ISA*00*Authorizat*00*Security I*ZZ*Interchange Sen*ZZ*Interchange Rec*030326*1037*U*00401*000031033*0*T*:
GS*HC*Sample Sen*Sample Rec*20030326*1037*123456*X*004010X098A1
ST*837*0021
BHT*0019*00*0123*20030315*1023*RP
REF*87*004010X098A1
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23
PER*IC*JERRY*TE*3055552222*EX*231
NM1*40*2*REPRICER XYZ*****46*66783JJT
HL*1**20*1
CUR*85*USD
NM1*85*2*PREMIER BILLING SERVICE*****24*58-7654321
N3*234 Seaway St
N4*Miami*FL*33111
NM1*87*2*KILDARE ASSOC*****24*58-1234567
N3*2345 OCEAN BLVD
N4*MIAMI*FL*33111
HL*2*1*22*0
SBR*P*18*12312-A******HM
NM1*IL*1*SMITH*TED****MI*000221111
N3*236 N MAIN ST
N4*MIAMI*FL*33413
DMG*D8*19430501*M
NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234
CLM*26462967*100***11::1*Y*A*Y*Y*C
DTP*431*D8*20021103
REF*D9*17312345600006351
HI*BK:0340*BF:V7389
NM1*82*1*KILDARE*BEN****34*112233334
PRV*PE*ZZ*203BF0100X
NM1*77*2*KILDARE ASSOCIATES*****24*58-1234567
N3*2345 OCEAN BLVD
N4*MIAMI*FL*33111
LX*1
SV1*HC:J1540*40*UN*1***1
DTP*472*D8*20021003
LX*2
SV1*HC:J1645*15*UN*1***1
DTP*472*D8*20021003
LX*3
SV1*HC:C1815*35*UN*1***2
DTP*472*D8*20021003
LX*4
SV1*HC:C1815*10*UN*1***2
DTP*472*D8*20021010
SE*43*0021
GE*1*123456
IEA*1*000031033