Remittances / GP99900000587

Granite Plains Mutual

Payment GP99900000587, electronic funds transfer dated Sep 1, 2026. From GPM_ERA_A.835, imported Sep 2, 2026 by Dana Whitfield.

Balances to the cent

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Payments dated Sep 1, 2026 to Sep 1, 2026, as of Oct 7, 2026. Whole organization, every site.

Payment

$21,833.51

Electronic funds transfer

Claims

69 matched to billed claims

Claim payments

$21,833.51

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
RHP100111	Claim number matched exactly	Paid as expected	$310.00	$152.22	$136.99 patient $15.23	$15.23
RHP100112	Claim number matched exactly	Denied	$312.00	$0.00	$0.00	$0.00	$153.40
RHP100113	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP100114	Claim number matched exactly	Underpaid	$210.00	$90.34	$90.34	$0.00	$12.32
RHP100115	Claim number matched exactly	Paid as expected	$480.00	$236.00	$236.00	$0.00
RHP100116	Claim number matched exactly	Partially denied	$461.00	$108.56	$108.56	$0.00	$118.00
RHP100117	Claim number matched exactly	Denied	$312.00	$0.00	$0.00	$0.00	$153.40
RHP100118	Claim number matched exactly	Partially denied	$461.00	$108.56	$108.56 patient $240.00	$240.00	$118.00
RHP100119	Claim number matched exactly	Denied	$140.00	$0.00	$0.00	$0.00	$68.44
RHP100400	Claim number matched exactly	Paid as expected	$228.00	$112.10	$87.10 patient $25.00	$25.00
RHP100401	Claim number matched exactly	Underpaid	$1,728.00	$773.14	$773.14	$0.00	$76.46
RHP100402	Claim number matched exactly	Paid as expected	$319.00	$156.94	$125.55 patient $31.39	$31.39
RHP100403	Claim number matched exactly	Paid as expected	$624.00	$306.80	$156.80 patient $150.00	$150.00
RHP100404	Claim number matched exactly	Paid as expected	$240.00	$118.00	$118.00	$0.00
RHP100405	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP100406	Claim number matched exactly	Denied	$439.00	$0.00	$0.00	$0.00	$215.94
RHP100407	Claim number matched exactly	Paid as expected	$912.00	$448.40	$448.40	$0.00
RHP100408	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP100409	Claim number matched exactly	Paid as expected	$528.00	$259.60	$207.68 patient $51.92	$51.92
RHP100410	Claim number matched exactly	Paid as expected	$449.00	$220.66	$220.66	$0.00
RHP100411	Claim number matched exactly	Underpaid	$2,520.00	$1,127.49	$1,127.49	$0.00	$111.51
RHP100412	Claim number matched exactly	Paid as expected	$140.00	$68.44	$54.75 patient $13.69	$13.69
RHP100413	Claim number matched exactly	Paid as expected	$576.00	$283.20	$233.20 patient $50.00	$50.00
RHP100414	Claim number matched exactly	Paid as expected	$310.00	$152.22	$152.22	$0.00
RHP100415	Claim number matched exactly	Paid as expected	$338.00	$166.38	$66.38 patient $100.00	$100.00
RHP100416	Claim number matched exactly	Paid as expected	$228.00	$112.10	$87.10 patient $25.00	$25.00
RHP100417	Claim number matched exactly	Underpaid	$1,728.00	$773.14	$773.14	$0.00	$76.46
RHP100418	Claim number matched exactly	Paid as expected	$319.00	$156.94	$125.55 patient $31.39	$31.39
RHP100419	Claim number matched exactly	Denied	$624.00	$0.00	$0.00	$0.00	$306.80
RHP100420	Claim number matched exactly	Paid as expected	$240.00	$118.00	$118.00	$0.00
RHP100421	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP100422	Claim number matched exactly	Paid as expected	$439.00	$215.94	$194.35 patient $21.59	$21.59
RHP100423	Claim number matched exactly	Paid as expected	$912.00	$448.40	$448.40	$0.00
RHP100424	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP100425	Claim number matched exactly	Paid as expected	$528.00	$259.60	$207.68 patient $51.92	$51.92
RHP100426	Claim number matched exactly	Paid as expected	$449.00	$220.66	$220.66	$0.00
RHP100427	Claim number matched exactly	Underpaid	$2,520.00	$1,127.49	$1,127.49	$0.00	$111.51
RHP100428	Claim number matched exactly	Paid as expected	$140.00	$68.44	$54.75 patient $13.69	$13.69
RHP100429	Claim number matched exactly	Paid as expected	$576.00	$283.20	$233.20 patient $50.00	$50.00
RHP100430	Claim number matched exactly	Paid as expected	$310.00	$152.22	$152.22	$0.00
RHP100431	Claim number matched exactly	Paid as expected	$338.00	$166.38	$66.38 patient $100.00	$100.00
RHP100432	Claim number matched exactly	Denied	$228.00	$0.00	$0.00	$0.00	$112.10
RHP100433	Claim number matched exactly	Underpaid	$1,728.00	$773.14	$773.14	$0.00	$76.46
RHP100434	Claim number matched exactly	Paid as expected	$319.00	$156.94	$125.55 patient $31.39	$31.39
RHP100435	Claim number matched exactly	Paid as expected	$624.00	$306.80	$156.80 patient $150.00	$150.00
RHP100436	Claim number matched exactly	Paid as expected	$240.00	$118.00	$118.00	$0.00
RHP100437	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP100438	Claim number matched exactly	Paid as expected	$439.00	$215.94	$194.35 patient $21.59	$21.59
RHP100439	Claim number matched exactly	Paid as expected	$912.00	$448.40	$448.40	$0.00
RHP100440	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP100441	Claim number matched exactly	Paid as expected	$528.00	$259.60	$207.68 patient $51.92	$51.92
RHP100442	Claim number matched exactly	Paid as expected	$449.00	$220.66	$220.66	$0.00
RHP100443	Claim number matched exactly	Underpaid	$2,520.00	$1,127.49	$1,127.49	$0.00	$111.51
RHP100444	Claim number matched exactly	Paid as expected	$140.00	$68.44	$54.75 patient $13.69	$13.69
RHP100445	Claim number matched exactly	Denied	$576.00	$0.00	$0.00	$0.00	$283.20
RHP100446	Claim number matched exactly	Paid as expected	$310.00	$152.22	$152.22	$0.00
RHP100447	Claim number matched exactly	Paid as expected	$338.00	$166.38	$66.38 patient $100.00	$100.00
RHP100448	Claim number matched exactly	Paid as expected	$228.00	$112.10	$87.10 patient $25.00	$25.00
RHP100449	Claim number matched exactly	Underpaid	$1,728.00	$773.14	$773.14	$0.00	$76.46
RHP100450	Claim number matched exactly	Paid as expected	$319.00	$156.94	$125.55 patient $31.39	$31.39
RHP100451	Claim number matched exactly	Paid as expected	$624.00	$306.80	$156.80 patient $150.00	$150.00
RHP100452	Claim number matched exactly	Paid as expected	$240.00	$118.00	$118.00	$0.00
RHP100453	Claim number matched exactly	Underpaid	$3,480.00	$1,557.01	$1,557.01	$0.00	$153.99
RHP100454	Claim number matched exactly	Paid as expected	$439.00	$215.94	$194.35 patient $21.59	$21.59
RHP100455	Claim number matched exactly	Paid as expected	$912.00	$448.40	$448.40	$0.00
RHP100456	Claim number matched exactly	Paid as expected	$269.00	$132.16	$92.16 patient $40.00	$40.00
RHP100457	Claim number matched exactly	Paid as expected	$528.00	$259.60	$207.68 patient $51.92	$51.92
RHP100458	Claim number matched exactly	Denied	$449.00	$0.00	$0.00	$0.00	$220.66
RHP100459	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, 888 segments.

Show the raw file (892 segments)

1  ISA*00*          *00*          *ZZ*PAYER99902     *ZZ*RIDGELINE999   *260831*0800*^*00501*000000104*0*T*:
2  GS*HP*PAYER99902*RIDGELINE999*20260831*0800*104*X*005010X221A1
3  ST*835*0001
4  BPR*I*21833.51*C*ACH*CCP*01*999999992*DA*000111222*1999999999**01*999999993*DA*000333444*20260901
5  TRN*1*GP99900000587*1999999902
6  DTM*405*20260831
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*RHP100111*1*310*136.99*15.23*CI*999020587001*11*1
13  NM1*QC*1*SYNTHETIC*PATIENT100111****MI*ZZ0100111
14  DTM*232*20260808
15  DTM*233*20260808
16  SVC*HC:99213*221*97.7**1
17  DTM*472*20260808
18  CAS*CO*45*112.44
19  CAS*PR*2*10.86
20  REF*6R*RHP100111-1
21  AMT*B6*108.56
22  SVC*HC:90471*41*18.05**1
23  DTM*472*20260808
24  CAS*CO*45*20.94
25  CAS*PR*2*2.01
26  REF*6R*RHP100111-2
27  AMT*B6*20.06
28  SVC*HC:90686*48*21.24**1
29  DTM*472*20260808
30  CAS*CO*45*24.4
31  CAS*PR*2*2.36
32  REF*6R*RHP100111-3
33  AMT*B6*23.6
34  LX*2
35  CLP*RHP100112*4*312*0*0*CI*999020587002*11*1
36  NM1*QC*1*SYNTHETIC*PATIENT100112****MI*ZZ0100112
37  DTM*232*20260219
38  DTM*233*20260219
39  SVC*HC:99214*312*0**1
40  DTM*472*20260219
41  CAS*CO*29*312
42  REF*6R*RHP100112-1
43  AMT*B6*0
44  LX*3
45  CLP*RHP100113*1*269*92.16*40*CI*999020587003*11*1
46  NM1*QC*1*SYNTHETIC*PATIENT100113****MI*ZZ0100113
47  DTM*232*20260810
48  DTM*233*20260810
49  SVC*HC:99203*269*92.16**1
50  DTM*472*20260810
51  CAS*CO*45*136.84
52  CAS*PR*3*40
53  REF*6R*RHP100113-1
54  AMT*B6*132.16
55  LX*4
56  CLP*RHP100114*1*210*90.34*0*CI*999020587004*11*1
57  NM1*QC*1*SYNTHETIC*PATIENT100114****MI*ZZ0100114
58  DTM*232*20260811
59  DTM*233*20260811
60  SVC*HC:97110*210*90.34**3
61  DTM*472*20260811
62  CAS*CO*45*119.66
63  REF*6R*RHP100114-1
64  AMT*B6*90.34
65  LX*5
66  CLP*RHP100115*1*480*236*0*CI*999020587005*11*1
67  NM1*QC*1*SYNTHETIC*PATIENT100115****MI*ZZ0100115
68  DTM*232*20260812
69  DTM*233*20260812
70  SVC*HC:99215*439*215.94**1
71  DTM*472*20260812
72  CAS*CO*45*223.06
73  REF*6R*RHP100115-1
74  AMT*B6*215.94
75  SVC*HC:93000*41*20.06**1
76  DTM*472*20260812
77  CAS*CO*45*20.94
78  REF*6R*RHP100115-2
79  AMT*B6*20.06
80  LX*6
81  CLP*RHP100116*1*461*108.56*0*CI*999020587006*11*1
82  NM1*QC*1*SYNTHETIC*PATIENT100116****MI*ZZ0100116
83  DTM*232*20260813
84  DTM*233*20260813
85  SVC*HC:99213:25*221*108.56**1
86  DTM*472*20260813
87  CAS*CO*45*112.44
88  REF*6R*RHP100116-1
89  AMT*B6*108.56
90  SVC*HC:11102*240*0**1
91  DTM*472*20260813
92  CAS*CO*4*240
93  REF*6R*RHP100116-2
94  AMT*B6*0
95  LX*7
96  CLP*RHP100117*4*312*0*0*CI*999020587007*11*1
97  NM1*QC*1*SYNTHETIC*PATIENT100117****MI*ZZ0100117
98  DTM*232*20260814
99  DTM*233*20260814
100  SVC*HC:99214*312*0**1
101  DTM*472*20260814
102  CAS*CO*27*312
103  REF*6R*RHP100117-1
104  AMT*B6*0
105  LX*8
106  CLP*RHP100118*1*461*108.56*240*CI*999020587008*11*1
107  NM1*QC*1*SYNTHETIC*PATIENT100118****MI*ZZ0100118
108  DTM*232*20260815
109  DTM*233*20260815
110  SVC*HC:99213:25*221*108.56**1
111  DTM*472*20260815
112  CAS*CO*45*112.44
113  REF*6R*RHP100118-1
114  AMT*B6*108.56
115  SVC*HC:11102*240*0**1
116  DTM*472*20260815
117  CAS*PR*96*240
118  REF*6R*RHP100118-2
119  AMT*B6*240
120  LQ*HE*N130
121  LX*9
122  CLP*RHP100119*4*140*0*0*CI*999020587009*11*1
123  NM1*QC*1*SYNTHETIC*PATIENT100119****MI*ZZ0100119
124  DTM*232*20260816
125  DTM*233*20260816
126  SVC*HC:97110*140*0**2
127  DTM*472*20260816
128  CAS*CO*96*140
129  REF*6R*RHP100119-1
130  AMT*B6*0
131  LQ*HE*N130
132  LX*10
133  CLP*RHP100400*1*228*87.1*25*CI*999020587010*11*1
134  NM1*QC*1*SYNTHETIC*PATIENT100400****MI*ZZ0100400
135  DTM*232*20260820
136  DTM*233*20260820
137  SVC*HC:99213*221*83.56**1
138  DTM*472*20260820
139  CAS*CO*45*112.44
140  CAS*PR*3*25
141  REF*6R*RHP100400-1
142  AMT*B6*108.56
143  SVC*HC:36415*7*3.54**1
144  DTM*472*20260820
145  CAS*CO*45*3.46
146  REF*6R*RHP100400-2
147  AMT*B6*3.54
148  LX*11
149  CLP*RHP100401*1*1728*773.14*0*CI*999020587011*11*1
150  NM1*QC*1*SYNTHETIC*PATIENT100401****MI*ZZ0100401
151  DTM*232*20260819
152  DTM*233*20260819
153  SVC*HC:29881*1728*773.14**1
154  DTM*472*20260819
155  CAS*CO*45*954.86
156  REF*6R*RHP100401-1
157  AMT*B6*773.14
158  LX*12
159  CLP*RHP100402*1*319*125.55*31.39*CI*999020587012*11*1
160  NM1*QC*1*SYNTHETIC*PATIENT100402****MI*ZZ0100402
161  DTM*232*20260818
162  DTM*233*20260818
163  SVC*HC:99214*312*122.72**1
164  DTM*472*20260818
165  CAS*CO*45*158.6
166  CAS*PR*2*30.68
167  REF*6R*RHP100402-1
168  AMT*B6*153.4
169  SVC*HC:36415*7*2.83**1
170  DTM*472*20260818
171  CAS*CO*45*3.46
172  CAS*PR*2*0.71
173  REF*6R*RHP100402-2
174  AMT*B6*3.54
175  LX*13
176  CLP*RHP100403*1*624*156.8*150*CI*999020587013*11*1
177  NM1*QC*1*SYNTHETIC*PATIENT100403****MI*ZZ0100403
178  DTM*232*20260817
179  DTM*233*20260817
180  SVC*HC:73721*624*156.8**1
181  DTM*472*20260817
182  CAS*CO*45*317.2
183  CAS*PR*1*150
184  REF*6R*RHP100403-1
185  AMT*B6*306.8
186  LX*14
187  CLP*RHP100404*1*240*118*0*CI*999020587014*11*1
188  NM1*QC*1*SYNTHETIC*PATIENT100404****MI*ZZ0100404
189  DTM*232*20260816
190  DTM*233*20260816
191  SVC*HC:99213*221*108.56**1
192  DTM*472*20260816
193  CAS*CO*45*112.44
194  REF*6R*RHP100404-1
195  AMT*B6*108.56
196  SVC*HC:85025*19*9.44**1
197  DTM*472*20260816
198  CAS*CO*45*9.56
199  REF*6R*RHP100404-2
200  AMT*B6*9.44
201  LX*15
202  CLP*RHP100405*1*3480*1557.01*0*CI*999020587015*11*1
203  NM1*QC*1*SYNTHETIC*PATIENT100405****MI*ZZ0100405
204  DTM*232*20260815
205  DTM*233*20260815
206  SVC*HC:27447*3480*1557.01**1
207  DTM*472*20260815
208  CAS*CO*45*1922.99
209  REF*6R*RHP100405-1
210  AMT*B6*1557.01
211  LX*16
212  CLP*RHP100406*4*439*0*0*CI*999020587016*11*1
213  NM1*QC*1*SYNTHETIC*PATIENT100406****MI*ZZ0100406
214  DTM*232*20260814
215  DTM*233*20260814
216  SVC*HC:99215*439*0**1
217  DTM*472*20260814
218  CAS*CO*22*439
219  REF*6R*RHP100406-1
220  AMT*B6*0
221  LX*17
222  CLP*RHP100407*1*912*448.4*0*CI*999020587017*11*1
223  NM1*QC*1*SYNTHETIC*PATIENT100407****MI*ZZ0100407
224  DTM*232*20260813
225  DTM*233*20260813
226  SVC*HC:45380*912*448.4**1
227  DTM*472*20260813
228  CAS*CO*45*463.6
229  REF*6R*RHP100407-1
230  AMT*B6*448.4
231  LX*18
232  CLP*RHP100408*1*269*92.16*40*CI*999020587018*11*1
233  NM1*QC*1*SYNTHETIC*PATIENT100408****MI*ZZ0100408
234  DTM*232*20260812
235  DTM*233*20260812
236  SVC*HC:99203*269*92.16**1
237  DTM*472*20260812
238  CAS*CO*45*136.84
239  CAS*PR*3*40
240  REF*6R*RHP100408-1
241  AMT*B6*132.16
242  LX*19
243  CLP*RHP100409*1*528*207.68*51.92*CI*999020587019*11*1
244  NM1*QC*1*SYNTHETIC*PATIENT100409****MI*ZZ0100409
245  DTM*232*20260811
246  DTM*233*20260811
247  SVC*HC:93306*528*207.68**1
248  DTM*472*20260811
249  CAS*CO*45*268.4
250  CAS*PR*2*51.92
251  REF*6R*RHP100409-1
252  AMT*B6*259.6
253  LX*20
254  CLP*RHP100410*1*449*220.66*0*CI*999020587020*11*1
255  NM1*QC*1*SYNTHETIC*PATIENT100410****MI*ZZ0100410
256  DTM*232*20260810
257  DTM*233*20260810
258  SVC*HC:99204*408*200.6**1
259  DTM*472*20260810
260  CAS*CO*45*207.4
261  REF*6R*RHP100410-1
262  AMT*B6*200.6
263  SVC*HC:93000*41*20.06**1
264  DTM*472*20260810
265  CAS*CO*45*20.94
266  REF*6R*RHP100410-2
267  AMT*B6*20.06
268  LX*21
269  CLP*RHP100411*1*2520*1127.49*0*CI*999020587021*11*1
270  NM1*QC*1*SYNTHETIC*PATIENT100411****MI*ZZ0100411
271  DTM*232*20260809
272  DTM*233*20260809
273  SVC*HC:29827*2520*1127.49**1
274  DTM*472*20260809
275  CAS*CO*45*1392.51
276  REF*6R*RHP100411-1
277  AMT*B6*1127.49
278  LX*22
279  CLP*RHP100412*1*140*54.75*13.69*CI*999020587022*11*1
280  NM1*QC*1*SYNTHETIC*PATIENT100412****MI*ZZ0100412
281  DTM*232*20260808
282  DTM*233*20260808
283  SVC*HC:97110*140*54.75**2
284  DTM*472*20260808
285  CAS*CO*45*71.56
286  CAS*PR*2*13.69
287  REF*6R*RHP100412-1
288  AMT*B6*68.44
289  LX*23
290  CLP*RHP100413*1*576*233.2*50*CI*999020587023*11*1
291  NM1*QC*1*SYNTHETIC*PATIENT100413****MI*ZZ0100413
292  DTM*232*20260807
293  DTM*233*20260807
294  SVC*HC:64483*576*233.2**1
295  DTM*472*20260807
296  CAS*CO*45*292.8
297  CAS*PR*3*50
298  REF*6R*RHP100413-1
299  AMT*B6*283.2
300  LX*24
301  CLP*RHP100414*1*310*152.22*0*CI*999020587024*11*1
302  NM1*QC*1*SYNTHETIC*PATIENT100414****MI*ZZ0100414
303  DTM*232*20260806
304  DTM*233*20260806
305  SVC*HC:99213*221*108.56**1
306  DTM*472*20260806
307  CAS*CO*45*112.44
308  REF*6R*RHP100414-1
309  AMT*B6*108.56
310  SVC*HC:90471*41*20.06**1
311  DTM*472*20260806
312  CAS*CO*45*20.94
313  REF*6R*RHP100414-2
314  AMT*B6*20.06
315  SVC*HC:90686*48*23.6**1
316  DTM*472*20260806
317  CAS*CO*45*24.4
318  REF*6R*RHP100414-3
319  AMT*B6*23.6
320  LX*25
321  CLP*RHP100415*1*338*66.38*100*CI*999020587025*11*1
322  NM1*QC*1*SYNTHETIC*PATIENT100415****MI*ZZ0100415
323  DTM*232*20260805
324  DTM*233*20260805
325  SVC*HC:99214*312*53.4**1
326  DTM*472*20260805
327  CAS*CO*45*158.6
328  CAS*PR*1*100
329  REF*6R*RHP100415-1
330  AMT*B6*153.4
331  SVC*HC:80053*26*12.98**1
332  DTM*472*20260805
333  CAS*CO*45*13.02
334  REF*6R*RHP100415-2
335  AMT*B6*12.98
336  LX*26
337  CLP*RHP100416*1*228*87.1*25*CI*999020587026*11*1
338  NM1*QC*1*SYNTHETIC*PATIENT100416****MI*ZZ0100416
339  DTM*232*20260804
340  DTM*233*20260804
341  SVC*HC:99213*221*83.56**1
342  DTM*472*20260804
343  CAS*CO*45*112.44
344  CAS*PR*3*25
345  REF*6R*RHP100416-1
346  AMT*B6*108.56
347  SVC*HC:36415*7*3.54**1
348  DTM*472*20260804
349  CAS*CO*45*3.46
350  REF*6R*RHP100416-2
351  AMT*B6*3.54
352  LX*27
353  CLP*RHP100417*1*1728*773.14*0*CI*999020587027*11*1
354  NM1*QC*1*SYNTHETIC*PATIENT100417****MI*ZZ0100417
355  DTM*232*20260803
356  DTM*233*20260803
357  SVC*HC:29881*1728*773.14**1
358  DTM*472*20260803
359  CAS*CO*45*954.86
360  REF*6R*RHP100417-1
361  AMT*B6*773.14
362  LX*28
363  CLP*RHP100418*1*319*125.55*31.39*CI*999020587028*11*1
364  NM1*QC*1*SYNTHETIC*PATIENT100418****MI*ZZ0100418
365  DTM*232*20260820
366  DTM*233*20260820
367  SVC*HC:99214*312*122.72**1
368  DTM*472*20260820
369  CAS*CO*45*158.6
370  CAS*PR*2*30.68
371  REF*6R*RHP100418-1
372  AMT*B6*153.4
373  SVC*HC:36415*7*2.83**1
374  DTM*472*20260820
375  CAS*CO*45*3.46
376  CAS*PR*2*0.71
377  REF*6R*RHP100418-2
378  AMT*B6*3.54
379  LX*29
380  CLP*RHP100419*4*624*0*0*CI*999020587029*11*1
381  NM1*QC*1*SYNTHETIC*PATIENT100419****MI*ZZ0100419
382  DTM*232*20260819
383  DTM*233*20260819
384  SVC*HC:73721*624*0**1
385  DTM*472*20260819
386  CAS*CO*197*624
387  REF*6R*RHP100419-1
388  AMT*B6*0
389  LX*30
390  CLP*RHP100420*1*240*118*0*CI*999020587030*11*1
391  NM1*QC*1*SYNTHETIC*PATIENT100420****MI*ZZ0100420
392  DTM*232*20260818
393  DTM*233*20260818
394  SVC*HC:99213*221*108.56**1
395  DTM*472*20260818
396  CAS*CO*45*112.44
397  REF*6R*RHP100420-1
398  AMT*B6*108.56
399  SVC*HC:85025*19*9.44**1
400  DTM*472*20260818
401  CAS*CO*45*9.56
402  REF*6R*RHP100420-2
403  AMT*B6*9.44
404  LX*31
405  CLP*RHP100421*1*3480*1557.01*0*CI*999020587031*11*1
406  NM1*QC*1*SYNTHETIC*PATIENT100421****MI*ZZ0100421
407  DTM*232*20260817
408  DTM*233*20260817
409  SVC*HC:27447*3480*1557.01**1
410  DTM*472*20260817
411  CAS*CO*45*1922.99
412  REF*6R*RHP100421-1
413  AMT*B6*1557.01
414  LX*32
415  CLP*RHP100422*1*439*194.35*21.59*CI*999020587032*11*1
416  NM1*QC*1*SYNTHETIC*PATIENT100422****MI*ZZ0100422
417  DTM*232*20260816
418  DTM*233*20260816
419  SVC*HC:99215*439*194.35**1
420  DTM*472*20260816
421  CAS*CO*45*223.06
422  CAS*PR*2*21.59
423  REF*6R*RHP100422-1
424  AMT*B6*215.94
425  LX*33
426  CLP*RHP100423*1*912*448.4*0*CI*999020587033*11*1
427  NM1*QC*1*SYNTHETIC*PATIENT100423****MI*ZZ0100423
428  DTM*232*20260815
429  DTM*233*20260815
430  SVC*HC:45380*912*448.4**1
431  DTM*472*20260815
432  CAS*CO*45*463.6
433  REF*6R*RHP100423-1
434  AMT*B6*448.4
435  LX*34
436  CLP*RHP100424*1*269*92.16*40*CI*999020587034*11*1
437  NM1*QC*1*SYNTHETIC*PATIENT100424****MI*ZZ0100424
438  DTM*232*20260814
439  DTM*233*20260814
440  SVC*HC:99203*269*92.16**1
441  DTM*472*20260814
442  CAS*CO*45*136.84
443  CAS*PR*3*40
444  REF*6R*RHP100424-1
445  AMT*B6*132.16
446  LX*35
447  CLP*RHP100425*1*528*207.68*51.92*CI*999020587035*11*1
448  NM1*QC*1*SYNTHETIC*PATIENT100425****MI*ZZ0100425
449  DTM*232*20260813
450  DTM*233*20260813
451  SVC*HC:93306*528*207.68**1
452  DTM*472*20260813
453  CAS*CO*45*268.4
454  CAS*PR*2*51.92
455  REF*6R*RHP100425-1
456  AMT*B6*259.6
457  LX*36
458  CLP*RHP100426*1*449*220.66*0*CI*999020587036*11*1
459  NM1*QC*1*SYNTHETIC*PATIENT100426****MI*ZZ0100426
460  DTM*232*20260812
461  DTM*233*20260812
462  SVC*HC:99204*408*200.6**1
463  DTM*472*20260812
464  CAS*CO*45*207.4
465  REF*6R*RHP100426-1
466  AMT*B6*200.6
467  SVC*HC:93000*41*20.06**1
468  DTM*472*20260812
469  CAS*CO*45*20.94
470  REF*6R*RHP100426-2
471  AMT*B6*20.06
472  LX*37
473  CLP*RHP100427*1*2520*1127.49*0*CI*999020587037*11*1
474  NM1*QC*1*SYNTHETIC*PATIENT100427****MI*ZZ0100427
475  DTM*232*20260811
476  DTM*233*20260811
477  SVC*HC:29827*2520*1127.49**1
478  DTM*472*20260811
479  CAS*CO*45*1392.51
480  REF*6R*RHP100427-1
481  AMT*B6*1127.49
482  LX*38
483  CLP*RHP100428*1*140*54.75*13.69*CI*999020587038*11*1
484  NM1*QC*1*SYNTHETIC*PATIENT100428****MI*ZZ0100428
485  DTM*232*20260810
486  DTM*233*20260810
487  SVC*HC:97110*140*54.75**2
488  DTM*472*20260810
489  CAS*CO*45*71.56
490  CAS*PR*2*13.69
491  REF*6R*RHP100428-1
492  AMT*B6*68.44
493  LX*39
494  CLP*RHP100429*1*576*233.2*50*CI*999020587039*11*1
495  NM1*QC*1*SYNTHETIC*PATIENT100429****MI*ZZ0100429
496  DTM*232*20260809
497  DTM*233*20260809
498  SVC*HC:64483*576*233.2**1
499  DTM*472*20260809
500  CAS*CO*45*292.8
501  CAS*PR*3*50
502  REF*6R*RHP100429-1
503  AMT*B6*283.2
504  LX*40
505  CLP*RHP100430*1*310*152.22*0*CI*999020587040*11*1
506  NM1*QC*1*SYNTHETIC*PATIENT100430****MI*ZZ0100430
507  DTM*232*20260808
508  DTM*233*20260808
509  SVC*HC:99213*221*108.56**1
510  DTM*472*20260808
511  CAS*CO*45*112.44
512  REF*6R*RHP100430-1
513  AMT*B6*108.56
514  SVC*HC:90471*41*20.06**1
515  DTM*472*20260808
516  CAS*CO*45*20.94
517  REF*6R*RHP100430-2
518  AMT*B6*20.06
519  SVC*HC:90686*48*23.6**1
520  DTM*472*20260808
521  CAS*CO*45*24.4
522  REF*6R*RHP100430-3
523  AMT*B6*23.6
524  LX*41
525  CLP*RHP100431*1*338*66.38*100*CI*999020587041*11*1
526  NM1*QC*1*SYNTHETIC*PATIENT100431****MI*ZZ0100431
527  DTM*232*20260807
528  DTM*233*20260807
529  SVC*HC:99214*312*53.4**1
530  DTM*472*20260807
531  CAS*CO*45*158.6
532  CAS*PR*1*100
533  REF*6R*RHP100431-1
534  AMT*B6*153.4
535  SVC*HC:80053*26*12.98**1
536  DTM*472*20260807
537  CAS*CO*45*13.02
538  REF*6R*RHP100431-2
539  AMT*B6*12.98
540  LX*42
541  CLP*RHP100432*4*228*0*0*CI*999020587042*11*1
542  NM1*QC*1*SYNTHETIC*PATIENT100432****MI*ZZ0100432
543  DTM*232*20260806
544  DTM*233*20260806
545  SVC*HC:99213*221*0**1
546  DTM*472*20260806
547  CAS*CO*4*221
548  REF*6R*RHP100432-1
549  AMT*B6*0
550  SVC*HC:36415*7*0**1
551  DTM*472*20260806
552  CAS*CO*4*7
553  REF*6R*RHP100432-2
554  AMT*B6*0
555  LX*43
556  CLP*RHP100433*1*1728*773.14*0*CI*999020587043*11*1
557  NM1*QC*1*SYNTHETIC*PATIENT100433****MI*ZZ0100433
558  DTM*232*20260805
559  DTM*233*20260805
560  SVC*HC:29881*1728*773.14**1
561  DTM*472*20260805
562  CAS*CO*45*954.86
563  REF*6R*RHP100433-1
564  AMT*B6*773.14
565  LX*44
566  CLP*RHP100434*1*319*125.55*31.39*CI*999020587044*11*1
567  NM1*QC*1*SYNTHETIC*PATIENT100434****MI*ZZ0100434
568  DTM*232*20260804
569  DTM*233*20260804
570  SVC*HC:99214*312*122.72**1
571  DTM*472*20260804
572  CAS*CO*45*158.6
573  CAS*PR*2*30.68
574  REF*6R*RHP100434-1
575  AMT*B6*153.4
576  SVC*HC:36415*7*2.83**1
577  DTM*472*20260804
578  CAS*CO*45*3.46
579  CAS*PR*2*0.71
580  REF*6R*RHP100434-2
581  AMT*B6*3.54
582  LX*45
583  CLP*RHP100435*1*624*156.8*150*CI*999020587045*11*1
584  NM1*QC*1*SYNTHETIC*PATIENT100435****MI*ZZ0100435
585  DTM*232*20260803
586  DTM*233*20260803
587  SVC*HC:73721*624*156.8**1
588  DTM*472*20260803
589  CAS*CO*45*317.2
590  CAS*PR*1*150
591  REF*6R*RHP100435-1
592  AMT*B6*306.8
593  LX*46
594  CLP*RHP100436*1*240*118*0*CI*999020587046*11*1
595  NM1*QC*1*SYNTHETIC*PATIENT100436****MI*ZZ0100436
596  DTM*232*20260820
597  DTM*233*20260820
598  SVC*HC:99213*221*108.56**1
599  DTM*472*20260820
600  CAS*CO*45*112.44
601  REF*6R*RHP100436-1
602  AMT*B6*108.56
603  SVC*HC:85025*19*9.44**1
604  DTM*472*20260820
605  CAS*CO*45*9.56
606  REF*6R*RHP100436-2
607  AMT*B6*9.44
608  LX*47
609  CLP*RHP100437*1*3480*1557.01*0*CI*999020587047*11*1
610  NM1*QC*1*SYNTHETIC*PATIENT100437****MI*ZZ0100437
611  DTM*232*20260819
612  DTM*233*20260819
613  SVC*HC:27447*3480*1557.01**1
614  DTM*472*20260819
615  CAS*CO*45*1922.99
616  REF*6R*RHP100437-1
617  AMT*B6*1557.01
618  LX*48
619  CLP*RHP100438*1*439*194.35*21.59*CI*999020587048*11*1
620  NM1*QC*1*SYNTHETIC*PATIENT100438****MI*ZZ0100438
621  DTM*232*20260818
622  DTM*233*20260818
623  SVC*HC:99215*439*194.35**1
624  DTM*472*20260818
625  CAS*CO*45*223.06
626  CAS*PR*2*21.59
627  REF*6R*RHP100438-1
628  AMT*B6*215.94
629  LX*49
630  CLP*RHP100439*1*912*448.4*0*CI*999020587049*11*1
631  NM1*QC*1*SYNTHETIC*PATIENT100439****MI*ZZ0100439
632  DTM*232*20260817
633  DTM*233*20260817
634  SVC*HC:45380*912*448.4**1
635  DTM*472*20260817
636  CAS*CO*45*463.6
637  REF*6R*RHP100439-1
638  AMT*B6*448.4
639  LX*50
640  CLP*RHP100440*1*269*92.16*40*CI*999020587050*11*1
641  NM1*QC*1*SYNTHETIC*PATIENT100440****MI*ZZ0100440
642  DTM*232*20260816
643  DTM*233*20260816
644  SVC*HC:99203*269*92.16**1
645  DTM*472*20260816
646  CAS*CO*45*136.84
647  CAS*PR*3*40
648  REF*6R*RHP100440-1
649  AMT*B6*132.16
650  LX*51
651  CLP*RHP100441*1*528*207.68*51.92*CI*999020587051*11*1
652  NM1*QC*1*SYNTHETIC*PATIENT100441****MI*ZZ0100441
653  DTM*232*20260815
654  DTM*233*20260815
655  SVC*HC:93306*528*207.68**1
656  DTM*472*20260815
657  CAS*CO*45*268.4
658  CAS*PR*2*51.92
659  REF*6R*RHP100441-1
660  AMT*B6*259.6
661  LX*52
662  CLP*RHP100442*1*449*220.66*0*CI*999020587052*11*1
663  NM1*QC*1*SYNTHETIC*PATIENT100442****MI*ZZ0100442
664  DTM*232*20260814
665  DTM*233*20260814
666  SVC*HC:99204*408*200.6**1
667  DTM*472*20260814
668  CAS*CO*45*207.4
669  REF*6R*RHP100442-1
670  AMT*B6*200.6
671  SVC*HC:93000*41*20.06**1
672  DTM*472*20260814
673  CAS*CO*45*20.94
674  REF*6R*RHP100442-2
675  AMT*B6*20.06
676  LX*53
677  CLP*RHP100443*1*2520*1127.49*0*CI*999020587053*11*1
678  NM1*QC*1*SYNTHETIC*PATIENT100443****MI*ZZ0100443
679  DTM*232*20260813
680  DTM*233*20260813
681  SVC*HC:29827*2520*1127.49**1
682  DTM*472*20260813
683  CAS*CO*45*1392.51
684  REF*6R*RHP100443-1
685  AMT*B6*1127.49
686  LX*54
687  CLP*RHP100444*1*140*54.75*13.69*CI*999020587054*11*1
688  NM1*QC*1*SYNTHETIC*PATIENT100444****MI*ZZ0100444
689  DTM*232*20260812
690  DTM*233*20260812
691  SVC*HC:97110*140*54.75**2
692  DTM*472*20260812
693  CAS*CO*45*71.56
694  CAS*PR*2*13.69
695  REF*6R*RHP100444-1
696  AMT*B6*68.44
697  LX*55
698  CLP*RHP100445*4*576*0*0*CI*999020587055*11*1
699  NM1*QC*1*SYNTHETIC*PATIENT100445****MI*ZZ0100445
700  DTM*232*20260811
701  DTM*233*20260811
702  SVC*HC:64483*576*0**1
703  DTM*472*20260811
704  CAS*CO*27*576
705  REF*6R*RHP100445-1
706  AMT*B6*0
707  LX*56
708  CLP*RHP100446*1*310*152.22*0*CI*999020587056*11*1
709  NM1*QC*1*SYNTHETIC*PATIENT100446****MI*ZZ0100446
710  DTM*232*20260810
711  DTM*233*20260810
712  SVC*HC:99213*221*108.56**1
713  DTM*472*20260810
714  CAS*CO*45*112.44
715  REF*6R*RHP100446-1
716  AMT*B6*108.56
717  SVC*HC:90471*41*20.06**1
718  DTM*472*20260810
719  CAS*CO*45*20.94
720  REF*6R*RHP100446-2
721  AMT*B6*20.06
722  SVC*HC:90686*48*23.6**1
723  DTM*472*20260810
724  CAS*CO*45*24.4
725  REF*6R*RHP100446-3
726  AMT*B6*23.6
727  LX*57
728  CLP*RHP100447*1*338*66.38*100*CI*999020587057*11*1
729  NM1*QC*1*SYNTHETIC*PATIENT100447****MI*ZZ0100447
730  DTM*232*20260809
731  DTM*233*20260809
732  SVC*HC:99214*312*53.4**1
733  DTM*472*20260809
734  CAS*CO*45*158.6
735  CAS*PR*1*100
736  REF*6R*RHP100447-1
737  AMT*B6*153.4
738  SVC*HC:80053*26*12.98**1
739  DTM*472*20260809
740  CAS*CO*45*13.02
741  REF*6R*RHP100447-2
742  AMT*B6*12.98
743  LX*58
744  CLP*RHP100448*1*228*87.1*25*CI*999020587058*11*1
745  NM1*QC*1*SYNTHETIC*PATIENT100448****MI*ZZ0100448
746  DTM*232*20260808
747  DTM*233*20260808
748  SVC*HC:99213*221*83.56**1
749  DTM*472*20260808
750  CAS*CO*45*112.44
751  CAS*PR*3*25
752  REF*6R*RHP100448-1
753  AMT*B6*108.56
754  SVC*HC:36415*7*3.54**1
755  DTM*472*20260808
756  CAS*CO*45*3.46
757  REF*6R*RHP100448-2
758  AMT*B6*3.54
759  LX*59
760  CLP*RHP100449*1*1728*773.14*0*CI*999020587059*11*1
761  NM1*QC*1*SYNTHETIC*PATIENT100449****MI*ZZ0100449
762  DTM*232*20260807
763  DTM*233*20260807
764  SVC*HC:29881*1728*773.14**1
765  DTM*472*20260807
766  CAS*CO*45*954.86
767  REF*6R*RHP100449-1
768  AMT*B6*773.14
769  LX*60
770  CLP*RHP100450*1*319*125.55*31.39*CI*999020587060*11*1
771  NM1*QC*1*SYNTHETIC*PATIENT100450****MI*ZZ0100450
772  DTM*232*20260806
773  DTM*233*20260806
774  SVC*HC:99214*312*122.72**1
775  DTM*472*20260806
776  CAS*CO*45*158.6
777  CAS*PR*2*30.68
778  REF*6R*RHP100450-1
779  AMT*B6*153.4
780  SVC*HC:36415*7*2.83**1
781  DTM*472*20260806
782  CAS*CO*45*3.46
783  CAS*PR*2*0.71
784  REF*6R*RHP100450-2
785  AMT*B6*3.54
786  LX*61
787  CLP*RHP100451*1*624*156.8*150*CI*999020587061*11*1
788  NM1*QC*1*SYNTHETIC*PATIENT100451****MI*ZZ0100451
789  DTM*232*20260805
790  DTM*233*20260805
791  SVC*HC:73721*624*156.8**1
792  DTM*472*20260805
793  CAS*CO*45*317.2
794  CAS*PR*1*150
795  REF*6R*RHP100451-1
796  AMT*B6*306.8
797  LX*62
798  CLP*RHP100452*1*240*118*0*CI*999020587062*11*1
799  NM1*QC*1*SYNTHETIC*PATIENT100452****MI*ZZ0100452
800  DTM*232*20260804
801  DTM*233*20260804
802  SVC*HC:99213*221*108.56**1
803  DTM*472*20260804
804  CAS*CO*45*112.44
805  REF*6R*RHP100452-1
806  AMT*B6*108.56
807  SVC*HC:85025*19*9.44**1
808  DTM*472*20260804
809  CAS*CO*45*9.56
810  REF*6R*RHP100452-2
811  AMT*B6*9.44
812  LX*63
813  CLP*RHP100453*1*3480*1557.01*0*CI*999020587063*11*1
814  NM1*QC*1*SYNTHETIC*PATIENT100453****MI*ZZ0100453
815  DTM*232*20260803
816  DTM*233*20260803
817  SVC*HC:27447*3480*1557.01**1
818  DTM*472*20260803
819  CAS*CO*45*1922.99
820  REF*6R*RHP100453-1
821  AMT*B6*1557.01
822  LX*64
823  CLP*RHP100454*1*439*194.35*21.59*CI*999020587064*11*1
824  NM1*QC*1*SYNTHETIC*PATIENT100454****MI*ZZ0100454
825  DTM*232*20260820
826  DTM*233*20260820
827  SVC*HC:99215*439*194.35**1
828  DTM*472*20260820
829  CAS*CO*45*223.06
830  CAS*PR*2*21.59
831  REF*6R*RHP100454-1
832  AMT*B6*215.94
833  LX*65
834  CLP*RHP100455*1*912*448.4*0*CI*999020587065*11*1
835  NM1*QC*1*SYNTHETIC*PATIENT100455****MI*ZZ0100455
836  DTM*232*20260819
837  DTM*233*20260819
838  SVC*HC:45380*912*448.4**1
839  DTM*472*20260819
840  CAS*CO*45*463.6
841  REF*6R*RHP100455-1
842  AMT*B6*448.4
843  LX*66
844  CLP*RHP100456*1*269*92.16*40*CI*999020587066*11*1
845  NM1*QC*1*SYNTHETIC*PATIENT100456****MI*ZZ0100456
846  DTM*232*20260818
847  DTM*233*20260818
848  SVC*HC:99203*269*92.16**1
849  DTM*472*20260818
850  CAS*CO*45*136.84
851  CAS*PR*3*40
852  REF*6R*RHP100456-1
853  AMT*B6*132.16
854  LX*67
855  CLP*RHP100457*1*528*207.68*51.92*CI*999020587067*11*1
856  NM1*QC*1*SYNTHETIC*PATIENT100457****MI*ZZ0100457
857  DTM*232*20260817
858  DTM*233*20260817
859  SVC*HC:93306*528*207.68**1
860  DTM*472*20260817
861  CAS*CO*45*268.4
862  CAS*PR*2*51.92
863  REF*6R*RHP100457-1
864  AMT*B6*259.6
865  LX*68
866  CLP*RHP100458*4*449*0*0*CI*999020587068*11*1
867  NM1*QC*1*SYNTHETIC*PATIENT100458****MI*ZZ0100458
868  DTM*232*20260816
869  DTM*233*20260816
870  SVC*HC:99204*408*0**1
871  DTM*472*20260816
872  CAS*CO*18*408
873  REF*6R*RHP100458-1
874  AMT*B6*0
875  SVC*HC:93000*41*0**1
876  DTM*472*20260816
877  CAS*CO*18*41
878  REF*6R*RHP100458-2
879  AMT*B6*0
880  LX*69
881  CLP*RHP100459*1*2520*1127.49*0*CI*999020587069*11*1
882  NM1*QC*1*SYNTHETIC*PATIENT100459****MI*ZZ0100459
883  DTM*232*20260815
884  DTM*233*20260815
885  SVC*HC:29827*2520*1127.49**1
886  DTM*472*20260815
887  CAS*CO*45*1392.51
888  REF*6R*RHP100459-1
889  AMT*B6*1127.49
890  SE*888*0001
891  GE*1*104
892  IEA*1*000000104