Remittances / 99900004301

Fernhollow Community Care

Payment 99900004301, paper check dated Aug 3, 2026. From FCC_835_0.edi, imported Aug 4, 2026 by Dana Whitfield.

Balances to the cent

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Payments dated Aug 3, 2026 to Aug 3, 2026, as of Oct 6, 2026. Whole organization, every site.

Payment

$12,468.30

Paper check

Claims

52 matched to billed claims

Claim payments

$12,468.30

Before provider adjustments

Provider adjustments

$0.00

Interest added, recoveries taken

Claims in this payment

Matched to what was billed and checked against the contract rate.

Claim	Match	Result	Charged	Allowed	Paid	Patient	At stake
RHP100201	Claim number matched exactly	Denied	$576.00	$0.00	$0.00	$0.00	$187.20
RHP100202 Superseded by a later result	Claim number matched exactly	Denied	$449.00	$0.00	$0.00	$0.00	$145.86
RHP101000	Claim number matched exactly	Paid as expected	$269.00	$87.36	$87.36	$0.00
RHP101001	Claim number matched exactly	Paid as expected	$528.00	$171.60	$171.60	$0.00
RHP101002	Claim number matched exactly	Paid as expected	$449.00	$145.86	$145.86	$0.00
RHP101003	Claim number matched exactly	Paid as expected	$2,520.00	$819.00	$819.00	$0.00
RHP101004	Claim number matched exactly	Denied	$140.00	$0.00	$0.00	$0.00	$45.24
RHP101005	Claim number matched exactly	Paid as expected	$576.00	$187.20	$187.20	$0.00
RHP101006	Claim number matched exactly	Paid as expected	$310.00	$100.62	$100.62	$0.00
RHP101007	Claim number matched exactly	Paid as expected	$338.00	$109.98	$109.98	$0.00
RHP101008	Claim number matched exactly	Paid as expected	$228.00	$74.10	$74.10	$0.00
RHP101009	Claim number matched exactly	Paid as expected	$1,728.00	$561.60	$561.60	$0.00
RHP101010	Claim number matched exactly	Paid as expected	$319.00	$103.74	$103.74	$0.00
RHP101011	Claim number matched exactly	Paid as expected	$624.00	$202.80	$202.80	$0.00
RHP101012	Claim number matched exactly	Paid as expected	$240.00	$78.00	$78.00	$0.00
RHP101013	Claim number matched exactly	Paid as expected	$3,480.00	$1,131.00	$1,131.00	$0.00
RHP101014	Claim number matched exactly	Paid as expected	$439.00	$142.74	$142.74	$0.00
RHP101015	Claim number matched exactly	Paid as expected	$912.00	$296.40	$296.40	$0.00
RHP101016	Claim number matched exactly	Paid as expected	$269.00	$87.36	$87.36	$0.00
RHP101017	Claim number matched exactly	Denied	$528.00	$0.00	$0.00	$0.00	$171.60
RHP101018	Claim number matched exactly	Paid as expected	$449.00	$145.86	$145.86	$0.00
RHP101019	Claim number matched exactly	Paid as expected	$2,520.00	$819.00	$819.00	$0.00
RHP101020	Claim number matched exactly	Paid as expected	$140.00	$45.24	$45.24	$0.00
RHP101021	Claim number matched exactly	Paid as expected	$576.00	$187.20	$187.20	$0.00
RHP101022	Claim number matched exactly	Paid as expected	$310.00	$100.62	$100.62	$0.00
RHP101023	Claim number matched exactly	Paid as expected	$338.00	$109.98	$109.98	$0.00
RHP101024	Claim number matched exactly	Paid as expected	$228.00	$74.10	$74.10	$0.00
RHP101025	Claim number matched exactly	Paid as expected	$1,728.00	$561.60	$561.60	$0.00
RHP101026	Claim number matched exactly	Paid as expected	$319.00	$103.74	$103.74	$0.00
RHP101027	Claim number matched exactly	Paid as expected	$624.00	$202.80	$202.80	$0.00
RHP101028	Claim number matched exactly	Paid as expected	$240.00	$78.00	$78.00	$0.00
RHP101029	Claim number matched exactly	Paid as expected	$3,480.00	$1,131.00	$1,131.00	$0.00
RHP101030	Claim number matched exactly	Denied	$439.00	$0.00	$0.00	$0.00	$142.74
RHP101031	Claim number matched exactly	Paid as expected	$912.00	$296.40	$296.40	$0.00
RHP101032	Claim number matched exactly	Paid as expected	$269.00	$87.36	$87.36	$0.00
RHP101033	Claim number matched exactly	Paid as expected	$528.00	$171.60	$171.60	$0.00
RHP101034	Claim number matched exactly	Paid as expected	$449.00	$145.86	$145.86	$0.00
RHP101035	Claim number matched exactly	Paid as expected	$2,520.00	$819.00	$819.00	$0.00
RHP101036	Claim number matched exactly	Paid as expected	$140.00	$45.24	$45.24	$0.00
RHP101037	Claim number matched exactly	Paid as expected	$576.00	$187.20	$187.20	$0.00
RHP101038	Claim number matched exactly	Paid as expected	$310.00	$100.62	$100.62	$0.00
RHP101039	Claim number matched exactly	Paid as expected	$338.00	$109.98	$109.98	$0.00
RHP101040	Claim number matched exactly	Paid as expected	$228.00	$74.10	$74.10	$0.00
RHP101041	Claim number matched exactly	Paid as expected	$1,728.00	$561.60	$561.60	$0.00
RHP101042	Claim number matched exactly	Paid as expected	$319.00	$103.74	$103.74	$0.00
RHP101043	Claim number matched exactly	Denied	$624.00	$0.00	$0.00	$0.00	$202.80
RHP101044	Claim number matched exactly	Paid as expected	$240.00	$78.00	$78.00	$0.00
RHP101045	Claim number matched exactly	Paid as expected	$3,480.00	$1,131.00	$1,131.00	$0.00
RHP101046	Claim number matched exactly	Paid as expected	$439.00	$142.74	$142.74	$0.00
RHP101047	Claim number matched exactly	Paid as expected	$912.00	$296.40	$296.40	$0.00
RHP101048	Claim number matched exactly	Paid as expected	$269.00	$87.36	$87.36	$0.00
RHP101049	Claim number matched exactly	Paid as expected	$528.00	$171.60	$171.60	$0.00

Scroll sideways to see every column.

The payer's remittance file (835)

Payer ID 99904. Payee RIDGELINE HEALTH PARTNERS, NPI 9999999001. Transaction 0001, 644 segments.

Show the raw file (648 segments)

1  ISA*00*          *00*          *ZZ*PAYER99904     *ZZ*RIDGELINE999   *260802*0800*^*00501*000000100*0*T*:
2  GS*HP*PAYER99904*RIDGELINE999*20260802*0800*100*X*005010X221A1
3  ST*835*0001
4  BPR*I*12468.3*C*CHK************20260803
5  TRN*1*99900004301*1999999904
6  DTM*405*20260802
7  N1*PR*FERNHOLLOW COMMUNITY CARE
8  REF*2U*99904
9  N1*PE*RIDGELINE HEALTH PARTNERS*XX*9999999001
10  REF*TJ*999999999
11  LX*1
12  CLP*RHP100201*4*576*0*0*MC*999044301001*11*1
13  NM1*QC*1*SYNTHETIC*PATIENT100201****MI*ZZ0100201
14  DTM*232*20260718
15  DTM*233*20260718
16  SVC*HC:64483*576*0**1
17  DTM*472*20260718
18  CAS*CO*50*576
19  REF*6R*RHP100201-1
20  AMT*B6*0
21  LQ*HE*N130
22  LX*2
23  CLP*RHP100202*4*449*0*0*MC*999044301002*11*1
24  NM1*QC*1*SYNTHETIC*PATIENT100202****MI*ZZ0100202
25  DTM*232*20260720
26  DTM*233*20260720
27  SVC*HC:99204*408*0**1
28  DTM*472*20260720
29  CAS*CO*16*408
30  REF*6R*RHP100202-1
31  AMT*B6*0
32  LQ*HE*MA130
33  SVC*HC:93000*41*0**1
34  DTM*472*20260720
35  CAS*CO*16*41
36  REF*6R*RHP100202-2
37  AMT*B6*0
38  LQ*HE*MA130
39  LX*3
40  CLP*RHP101000*1*269*87.36*0*MC*999044301003*11*1
41  NM1*QC*1*SYNTHETIC*PATIENT101000****MI*ZZ0101000
42  DTM*232*20260722
43  DTM*233*20260722
44  SVC*HC:99203*269*87.36**1
45  DTM*472*20260722
46  CAS*CO*45*181.64
47  REF*6R*RHP101000-1
48  AMT*B6*87.36
49  LX*4
50  CLP*RHP101001*1*528*171.6*0*MC*999044301004*11*1
51  NM1*QC*1*SYNTHETIC*PATIENT101001****MI*ZZ0101001
52  DTM*232*20260721
53  DTM*233*20260721
54  SVC*HC:93306*528*171.6**1
55  DTM*472*20260721
56  CAS*CO*45*356.4
57  REF*6R*RHP101001-1
58  AMT*B6*171.6
59  LX*5
60  CLP*RHP101002*1*449*145.86*0*MC*999044301005*11*1
61  NM1*QC*1*SYNTHETIC*PATIENT101002****MI*ZZ0101002
62  DTM*232*20260720
63  DTM*233*20260720
64  SVC*HC:99204*408*132.6**1
65  DTM*472*20260720
66  CAS*CO*45*275.4
67  REF*6R*RHP101002-1
68  AMT*B6*132.6
69  SVC*HC:93000*41*13.26**1
70  DTM*472*20260720
71  CAS*CO*45*27.74
72  REF*6R*RHP101002-2
73  AMT*B6*13.26
74  LX*6
75  CLP*RHP101003*1*2520*819*0*MC*999044301006*11*1
76  NM1*QC*1*SYNTHETIC*PATIENT101003****MI*ZZ0101003
77  DTM*232*20260719
78  DTM*233*20260719
79  SVC*HC:29827*2520*819**1
80  DTM*472*20260719
81  CAS*CO*45*1701
82  REF*6R*RHP101003-1
83  AMT*B6*819
84  LX*7
85  CLP*RHP101004*4*140*0*0*MC*999044301007*11*1
86  NM1*QC*1*SYNTHETIC*PATIENT101004****MI*ZZ0101004
87  DTM*232*20260718
88  DTM*233*20260718
89  SVC*HC:97110*140*0**2
90  DTM*472*20260718
91  CAS*CO*16*140
92  REF*6R*RHP101004-1
93  AMT*B6*0
94  LQ*HE*MA130
95  LX*8
96  CLP*RHP101005*1*576*187.2*0*MC*999044301008*11*1
97  NM1*QC*1*SYNTHETIC*PATIENT101005****MI*ZZ0101005
98  DTM*232*20260717
99  DTM*233*20260717
100  SVC*HC:64483*576*187.2**1
101  DTM*472*20260717
102  CAS*CO*45*388.8
103  REF*6R*RHP101005-1
104  AMT*B6*187.2
105  LX*9
106  CLP*RHP101006*1*310*100.62*0*MC*999044301009*11*1
107  NM1*QC*1*SYNTHETIC*PATIENT101006****MI*ZZ0101006
108  DTM*232*20260716
109  DTM*233*20260716
110  SVC*HC:99213*221*71.76**1
111  DTM*472*20260716
112  CAS*CO*45*149.24
113  REF*6R*RHP101006-1
114  AMT*B6*71.76
115  SVC*HC:90471*41*13.26**1
116  DTM*472*20260716
117  CAS*CO*45*27.74
118  REF*6R*RHP101006-2
119  AMT*B6*13.26
120  SVC*HC:90686*48*15.6**1
121  DTM*472*20260716
122  CAS*CO*45*32.4
123  REF*6R*RHP101006-3
124  AMT*B6*15.6
125  LX*10
126  CLP*RHP101007*1*338*109.98*0*MC*999044301010*11*1
127  NM1*QC*1*SYNTHETIC*PATIENT101007****MI*ZZ0101007
128  DTM*232*20260715
129  DTM*233*20260715
130  SVC*HC:99214*312*101.4**1
131  DTM*472*20260715
132  CAS*CO*45*210.6
133  REF*6R*RHP101007-1
134  AMT*B6*101.4
135  SVC*HC:80053*26*8.58**1
136  DTM*472*20260715
137  CAS*CO*45*17.42
138  REF*6R*RHP101007-2
139  AMT*B6*8.58
140  LX*11
141  CLP*RHP101008*1*228*74.1*0*MC*999044301011*11*1
142  NM1*QC*1*SYNTHETIC*PATIENT101008****MI*ZZ0101008
143  DTM*232*20260714
144  DTM*233*20260714
145  SVC*HC:99213*221*71.76**1
146  DTM*472*20260714
147  CAS*CO*45*149.24
148  REF*6R*RHP101008-1
149  AMT*B6*71.76
150  SVC*HC:36415*7*2.34**1
151  DTM*472*20260714
152  CAS*CO*45*4.66
153  REF*6R*RHP101008-2
154  AMT*B6*2.34
155  LX*12
156  CLP*RHP101009*1*1728*561.6*0*MC*999044301012*11*1
157  NM1*QC*1*SYNTHETIC*PATIENT101009****MI*ZZ0101009
158  DTM*232*20260713
159  DTM*233*20260713
160  SVC*HC:29881*1728*561.6**1
161  DTM*472*20260713
162  CAS*CO*45*1166.4
163  REF*6R*RHP101009-1
164  AMT*B6*561.6
165  LX*13
166  CLP*RHP101010*1*319*103.74*0*MC*999044301013*11*1
167  NM1*QC*1*SYNTHETIC*PATIENT101010****MI*ZZ0101010
168  DTM*232*20260712
169  DTM*233*20260712
170  SVC*HC:99214*312*101.4**1
171  DTM*472*20260712
172  CAS*CO*45*210.6
173  REF*6R*RHP101010-1
174  AMT*B6*101.4
175  SVC*HC:36415*7*2.34**1
176  DTM*472*20260712
177  CAS*CO*45*4.66
178  REF*6R*RHP101010-2
179  AMT*B6*2.34
180  LX*14
181  CLP*RHP101011*1*624*202.8*0*MC*999044301014*11*1
182  NM1*QC*1*SYNTHETIC*PATIENT101011****MI*ZZ0101011
183  DTM*232*20260711
184  DTM*233*20260711
185  SVC*HC:73721*624*202.8**1
186  DTM*472*20260711
187  CAS*CO*45*421.2
188  REF*6R*RHP101011-1
189  AMT*B6*202.8
190  LX*15
191  CLP*RHP101012*1*240*78*0*MC*999044301015*11*1
192  NM1*QC*1*SYNTHETIC*PATIENT101012****MI*ZZ0101012
193  DTM*232*20260710
194  DTM*233*20260710
195  SVC*HC:99213*221*71.76**1
196  DTM*472*20260710
197  CAS*CO*45*149.24
198  REF*6R*RHP101012-1
199  AMT*B6*71.76
200  SVC*HC:85025*19*6.24**1
201  DTM*472*20260710
202  CAS*CO*45*12.76
203  REF*6R*RHP101012-2
204  AMT*B6*6.24
205  LX*16
206  CLP*RHP101013*1*3480*1131*0*MC*999044301016*11*1
207  NM1*QC*1*SYNTHETIC*PATIENT101013****MI*ZZ0101013
208  DTM*232*20260709
209  DTM*233*20260709
210  SVC*HC:27447*3480*1131**1
211  DTM*472*20260709
212  CAS*CO*45*2349
213  REF*6R*RHP101013-1
214  AMT*B6*1131
215  LX*17
216  CLP*RHP101014*1*439*142.74*0*MC*999044301017*11*1
217  NM1*QC*1*SYNTHETIC*PATIENT101014****MI*ZZ0101014
218  DTM*232*20260708
219  DTM*233*20260708
220  SVC*HC:99215*439*142.74**1
221  DTM*472*20260708
222  CAS*CO*45*296.26
223  REF*6R*RHP101014-1
224  AMT*B6*142.74
225  LX*18
226  CLP*RHP101015*1*912*296.4*0*MC*999044301018*11*1
227  NM1*QC*1*SYNTHETIC*PATIENT101015****MI*ZZ0101015
228  DTM*232*20260707
229  DTM*233*20260707
230  SVC*HC:45380*912*296.4**1
231  DTM*472*20260707
232  CAS*CO*45*615.6
233  REF*6R*RHP101015-1
234  AMT*B6*296.4
235  LX*19
236  CLP*RHP101016*1*269*87.36*0*MC*999044301019*11*1
237  NM1*QC*1*SYNTHETIC*PATIENT101016****MI*ZZ0101016
238  DTM*232*20260706
239  DTM*233*20260706
240  SVC*HC:99203*269*87.36**1
241  DTM*472*20260706
242  CAS*CO*45*181.64
243  REF*6R*RHP101016-1
244  AMT*B6*87.36
245  LX*20
246  CLP*RHP101017*4*528*0*0*MC*999044301020*11*1
247  NM1*QC*1*SYNTHETIC*PATIENT101017****MI*ZZ0101017
248  DTM*232*20260705
249  DTM*233*20260705
250  SVC*HC:93306*528*0**1
251  DTM*472*20260705
252  CAS*CO*50*528
253  REF*6R*RHP101017-1
254  AMT*B6*0
255  LQ*HE*N130
256  LX*21
257  CLP*RHP101018*1*449*145.86*0*MC*999044301021*11*1
258  NM1*QC*1*SYNTHETIC*PATIENT101018****MI*ZZ0101018
259  DTM*232*20260722
260  DTM*233*20260722
261  SVC*HC:99204*408*132.6**1
262  DTM*472*20260722
263  CAS*CO*45*275.4
264  REF*6R*RHP101018-1
265  AMT*B6*132.6
266  SVC*HC:93000*41*13.26**1
267  DTM*472*20260722
268  CAS*CO*45*27.74
269  REF*6R*RHP101018-2
270  AMT*B6*13.26
271  LX*22
272  CLP*RHP101019*1*2520*819*0*MC*999044301022*11*1
273  NM1*QC*1*SYNTHETIC*PATIENT101019****MI*ZZ0101019
274  DTM*232*20260721
275  DTM*233*20260721
276  SVC*HC:29827*2520*819**1
277  DTM*472*20260721
278  CAS*CO*45*1701
279  REF*6R*RHP101019-1
280  AMT*B6*819
281  LX*23
282  CLP*RHP101020*1*140*45.24*0*MC*999044301023*11*1
283  NM1*QC*1*SYNTHETIC*PATIENT101020****MI*ZZ0101020
284  DTM*232*20260720
285  DTM*233*20260720
286  SVC*HC:97110*140*45.24**2
287  DTM*472*20260720
288  CAS*CO*45*94.76
289  REF*6R*RHP101020-1
290  AMT*B6*45.24
291  LX*24
292  CLP*RHP101021*1*576*187.2*0*MC*999044301024*11*1
293  NM1*QC*1*SYNTHETIC*PATIENT101021****MI*ZZ0101021
294  DTM*232*20260719
295  DTM*233*20260719
296  SVC*HC:64483*576*187.2**1
297  DTM*472*20260719
298  CAS*CO*45*388.8
299  REF*6R*RHP101021-1
300  AMT*B6*187.2
301  LX*25
302  CLP*RHP101022*1*310*100.62*0*MC*999044301025*11*1
303  NM1*QC*1*SYNTHETIC*PATIENT101022****MI*ZZ0101022
304  DTM*232*20260718
305  DTM*233*20260718
306  SVC*HC:99213*221*71.76**1
307  DTM*472*20260718
308  CAS*CO*45*149.24
309  REF*6R*RHP101022-1
310  AMT*B6*71.76
311  SVC*HC:90471*41*13.26**1
312  DTM*472*20260718
313  CAS*CO*45*27.74
314  REF*6R*RHP101022-2
315  AMT*B6*13.26
316  SVC*HC:90686*48*15.6**1
317  DTM*472*20260718
318  CAS*CO*45*32.4
319  REF*6R*RHP101022-3
320  AMT*B6*15.6
321  LX*26
322  CLP*RHP101023*1*338*109.98*0*MC*999044301026*11*1
323  NM1*QC*1*SYNTHETIC*PATIENT101023****MI*ZZ0101023
324  DTM*232*20260717
325  DTM*233*20260717
326  SVC*HC:99214*312*101.4**1
327  DTM*472*20260717
328  CAS*CO*45*210.6
329  REF*6R*RHP101023-1
330  AMT*B6*101.4
331  SVC*HC:80053*26*8.58**1
332  DTM*472*20260717
333  CAS*CO*45*17.42
334  REF*6R*RHP101023-2
335  AMT*B6*8.58
336  LX*27
337  CLP*RHP101024*1*228*74.1*0*MC*999044301027*11*1
338  NM1*QC*1*SYNTHETIC*PATIENT101024****MI*ZZ0101024
339  DTM*232*20260716
340  DTM*233*20260716
341  SVC*HC:99213*221*71.76**1
342  DTM*472*20260716
343  CAS*CO*45*149.24
344  REF*6R*RHP101024-1
345  AMT*B6*71.76
346  SVC*HC:36415*7*2.34**1
347  DTM*472*20260716
348  CAS*CO*45*4.66
349  REF*6R*RHP101024-2
350  AMT*B6*2.34
351  LX*28
352  CLP*RHP101025*1*1728*561.6*0*MC*999044301028*11*1
353  NM1*QC*1*SYNTHETIC*PATIENT101025****MI*ZZ0101025
354  DTM*232*20260715
355  DTM*233*20260715
356  SVC*HC:29881*1728*561.6**1
357  DTM*472*20260715
358  CAS*CO*45*1166.4
359  REF*6R*RHP101025-1
360  AMT*B6*561.6
361  LX*29
362  CLP*RHP101026*1*319*103.74*0*MC*999044301029*11*1
363  NM1*QC*1*SYNTHETIC*PATIENT101026****MI*ZZ0101026
364  DTM*232*20260714
365  DTM*233*20260714
366  SVC*HC:99214*312*101.4**1
367  DTM*472*20260714
368  CAS*CO*45*210.6
369  REF*6R*RHP101026-1
370  AMT*B6*101.4
371  SVC*HC:36415*7*2.34**1
372  DTM*472*20260714
373  CAS*CO*45*4.66
374  REF*6R*RHP101026-2
375  AMT*B6*2.34
376  LX*30
377  CLP*RHP101027*1*624*202.8*0*MC*999044301030*11*1
378  NM1*QC*1*SYNTHETIC*PATIENT101027****MI*ZZ0101027
379  DTM*232*20260713
380  DTM*233*20260713
381  SVC*HC:73721*624*202.8**1
382  DTM*472*20260713
383  CAS*CO*45*421.2
384  REF*6R*RHP101027-1
385  AMT*B6*202.8
386  LX*31
387  CLP*RHP101028*1*240*78*0*MC*999044301031*11*1
388  NM1*QC*1*SYNTHETIC*PATIENT101028****MI*ZZ0101028
389  DTM*232*20260712
390  DTM*233*20260712
391  SVC*HC:99213*221*71.76**1
392  DTM*472*20260712
393  CAS*CO*45*149.24
394  REF*6R*RHP101028-1
395  AMT*B6*71.76
396  SVC*HC:85025*19*6.24**1
397  DTM*472*20260712
398  CAS*CO*45*12.76
399  REF*6R*RHP101028-2
400  AMT*B6*6.24
401  LX*32
402  CLP*RHP101029*1*3480*1131*0*MC*999044301032*11*1
403  NM1*QC*1*SYNTHETIC*PATIENT101029****MI*ZZ0101029
404  DTM*232*20260711
405  DTM*233*20260711
406  SVC*HC:27447*3480*1131**1
407  DTM*472*20260711
408  CAS*CO*45*2349
409  REF*6R*RHP101029-1
410  AMT*B6*1131
411  LX*33
412  CLP*RHP101030*4*439*0*0*MC*999044301033*11*1
413  NM1*QC*1*SYNTHETIC*PATIENT101030****MI*ZZ0101030
414  DTM*232*20260710
415  DTM*233*20260710
416  SVC*HC:99215*439*0**1
417  DTM*472*20260710
418  CAS*CO*22*439
419  REF*6R*RHP101030-1
420  AMT*B6*0
421  LX*34
422  CLP*RHP101031*1*912*296.4*0*MC*999044301034*11*1
423  NM1*QC*1*SYNTHETIC*PATIENT101031****MI*ZZ0101031
424  DTM*232*20260709
425  DTM*233*20260709
426  SVC*HC:45380*912*296.4**1
427  DTM*472*20260709
428  CAS*CO*45*615.6
429  REF*6R*RHP101031-1
430  AMT*B6*296.4
431  LX*35
432  CLP*RHP101032*1*269*87.36*0*MC*999044301035*11*1
433  NM1*QC*1*SYNTHETIC*PATIENT101032****MI*ZZ0101032
434  DTM*232*20260708
435  DTM*233*20260708
436  SVC*HC:99203*269*87.36**1
437  DTM*472*20260708
438  CAS*CO*45*181.64
439  REF*6R*RHP101032-1
440  AMT*B6*87.36
441  LX*36
442  CLP*RHP101033*1*528*171.6*0*MC*999044301036*11*1
443  NM1*QC*1*SYNTHETIC*PATIENT101033****MI*ZZ0101033
444  DTM*232*20260707
445  DTM*233*20260707
446  SVC*HC:93306*528*171.6**1
447  DTM*472*20260707
448  CAS*CO*45*356.4
449  REF*6R*RHP101033-1
450  AMT*B6*171.6
451  LX*37
452  CLP*RHP101034*1*449*145.86*0*MC*999044301037*11*1
453  NM1*QC*1*SYNTHETIC*PATIENT101034****MI*ZZ0101034
454  DTM*232*20260706
455  DTM*233*20260706
456  SVC*HC:99204*408*132.6**1
457  DTM*472*20260706
458  CAS*CO*45*275.4
459  REF*6R*RHP101034-1
460  AMT*B6*132.6
461  SVC*HC:93000*41*13.26**1
462  DTM*472*20260706
463  CAS*CO*45*27.74
464  REF*6R*RHP101034-2
465  AMT*B6*13.26
466  LX*38
467  CLP*RHP101035*1*2520*819*0*MC*999044301038*11*1
468  NM1*QC*1*SYNTHETIC*PATIENT101035****MI*ZZ0101035
469  DTM*232*20260705
470  DTM*233*20260705
471  SVC*HC:29827*2520*819**1
472  DTM*472*20260705
473  CAS*CO*45*1701
474  REF*6R*RHP101035-1
475  AMT*B6*819
476  LX*39
477  CLP*RHP101036*1*140*45.24*0*MC*999044301039*11*1
478  NM1*QC*1*SYNTHETIC*PATIENT101036****MI*ZZ0101036
479  DTM*232*20260722
480  DTM*233*20260722
481  SVC*HC:97110*140*45.24**2
482  DTM*472*20260722
483  CAS*CO*45*94.76
484  REF*6R*RHP101036-1
485  AMT*B6*45.24
486  LX*40
487  CLP*RHP101037*1*576*187.2*0*MC*999044301040*11*1
488  NM1*QC*1*SYNTHETIC*PATIENT101037****MI*ZZ0101037
489  DTM*232*20260721
490  DTM*233*20260721
491  SVC*HC:64483*576*187.2**1
492  DTM*472*20260721
493  CAS*CO*45*388.8
494  REF*6R*RHP101037-1
495  AMT*B6*187.2
496  LX*41
497  CLP*RHP101038*1*310*100.62*0*MC*999044301041*11*1
498  NM1*QC*1*SYNTHETIC*PATIENT101038****MI*ZZ0101038
499  DTM*232*20260720
500  DTM*233*20260720
501  SVC*HC:99213*221*71.76**1
502  DTM*472*20260720
503  CAS*CO*45*149.24
504  REF*6R*RHP101038-1
505  AMT*B6*71.76
506  SVC*HC:90471*41*13.26**1
507  DTM*472*20260720
508  CAS*CO*45*27.74
509  REF*6R*RHP101038-2
510  AMT*B6*13.26
511  SVC*HC:90686*48*15.6**1
512  DTM*472*20260720
513  CAS*CO*45*32.4
514  REF*6R*RHP101038-3
515  AMT*B6*15.6
516  LX*42
517  CLP*RHP101039*1*338*109.98*0*MC*999044301042*11*1
518  NM1*QC*1*SYNTHETIC*PATIENT101039****MI*ZZ0101039
519  DTM*232*20260719
520  DTM*233*20260719
521  SVC*HC:99214*312*101.4**1
522  DTM*472*20260719
523  CAS*CO*45*210.6
524  REF*6R*RHP101039-1
525  AMT*B6*101.4
526  SVC*HC:80053*26*8.58**1
527  DTM*472*20260719
528  CAS*CO*45*17.42
529  REF*6R*RHP101039-2
530  AMT*B6*8.58
531  LX*43
532  CLP*RHP101040*1*228*74.1*0*MC*999044301043*11*1
533  NM1*QC*1*SYNTHETIC*PATIENT101040****MI*ZZ0101040
534  DTM*232*20260718
535  DTM*233*20260718
536  SVC*HC:99213*221*71.76**1
537  DTM*472*20260718
538  CAS*CO*45*149.24
539  REF*6R*RHP101040-1
540  AMT*B6*71.76
541  SVC*HC:36415*7*2.34**1
542  DTM*472*20260718
543  CAS*CO*45*4.66
544  REF*6R*RHP101040-2
545  AMT*B6*2.34
546  LX*44
547  CLP*RHP101041*1*1728*561.6*0*MC*999044301044*11*1
548  NM1*QC*1*SYNTHETIC*PATIENT101041****MI*ZZ0101041
549  DTM*232*20260717
550  DTM*233*20260717
551  SVC*HC:29881*1728*561.6**1
552  DTM*472*20260717
553  CAS*CO*45*1166.4
554  REF*6R*RHP101041-1
555  AMT*B6*561.6
556  LX*45
557  CLP*RHP101042*1*319*103.74*0*MC*999044301045*11*1
558  NM1*QC*1*SYNTHETIC*PATIENT101042****MI*ZZ0101042
559  DTM*232*20260716
560  DTM*233*20260716
561  SVC*HC:99214*312*101.4**1
562  DTM*472*20260716
563  CAS*CO*45*210.6
564  REF*6R*RHP101042-1
565  AMT*B6*101.4
566  SVC*HC:36415*7*2.34**1
567  DTM*472*20260716
568  CAS*CO*45*4.66
569  REF*6R*RHP101042-2
570  AMT*B6*2.34
571  LX*46
572  CLP*RHP101043*4*624*0*0*MC*999044301046*11*1
573  NM1*QC*1*SYNTHETIC*PATIENT101043****MI*ZZ0101043
574  DTM*232*20260715
575  DTM*233*20260715
576  SVC*HC:73721*624*0**1
577  DTM*472*20260715
578  CAS*CO*197*624
579  REF*6R*RHP101043-1
580  AMT*B6*0
581  LX*47
582  CLP*RHP101044*1*240*78*0*MC*999044301047*11*1
583  NM1*QC*1*SYNTHETIC*PATIENT101044****MI*ZZ0101044
584  DTM*232*20260714
585  DTM*233*20260714
586  SVC*HC:99213*221*71.76**1
587  DTM*472*20260714
588  CAS*CO*45*149.24
589  REF*6R*RHP101044-1
590  AMT*B6*71.76
591  SVC*HC:85025*19*6.24**1
592  DTM*472*20260714
593  CAS*CO*45*12.76
594  REF*6R*RHP101044-2
595  AMT*B6*6.24
596  LX*48
597  CLP*RHP101045*1*3480*1131*0*MC*999044301048*11*1
598  NM1*QC*1*SYNTHETIC*PATIENT101045****MI*ZZ0101045
599  DTM*232*20260713
600  DTM*233*20260713
601  SVC*HC:27447*3480*1131**1
602  DTM*472*20260713
603  CAS*CO*45*2349
604  REF*6R*RHP101045-1
605  AMT*B6*1131
606  LX*49
607  CLP*RHP101046*1*439*142.74*0*MC*999044301049*11*1
608  NM1*QC*1*SYNTHETIC*PATIENT101046****MI*ZZ0101046
609  DTM*232*20260712
610  DTM*233*20260712
611  SVC*HC:99215*439*142.74**1
612  DTM*472*20260712
613  CAS*CO*45*296.26
614  REF*6R*RHP101046-1
615  AMT*B6*142.74
616  LX*50
617  CLP*RHP101047*1*912*296.4*0*MC*999044301050*11*1
618  NM1*QC*1*SYNTHETIC*PATIENT101047****MI*ZZ0101047
619  DTM*232*20260711
620  DTM*233*20260711
621  SVC*HC:45380*912*296.4**1
622  DTM*472*20260711
623  CAS*CO*45*615.6
624  REF*6R*RHP101047-1
625  AMT*B6*296.4
626  LX*51
627  CLP*RHP101048*1*269*87.36*0*MC*999044301051*11*1
628  NM1*QC*1*SYNTHETIC*PATIENT101048****MI*ZZ0101048
629  DTM*232*20260710
630  DTM*233*20260710
631  SVC*HC:99203*269*87.36**1
632  DTM*472*20260710
633  CAS*CO*45*181.64
634  REF*6R*RHP101048-1
635  AMT*B6*87.36
636  LX*52
637  CLP*RHP101049*1*528*171.6*0*MC*999044301052*11*1
638  NM1*QC*1*SYNTHETIC*PATIENT101049****MI*ZZ0101049
639  DTM*232*20260709
640  DTM*233*20260709
641  SVC*HC:93306*528*171.6**1
642  DTM*472*20260709
643  CAS*CO*45*356.4
644  REF*6R*RHP101049-1
645  AMT*B6*171.6
646  SE*644*0001
647  GE*1*100
648  IEA*1*000000100