*13*0000762566 0000004431*11*1**303~ NM1*QC*1*SMITH*JOHN~ NM1*IL*1*JONES*JAMES****MI*999251111~ NM1*74*1*SMITH*JOHN****C*992555974~ REF*CE*CHOYC+~ REF*1L*195910~ DTM*232*20110108~ DTM*233*20110117~ DTM*050*20110124~ AMT*AU*125859.2~ SVC*NU:0111*9072*1854**9~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*197*5850**94*-1250~ CAS*PR*2*206**3*90**96*2322~ REF*6R*000001~ AMT*B6*8000~ LQ*HE*N174~ LQ*HE*N385~ SVC*NU:0250*25680.6*1080**1~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*45*24480.6~ CAS*PR*2*120~ REF*6R*000002~ AMT*B6*1200~ SVC*NU:0250*1710*0**0*NU:0255~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*1710~ REF*6R*000003~ SVC*NU:0250*17268.5*0**0*NU:0258~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*17268.5~ REF*6R*000004~ SVC*NU:0250*3143.9*0**0*NU:0270~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*3143.9~ REF*6R*000005~ SVC*NU:0250*1231.9*0**0*NU:0271~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*1231.9~ REF*6R*000006~ SVC*NU:0250*4717.3*0**0*NU:0272~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*4717.3~ REF*6R*000007~ SVC*NU:0250*3433.2*0**0*NU:0278~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*3433.2~ REF*6R*000008~ SVC*NU:0250*13373.2*0**0*NU:0300~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*13373.2~ REF*6R*000009~ SVC*NU:0250*1932.4*0**0*NU:0310~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*1932.4~ REF*6R*000010~ SVC*NU:0250*2106.4*0**0*NU:0320~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*2106.4~ REF*6R*000011~ SVC*NU:0250*6737.6*0**0*NU:0350~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*6737.6~ REF*6R*000012~ SVC*NU:0250*11523.8*0**0*NU:0360~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*11523.8~ REF*6R*000013~ SVC*NU:0250*1627.5*0**0*NU:0370~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*1627.5~ REF*6R*000014~ SVC*NU:0250*754.7*0**0*NU:0402~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*754.7~ REF*6R*000015~ SVC*NU:0250*1253.7*0**0*NU:0420~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*1253.7~ REF*6R*000016~ SVC*NU:0250*644.2*0**0*NU:0424~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*644.2~ REF*6R*000017~ SVC*NU:0111*2775.6*0**1*NU:0450~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*2775.6~ REF*6R*000018~ SVC*NU:0111*5900.3*0**1*NU:0636~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*5900.3~ REF*6R*000019~ SVC*NU:0111*1128.8*0**0*NU:0710~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*1128.8~ REF*6R*000020~ SVC*NU:0111*9843.6*0**0*NU:0750~ DTM*150*20110108~ DTM*151*20110117~ CAS*CO*97*9843.6~ REF*6R*000021~ SE*139*3 ~ ST*835*4 ~ BPR*I*482*C*BOP**01*124384877*DA*0*1411289245*PE0087726*01*124384877*DA*62431XXXX*20110207~ TRN*1*RZ00006924*1411289245*PE0087726~ REF*EV*TSTSUB1~ DTM*405*20110202~ 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*1122333341~ N3*PO BOX 12345~ N4*HOUSTON*TX*772160000~ REF*TJ*999111112~ LX*1~ TS3*111222444*13*20111231*1*3000~ CLP*TP-TESTCLAIM3*1*3000*482*150*13*0000762679 0000002016*13*1~ NM1*QC*1*SMITH*JUNE~ NM1*IL*1*SMITH*JAMES****MI*999251099~ REF*1L*215930~ REF*CE*CHOYC+~ DTM*232*20110118~ DTM*050*20110124~ AMT*AU*3000~ SVC*HC:99283*1000*482*0450*1~ DTM*472*20110118~ CAS*CO*45*368~ CAS*PR*3*150~ REF*6R*000001~ AMT*B6*632~ SVC*HC:99283*1000*0*0450*0~ DTM*472*20110118~ CAS*CO*97*1000~ REF*6R*000002~ SVC*HC:99283*1000*0*0450*0*NU:0250~ DTM*472*20110118~ CAS*CO*97*1000~ REF*6R*000003~ SE*40*4 ~ ST*835*5 ~ BPR*I*90*C*BOP**01*124384877*DA*0*1411289245*PE0087726*01*124384877*DA*62431XXXX*20110207~ TRN*1*RZ00006922*1411289245*PE0087726~ REF*EV*TSTSUB1~ DTM*405*20110202~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*TAMPA SERVICE CENTER*P O BOX 740800~ N4*ATLANTA*GA*303740800~ REF*2U*87726~ PER*CX*TAMPA SERVICE CENTER*TE*8775553210~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*PHILADELPHIA*PA*191820000~ REF*TJ*999111113~ LX*1~ TS3*111222555*13*20111231*2*600~ CLP*TP-TESTCLAIM4*2*200*90**13*0000760551 0000017492*13*1~ CAS*OA*23*10~ NM1*QC*1*SMITH*JOHN****MI*999251100~ NM1*74*1*JONES*JAMES*D***C*988555217~ REF*1L*242326~ REF*CE*SEL+POS~ DTM*232*20101225~ DTM*050*20110115~ AMT*AU*200~ SVC*NU:0300*200*100**0~ DTM*472*20101225~ CAS*CO*45*100~ REF*6R*000001~ AMT*B6*100~ CLP*TP-TESTCLAIM5*1*400*0*400*13*0000762324 0000017491*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251101~ NM1*74*1*JONES*JAMES*D***C*981555176~ REF*1L*242326~ REF*CE*CHOYC+~ DTM*232*20110101~ DTM*050*20110123~ SVC*NU:0500*200*0**0*NU:0250~ DTM*472*20110101~ CAS*PR*22*200~ REF*6R*000001~ LQ*HE*N36~ SVC*NU:0300*100*0**0~ DTM*472*20110101~ CAS*PR*22*100~ REF*6R*000002~ LQ*HE*N36~ SVC*NU:0500*100*0**0*NU:0990~ DTM*472*20110101~ CAS*PR*22*100~ REF*6R*000003~ LQ*HE*N36~ SE*54*5 ~ ST*835*6 ~ BPR*I*250*C*CHK************20110201~ TRN*1*RZ30007297*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*TAMPA SERVICE CENTER*P O BOX 740800~ N4*ATLANTA*GA*303740800~ REF*2U*87726~ PER*CX*TAMPA SERVICE CENTER*TE*8775553210~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*WACONIA*MN*553870000~ REF*TJ*999111113~ LX*1~ TS3*111333888*11*20111231*2*2000~ CLP*TP-TESTCLAIM20*2*1000*250**13*0000762508 0000017449*11*1**639~ CAS*OA*23*750~ NM1*QC*1*SMITH*JOHN****MI*999251111~ NM1*74*1*JONES*JAMES*D***C*985555357~ REF*CE*SEL+POS~ REF*1L*242326~ DTM*232*20110121~ DTM*233*20110125~ DTM*050*20110125~ AMT*AU*1000~ CLP*TP-TESTCLAIM21*2*1000*0*250*13*0000762509 0000017450*11*1**639~ CAS*OA*23*750~ CAS*PR*96*250~ NM1*QC*1*SMITH*JOHN****MI*999251111~ NM1*74*1*JONES*JAMES*D***C*985555357~ MIA*0****N536***************M86~ REF*CE*SEL+POS~ REF*1L*242326~ DTM*232*20110121~ DTM*233*20110125~ DTM*050*20110126~ SE*39*6 ~ ST*835*7 ~ BPR*H*0*C*NON************20110218~ TRN*1*RZ90001085*1411490988*000094265~ REF*EV*TSTSUB1~ DTM*405*20110218~ N1*PR*MEDICA INSURANCE COMPANY~ N3*PO BOX 30990~ N4*SALT LAKE CITY*UT*841300990~ REF*2U*94265~ PER*CX*MEDICA*TE*8005555512~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*WEST FARGO*ND*580780000~ REF*TJ*999111126~ LX*1~ TS3*111333999*11*20111231*1*150~ CLP*TP-TESTCLAIM22*1*150*0*100.98*13*0004102087 0000107294*11~ NM1*QC*1*SMITH*JUNE****MI*999251112~ NM1*74*1*JONES*JANE~ REF*CE*CHOICE~ REF*1L*4J2116~ DTM*232*20101127~ DTM*050*20110215~ SVC*HC:99213*150*0**1~ DTM*472*20101127~ CAS*CO*45*49.02~ CAS*PR*1*70.98**3*30~ REF*6R*000001~ AMT*B6*100.98~ SE*31*7 ~ ST*835*8 ~ BPR*H*0*C*NON************20110214~ TRN*1*RZ90001084*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110214~ N1*PR*MEDICA INSURANCE COMPANY~ N3*PO BOX 30990~ N4*SALT LAKE CITY*UT*841300990~ REF*2U*87726~ PER*CX*MEDICA*TE*8005555512~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*ANOKA*MN*553030000~ REF*TJ*999111127~ LX*1~ TS3*111444111*13*20111231*1*255~ CLP*TP-TESTCLAIM23*1*255*0*255*13*0003101453 0000107292*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251113~ NM1*74*1*JONES*JAMES*R***C*823555327~ REF*CE*CHOICE~ REF*1L*2H9531~ DTM*232*20110129~ DTM*050*20110205~ SVC*NU:0999*255*0**1*NU:0911~ DTM*472*20110129~ CAS*PR*1*255~ REF*6R*000001~ AMT*B6*255~ SE*30*8 ~ ST*835*9 ~ BPR*I*668.16*C*BOP**01*124384877*DA*0*1411289245*PE0087726*01*124384877*DA*62431XXXX*20110207~ TRN*1*RZ00006918*1411289245*PE0087726~ REF*EV*TSTSUB1~ DTM*405*20110202~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*SPRINGFIELD SERVICE CENTER*P O BOX 30555~ N4*SALT LAKE CITY*UT*841300555~ 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*1122333341~ N3*PO BOX 12345~ N4*WACONIA*MN*553870000~ REF*TJ*999111114~ LX*1~ TS3*111222666*13*20111231*1*1393~ CLP*TP-TESTCLAIM6*1*1393*668.16*167.04*12*0000762624 0000017226*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251102~ NM1*74*1*SNITH*JAMES****C*988555255~ REF*1L*704075~ REF*CE*OPT/PPO~ DTM*232*20110119~ DTM*050*20110124~ AMT*AU*1393~ SVC*HC:36415*20*11.52*0300*11~ DTM*472*20110119~ CAS*CO*45*5.6~ CAS*PR*2*2.88~ REF*6R*000001~ AMT*B6*14.4~ SVC*HC:80053*210*120.96*0301*0~ DTM*472*20110119~ CAS*CO*45*58.8~ CAS*PR*2*30.24~ REF*6R*000002~ AMT*B6*151.2~ SVC*HC:36415*106*0*0300*0*NU:0301~ DTM*472*20110119~ CAS*CO*97*106~ REF*6R*000003~ SVC*HC:82607*193*111.17*0301*0~ DTM*472*20110119~ CAS*CO*45*54.04~ CAS*PR*2*27.79~ REF*6R*000004~ AMT*B6*138.96~ SVC*HC:82728*260*149.76*0301*0~ DTM*472*20110119~ CAS*CO*45*72.8~ CAS*PR*2*37.44~ REF*6R*000005~ AMT*B6*187.2~ SVC*HC:82746*167*96.19*0301*0~ DTM*472*20110119~ CAS*CO*45*46.76~ CAS*PR*2*24.05~ REF*6R*000006~ AMT*B6*120.24~ SVC*HC:83540*160*92.16*0301*0~ DTM*472*20110119~ CAS*CO*45*44.8~ CAS*PR*2*23.04~ REF*6R*000007~ AMT*B6*115.2~ SVC*HC:36415*40*0*0300*0*NU:0301~ DTM*472*20110119~ CAS*CO*97*40~ REF*6R*000008~ SVC*HC:84439*75*43.2*0301*0~ DTM*472*20110119~ CAS*CO*45*21~ CAS*PR*2*10.8~ REF*6R*000009~ AMT*B6*54~ SVC*HC:84443*75*43.2*0301*0~ DTM*472*20110119~ CAS*CO*45*21~ CAS*PR*2*10.8~ REF*6R*000010~ AMT*B6*54~ SVC*HC:36415*87*0*0300*0*NU:0305~ DTM*472*20110119~ CAS*CO*97*87~ REF*6R*000011~ SE*86*9 ~ ST*835*10 ~ BPR*I*1540*C*CHK************20110214~ TRN*1*RZ00330330*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110214~ N1*PR*MEDICA SELF-INSURED - A THIRD PARTY ADMINISTRATOR FOR SELF-F~ N3*MEDICA*PO BOX 30990~ N4*SALT LAKE CITY*UT*841300990~ REF*2U*87726~ PER*CX*MEDICA*TE*8005555512~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*ANOKA*MN*553030000~ REF*TJ*999111128~ LX*1~ TS3*111444222*13*20111231*1*4200~ CLP*TP-TESTCLAIM24*1*4200*1540*2660*12*0003101452 0000197651*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251114~ NM1*74*1*JONES*JAMES*S***C*850555912~ REF*CE*CHOICEP~ REF*1L*712926~ DTM*232*20110203~ DTM*050*20110205~ AMT*AU*4200~ SVC*NU:0999*4200*1540**1*HC:90806~ DTM*472*20110203~ CAS*PR*1*2000**2*660~ REF*6R*000001~ AMT*B6*4200~ SE*31*10 ~ ST*835*11 ~ BPR*I*100*C*CHK************20110214~ TRN*1*RZ05000861*1411490988*000094265~ REF*EV*TSTSUB1~ DTM*405*20110214~ N1*PR*MEDICA INSURANCE COMPANY~ N3*PO BOX 30990~ N4*SALT LAKE CITY*UT*841300990~ REF*2U*94265~ PER*CX*MEDICA*TE*8005555512~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*WEST FARGO*ND*580780000~ REF*TJ*999111129~ LX*1~ TS3*111444333*11*20111231*1*150~ CLP*TP-TESTCLAIM25*1*150*100*100.98*13*0004102083 0000107291*11~ NM1*QC*1*SMITH*JUNE****MI*999251115~ NM1*74*1*JONES*ROXANNE*M***C*902555804~ REF*CE*CHOICE~ REF*1L*4J2116~ DTM*232*20101122~ DTM*050*20110210~ AMT*AU*150~ SVC*HC:99213*150*100**1~ DTM*472*20101122~ CAS*CO*94*-50.98~ CAS*PR*1*100.98~ REF*6R*000001~ AMT*B6*150~ SE*32*11 ~ ST*835*12 ~ BPR*H*0*C*NON************20110217~ TRN*1*RZ00026324*1411490988*PE0094265~ REF*EV*TSTSUB1~ DTM*405*20110214~ N1*PR*MEDICA~ N3*MEDICA*PO BOX 30990~ N4*SALT LAKE CITY*UT*841300990~ REF*2U*94265~ PER*CX*MEDICA*TE*8005555512~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*SIOUX FALLS*SD*571170000~ REF*TJ*999111130~ LX*1~ TS3*111444555*11*20111231*1*100~ CLP*TP-TESTCLAIM26*1*100*0*100*13*0004102085 0000013055*11~ NM1*QC*1*SMITH*JOHN****MI*999251116~ NM1*74*1*JONES*JAMES*L***C*908555985~ REF*1L*708550~ REF*CE*CHOICEP~ DTM*232*20110131~ DTM*050*20110207~ SVC*HC:99214*100*0**1~ DTM*472*20110131~ CAS*PR*1*100~ REF*6R*000001~ AMT*B6*100~ SE*30*12 ~ ST*835*14 ~ BPR*I*1000*C*CHK************20110202~ TRN*1*RZ30007310*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110202~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*OLDSMAR SERVICE CENTER*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*1122333341~ N3*PO BOX 12345~ N4*DANSVILLE*NY*144370000~ REF*TJ*999111116~ LX*1~ TS3*111222888*13*20111231*1*2200~ CLP*TP-TESTCLAIM8*1*2200*1000*350*12*0000757110 0000004442*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251104~ NM1*74*1*JONES*JAMES****C*989555876~ REF*CE*OPT/PPO~ REF*1L*195910~ DTM*232*20101217~ DTM*050*20110105~ AMT*AU*2200~ SVC*NU:0450*1200*740.74**1~ DTM*472*20101217~ CAS*CO*45*200~ CAS*PR*2*185.19**3*74.07~ REF*6R*000001~ AMT*B6*1000~ SVC*NU:0271*500*259.26**0~ DTM*472*20101217~ CAS*CO*45*150~ CAS*PR*2*64.81**3*25.93~ REF*6R*000002~ AMT*B6*350~ SVC*NU:0450*500*0**0*NU:0983~ DTM*472*20101217~ CAS*CO*97*500~ REF*6R*000003~ SE*42*14 ~ ST*835*15 ~ BPR*H*0*C*NON************20110214~ TRN*1*RZ90001083*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110214~ N1*PR*MEDICA INSURANCE COMPANY~ N3*PO BOX 30990~ N4*SALT LAKE CITY*UT*841300990~ REF*2U*87726~ PER*CX*MEDICA*TE*8005555512~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*DULUTH*MN*558110000~ REF*TJ*999111131~ LX*1~ TS3*111444666*11*20111231*1*150~ CLP*TP-TESTCLAIM27*1*150*0*150*13*0004102074 0000107293*11~ NM1*QC*1*SMITH*JOHN****MI*999251117~ NM1*74*1*JONES*JAMES*L***C*863555825~ REF*CE*CHOICE~ REF*1L*4H0646~ DTM*232*20110124~ DTM*050*20110205~ SVC*HC:90801*150*0**1~ DTM*472*20110124~ CAS*PR*1*150~ REF*6R*000001~ AMT*B6*150~ SE*30*15 ~ ST*835*17 ~ BPR*I*2940*C*CHK************20110216~ TRN*1*RZ00330331*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110216~ N1*PR*MEDICA SELF-INSURED - A THIRD PARTY ADMINISTRATOR FOR SELF-F~ N3*MEDICA*PO BOX 30990~ N4*SALT LAKE CITY*UT*841300990~ REF*2U*87726~ PER*CX*MEDICA*TE*8005555512~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*ANOKA*MN*553030000~ REF*TJ*999111133~ LX*1~ TS3*111444888*13*20111231*1*4200~ CLP*TP-TESTCLAIM29*1*4200*2940*1260*12*0003101347 0000197652*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251119~ NM1*74*1*JONES*JAMES*S***C*850555912~ REF*CE*CHOICEP~ REF*1L*712926~ DTM*232*20110115~ DTM*050*20110117~ AMT*AU*3940~ SVC*NU:0999*4200*2940**1*HC:90806~ DTM*472*20110115~ CAS*PR*2*1260~ REF*6R*000001~ AMT*B6*4200~ SE*31*17 ~ ST*835*18 ~ BPR*I*441.6*C*BOP**01*124384877*DA*0*1411289245*PE0087726*01*124384877*DA*62431XXXX*20110204~ TRN*1*RZ00006893*1411289245*PE0087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*TAMPA SERVICE CENTER*P.O. BOX 740800~ N4*ATLANTA*GA*303740800~ REF*2U*87726~ PER*CX*TAMPA SERVICE CENTER*TE*8775553210~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*MCHENRY*IL*600510000~ REF*TJ*999111117~ LX*1~ TS3*111222999*13*20111231*1*1067.04~ CLP*TP-TESTCLAIM9*1*1067.04*441.6*110.4*13*0000762670 0000000327*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251105~ NM1*74*1*JONES*JAMES****C*995555303~ REF*CE*CHOYC+~ REF*1L*717292~ DTM*232*20110114~ DTM*050*20110124~ AMT*AU*1041.6~ SVC*HC:97110*91.02*441.6*0420*1~ DTM*472*20110114~ CAS*CO*94*-460.98~ CAS*PR*2*110.4~ REF*6R*000001~ AMT*B6*552~ SVC*HC:97110*95.22*0*0420*0~ DTM*472*20110114~ CAS*CO*97*95.22~ REF*6R*000002~ SVC*HC:97110*78.42*0*0420*0~ DTM*472*20110114~ CAS*CO*97*78.42~ REF*6R*000003~ SVC*HC:97110*156.84*0*0420*0~ DTM*472*20110114~ CAS*CO*97*156.84~ REF*6R*000004~ SVC*HC:97110*95.22*0*0420*0~ DTM*472*20110114~ CAS*CO*97*95.22~ REF*6R*000005~ SVC*HC:97110*95.22*0*0420*0~ DTM*472*20110114~ CAS*CO*97*95.22~ REF*6R*000006~ SVC*HC:97110*91.02*0*0420*0~ DTM*472*20110114~ CAS*CO*97*91.02~ REF*6R*000007~ SVC*HC:97110*78.42*0*0420*0~ DTM*472*20110114~ CAS*CO*97*78.42~ REF*6R*000008~ SVC*HC:97110*285.66*0*0420*0*NU:0430~ DTM*472*20110114~ CAS*CO*97*285.66~ REF*6R*000009~ SE*64*18 ~ ST*835*19 ~ BPR*I*1992*C*BOP**01*124384877*DA*0*1411289245*PE0087726*01*124384877*DA*62431XXXX*20110204~ TRN*1*RZ00006890*1411289245*PE0087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*TAMPA SERVICE CENTER*P.O. BOX 740800~ N4*ATLANTA*GA*303740800~ REF*2U*87726~ PER*CX*TAMPA SERVICE CENTER*TE*8775553210~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*FORT WORTH*TX*761910000~ REF*TJ*999111118~ LX*1~ TS3*111333111*11*20111231*1*3061~ CLP*TP-TESTCLAIM10*1*3061*1992*498*13*0000762577 0000000329*11*1**305~ NM1*QC*1*SMITH*JOHN****MI*999251106~ NM1*74*1*JONES*JAMES****C*984555222~ REF*1L*717292~ REF*CE*CHOYC+~ DTM*232*20110117~ DTM*233*20110122~ DTM*050*20110124~ AMT*AU*2992~ SVC*NU:0120*1948*1558.4**5*NU:0112~ DTM*150*20110117~ DTM*151*20110122~ CAS*PR*2*389.6~ REF*6R*000001~ AMT*B6*1948~ SVC*NU:0120*191*0**1*NU:0300~ DTM*150*20110117~ DTM*151*20110122~ CAS*CO*97*191~ REF*6R*000002~ SVC*NU:0120*193*0**0*NU:0302~ DTM*150*20110117~ DTM*151*20110122~ CAS*CO*97*193~ REF*6R*000003~ SVC*NU:0120*110*0**0*NU:0305~ DTM*150*20110117~ DTM*151*20110122~ CAS*CO*97*110~ REF*6R*000004~ SVC*NU:0120*77*0**0*NU:0306~ DTM*150*20110117~ DTM*151*20110122~ CAS*CO*97*77~ REF*6R*000005~ SVC*HC:36012*542*433.6*0450*1~ DTM*150*20110117~ DTM*151*20110122~ CAS*PR*2*108.4~ REF*6R*000006~ AMT*B6*542~ SE*59*19 ~ ST*835*20 ~ BPR*I*396*C*CHK************20110201~ TRN*1*RZ30005283*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*SPRINGFIELD SERVICE CENTER*P O BOX 30555~ N4*SALT LAKE CITY*UT*84130~ 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*1122333341~ N3*PO BOX 12345~ N4*CHICAGO*IL*606940000~ REF*TJ*999111119~ LX*1~ TS3*111333222*13*20111231*1*1750~ CLP*TP-TESTCLAIM11*1*1750*396*54*13*0000762572 0000001309*13*1~ NM1*QC*1*SMITH*JUNE~ NM1*IL*1*SMITH*JAMES****MI*999251106~ REF*CE*SEL+POS~ REF*1L*140000~ DTM*232*20110116~ DTM*050*20110124~ AMT*AU*1596~ SVC*HC:78585*1000*0*0341*1~ DTM*472*20110116~ CAS*CO*197*1000~ REF*6R*000001~ LQ*HE*N54~ SVC*NU:0256*250*126**1~ DTM*472*20110116~ CAS*CO*45*100~ CAS*PR*2*14**3*10~ REF*6R*000002~ AMT*B6*150~ SVC*NU:0250*500*270**1~ DTM*472*20110116~ CAS*CO*45*200~ CAS*PR*2*30~ REF*6R*000003~ AMT*B6*300~ SE*43*20 ~ ST*835*21 ~ BPR*I*2610*C*CHK************20110201~ TRN*1*RZ30005282*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*TAMPA SERVICE CENTER*P O BOX 740800~ N4*ATLANTA*GA*303740800~ REF*2U*87726~ PER*CX*TAMPA SERVICE CENTER*TE*8775553210~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*CHICAGO*IL*606940000~ REF*TJ*999111120~ LX*1~ TS3*111333333*11*20111231*1*3000~ CLP*TP-TESTCLAIM12*1*3000*2610*390*13*0000762570 0002189261*11*1**282~ NM1*QC*1*SMITH*JUNE*C~ NM1*IL*1*SMITH*JAMES*C**SR*MI*999251107~ NM1*74*1*JONES*JIMMY***JR~ REF*CE*SEL+POS~ REF*1L*126997~ DTM*232*20110117~ DTM*050*20110124~ AMT*AU*2460~ SVC*NU:0121*1000*810**1~ DTM*472*20110117~ CAS*PR*2*90**3*100~ REF*6R*0001~ AMT*B6*1000~ SVC*NU:0250*1000*1800**1~ DTM*472*20110117~ CAS*CO*94*-1000~ CAS*PR*2*200~ REF*6R*0002~ AMT*B6*2000~ SVC*NU:0250*1000*0**0*NU:0320~ DTM*472*20110117~ CAS*CO*97*1000~ REF*6R*0003~ SE*42*21 ~ ST*835*22 ~ BPR*I*2070.52*C*CHK************20110201~ TRN*1*RZ30005281*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*BUFFALO SERVICE CENTER*PO BOX 30555~ N4*SALT LAKE CITY*UT*841300555~ REF*2U*87726~ PER*CX*BUFFALO SERVICE CENTER*TE*8775553210~ PER*BL**UR*WWW.UNITEDHEALTHCAREONLINE.COM/B2C/CONTACTUS.DO~ N1*PE*UHG GENERIC COMMUNITY HOSPITAL*XX*1122333341~ N3*PO BOX 12345~ N4*CHICAGO*IL*606940000~ REF*TJ*999111121~ LX*1~ TS3*111333444*11*20111231*1*20907.52~ CLP*TP-TESTCLAIM13*1*20907.52*2070.52*887.37*13*0000762571 0000002165*11*1**305~ NM1*QC*1*SMITH*JOHN****MI*999251107~ REF*CE*CHOYC+~ REF*1L*701182~ DTM*232*20110117~ DTM*233*20110123~ DTM*050*20110124~ AMT*AU*18370.52~ SVC*NU:0112*1833.26*2070.52**2~ DTM*150*20110117~ DTM*151*20110118~ CAS*CO*94*-1124.63~ CAS*PR*2*887.37~ REF*6R*0001~ AMT*B6*2957.89~ SVC*NU:0112*6668.16*0**4*NU:0122~ DTM*150*20110119~ DTM*151*20110123~ CAS*CO*97*6668.16~ REF*6R*0002~ SVC*NU:0112*2720.55*0**1*NU:0259~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*2720.55~ REF*6R*0003~ SVC*NU:0112*902.94*0**0*NU:0270~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*902.94~ REF*6R*0004~ SVC*NU:0112*150.15*0**0*NU:0272~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*150.15~ REF*6R*0005~ SVC*NU:0112*18.8*0**0*NU:0300~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*18.8~ REF*6R*0006~ SVC*NU:0112*113*0**0*NU:0305~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*113~ REF*6R*0007~ SVC*NU:0112*70.7*0**0*NU:0306~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*70.7~ REF*6R*0008~ SVC*NU:0112*27.8*0**0*NU:0307~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*27.8~ REF*6R*0009~ SVC*NU:0112*341.14*0**0*NU:0310~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*341.14~ REF*6R*0010~ SVC*NU:0112*3444.63*0**0*NU:0360~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*3444.63~ REF*6R*0011~ SVC*NU:0112*1667*0**0*NU:0361~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*1667~ REF*6R*0012~ SVC*NU:0112*2810.47*0**0*NU:0370~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*2810.47~ REF*6R*0013~ SVC*NU:0112*138.92*0**0*NU:0710~ DTM*150*20110117~ DTM*151*20110123~ CAS*CO*97*138.92~ REF*6R*0014~ SE*98*22 ~ ST*835*23 ~ BPR*H*0*C*NON************20110201~ TRN*1*RZ80005557*1411289245*000087726~ REF*EV*TSTSUB1~ DTM*405*20110201~ N1*PR*UNITEDHEALTHCARE INSURANCE COMPANY~ N3*SPRINGFIELD SERVICE CENTER*P O BOX 30555~ N4*SALT LAKE CITY*UT*841300555~ 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*1122333341~ N4*LOS ANGELES*CA*900840000~ REF*TJ*999111122~ LX*1~ TS3*111333555*13*20111231*3*4800~ CLP*TP-TESTCLAIM14*1*1600*0*1600*15*0000762558 0000000204*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251108~ NM1*74*1*JONES*JAMES****C*986555700~ REF*F8*0000762558 0000000203~ REF*CE*IND~ REF*1L*879146~ DTM*232*20101210~ DTM*050*20110101~ SVC*NU:0500*900*0**1*NU:0360~ DTM*472*20101210~ CAS*PI*94*-700~ CAS*PR*227*1600~ REF*6R*000001~ LQ*HE*MA130~ SVC*NU:0500*500*0**0*NU:0259~ DTM*472*20101210~ CAS*PI*97*500~ REF*6R*000002~ SVC*NU:0500*200*0**0*NU:0636~ DTM*472*20101210~ CAS*PI*97*200~ REF*6R*000003~ CLP*TP-TESTCLAIM15*1*1600*0*1600*15*0000762559 0000000205*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251109~ NM1*74*1*JONES*JAMES****C*986555700~ REF*1L*879146~ REF*CE*IND~ REF*F8*0000762559 0000000203~ DTM*232*20101210~ DTM*050*20110101~ SVC*NU:0500*900*0**1*NU:0360~ DTM*472*20101210~ CAS*PI*94*-700~ CAS*PR*227*1600~ REF*6R*000001~ LQ*HE*MA130~ SVC*NU:0500*500*0**0*NU:0259~ DTM*472*20101210~ CAS*PI*97*500~ REF*6R*000002~ SVC*NU:0500*200*0**0*NU:0636~ DTM*472*20101210~ CAS*PI*97*200~ REF*6R*000003~ CLP*TP-TESTCLAIM16*1*1600*0*1600*15*0000762560 0000000206*13*1~ NM1*QC*1*SMITH*JOHN****MI*999251109~ NM1*74*1*JONES*JAMES****C*985550700~ REF*1L*879146~ REF*CE*IND~ REF*F8*0000762560 0000000203~ DTM*232*20101210~ DTM*050*20110101~ SVC*NU:0500*900*0**1*NU:0360~ DTM*472*20101210~ CAS*PI*94*-700~ CAS*PR*227*1600~ REF*6R*000001~ LQ*HE*MA130~ SVC*NU:0500*500*0**0*NU:0259~ DTM*472*20101210~ CAS*PI*97*500~ REF*6R*000002~ SVC*NU:0500*200*0**0*NU:0636~ DTM*472*20101210~ CAS*PI*97*200~ REF*6R*000003~ SE*83*23 ~ GE*21*61145958~ IEA*1*061145958~