Summary Table
Categories |
Total Count |
PII |
0 |
URL |
0 |
DNS |
0 |
EKL |
0 |
IP |
0 |
PORT |
0 |
VsID |
0 |
CF |
0 |
AI |
0 |
VPD |
0 |
PL |
0 |
Other |
0 |
File Content
ISA*00* *00* *ZZ*999999999 *ZZ*121150001 *180819*2003*$*00501*000000001*0*P*:~
GS*HC*999999999*121150001*20180819*200359*0001*X*005010X223A2~
ST*837*000000001*005010X223A2~
BHT*0019*00*12345678*20180818*200359*CH~
NM1*41*2*EMDEON*****46*999999999~
PER*IC*EMDEON CUSTOMER SOLUTIONS*TE*3211231234~
NM1*40*2*VETERANS ADMINISTRATION*****46*121150001~
HL*1**20*1~
PRV*BI*PXC*123PRVTAXCODEX~
NM1*85*2*BILLING PROVIDER NAME*****XX*99999999999~
N3*123 FAKE ST~
N4*PALM BAY*FL*329079998~
REF*EI*123123123~
PER*IC*CLAIMS CLEARINGHOUSE*EM*CLAIMSCLEARINGHOUSE@EMAILADDRESS.COM~
NM1*87*2~
N3*123 PAY TO ADDRESS LN~
N4*PALM BAY*FL*329079998~
HL*2*1*22*0~
SBR*S*18*VA******VA~
NM1*IL*1*PATIENT*JOHN*T***MI*999999999~
N3*123 PATIENT LANE~
N4*PALM BAY*FL*32907~
DMG*D8*19810101*M~
NM1*PR*2*VETERANS ADMINISTRATION*****PI*12115~
CLM*PATCTRL999*4056.22***13:A:1**A*Y*Y~
DTP*434*RD8*20181031-20181031~
CL1*1*2*01~
REF*EA*M9999999~
REF*D9*999999999999999~
HI*ABK:R1084~
HI*APR:R109~
HI*ABF:Z87442~
HI*BH:11:D8:20180731~
NM1*71*1*PROVIDER*ATTENDING***MD*XX*9999999999~
NM1*82*1*PROVIDER*RENDERING***MD*XX*9999999999~
SBR*P*18*00000099******BL~
CAS*CO*45*1880.59**97*241.45~
CAS*PR*1*750**2*236.84~
AMT*EAF*986.84~
AMT*D*947.34~
OI***Y***Y~
NM1*IL*1*SUBSCRIBER*OTHER*T***MI*9999999999999~
N3*123 FAKE DR~
N4*PALM BAY*FL*32907~
NM1*PR*2*BLUE CROSS*****PI*99999~
DTP*573*D8*20181217~
REF*F8*CLMCTRL99999~
LX*1~
SV2*0250**95.9*UN*2~
DTP*472*D8*20181131~
REF*6R*999999.20181131.1~
LX*2~
SV2*0254*HC:Q9967*93.3*UN*100~
DTP*472*D8*20181131~
REF*6R*999999.20181131.2~
LX*3~
SV2*0258*HC:J7030*67.35*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.3~
LX*4~
SV2*0260*HC:96361:59*41.4*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.4~
LX*5~
SV2*0260*HC:96374:59*200.05*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.5~
LX*6~
SV2*0300*HC:36415*18.3*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.6~
LX*7~
SV2*0301*HC:80053*99.15*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.7~
LX*8~
SV2*0305*HC:85025*49.7*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.8~
LX*9~
SV2*0307*HC:81003*23.2*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.9~
LX*10~
SV2*0352*HC:74177*2284.4*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.10~
LX*11~
SV2*0450*HC:99284:25*1004.85*UN*1~
DTP*472*D8*20181131~
REF*6R*999999.20181131.11~
LX*12~
SV2*0636*HC:J1885*49.77*UN*2~
DTP*472*D8*20181131~
REF*6R*999999.20181131.12~
LX*13~
SV2*0636*HC:Q0162*28.85*UN*4~
DTP*472*D8*20181131~
REF*6R*999999.20181131.13~
SE*98*000000001~
GE*1*0001~
IEA*1*000000001~