ISA*00* *00* *ZZ*19311 *ZZ*CLAIMMD *240902*0209*^*00401*009020256*1*P*:~
GS*HC*19311*CLAIMMD*20240902*0209*120264701*X*005010X222A1~
ST*837*49731*005010X222A1~
BHT*0019*00*202647*20210818*0939*CH~
NM1*41*2*ANVICARE*****46*582628754~
PER*IC*QUOC NGUYEN*TE*2813250208*EM*QDN@ANVICARE.COM*FX*2813130925~
NM1*40*2*MCO AETNA MMCP SC*****46*68024~
HL*1**20*1~
PRV*BI*PXC*376J00000X~
NM1*85*2*MEDICAL GEAR LLC~
N3*3501 ALGONQUIN RD SUITE 560~
N4*ROLLING MEADOWS*IL*600083103~
REF*EI*870758683~
PER*IC*MEDICAL GEAR LLC*TE*8005551212~
HL*2*1*22*0~
SBR*P*18*******CI~
NM1*IL*1*CHANDLER  DRIVER*JOYCE****MI*016013245~
N3*1813 W.ELLEN ~
N4*CHICAGO*IL*60622~
DMG*D8*19480219*F~
NM1*PR*2*MCO AETNA MMCP SC*****PI*68024~
N3*AETNA BETTER HEALTH OF ILLINOI~
N4*PHOENIX*AZ*85082~
REF*G2*870758683912~
CLM*68024*1096.99***12:B:1*Y*A*Y*Y*P~
REF*G1*DY2204251542482~
REF*D9*73629855~
HI*ABK:R6889~
SE*57*49731~
GE*1*120264701~
IEA*1*001202647~
