Remittances / GP99900000544

Granite Plains Mutual

Payment GP99900000544, electronic funds transfer dated Aug 17, 2026. From GPM_ERA_0.835, imported Aug 18, 2026 by Dana Whitfield.

Balances to the cent

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Payments dated Aug 17, 2026 to Aug 17, 2026, as of Oct 6, 2026. Whole organization, every site.

Payment

$22,896.44

Electronic funds transfer

Claims

62 matched to billed claims

Claim payments

$22,896.44

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
RHP100231	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP100232 Superseded by a later result	Claim number matched exactly	Denied	$624.00	$0.00	$0.00	$0.00	$306.80
RHP101200	Claim number matched exactly	Paid as expected	$228.00	$112.10	$87.10 patient $25.00	$25.00
RHP101201	Claim number matched exactly	Underpaid	$1,728.00	$773.14	$773.14	$0.00	$76.46
RHP101202	Claim number matched exactly	Paid as expected	$319.00	$156.94	$125.55 patient $31.39	$31.39
RHP101203	Claim number matched exactly	Paid as expected	$624.00	$306.80	$156.80 patient $150.00	$150.00
RHP101204	Claim number matched exactly	Paid as expected	$240.00	$118.00	$118.00	$0.00
RHP101205	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP101206	Claim number matched exactly	Paid as expected	$439.00	$215.94	$194.35 patient $21.59	$21.59
RHP101207	Claim number matched exactly	Paid as expected	$912.00	$448.40	$448.40	$0.00
RHP101208	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP101209	Claim number matched exactly	Paid as expected	$528.00	$259.60	$207.68 patient $51.92	$51.92
RHP101210	Claim number matched exactly	Paid as expected	$449.00	$220.66	$220.66	$0.00
RHP101211	Claim number matched exactly	Underpaid	$2,520.00	$1,127.49	$1,127.49	$0.00	$111.51
RHP101212	Claim number matched exactly	Denied	$140.00	$0.00	$0.00	$0.00	$68.44
RHP101213	Claim number matched exactly	Paid as expected	$576.00	$283.20	$233.20 patient $50.00	$50.00
RHP101214	Claim number matched exactly	Paid as expected	$310.00	$152.22	$152.22	$0.00
RHP101215	Claim number matched exactly	Paid as expected	$338.00	$166.38	$66.38 patient $100.00	$100.00
RHP101216	Claim number matched exactly	Paid as expected	$228.00	$112.10	$87.10 patient $25.00	$25.00
RHP101217	Claim number matched exactly	Underpaid	$1,728.00	$773.14	$773.14	$0.00	$76.46
RHP101218	Claim number matched exactly	Paid as expected	$319.00	$156.94	$125.55 patient $31.39	$31.39
RHP101219	Claim number matched exactly	Paid as expected	$624.00	$306.80	$156.80 patient $150.00	$150.00
RHP101220	Claim number matched exactly	Paid as expected	$240.00	$118.00	$118.00	$0.00
RHP101221	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP101222	Claim number matched exactly	Paid as expected	$439.00	$215.94	$194.35 patient $21.59	$21.59
RHP101223	Claim number matched exactly	Paid as expected	$912.00	$448.40	$448.40	$0.00
RHP101224	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP101225	Claim number matched exactly	Denied	$528.00	$0.00	$0.00	$0.00	$259.60
RHP101226	Claim number matched exactly	Paid as expected	$449.00	$220.66	$220.66	$0.00
RHP101227	Claim number matched exactly	Underpaid	$2,520.00	$1,127.49	$1,127.49	$0.00	$111.51
RHP101228	Claim number matched exactly	Paid as expected	$140.00	$68.44	$54.75 patient $13.69	$13.69
RHP101229	Claim number matched exactly	Paid as expected	$576.00	$283.20	$233.20 patient $50.00	$50.00
RHP101230	Claim number matched exactly	Paid as expected	$310.00	$152.22	$152.22	$0.00
RHP101231	Claim number matched exactly	Paid as expected	$338.00	$166.38	$66.38 patient $100.00	$100.00
RHP101232	Claim number matched exactly	Paid as expected	$228.00	$112.10	$87.10 patient $25.00	$25.00
RHP101233	Claim number matched exactly	Underpaid	$1,728.00	$773.14	$773.14	$0.00	$76.46
RHP101234	Claim number matched exactly	Paid as expected	$319.00	$156.94	$125.55 patient $31.39	$31.39
RHP101235	Claim number matched exactly	Paid as expected	$624.00	$306.80	$156.80 patient $150.00	$150.00
RHP101236	Claim number matched exactly	Paid as expected	$240.00	$118.00	$118.00	$0.00
RHP101237	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP101238	Claim number matched exactly	Denied	$439.00	$0.00	$0.00	$0.00	$215.94
RHP101239	Claim number matched exactly	Paid as expected	$912.00	$448.40	$448.40	$0.00
RHP101240	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP101241	Claim number matched exactly	Paid as expected	$528.00	$259.60	$207.68 patient $51.92	$51.92
RHP101242	Claim number matched exactly	Paid as expected	$449.00	$220.66	$220.66	$0.00
RHP101243	Claim number matched exactly	Underpaid	$2,520.00	$1,127.49	$1,127.49	$0.00	$111.51
RHP101244	Claim number matched exactly	Paid as expected	$140.00	$68.44	$54.75 patient $13.69	$13.69
RHP101245	Claim number matched exactly	Paid as expected	$576.00	$283.20	$233.20 patient $50.00	$50.00
RHP101246	Claim number matched exactly	Paid as expected	$310.00	$152.22	$152.22	$0.00
RHP101247	Claim number matched exactly	Paid as expected	$338.00	$166.38	$66.38 patient $100.00	$100.00
RHP101248	Claim number matched exactly	Paid as expected	$228.00	$112.10	$87.10 patient $25.00	$25.00
RHP101249	Claim number matched exactly	Underpaid	$1,728.00	$773.14	$773.14	$0.00	$76.46
RHP101250	Claim number matched exactly	Paid as expected	$319.00	$156.94	$125.55 patient $31.39	$31.39
RHP101251	Claim number matched exactly	Denied	$624.00	$0.00	$0.00	$0.00	$306.80
RHP101252	Claim number matched exactly	Paid as expected	$240.00	$118.00	$118.00	$0.00
RHP101253	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP101254	Claim number matched exactly	Paid as expected	$439.00	$215.94	$194.35 patient $21.59	$21.59
RHP101255	Claim number matched exactly	Paid as expected	$912.00	$448.40	$448.40	$0.00
RHP101256	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP101257	Claim number matched exactly	Paid as expected	$528.00	$259.60	$207.68 patient $51.92	$51.92
RHP101258	Claim number matched exactly	Paid as expected	$449.00	$220.66	$220.66	$0.00
RHP101259	Claim number matched exactly	Underpaid	$2,520.00	$1,127.49	$1,127.49	$0.00	$111.51

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The payer's remittance file (835)

Payer ID 99902. Payee RIDGELINE HEALTH PARTNERS, NPI 9999999001. Transaction 0001, 789 segments.

Show the raw file (793 segments)

1  ISA*00*          *00*          *ZZ*PAYER99902     *ZZ*RIDGELINE999   *260816*0800*^*00501*000000102*0*T*:
2  GS*HP*PAYER99902*RIDGELINE999*20260816*0800*102*X*005010X221A1
3  ST*835*0001
4  BPR*I*22896.44*C*ACH*CCP*01*999999992*DA*000111222*1999999999**01*999999993*DA*000333444*20260817
5  TRN*1*GP99900000544*1999999902
6  DTM*405*20260816
7  N1*PR*GRANITE PLAINS MUTUAL
8  REF*2U*99902
9  N1*PE*RIDGELINE HEALTH PARTNERS*XX*9999999001
10  REF*TJ*999999999
11  LX*1
12  CLP*RHP100231*1*3480*1557.01*0*CI*999020544001*11*1
13  NM1*QC*1*SYNTHETIC*PATIENT100231****MI*ZZ0100231
14  DTM*232*20260803
15  DTM*233*20260803
16  SVC*HC:27447*3480*1557.01**1
17  DTM*472*20260803
18  CAS*CO*45*1922.99
19  REF*6R*RHP100231-1
20  AMT*B6*1557.01
21  LX*2
22  CLP*RHP100232*4*624*0*0*CI*999020544002*11*1
23  NM1*QC*1*SYNTHETIC*PATIENT100232****MI*ZZ0100232
24  DTM*232*20260805
25  DTM*233*20260805
26  SVC*HC:73721*624*0**1
27  DTM*472*20260805
28  CAS*CO*197*624
29  REF*6R*RHP100232-1
30  AMT*B6*0
31  LX*3
32  CLP*RHP101200*1*228*87.1*25*CI*999020544003*11*1
33  NM1*QC*1*SYNTHETIC*PATIENT101200****MI*ZZ0101200
34  DTM*232*20260805
35  DTM*233*20260805
36  SVC*HC:99213*221*83.56**1
37  DTM*472*20260805
38  CAS*CO*45*112.44
39  CAS*PR*3*25
40  REF*6R*RHP101200-1
41  AMT*B6*108.56
42  SVC*HC:36415*7*3.54**1
43  DTM*472*20260805
44  CAS*CO*45*3.46
45  REF*6R*RHP101200-2
46  AMT*B6*3.54
47  LX*4
48  CLP*RHP101201*1*1728*773.14*0*CI*999020544004*11*1
49  NM1*QC*1*SYNTHETIC*PATIENT101201****MI*ZZ0101201
50  DTM*232*20260804
51  DTM*233*20260804
52  SVC*HC:29881*1728*773.14**1
53  DTM*472*20260804
54  CAS*CO*45*954.86
55  REF*6R*RHP101201-1
56  AMT*B6*773.14
57  LX*5
58  CLP*RHP101202*1*319*125.55*31.39*CI*999020544005*11*1
59  NM1*QC*1*SYNTHETIC*PATIENT101202****MI*ZZ0101202
60  DTM*232*20260803
61  DTM*233*20260803
62  SVC*HC:99214*312*122.72**1
63  DTM*472*20260803
64  CAS*CO*45*158.6
65  CAS*PR*2*30.68
66  REF*6R*RHP101202-1
67  AMT*B6*153.4
68  SVC*HC:36415*7*2.83**1
69  DTM*472*20260803
70  CAS*CO*45*3.46
71  CAS*PR*2*0.71
72  REF*6R*RHP101202-2
73  AMT*B6*3.54
74  LX*6
75  CLP*RHP101203*1*624*156.8*150*CI*999020544006*11*1
76  NM1*QC*1*SYNTHETIC*PATIENT101203****MI*ZZ0101203
77  DTM*232*20260802
78  DTM*233*20260802
79  SVC*HC:73721*624*156.8**1
80  DTM*472*20260802
81  CAS*CO*45*317.2
82  CAS*PR*1*150
83  REF*6R*RHP101203-1
84  AMT*B6*306.8
85  LX*7
86  CLP*RHP101204*1*240*118*0*CI*999020544007*11*1
87  NM1*QC*1*SYNTHETIC*PATIENT101204****MI*ZZ0101204
88  DTM*232*20260801
89  DTM*233*20260801
90  SVC*HC:99213*221*108.56**1
91  DTM*472*20260801
92  CAS*CO*45*112.44
93  REF*6R*RHP101204-1
94  AMT*B6*108.56
95  SVC*HC:85025*19*9.44**1
96  DTM*472*20260801
97  CAS*CO*45*9.56
98  REF*6R*RHP101204-2
99  AMT*B6*9.44
100  LX*8
101  CLP*RHP101205*1*3480*1557.01*0*CI*999020544008*11*1
102  NM1*QC*1*SYNTHETIC*PATIENT101205****MI*ZZ0101205
103  DTM*232*20260731
104  DTM*233*20260731
105  SVC*HC:27447*3480*1557.01**1
106  DTM*472*20260731
107  CAS*CO*45*1922.99
108  REF*6R*RHP101205-1
109  AMT*B6*1557.01
110  LX*9
111  CLP*RHP101206*1*439*194.35*21.59*CI*999020544009*11*1
112  NM1*QC*1*SYNTHETIC*PATIENT101206****MI*ZZ0101206
113  DTM*232*20260730
114  DTM*233*20260730
115  SVC*HC:99215*439*194.35**1
116  DTM*472*20260730
117  CAS*CO*45*223.06
118  CAS*PR*2*21.59
119  REF*6R*RHP101206-1
120  AMT*B6*215.94
121  LX*10
122  CLP*RHP101207*1*912*448.4*0*CI*999020544010*11*1
123  NM1*QC*1*SYNTHETIC*PATIENT101207****MI*ZZ0101207
124  DTM*232*20260729
125  DTM*233*20260729
126  SVC*HC:45380*912*448.4**1
127  DTM*472*20260729
128  CAS*CO*45*463.6
129  REF*6R*RHP101207-1
130  AMT*B6*448.4
131  LX*11
132  CLP*RHP101208*1*269*92.16*40*CI*999020544011*11*1
133  NM1*QC*1*SYNTHETIC*PATIENT101208****MI*ZZ0101208
134  DTM*232*20260728
135  DTM*233*20260728
136  SVC*HC:99203*269*92.16**1
137  DTM*472*20260728
138  CAS*CO*45*136.84
139  CAS*PR*3*40
140  REF*6R*RHP101208-1
141  AMT*B6*132.16
142  LX*12
143  CLP*RHP101209*1*528*207.68*51.92*CI*999020544012*11*1
144  NM1*QC*1*SYNTHETIC*PATIENT101209****MI*ZZ0101209
145  DTM*232*20260727
146  DTM*233*20260727
147  SVC*HC:93306*528*207.68**1
148  DTM*472*20260727
149  CAS*CO*45*268.4
150  CAS*PR*2*51.92
151  REF*6R*RHP101209-1
152  AMT*B6*259.6
153  LX*13
154  CLP*RHP101210*1*449*220.66*0*CI*999020544013*11*1
155  NM1*QC*1*SYNTHETIC*PATIENT101210****MI*ZZ0101210
156  DTM*232*20260726
157  DTM*233*20260726
158  SVC*HC:99204*408*200.6**1
159  DTM*472*20260726
160  CAS*CO*45*207.4
161  REF*6R*RHP101210-1
162  AMT*B6*200.6
163  SVC*HC:93000*41*20.06**1
164  DTM*472*20260726
165  CAS*CO*45*20.94
166  REF*6R*RHP101210-2
167  AMT*B6*20.06
168  LX*14
169  CLP*RHP101211*1*2520*1127.49*0*CI*999020544014*11*1
170  NM1*QC*1*SYNTHETIC*PATIENT101211****MI*ZZ0101211
171  DTM*232*20260725
172  DTM*233*20260725
173  SVC*HC:29827*2520*1127.49**1
174  DTM*472*20260725
175  CAS*CO*45*1392.51
176  REF*6R*RHP101211-1
177  AMT*B6*1127.49
178  LX*15
179  CLP*RHP101212*4*140*0*0*CI*999020544015*11*1
180  NM1*QC*1*SYNTHETIC*PATIENT101212****MI*ZZ0101212
181  DTM*232*20260724
182  DTM*233*20260724
183  SVC*HC:97110*140*0**2
184  DTM*472*20260724
185  CAS*CO*16*140
186  REF*6R*RHP101212-1
187  AMT*B6*0
188  LQ*HE*MA130
189  LX*16
190  CLP*RHP101213*1*576*233.2*50*CI*999020544016*11*1
191  NM1*QC*1*SYNTHETIC*PATIENT101213****MI*ZZ0101213
192  DTM*232*20260723
193  DTM*233*20260723
194  SVC*HC:64483*576*233.2**1
195  DTM*472*20260723
196  CAS*CO*45*292.8
197  CAS*PR*3*50
198  REF*6R*RHP101213-1
199  AMT*B6*283.2
200  LX*17
201  CLP*RHP101214*1*310*152.22*0*CI*999020544017*11*1
202  NM1*QC*1*SYNTHETIC*PATIENT101214****MI*ZZ0101214
203  DTM*232*20260722
204  DTM*233*20260722
205  SVC*HC:99213*221*108.56**1
206  DTM*472*20260722
207  CAS*CO*45*112.44
208  REF*6R*RHP101214-1
209  AMT*B6*108.56
210  SVC*HC:90471*41*20.06**1
211  DTM*472*20260722
212  CAS*CO*45*20.94
213  REF*6R*RHP101214-2
214  AMT*B6*20.06
215  SVC*HC:90686*48*23.6**1
216  DTM*472*20260722
217  CAS*CO*45*24.4
218  REF*6R*RHP101214-3
219  AMT*B6*23.6
220  LX*18
221  CLP*RHP101215*1*338*66.38*100*CI*999020544018*11*1
222  NM1*QC*1*SYNTHETIC*PATIENT101215****MI*ZZ0101215
223  DTM*232*20260721
224  DTM*233*20260721
225  SVC*HC:99214*312*53.4**1
226  DTM*472*20260721
227  CAS*CO*45*158.6
228  CAS*PR*1*100
229  REF*6R*RHP101215-1
230  AMT*B6*153.4
231  SVC*HC:80053*26*12.98**1
232  DTM*472*20260721
233  CAS*CO*45*13.02
234  REF*6R*RHP101215-2
235  AMT*B6*12.98
236  LX*19
237  CLP*RHP101216*1*228*87.1*25*CI*999020544019*11*1
238  NM1*QC*1*SYNTHETIC*PATIENT101216****MI*ZZ0101216
239  DTM*232*20260720
240  DTM*233*20260720
241  SVC*HC:99213*221*83.56**1
242  DTM*472*20260720
243  CAS*CO*45*112.44
244  CAS*PR*3*25
245  REF*6R*RHP101216-1
246  AMT*B6*108.56
247  SVC*HC:36415*7*3.54**1
248  DTM*472*20260720
249  CAS*CO*45*3.46
250  REF*6R*RHP101216-2
251  AMT*B6*3.54
252  LX*20
253  CLP*RHP101217*1*1728*773.14*0*CI*999020544020*11*1
254  NM1*QC*1*SYNTHETIC*PATIENT101217****MI*ZZ0101217
255  DTM*232*20260719
256  DTM*233*20260719
257  SVC*HC:29881*1728*773.14**1
258  DTM*472*20260719
259  CAS*CO*45*954.86
260  REF*6R*RHP101217-1
261  AMT*B6*773.14
262  LX*21
263  CLP*RHP101218*1*319*125.55*31.39*CI*999020544021*11*1
264  NM1*QC*1*SYNTHETIC*PATIENT101218****MI*ZZ0101218
265  DTM*232*20260805
266  DTM*233*20260805
267  SVC*HC:99214*312*122.72**1
268  DTM*472*20260805
269  CAS*CO*45*158.6
270  CAS*PR*2*30.68
271  REF*6R*RHP101218-1
272  AMT*B6*153.4
273  SVC*HC:36415*7*2.83**1
274  DTM*472*20260805
275  CAS*CO*45*3.46
276  CAS*PR*2*0.71
277  REF*6R*RHP101218-2
278  AMT*B6*3.54
279  LX*22
280  CLP*RHP101219*1*624*156.8*150*CI*999020544022*11*1
281  NM1*QC*1*SYNTHETIC*PATIENT101219****MI*ZZ0101219
282  DTM*232*20260804
283  DTM*233*20260804
284  SVC*HC:73721*624*156.8**1
285  DTM*472*20260804
286  CAS*CO*45*317.2
287  CAS*PR*1*150
288  REF*6R*RHP101219-1
289  AMT*B6*306.8
290  LX*23
291  CLP*RHP101220*1*240*118*0*CI*999020544023*11*1
292  NM1*QC*1*SYNTHETIC*PATIENT101220****MI*ZZ0101220
293  DTM*232*20260803
294  DTM*233*20260803
295  SVC*HC:99213*221*108.56**1
296  DTM*472*20260803
297  CAS*CO*45*112.44
298  REF*6R*RHP101220-1
299  AMT*B6*108.56
300  SVC*HC:85025*19*9.44**1
301  DTM*472*20260803
302  CAS*CO*45*9.56
303  REF*6R*RHP101220-2
304  AMT*B6*9.44
305  LX*24
306  CLP*RHP101221*1*3480*1557.01*0*CI*999020544024*11*1
307  NM1*QC*1*SYNTHETIC*PATIENT101221****MI*ZZ0101221
308  DTM*232*20260802
309  DTM*233*20260802
310  SVC*HC:27447*3480*1557.01**1
311  DTM*472*20260802
312  CAS*CO*45*1922.99
313  REF*6R*RHP101221-1
314  AMT*B6*1557.01
315  LX*25
316  CLP*RHP101222*1*439*194.35*21.59*CI*999020544025*11*1
317  NM1*QC*1*SYNTHETIC*PATIENT101222****MI*ZZ0101222
318  DTM*232*20260801
319  DTM*233*20260801
320  SVC*HC:99215*439*194.35**1
321  DTM*472*20260801
322  CAS*CO*45*223.06
323  CAS*PR*2*21.59
324  REF*6R*RHP101222-1
325  AMT*B6*215.94
326  LX*26
327  CLP*RHP101223*1*912*448.4*0*CI*999020544026*11*1
328  NM1*QC*1*SYNTHETIC*PATIENT101223****MI*ZZ0101223
329  DTM*232*20260731
330  DTM*233*20260731
331  SVC*HC:45380*912*448.4**1
332  DTM*472*20260731
333  CAS*CO*45*463.6
334  REF*6R*RHP101223-1
335  AMT*B6*448.4
336  LX*27
337  CLP*RHP101224*1*269*92.16*40*CI*999020544027*11*1
338  NM1*QC*1*SYNTHETIC*PATIENT101224****MI*ZZ0101224
339  DTM*232*20260730
340  DTM*233*20260730
341  SVC*HC:99203*269*92.16**1
342  DTM*472*20260730
343  CAS*CO*45*136.84
344  CAS*PR*3*40
345  REF*6R*RHP101224-1
346  AMT*B6*132.16
347  LX*28
348  CLP*RHP101225*4*528*0*0*CI*999020544028*11*1
349  NM1*QC*1*SYNTHETIC*PATIENT101225****MI*ZZ0101225
350  DTM*232*20260729
351  DTM*233*20260729
352  SVC*HC:93306*528*0**1
353  DTM*472*20260729
354  CAS*CO*50*528
355  REF*6R*RHP101225-1
356  AMT*B6*0
357  LQ*HE*N130
358  LX*29
359  CLP*RHP101226*1*449*220.66*0*CI*999020544029*11*1
360  NM1*QC*1*SYNTHETIC*PATIENT101226****MI*ZZ0101226
361  DTM*232*20260728
362  DTM*233*20260728
363  SVC*HC:99204*408*200.6**1
364  DTM*472*20260728
365  CAS*CO*45*207.4
366  REF*6R*RHP101226-1
367  AMT*B6*200.6
368  SVC*HC:93000*41*20.06**1
369  DTM*472*20260728
370  CAS*CO*45*20.94
371  REF*6R*RHP101226-2
372  AMT*B6*20.06
373  LX*30
374  CLP*RHP101227*1*2520*1127.49*0*CI*999020544030*11*1
375  NM1*QC*1*SYNTHETIC*PATIENT101227****MI*ZZ0101227
376  DTM*232*20260727
377  DTM*233*20260727
378  SVC*HC:29827*2520*1127.49**1
379  DTM*472*20260727
380  CAS*CO*45*1392.51
381  REF*6R*RHP101227-1
382  AMT*B6*1127.49
383  LX*31
384  CLP*RHP101228*1*140*54.75*13.69*CI*999020544031*11*1
385  NM1*QC*1*SYNTHETIC*PATIENT101228****MI*ZZ0101228
386  DTM*232*20260726
387  DTM*233*20260726
388  SVC*HC:97110*140*54.75**2
389  DTM*472*20260726
390  CAS*CO*45*71.56
391  CAS*PR*2*13.69
392  REF*6R*RHP101228-1
393  AMT*B6*68.44
394  LX*32
395  CLP*RHP101229*1*576*233.2*50*CI*999020544032*11*1
396  NM1*QC*1*SYNTHETIC*PATIENT101229****MI*ZZ0101229
397  DTM*232*20260725
398  DTM*233*20260725
399  SVC*HC:64483*576*233.2**1
400  DTM*472*20260725
401  CAS*CO*45*292.8
402  CAS*PR*3*50
403  REF*6R*RHP101229-1
404  AMT*B6*283.2
405  LX*33
406  CLP*RHP101230*1*310*152.22*0*CI*999020544033*11*1
407  NM1*QC*1*SYNTHETIC*PATIENT101230****MI*ZZ0101230
408  DTM*232*20260724
409  DTM*233*20260724
410  SVC*HC:99213*221*108.56**1
411  DTM*472*20260724
412  CAS*CO*45*112.44
413  REF*6R*RHP101230-1
414  AMT*B6*108.56
415  SVC*HC:90471*41*20.06**1
416  DTM*472*20260724
417  CAS*CO*45*20.94
418  REF*6R*RHP101230-2
419  AMT*B6*20.06
420  SVC*HC:90686*48*23.6**1
421  DTM*472*20260724
422  CAS*CO*45*24.4
423  REF*6R*RHP101230-3
424  AMT*B6*23.6
425  LX*34
426  CLP*RHP101231*1*338*66.38*100*CI*999020544034*11*1
427  NM1*QC*1*SYNTHETIC*PATIENT101231****MI*ZZ0101231
428  DTM*232*20260723
429  DTM*233*20260723
430  SVC*HC:99214*312*53.4**1
431  DTM*472*20260723
432  CAS*CO*45*158.6
433  CAS*PR*1*100
434  REF*6R*RHP101231-1
435  AMT*B6*153.4
436  SVC*HC:80053*26*12.98**1
437  DTM*472*20260723
438  CAS*CO*45*13.02
439  REF*6R*RHP101231-2
440  AMT*B6*12.98
441  LX*35
442  CLP*RHP101232*1*228*87.1*25*CI*999020544035*11*1
443  NM1*QC*1*SYNTHETIC*PATIENT101232****MI*ZZ0101232
444  DTM*232*20260722
445  DTM*233*20260722
446  SVC*HC:99213*221*83.56**1
447  DTM*472*20260722
448  CAS*CO*45*112.44
449  CAS*PR*3*25
450  REF*6R*RHP101232-1
451  AMT*B6*108.56
452  SVC*HC:36415*7*3.54**1
453  DTM*472*20260722
454  CAS*CO*45*3.46
455  REF*6R*RHP101232-2
456  AMT*B6*3.54
457  LX*36
458  CLP*RHP101233*1*1728*773.14*0*CI*999020544036*11*1
459  NM1*QC*1*SYNTHETIC*PATIENT101233****MI*ZZ0101233
460  DTM*232*20260721
461  DTM*233*20260721
462  SVC*HC:29881*1728*773.14**1
463  DTM*472*20260721
464  CAS*CO*45*954.86
465  REF*6R*RHP101233-1
466  AMT*B6*773.14
467  LX*37
468  CLP*RHP101234*1*319*125.55*31.39*CI*999020544037*11*1
469  NM1*QC*1*SYNTHETIC*PATIENT101234****MI*ZZ0101234
470  DTM*232*20260720
471  DTM*233*20260720
472  SVC*HC:99214*312*122.72**1
473  DTM*472*20260720
474  CAS*CO*45*158.6
475  CAS*PR*2*30.68
476  REF*6R*RHP101234-1
477  AMT*B6*153.4
478  SVC*HC:36415*7*2.83**1
479  DTM*472*20260720
480  CAS*CO*45*3.46
481  CAS*PR*2*0.71
482  REF*6R*RHP101234-2
483  AMT*B6*3.54
484  LX*38
485  CLP*RHP101235*1*624*156.8*150*CI*999020544038*11*1
486  NM1*QC*1*SYNTHETIC*PATIENT101235****MI*ZZ0101235
487  DTM*232*20260719
488  DTM*233*20260719
489  SVC*HC:73721*624*156.8**1
490  DTM*472*20260719
491  CAS*CO*45*317.2
492  CAS*PR*1*150
493  REF*6R*RHP101235-1
494  AMT*B6*306.8
495  LX*39
496  CLP*RHP101236*1*240*118*0*CI*999020544039*11*1
497  NM1*QC*1*SYNTHETIC*PATIENT101236****MI*ZZ0101236
498  DTM*232*20260805
499  DTM*233*20260805
500  SVC*HC:99213*221*108.56**1
501  DTM*472*20260805
502  CAS*CO*45*112.44
503  REF*6R*RHP101236-1
504  AMT*B6*108.56
505  SVC*HC:85025*19*9.44**1
506  DTM*472*20260805
507  CAS*CO*45*9.56
508  REF*6R*RHP101236-2
509  AMT*B6*9.44
510  LX*40
511  CLP*RHP101237*1*3480*1557.01*0*CI*999020544040*11*1
512  NM1*QC*1*SYNTHETIC*PATIENT101237****MI*ZZ0101237
513  DTM*232*20260804
514  DTM*233*20260804
515  SVC*HC:27447*3480*1557.01**1
516  DTM*472*20260804
517  CAS*CO*45*1922.99
518  REF*6R*RHP101237-1
519  AMT*B6*1557.01
520  LX*41
521  CLP*RHP101238*4*439*0*0*CI*999020544041*11*1
522  NM1*QC*1*SYNTHETIC*PATIENT101238****MI*ZZ0101238
523  DTM*232*20260803
524  DTM*233*20260803
525  SVC*HC:99215*439*0**1
526  DTM*472*20260803
527  CAS*CO*22*439
528  REF*6R*RHP101238-1
529  AMT*B6*0
530  LX*42
531  CLP*RHP101239*1*912*448.4*0*CI*999020544042*11*1
532  NM1*QC*1*SYNTHETIC*PATIENT101239****MI*ZZ0101239
533  DTM*232*20260802
534  DTM*233*20260802
535  SVC*HC:45380*912*448.4**1
536  DTM*472*20260802
537  CAS*CO*45*463.6
538  REF*6R*RHP101239-1
539  AMT*B6*448.4
540  LX*43
541  CLP*RHP101240*1*269*92.16*40*CI*999020544043*11*1
542  NM1*QC*1*SYNTHETIC*PATIENT101240****MI*ZZ0101240
543  DTM*232*20260801
544  DTM*233*20260801
545  SVC*HC:99203*269*92.16**1
546  DTM*472*20260801
547  CAS*CO*45*136.84
548  CAS*PR*3*40
549  REF*6R*RHP101240-1
550  AMT*B6*132.16
551  LX*44
552  CLP*RHP101241*1*528*207.68*51.92*CI*999020544044*11*1
553  NM1*QC*1*SYNTHETIC*PATIENT101241****MI*ZZ0101241
554  DTM*232*20260731
555  DTM*233*20260731
556  SVC*HC:93306*528*207.68**1
557  DTM*472*20260731
558  CAS*CO*45*268.4
559  CAS*PR*2*51.92
560  REF*6R*RHP101241-1
561  AMT*B6*259.6
562  LX*45
563  CLP*RHP101242*1*449*220.66*0*CI*999020544045*11*1
564  NM1*QC*1*SYNTHETIC*PATIENT101242****MI*ZZ0101242
565  DTM*232*20260730
566  DTM*233*20260730
567  SVC*HC:99204*408*200.6**1
568  DTM*472*20260730
569  CAS*CO*45*207.4
570  REF*6R*RHP101242-1
571  AMT*B6*200.6
572  SVC*HC:93000*41*20.06**1
573  DTM*472*20260730
574  CAS*CO*45*20.94
575  REF*6R*RHP101242-2
576  AMT*B6*20.06
577  LX*46
578  CLP*RHP101243*1*2520*1127.49*0*CI*999020544046*11*1
579  NM1*QC*1*SYNTHETIC*PATIENT101243****MI*ZZ0101243
580  DTM*232*20260729
581  DTM*233*20260729
582  SVC*HC:29827*2520*1127.49**1
583  DTM*472*20260729
584  CAS*CO*45*1392.51
585  REF*6R*RHP101243-1
586  AMT*B6*1127.49
587  LX*47
588  CLP*RHP101244*1*140*54.75*13.69*CI*999020544047*11*1
589  NM1*QC*1*SYNTHETIC*PATIENT101244****MI*ZZ0101244
590  DTM*232*20260728
591  DTM*233*20260728
592  SVC*HC:97110*140*54.75**2
593  DTM*472*20260728
594  CAS*CO*45*71.56
595  CAS*PR*2*13.69
596  REF*6R*RHP101244-1
597  AMT*B6*68.44
598  LX*48
599  CLP*RHP101245*1*576*233.2*50*CI*999020544048*11*1
600  NM1*QC*1*SYNTHETIC*PATIENT101245****MI*ZZ0101245
601  DTM*232*20260727
602  DTM*233*20260727
603  SVC*HC:64483*576*233.2**1
604  DTM*472*20260727
605  CAS*CO*45*292.8
606  CAS*PR*3*50
607  REF*6R*RHP101245-1
608  AMT*B6*283.2
609  LX*49
610  CLP*RHP101246*1*310*152.22*0*CI*999020544049*11*1
611  NM1*QC*1*SYNTHETIC*PATIENT101246****MI*ZZ0101246
612  DTM*232*20260726
613  DTM*233*20260726
614  SVC*HC:99213*221*108.56**1
615  DTM*472*20260726
616  CAS*CO*45*112.44
617  REF*6R*RHP101246-1
618  AMT*B6*108.56
619  SVC*HC:90471*41*20.06**1
620  DTM*472*20260726
621  CAS*CO*45*20.94
622  REF*6R*RHP101246-2
623  AMT*B6*20.06
624  SVC*HC:90686*48*23.6**1
625  DTM*472*20260726
626  CAS*CO*45*24.4
627  REF*6R*RHP101246-3
628  AMT*B6*23.6
629  LX*50
630  CLP*RHP101247*1*338*66.38*100*CI*999020544050*11*1
631  NM1*QC*1*SYNTHETIC*PATIENT101247****MI*ZZ0101247
632  DTM*232*20260725
633  DTM*233*20260725
634  SVC*HC:99214*312*53.4**1
635  DTM*472*20260725
636  CAS*CO*45*158.6
637  CAS*PR*1*100
638  REF*6R*RHP101247-1
639  AMT*B6*153.4
640  SVC*HC:80053*26*12.98**1
641  DTM*472*20260725
642  CAS*CO*45*13.02
643  REF*6R*RHP101247-2
644  AMT*B6*12.98
645  LX*51
646  CLP*RHP101248*1*228*87.1*25*CI*999020544051*11*1
647  NM1*QC*1*SYNTHETIC*PATIENT101248****MI*ZZ0101248
648  DTM*232*20260724
649  DTM*233*20260724
650  SVC*HC:99213*221*83.56**1
651  DTM*472*20260724
652  CAS*CO*45*112.44
653  CAS*PR*3*25
654  REF*6R*RHP101248-1
655  AMT*B6*108.56
656  SVC*HC:36415*7*3.54**1
657  DTM*472*20260724
658  CAS*CO*45*3.46
659  REF*6R*RHP101248-2
660  AMT*B6*3.54
661  LX*52
662  CLP*RHP101249*1*1728*773.14*0*CI*999020544052*11*1
663  NM1*QC*1*SYNTHETIC*PATIENT101249****MI*ZZ0101249
664  DTM*232*20260723
665  DTM*233*20260723
666  SVC*HC:29881*1728*773.14**1
667  DTM*472*20260723
668  CAS*CO*45*954.86
669  REF*6R*RHP101249-1
670  AMT*B6*773.14
671  LX*53
672  CLP*RHP101250*1*319*125.55*31.39*CI*999020544053*11*1
673  NM1*QC*1*SYNTHETIC*PATIENT101250****MI*ZZ0101250
674  DTM*232*20260722
675  DTM*233*20260722
676  SVC*HC:99214*312*122.72**1
677  DTM*472*20260722
678  CAS*CO*45*158.6
679  CAS*PR*2*30.68
680  REF*6R*RHP101250-1
681  AMT*B6*153.4
682  SVC*HC:36415*7*2.83**1
683  DTM*472*20260722
684  CAS*CO*45*3.46
685  CAS*PR*2*0.71
686  REF*6R*RHP101250-2
687  AMT*B6*3.54
688  LX*54
689  CLP*RHP101251*4*624*0*0*CI*999020544054*11*1
690  NM1*QC*1*SYNTHETIC*PATIENT101251****MI*ZZ0101251
691  DTM*232*20260721
692  DTM*233*20260721
693  SVC*HC:73721*624*0**1
694  DTM*472*20260721
695  CAS*CO*197*624
696  REF*6R*RHP101251-1
697  AMT*B6*0
698  LX*55
699  CLP*RHP101252*1*240*118*0*CI*999020544055*11*1
700  NM1*QC*1*SYNTHETIC*PATIENT101252****MI*ZZ0101252
701  DTM*232*20260720
702  DTM*233*20260720
703  SVC*HC:99213*221*108.56**1
704  DTM*472*20260720
705  CAS*CO*45*112.44
706  REF*6R*RHP101252-1
707  AMT*B6*108.56
708  SVC*HC:85025*19*9.44**1
709  DTM*472*20260720
710  CAS*CO*45*9.56
711  REF*6R*RHP101252-2
712  AMT*B6*9.44
713  LX*56
714  CLP*RHP101253*1*3480*1557.01*0*CI*999020544056*11*1
715  NM1*QC*1*SYNTHETIC*PATIENT101253****MI*ZZ0101253
716  DTM*232*20260719
717  DTM*233*20260719
718  SVC*HC:27447*3480*1557.01**1
719  DTM*472*20260719
720  CAS*CO*45*1922.99
721  REF*6R*RHP101253-1
722  AMT*B6*1557.01
723  LX*57
724  CLP*RHP101254*1*439*194.35*21.59*CI*999020544057*11*1
725  NM1*QC*1*SYNTHETIC*PATIENT101254****MI*ZZ0101254
726  DTM*232*20260805
727  DTM*233*20260805
728  SVC*HC:99215*439*194.35**1
729  DTM*472*20260805
730  CAS*CO*45*223.06
731  CAS*PR*2*21.59
732  REF*6R*RHP101254-1
733  AMT*B6*215.94
734  LX*58
735  CLP*RHP101255*1*912*448.4*0*CI*999020544058*11*1
736  NM1*QC*1*SYNTHETIC*PATIENT101255****MI*ZZ0101255
737  DTM*232*20260804
738  DTM*233*20260804
739  SVC*HC:45380*912*448.4**1
740  DTM*472*20260804
741  CAS*CO*45*463.6
742  REF*6R*RHP101255-1
743  AMT*B6*448.4
744  LX*59
745  CLP*RHP101256*1*269*92.16*40*CI*999020544059*11*1
746  NM1*QC*1*SYNTHETIC*PATIENT101256****MI*ZZ0101256
747  DTM*232*20260803
748  DTM*233*20260803
749  SVC*HC:99203*269*92.16**1
750  DTM*472*20260803
751  CAS*CO*45*136.84
752  CAS*PR*3*40
753  REF*6R*RHP101256-1
754  AMT*B6*132.16
755  LX*60
756  CLP*RHP101257*1*528*207.68*51.92*CI*999020544060*11*1
757  NM1*QC*1*SYNTHETIC*PATIENT101257****MI*ZZ0101257
758  DTM*232*20260802
759  DTM*233*20260802
760  SVC*HC:93306*528*207.68**1
761  DTM*472*20260802
762  CAS*CO*45*268.4
763  CAS*PR*2*51.92
764  REF*6R*RHP101257-1
765  AMT*B6*259.6
766  LX*61
767  CLP*RHP101258*1*449*220.66*0*CI*999020544061*11*1
768  NM1*QC*1*SYNTHETIC*PATIENT101258****MI*ZZ0101258
769  DTM*232*20260801
770  DTM*233*20260801
771  SVC*HC:99204*408*200.6**1
772  DTM*472*20260801
773  CAS*CO*45*207.4
774  REF*6R*RHP101258-1
775  AMT*B6*200.6
776  SVC*HC:93000*41*20.06**1
777  DTM*472*20260801
778  CAS*CO*45*20.94
779  REF*6R*RHP101258-2
780  AMT*B6*20.06
781  LX*62
782  CLP*RHP101259*1*2520*1127.49*0*CI*999020544062*11*1
783  NM1*QC*1*SYNTHETIC*PATIENT101259****MI*ZZ0101259
784  DTM*232*20260731
785  DTM*233*20260731
786  SVC*HC:29827*2520*1127.49**1
787  DTM*472*20260731
788  CAS*CO*45*1392.51
789  REF*6R*RHP101259-1
790  AMT*B6*1127.49
791  SE*789*0001
792  GE*1*102
793  IEA*1*000000102