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GS*HC*19311*CLAIMMD*20240918*1009*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*ROSA*JOSE****MI*155290075~
N3*722 CLAIM STREET ~
N4*AURORA*IL*60505~
DMG*D8*19630819*M~
NM1*PR*2*MCO AETNA MMCP SC*****PI*68024~
N3*AETNA BETTER HEALTH OF ILLINOI~
N4*PHOENIX*AZ*85082~
REF*G2*870758683902~
CLM*68024*2457.00***12:B:1*Y*A*Y*Y*P~
REF*G1*~
REF*D9*73629855~
HI*ABK:R6889~
LX*1~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240619-20240619~
REF*6R*7362985501~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*2~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240620-20240620~
REF*6R*7362985502~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*3~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240621-20240621~
REF*6R*7362985503~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*4~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240624-20240624~
REF*6R*7362985504~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*5~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240625-20240625~
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NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*6~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240626-20240626~
REF*6R*7362985506~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*7~
SV1*HC:S5130:::::HOMAKER SRVC*112.32*UN*16*12**1~
DTP*472*RD8*20240611-20240611~
REF*6R*7362985501~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*8~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240612-20240612~
REF*6R*7362985502~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*9~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240613-20240613~
REF*6R*7362985503~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*10~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240614-20240614~
REF*6R*7362985504~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*11~
SV1*HC:S5130:::::HOMAKER SRVC*238.68*UN*34*12**1~
DTP*472*RD8*20240617-20240617~
REF*6R*7362985505~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*12~
SV1*HC:S5130:::::HOMAKER SRVC*126.36*UN*18*12**1~
DTP*472*RD8*20240618-20240618~
REF*6R*7362985506~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*13~
SV1*HC:S5130:::::HOMAKER SRVC*112.32*UN*16*12**1~
DTP*472*RD8*20240603-20240603~
REF*6R*7362985501~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*14~
SV1*HC:S5130:::::HOMAKER SRVC*98.28*UN*14*12**1~
DTP*472*RD8*20240604-20240604~
REF*6R*7362985502~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*15~
SV1*HC:S5130:::::HOMAKER SRVC*112.32*UN*16*12**1~
DTP*472*RD8*20240605-20240605~
REF*6R*7362985503~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*16~
SV1*HC:S5130:::::HOMAKER SRVC*112.32*UN*16*12**1~
DTP*472*RD8*20240606-20240606~
REF*6R*7362985504~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*17~
SV1*HC:S5130:::::HOMAKER SRVC*112.32*UN*16*12**1~
DTP*472*RD8*20240607-20240607~
REF*6R*7362985505~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*18~
SV1*HC:S5130:::::HOMAKER SRVC*112.32*UN*16*12**1~
DTP*472*RD8*20240610-20240610~
REF*6R*7362985506~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*19~
SV1*HC:S5130:::::HOMAKER SRVC*112.32*UN*16*12**1~
DTP*472*RD8*20240627-20240627~
REF*6R*7362985501~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
LX*20~
SV1*HC:S5130:::::HOMAKER SRVC*70.20*UN*10*12**1~
DTP*472*RD8*20240628-20240628~
REF*6R*7362985502~
NTE*ADD*HOMEMAKER SERVICE  NOS  PER 15 MINUTES~
SE*57*49731~
GE*1*120264701~
IEA*1*001202647~
