Remittances / SM9990031102

Silver Mesa Senior Advantage

Payment SM9990031102, electronic funds transfer dated Aug 13, 2026. From SMA_REMIT_0.txt, imported Aug 14, 2026 by Dana Whitfield.

Balances to the cent

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Payments dated Aug 13, 2026 to Aug 13, 2026, as of Oct 7, 2026. Whole organization, every site.

Payment

$14,318.96

Electronic funds transfer

Claims

63 matched to billed claims

Claim payments

$14,318.96

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
RHP100221	Claim number matched exactly	Denied	$353.00	$0.00	$0.00	$0.00	$147.00
RHP100222 Superseded by a later result	Claim number matched exactly	Denied	$1,728.00	$0.00	$0.00	$0.00	$720.00
RHP100223	Claim number matched exactly	Denied	$528.00	$0.00	$0.00	$0.00	$220.00
RHP101100	Claim number matched exactly	Paid as expected	$140.00	$58.00	$45.47 patient $11.60	$11.60
RHP101101	Claim number matched exactly	Paid as expected	$576.00	$240.00	$188.16 patient $48.00	$48.00
RHP101102	Claim number matched exactly	Paid as expected	$310.00	$129.00	$101.14 patient $25.80	$25.80
RHP101103	Claim number matched exactly	Paid as expected	$338.00	$141.00	$110.54 patient $28.20	$28.20
RHP101104	Claim number matched exactly	Paid as expected	$228.00	$95.00	$74.48 patient $19.00	$19.00
RHP101105	Claim number matched exactly	Paid as expected	$1,728.00	$720.00	$564.48 patient $144.00	$144.00
RHP101106	Claim number matched exactly	Paid as expected	$319.00	$133.00	$104.27 patient $26.60	$26.60
RHP101107	Claim number matched exactly	Paid as expected	$624.00	$260.00	$203.84 patient $52.00	$52.00
RHP101108	Claim number matched exactly	Denied	$240.00	$0.00	$0.00	$0.00	$100.00
RHP101109	Claim number matched exactly	Paid as expected	$3,480.00	$1,450.00	$1,136.80 patient $290.00	$290.00
RHP101110	Claim number matched exactly	Paid as expected	$439.00	$183.00	$143.47 patient $36.60	$36.60
RHP101111	Claim number matched exactly	Paid as expected	$912.00	$380.00	$297.92 patient $76.00	$76.00
RHP101112	Claim number matched exactly	Paid as expected	$269.00	$112.00	$87.81 patient $22.40	$22.40
RHP101113	Claim number matched exactly	Paid as expected	$528.00	$220.00	$172.48 patient $44.00	$44.00
RHP101114	Claim number matched exactly	Paid as expected	$449.00	$187.00	$146.61 patient $37.40	$37.40
RHP101115	Claim number matched exactly	Paid as expected	$2,520.00	$1,050.00	$823.20 patient $210.00	$210.00
RHP101116	Claim number matched exactly	Paid as expected	$140.00	$58.00	$45.47 patient $11.60	$11.60
RHP101117	Claim number matched exactly	Paid as expected	$576.00	$240.00	$188.16 patient $48.00	$48.00
RHP101118	Claim number matched exactly	Paid as expected	$310.00	$129.00	$101.14 patient $25.80	$25.80
RHP101119	Claim number matched exactly	Paid as expected	$338.00	$141.00	$110.54 patient $28.20	$28.20
RHP101120	Claim number matched exactly	Paid as expected	$228.00	$95.00	$74.48 patient $19.00	$19.00
RHP101121	Claim number matched exactly	Denied	$1,728.00	$0.00	$0.00	$0.00	$720.00
RHP101122	Claim number matched exactly	Paid as expected	$319.00	$133.00	$104.27 patient $26.60	$26.60
RHP101123	Claim number matched exactly	Paid as expected	$624.00	$260.00	$203.84 patient $52.00	$52.00
RHP101124	Claim number matched exactly	Paid as expected	$240.00	$100.00	$78.40 patient $20.00	$20.00
RHP101125	Claim number matched exactly	Paid as expected	$3,480.00	$1,450.00	$1,136.80 patient $290.00	$290.00
RHP101126	Claim number matched exactly	Paid as expected	$439.00	$183.00	$143.47 patient $36.60	$36.60
RHP101127	Claim number matched exactly	Paid as expected	$912.00	$380.00	$297.92 patient $76.00	$76.00
RHP101128	Claim number matched exactly	Paid as expected	$269.00	$112.00	$87.81 patient $22.40	$22.40
RHP101129	Claim number matched exactly	Paid as expected	$528.00	$220.00	$172.48 patient $44.00	$44.00
RHP101130	Claim number matched exactly	Paid as expected	$449.00	$187.00	$146.61 patient $37.40	$37.40
RHP101131	Claim number matched exactly	Paid as expected	$2,520.00	$1,050.00	$823.20 patient $210.00	$210.00
RHP101132	Claim number matched exactly	Paid as expected	$140.00	$58.00	$45.47 patient $11.60	$11.60
RHP101133	Claim number matched exactly	Paid as expected	$576.00	$240.00	$188.16 patient $48.00	$48.00
RHP101134	Claim number matched exactly	Denied	$310.00	$0.00	$0.00	$0.00	$129.00
RHP101135	Claim number matched exactly	Paid as expected	$338.00	$141.00	$110.54 patient $28.20	$28.20
RHP101136	Claim number matched exactly	Paid as expected	$228.00	$95.00	$74.48 patient $19.00	$19.00
RHP101137	Claim number matched exactly	Paid as expected	$1,728.00	$720.00	$564.48 patient $144.00	$144.00
RHP101138	Claim number matched exactly	Paid as expected	$319.00	$133.00	$104.27 patient $26.60	$26.60
RHP101139	Claim number matched exactly	Paid as expected	$624.00	$260.00	$203.84 patient $52.00	$52.00
RHP101140	Claim number matched exactly	Paid as expected	$240.00	$100.00	$78.40 patient $20.00	$20.00
RHP101141	Claim number matched exactly	Paid as expected	$3,480.00	$1,450.00	$1,136.80 patient $290.00	$290.00
RHP101142	Claim number matched exactly	Paid as expected	$439.00	$183.00	$143.47 patient $36.60	$36.60
RHP101143	Claim number matched exactly	Paid as expected	$912.00	$380.00	$297.92 patient $76.00	$76.00
RHP101144	Claim number matched exactly	Paid as expected	$269.00	$112.00	$87.81 patient $22.40	$22.40
RHP101145	Claim number matched exactly	Paid as expected	$528.00	$220.00	$172.48 patient $44.00	$44.00
RHP101146	Claim number matched exactly	Paid as expected	$449.00	$187.00	$146.61 patient $37.40	$37.40
RHP101147	Claim number matched exactly	Denied	$2,520.00	$0.00	$0.00	$0.00	$1,050.00
RHP101148	Claim number matched exactly	Paid as expected	$140.00	$58.00	$45.47 patient $11.60	$11.60
RHP101149	Claim number matched exactly	Paid as expected	$576.00	$240.00	$188.16 patient $48.00	$48.00
RHP101150	Claim number matched exactly	Paid as expected	$310.00	$129.00	$101.14 patient $25.80	$25.80
RHP101151	Claim number matched exactly	Paid as expected	$338.00	$141.00	$110.54 patient $28.20	$28.20
RHP101152	Claim number matched exactly	Paid as expected	$228.00	$95.00	$74.48 patient $19.00	$19.00
RHP101153	Claim number matched exactly	Paid as expected	$1,728.00	$720.00	$564.48 patient $144.00	$144.00
RHP101154	Claim number matched exactly	Paid as expected	$319.00	$133.00	$104.27 patient $26.60	$26.60
RHP101155	Claim number matched exactly	Paid as expected	$624.00	$260.00	$203.84 patient $52.00	$52.00
RHP101156	Claim number matched exactly	Paid as expected	$240.00	$100.00	$78.40 patient $20.00	$20.00
RHP101157	Claim number matched exactly	Paid as expected	$3,480.00	$1,450.00	$1,136.80 patient $290.00	$290.00
RHP101158	Claim number matched exactly	Paid as expected	$439.00	$183.00	$143.47 patient $36.60	$36.60
RHP101159	Claim number matched exactly	Paid as expected	$912.00	$380.00	$297.92 patient $76.00	$76.00

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The payer's remittance file (835)

Payer ID 99903. Payee RIDGELINE HEALTH PARTNERS, NPI 9999999001. Transaction 0001, 865 segments.

Show the raw file (869 segments)

1  ISA*00*          *00*          *ZZ*PAYER99903     *ZZ*RIDGELINE999   *260812*0800*^*00501*000000101*0*T*:
2  GS*HP*PAYER99903*RIDGELINE999*20260812*0800*101*X*005010X221A1
3  ST*835*0001
4  BPR*I*14318.96*C*ACH*CCP*01*999999992*DA*000111222*1999999999**01*999999993*DA*000333444*20260813
5  TRN*1*SM9990031102*1999999903
6  DTM*405*20260812
7  N1*PR*SILVER MESA SENIOR ADVANTAGE
8  REF*2U*99903
9  N1*PE*RIDGELINE HEALTH PARTNERS*XX*9999999001
10  REF*TJ*999999999
11  LX*1
12  CLP*RHP100221*4*353*0*0*HM*999031102001*11*1
13  NM1*QC*1*SYNTHETIC*PATIENT100221****MI*ZZ0100221
14  DTM*232*20260731
15  DTM*233*20260731
16  SVC*HC:99214*312*0**1
17  DTM*472*20260731
18  CAS*CO*185*312
19  REF*6R*RHP100221-1
20  AMT*B6*0
21  LQ*HE*N290
22  SVC*HC:93000*41*0**1
23  DTM*472*20260731
24  CAS*CO*185*41
25  REF*6R*RHP100221-2
26  AMT*B6*0
27  LQ*HE*N290
28  LX*2
29  CLP*RHP100222*4*1728*0*0*HM*999031102002*11*1
30  NM1*QC*1*SYNTHETIC*PATIENT100222****MI*ZZ0100222
31  DTM*232*20260802
32  DTM*233*20260802
33  SVC*HC:29881*1728*0**1
34  DTM*472*20260802
35  CAS*CO*197*1728
36  REF*6R*RHP100222-1
37  AMT*B6*0
38  LX*3
39  CLP*RHP100223*4*528*0*0*HM*999031102003*11*1
40  NM1*QC*1*SYNTHETIC*PATIENT100223****MI*ZZ0100223
41  DTM*232*20260803
42  DTM*233*20260803
43  SVC*HC:93306*528*0**1
44  DTM*472*20260803
45  CAS*CO*50*528
46  REF*6R*RHP100223-1
47  AMT*B6*0
48  LQ*HE*N130
49  LX*4
50  CLP*RHP101100*1*140*45.47*11.6*HM*999031102004*11*1
51  NM1*QC*1*SYNTHETIC*PATIENT101100****MI*ZZ0101100
52  DTM*232*20260801
53  DTM*233*20260801
54  SVC*HC:97110*140*45.47**2
55  DTM*472*20260801
56  CAS*CO*45*82**253*0.93
57  CAS*PR*2*11.6
58  REF*6R*RHP101100-1
59  AMT*B6*58
60  LX*5
61  CLP*RHP101101*1*576*188.16*48*HM*999031102005*11*1
62  NM1*QC*1*SYNTHETIC*PATIENT101101****MI*ZZ0101101
63  DTM*232*20260731
64  DTM*233*20260731
65  SVC*HC:64483*576*188.16**1
66  DTM*472*20260731
67  CAS*CO*45*336**253*3.84
68  CAS*PR*2*48
69  REF*6R*RHP101101-1
70  AMT*B6*240
71  LX*6
72  CLP*RHP101102*1*310*101.14*25.8*HM*999031102006*11*1
73  NM1*QC*1*SYNTHETIC*PATIENT101102****MI*ZZ0101102
74  DTM*232*20260730
75  DTM*233*20260730
76  SVC*HC:99213*221*72.13**1
77  DTM*472*20260730
78  CAS*CO*45*129**253*1.47
79  CAS*PR*2*18.4
80  REF*6R*RHP101102-1
81  AMT*B6*92
82  SVC*HC:90471*41*13.33**1
83  DTM*472*20260730
84  CAS*CO*45*24**253*0.27
85  CAS*PR*2*3.4
86  REF*6R*RHP101102-2
87  AMT*B6*17
88  SVC*HC:90686*48*15.68**1
89  DTM*472*20260730
90  CAS*CO*45*28**253*0.32
91  CAS*PR*2*4
92  REF*6R*RHP101102-3
93  AMT*B6*20
94  LX*7
95  CLP*RHP101103*1*338*110.54*28.2*HM*999031102007*11*1
96  NM1*QC*1*SYNTHETIC*PATIENT101103****MI*ZZ0101103
97  DTM*232*20260729
98  DTM*233*20260729
99  SVC*HC:99214*312*101.92**1
100  DTM*472*20260729
101  CAS*CO*45*182**253*2.08
102  CAS*PR*2*26
103  REF*6R*RHP101103-1
104  AMT*B6*130
105  SVC*HC:80053*26*8.62**1
106  DTM*472*20260729
107  CAS*CO*45*15**253*0.18
108  CAS*PR*2*2.2
109  REF*6R*RHP101103-2
110  AMT*B6*11
111  LX*8
112  CLP*RHP101104*1*228*74.48*19*HM*999031102008*11*1
113  NM1*QC*1*SYNTHETIC*PATIENT101104****MI*ZZ0101104
114  DTM*232*20260728
115  DTM*233*20260728
116  SVC*HC:99213*221*72.13**1
117  DTM*472*20260728
118  CAS*CO*45*129**253*1.47
119  CAS*PR*2*18.4
120  REF*6R*RHP101104-1
121  AMT*B6*92
122  SVC*HC:36415*7*2.35**1
123  DTM*472*20260728
124  CAS*CO*45*4**253*0.05
125  CAS*PR*2*0.6
126  REF*6R*RHP101104-2
127  AMT*B6*3
128  LX*9
129  CLP*RHP101105*1*1728*564.48*144*HM*999031102009*11*1
130  NM1*QC*1*SYNTHETIC*PATIENT101105****MI*ZZ0101105
131  DTM*232*20260727
132  DTM*233*20260727
133  SVC*HC:29881*1728*564.48**1
134  DTM*472*20260727
135  CAS*CO*45*1008**253*11.52
136  CAS*PR*2*144
137  REF*6R*RHP101105-1
138  AMT*B6*720
139  LX*10
140  CLP*RHP101106*1*319*104.27*26.6*HM*999031102010*11*1
141  NM1*QC*1*SYNTHETIC*PATIENT101106****MI*ZZ0101106
142  DTM*232*20260726
143  DTM*233*20260726
144  SVC*HC:99214*312*101.92**1
145  DTM*472*20260726
146  CAS*CO*45*182**253*2.08
147  CAS*PR*2*26
148  REF*6R*RHP101106-1
149  AMT*B6*130
150  SVC*HC:36415*7*2.35**1
151  DTM*472*20260726
152  CAS*CO*45*4**253*0.05
153  CAS*PR*2*0.6
154  REF*6R*RHP101106-2
155  AMT*B6*3
156  LX*11
157  CLP*RHP101107*1*624*203.84*52*HM*999031102011*11*1
158  NM1*QC*1*SYNTHETIC*PATIENT101107****MI*ZZ0101107
159  DTM*232*20260725
160  DTM*233*20260725
161  SVC*HC:73721*624*203.84**1
162  DTM*472*20260725
163  CAS*CO*45*364**253*4.16
164  CAS*PR*2*52
165  REF*6R*RHP101107-1
166  AMT*B6*260
167  LX*12
168  CLP*RHP101108*4*240*0*0*HM*999031102012*11*1
169  NM1*QC*1*SYNTHETIC*PATIENT101108****MI*ZZ0101108
170  DTM*232*20260724
171  DTM*233*20260724
172  SVC*HC:99213*221*0**1
173  DTM*472*20260724
174  CAS*CO*16*221
175  REF*6R*RHP101108-1
176  AMT*B6*0
177  LQ*HE*MA130
178  SVC*HC:85025*19*0**1
179  DTM*472*20260724
180  CAS*CO*16*19
181  REF*6R*RHP101108-2
182  AMT*B6*0
183  LQ*HE*MA130
184  LX*13
185  CLP*RHP101109*1*3480*1136.8*290*HM*999031102013*11*1
186  NM1*QC*1*SYNTHETIC*PATIENT101109****MI*ZZ0101109
187  DTM*232*20260723
188  DTM*233*20260723
189  SVC*HC:27447*3480*1136.8**1
190  DTM*472*20260723
191  CAS*CO*45*2030**253*23.2
192  CAS*PR*2*290
193  REF*6R*RHP101109-1
194  AMT*B6*1450
195  LX*14
196  CLP*RHP101110*1*439*143.47*36.6*HM*999031102014*11*1
197  NM1*QC*1*SYNTHETIC*PATIENT101110****MI*ZZ0101110
198  DTM*232*20260722
199  DTM*233*20260722
200  SVC*HC:99215*439*143.47**1
201  DTM*472*20260722
202  CAS*CO*45*256**253*2.93
203  CAS*PR*2*36.6
204  REF*6R*RHP101110-1
205  AMT*B6*183
206  LX*15
207  CLP*RHP101111*1*912*297.92*76*HM*999031102015*11*1
208  NM1*QC*1*SYNTHETIC*PATIENT101111****MI*ZZ0101111
209  DTM*232*20260721
210  DTM*233*20260721
211  SVC*HC:45380*912*297.92**1
212  DTM*472*20260721
213  CAS*CO*45*532**253*6.08
214  CAS*PR*2*76
215  REF*6R*RHP101111-1
216  AMT*B6*380
217  LX*16
218  CLP*RHP101112*1*269*87.81*22.4*HM*999031102016*11*1
219  NM1*QC*1*SYNTHETIC*PATIENT101112****MI*ZZ0101112
220  DTM*232*20260720
221  DTM*233*20260720
222  SVC*HC:99203*269*87.81**1
223  DTM*472*20260720
224  CAS*CO*45*157**253*1.79
225  CAS*PR*2*22.4
226  REF*6R*RHP101112-1
227  AMT*B6*112
228  LX*17
229  CLP*RHP101113*1*528*172.48*44*HM*999031102017*11*1
230  NM1*QC*1*SYNTHETIC*PATIENT101113****MI*ZZ0101113
231  DTM*232*20260719
232  DTM*233*20260719
233  SVC*HC:93306*528*172.48**1
234  DTM*472*20260719
235  CAS*CO*45*308**253*3.52
236  CAS*PR*2*44
237  REF*6R*RHP101113-1
238  AMT*B6*220
239  LX*18
240  CLP*RHP101114*1*449*146.61*37.4*HM*999031102018*11*1
241  NM1*QC*1*SYNTHETIC*PATIENT101114****MI*ZZ0101114
242  DTM*232*20260718
243  DTM*233*20260718
244  SVC*HC:99204*408*133.28**1
245  DTM*472*20260718
246  CAS*CO*45*238**253*2.72
247  CAS*PR*2*34
248  REF*6R*RHP101114-1
249  AMT*B6*170
250  SVC*HC:93000*41*13.33**1
251  DTM*472*20260718
252  CAS*CO*45*24**253*0.27
253  CAS*PR*2*3.4
254  REF*6R*RHP101114-2
255  AMT*B6*17
256  LX*19
257  CLP*RHP101115*1*2520*823.2*210*HM*999031102019*11*1
258  NM1*QC*1*SYNTHETIC*PATIENT101115****MI*ZZ0101115
259  DTM*232*20260717
260  DTM*233*20260717
261  SVC*HC:29827*2520*823.2**1
262  DTM*472*20260717
263  CAS*CO*45*1470**253*16.8
264  CAS*PR*2*210
265  REF*6R*RHP101115-1
266  AMT*B6*1050
267  LX*20
268  CLP*RHP101116*1*140*45.47*11.6*HM*999031102020*11*1
269  NM1*QC*1*SYNTHETIC*PATIENT101116****MI*ZZ0101116
270  DTM*232*20260716
271  DTM*233*20260716
272  SVC*HC:97110*140*45.47**2
273  DTM*472*20260716
274  CAS*CO*45*82**253*0.93
275  CAS*PR*2*11.6
276  REF*6R*RHP101116-1
277  AMT*B6*58
278  LX*21
279  CLP*RHP101117*1*576*188.16*48*HM*999031102021*11*1
280  NM1*QC*1*SYNTHETIC*PATIENT101117****MI*ZZ0101117
281  DTM*232*20260715
282  DTM*233*20260715
283  SVC*HC:64483*576*188.16**1
284  DTM*472*20260715
285  CAS*CO*45*336**253*3.84
286  CAS*PR*2*48
287  REF*6R*RHP101117-1
288  AMT*B6*240
289  LX*22
290  CLP*RHP101118*1*310*101.14*25.8*HM*999031102022*11*1
291  NM1*QC*1*SYNTHETIC*PATIENT101118****MI*ZZ0101118
292  DTM*232*20260801
293  DTM*233*20260801
294  SVC*HC:99213*221*72.13**1
295  DTM*472*20260801
296  CAS*CO*45*129**253*1.47
297  CAS*PR*2*18.4
298  REF*6R*RHP101118-1
299  AMT*B6*92
300  SVC*HC:90471*41*13.33**1
301  DTM*472*20260801
302  CAS*CO*45*24**253*0.27
303  CAS*PR*2*3.4
304  REF*6R*RHP101118-2
305  AMT*B6*17
306  SVC*HC:90686*48*15.68**1
307  DTM*472*20260801
308  CAS*CO*45*28**253*0.32
309  CAS*PR*2*4
310  REF*6R*RHP101118-3
311  AMT*B6*20
312  LX*23
313  CLP*RHP101119*1*338*110.54*28.2*HM*999031102023*11*1
314  NM1*QC*1*SYNTHETIC*PATIENT101119****MI*ZZ0101119
315  DTM*232*20260731
316  DTM*233*20260731
317  SVC*HC:99214*312*101.92**1
318  DTM*472*20260731
319  CAS*CO*45*182**253*2.08
320  CAS*PR*2*26
321  REF*6R*RHP101119-1
322  AMT*B6*130
323  SVC*HC:80053*26*8.62**1
324  DTM*472*20260731
325  CAS*CO*45*15**253*0.18
326  CAS*PR*2*2.2
327  REF*6R*RHP101119-2
328  AMT*B6*11
329  LX*24
330  CLP*RHP101120*1*228*74.48*19*HM*999031102024*11*1
331  NM1*QC*1*SYNTHETIC*PATIENT101120****MI*ZZ0101120
332  DTM*232*20260730
333  DTM*233*20260730
334  SVC*HC:99213*221*72.13**1
335  DTM*472*20260730
336  CAS*CO*45*129**253*1.47
337  CAS*PR*2*18.4
338  REF*6R*RHP101120-1
339  AMT*B6*92
340  SVC*HC:36415*7*2.35**1
341  DTM*472*20260730
342  CAS*CO*45*4**253*0.05
343  CAS*PR*2*0.6
344  REF*6R*RHP101120-2
345  AMT*B6*3
346  LX*25
347  CLP*RHP101121*4*1728*0*0*HM*999031102025*11*1
348  NM1*QC*1*SYNTHETIC*PATIENT101121****MI*ZZ0101121
349  DTM*232*20260729
350  DTM*233*20260729
351  SVC*HC:29881*1728*0**1
352  DTM*472*20260729
353  CAS*CO*50*1728
354  REF*6R*RHP101121-1
355  AMT*B6*0
356  LQ*HE*N130
357  LX*26
358  CLP*RHP101122*1*319*104.27*26.6*HM*999031102026*11*1
359  NM1*QC*1*SYNTHETIC*PATIENT101122****MI*ZZ0101122
360  DTM*232*20260728
361  DTM*233*20260728
362  SVC*HC:99214*312*101.92**1
363  DTM*472*20260728
364  CAS*CO*45*182**253*2.08
365  CAS*PR*2*26
366  REF*6R*RHP101122-1
367  AMT*B6*130
368  SVC*HC:36415*7*2.35**1
369  DTM*472*20260728
370  CAS*CO*45*4**253*0.05
371  CAS*PR*2*0.6
372  REF*6R*RHP101122-2
373  AMT*B6*3
374  LX*27
375  CLP*RHP101123*1*624*203.84*52*HM*999031102027*11*1
376  NM1*QC*1*SYNTHETIC*PATIENT101123****MI*ZZ0101123
377  DTM*232*20260727
378  DTM*233*20260727
379  SVC*HC:73721*624*203.84**1
380  DTM*472*20260727
381  CAS*CO*45*364**253*4.16
382  CAS*PR*2*52
383  REF*6R*RHP101123-1
384  AMT*B6*260
385  LX*28
386  CLP*RHP101124*1*240*78.4*20*HM*999031102028*11*1
387  NM1*QC*1*SYNTHETIC*PATIENT101124****MI*ZZ0101124
388  DTM*232*20260726
389  DTM*233*20260726
390  SVC*HC:99213*221*72.13**1
391  DTM*472*20260726
392  CAS*CO*45*129**253*1.47
393  CAS*PR*2*18.4
394  REF*6R*RHP101124-1
395  AMT*B6*92
396  SVC*HC:85025*19*6.27**1
397  DTM*472*20260726
398  CAS*CO*45*11**253*0.13
399  CAS*PR*2*1.6
400  REF*6R*RHP101124-2
401  AMT*B6*8
402  LX*29
403  CLP*RHP101125*1*3480*1136.8*290*HM*999031102029*11*1
404  NM1*QC*1*SYNTHETIC*PATIENT101125****MI*ZZ0101125
405  DTM*232*20260725
406  DTM*233*20260725
407  SVC*HC:27447*3480*1136.8**1
408  DTM*472*20260725
409  CAS*CO*45*2030**253*23.2
410  CAS*PR*2*290
411  REF*6R*RHP101125-1
412  AMT*B6*1450
413  LX*30
414  CLP*RHP101126*1*439*143.47*36.6*HM*999031102030*11*1
415  NM1*QC*1*SYNTHETIC*PATIENT101126****MI*ZZ0101126
416  DTM*232*20260724
417  DTM*233*20260724
418  SVC*HC:99215*439*143.47**1
419  DTM*472*20260724
420  CAS*CO*45*256**253*2.93
421  CAS*PR*2*36.6
422  REF*6R*RHP101126-1
423  AMT*B6*183
424  LX*31
425  CLP*RHP101127*1*912*297.92*76*HM*999031102031*11*1
426  NM1*QC*1*SYNTHETIC*PATIENT101127****MI*ZZ0101127
427  DTM*232*20260723
428  DTM*233*20260723
429  SVC*HC:45380*912*297.92**1
430  DTM*472*20260723
431  CAS*CO*45*532**253*6.08
432  CAS*PR*2*76
433  REF*6R*RHP101127-1
434  AMT*B6*380
435  LX*32
436  CLP*RHP101128*1*269*87.81*22.4*HM*999031102032*11*1
437  NM1*QC*1*SYNTHETIC*PATIENT101128****MI*ZZ0101128
438  DTM*232*20260722
439  DTM*233*20260722
440  SVC*HC:99203*269*87.81**1
441  DTM*472*20260722
442  CAS*CO*45*157**253*1.79
443  CAS*PR*2*22.4
444  REF*6R*RHP101128-1
445  AMT*B6*112
446  LX*33
447  CLP*RHP101129*1*528*172.48*44*HM*999031102033*11*1
448  NM1*QC*1*SYNTHETIC*PATIENT101129****MI*ZZ0101129
449  DTM*232*20260721
450  DTM*233*20260721
451  SVC*HC:93306*528*172.48**1
452  DTM*472*20260721
453  CAS*CO*45*308**253*3.52
454  CAS*PR*2*44
455  REF*6R*RHP101129-1
456  AMT*B6*220
457  LX*34
458  CLP*RHP101130*1*449*146.61*37.4*HM*999031102034*11*1
459  NM1*QC*1*SYNTHETIC*PATIENT101130****MI*ZZ0101130
460  DTM*232*20260720
461  DTM*233*20260720
462  SVC*HC:99204*408*133.28**1
463  DTM*472*20260720
464  CAS*CO*45*238**253*2.72
465  CAS*PR*2*34
466  REF*6R*RHP101130-1
467  AMT*B6*170
468  SVC*HC:93000*41*13.33**1
469  DTM*472*20260720
470  CAS*CO*45*24**253*0.27
471  CAS*PR*2*3.4
472  REF*6R*RHP101130-2
473  AMT*B6*17
474  LX*35
475  CLP*RHP101131*1*2520*823.2*210*HM*999031102035*11*1
476  NM1*QC*1*SYNTHETIC*PATIENT101131****MI*ZZ0101131
477  DTM*232*20260719
478  DTM*233*20260719
479  SVC*HC:29827*2520*823.2**1
480  DTM*472*20260719
481  CAS*CO*45*1470**253*16.8
482  CAS*PR*2*210
483  REF*6R*RHP101131-1
484  AMT*B6*1050
485  LX*36
486  CLP*RHP101132*1*140*45.47*11.6*HM*999031102036*11*1
487  NM1*QC*1*SYNTHETIC*PATIENT101132****MI*ZZ0101132
488  DTM*232*20260718
489  DTM*233*20260718
490  SVC*HC:97110*140*45.47**2
491  DTM*472*20260718
492  CAS*CO*45*82**253*0.93
493  CAS*PR*2*11.6
494  REF*6R*RHP101132-1
495  AMT*B6*58
496  LX*37
497  CLP*RHP101133*1*576*188.16*48*HM*999031102037*11*1
498  NM1*QC*1*SYNTHETIC*PATIENT101133****MI*ZZ0101133
499  DTM*232*20260717
500  DTM*233*20260717
501  SVC*HC:64483*576*188.16**1
502  DTM*472*20260717
503  CAS*CO*45*336**253*3.84
504  CAS*PR*2*48
505  REF*6R*RHP101133-1
506  AMT*B6*240
507  LX*38
508  CLP*RHP101134*4*310*0*0*HM*999031102038*11*1
509  NM1*QC*1*SYNTHETIC*PATIENT101134****MI*ZZ0101134
510  DTM*232*20260716
511  DTM*233*20260716
512  SVC*HC:99213*221*0**1
513  DTM*472*20260716
514  CAS*CO*22*221
515  REF*6R*RHP101134-1
516  AMT*B6*0
517  SVC*HC:90471*41*0**1
518  DTM*472*20260716
519  CAS*CO*22*41
520  REF*6R*RHP101134-2
521  AMT*B6*0
522  SVC*HC:90686*48*0**1
523  DTM*472*20260716
524  CAS*CO*22*48
525  REF*6R*RHP101134-3
526  AMT*B6*0
527  LX*39
528  CLP*RHP101135*1*338*110.54*28.2*HM*999031102039*11*1
529  NM1*QC*1*SYNTHETIC*PATIENT101135****MI*ZZ0101135
530  DTM*232*20260715
531  DTM*233*20260715
532  SVC*HC:99214*312*101.92**1
533  DTM*472*20260715
534  CAS*CO*45*182**253*2.08
535  CAS*PR*2*26
536  REF*6R*RHP101135-1
537  AMT*B6*130
538  SVC*HC:80053*26*8.62**1
539  DTM*472*20260715
540  CAS*CO*45*15**253*0.18
541  CAS*PR*2*2.2
542  REF*6R*RHP101135-2
543  AMT*B6*11
544  LX*40
545  CLP*RHP101136*1*228*74.48*19*HM*999031102040*11*1
546  NM1*QC*1*SYNTHETIC*PATIENT101136****MI*ZZ0101136
547  DTM*232*20260801
548  DTM*233*20260801
549  SVC*HC:99213*221*72.13**1
550  DTM*472*20260801
551  CAS*CO*45*129**253*1.47
552  CAS*PR*2*18.4
553  REF*6R*RHP101136-1
554  AMT*B6*92
555  SVC*HC:36415*7*2.35**1
556  DTM*472*20260801
557  CAS*CO*45*4**253*0.05
558  CAS*PR*2*0.6
559  REF*6R*RHP101136-2
560  AMT*B6*3
561  LX*41
562  CLP*RHP101137*1*1728*564.48*144*HM*999031102041*11*1
563  NM1*QC*1*SYNTHETIC*PATIENT101137****MI*ZZ0101137
564  DTM*232*20260731
565  DTM*233*20260731
566  SVC*HC:29881*1728*564.48**1
567  DTM*472*20260731
568  CAS*CO*45*1008**253*11.52
569  CAS*PR*2*144
570  REF*6R*RHP101137-1
571  AMT*B6*720
572  LX*42
573  CLP*RHP101138*1*319*104.27*26.6*HM*999031102042*11*1
574  NM1*QC*1*SYNTHETIC*PATIENT101138****MI*ZZ0101138
575  DTM*232*20260730
576  DTM*233*20260730
577  SVC*HC:99214*312*101.92**1
578  DTM*472*20260730
579  CAS*CO*45*182**253*2.08
580  CAS*PR*2*26
581  REF*6R*RHP101138-1
582  AMT*B6*130
583  SVC*HC:36415*7*2.35**1
584  DTM*472*20260730
585  CAS*CO*45*4**253*0.05
586  CAS*PR*2*0.6
587  REF*6R*RHP101138-2
588  AMT*B6*3
589  LX*43
590  CLP*RHP101139*1*624*203.84*52*HM*999031102043*11*1
591  NM1*QC*1*SYNTHETIC*PATIENT101139****MI*ZZ0101139
592  DTM*232*20260729
593  DTM*233*20260729
594  SVC*HC:73721*624*203.84**1
595  DTM*472*20260729
596  CAS*CO*45*364**253*4.16
597  CAS*PR*2*52
598  REF*6R*RHP101139-1
599  AMT*B6*260
600  LX*44
601  CLP*RHP101140*1*240*78.4*20*HM*999031102044*11*1
602  NM1*QC*1*SYNTHETIC*PATIENT101140****MI*ZZ0101140
603  DTM*232*20260728
604  DTM*233*20260728
605  SVC*HC:99213*221*72.13**1
606  DTM*472*20260728
607  CAS*CO*45*129**253*1.47
608  CAS*PR*2*18.4
609  REF*6R*RHP101140-1
610  AMT*B6*92
611  SVC*HC:85025*19*6.27**1
612  DTM*472*20260728
613  CAS*CO*45*11**253*0.13
614  CAS*PR*2*1.6
615  REF*6R*RHP101140-2
616  AMT*B6*8
617  LX*45
618  CLP*RHP101141*1*3480*1136.8*290*HM*999031102045*11*1
619  NM1*QC*1*SYNTHETIC*PATIENT101141****MI*ZZ0101141
620  DTM*232*20260727
621  DTM*233*20260727
622  SVC*HC:27447*3480*1136.8**1
623  DTM*472*20260727
624  CAS*CO*45*2030**253*23.2
625  CAS*PR*2*290
626  REF*6R*RHP101141-1
627  AMT*B6*1450
628  LX*46
629  CLP*RHP101142*1*439*143.47*36.6*HM*999031102046*11*1
630  NM1*QC*1*SYNTHETIC*PATIENT101142****MI*ZZ0101142
631  DTM*232*20260726
632  DTM*233*20260726
633  SVC*HC:99215*439*143.47**1
634  DTM*472*20260726
635  CAS*CO*45*256**253*2.93
636  CAS*PR*2*36.6
637  REF*6R*RHP101142-1
638  AMT*B6*183
639  LX*47
640  CLP*RHP101143*1*912*297.92*76*HM*999031102047*11*1
641  NM1*QC*1*SYNTHETIC*PATIENT101143****MI*ZZ0101143
642  DTM*232*20260725
643  DTM*233*20260725
644  SVC*HC:45380*912*297.92**1
645  DTM*472*20260725
646  CAS*CO*45*532**253*6.08
647  CAS*PR*2*76
648  REF*6R*RHP101143-1
649  AMT*B6*380
650  LX*48
651  CLP*RHP101144*1*269*87.81*22.4*HM*999031102048*11*1
652  NM1*QC*1*SYNTHETIC*PATIENT101144****MI*ZZ0101144
653  DTM*232*20260724
654  DTM*233*20260724
655  SVC*HC:99203*269*87.81**1
656  DTM*472*20260724
657  CAS*CO*45*157**253*1.79
658  CAS*PR*2*22.4
659  REF*6R*RHP101144-1
660  AMT*B6*112
661  LX*49
662  CLP*RHP101145*1*528*172.48*44*HM*999031102049*11*1
663  NM1*QC*1*SYNTHETIC*PATIENT101145****MI*ZZ0101145
664  DTM*232*20260723
665  DTM*233*20260723
666  SVC*HC:93306*528*172.48**1
667  DTM*472*20260723
668  CAS*CO*45*308**253*3.52
669  CAS*PR*2*44
670  REF*6R*RHP101145-1
671  AMT*B6*220
672  LX*50
673  CLP*RHP101146*1*449*146.61*37.4*HM*999031102050*11*1
674  NM1*QC*1*SYNTHETIC*PATIENT101146****MI*ZZ0101146
675  DTM*232*20260722
676  DTM*233*20260722
677  SVC*HC:99204*408*133.28**1
678  DTM*472*20260722
679  CAS*CO*45*238**253*2.72
680  CAS*PR*2*34
681  REF*6R*RHP101146-1
682  AMT*B6*170
683  SVC*HC:93000*41*13.33**1
684  DTM*472*20260722
685  CAS*CO*45*24**253*0.27
686  CAS*PR*2*3.4
687  REF*6R*RHP101146-2
688  AMT*B6*17
689  LX*51
690  CLP*RHP101147*4*2520*0*0*HM*999031102051*11*1
691  NM1*QC*1*SYNTHETIC*PATIENT101147****MI*ZZ0101147
692  DTM*232*20260721
693  DTM*233*20260721
694  SVC*HC:29827*2520*0**1
695  DTM*472*20260721
696  CAS*CO*197*2520
697  REF*6R*RHP101147-1
698  AMT*B6*0
699  LX*52
700  CLP*RHP101148*1*140*45.47*11.6*HM*999031102052*11*1
701  NM1*QC*1*SYNTHETIC*PATIENT101148****MI*ZZ0101148
702  DTM*232*20260720
703  DTM*233*20260720
704  SVC*HC:97110*140*45.47**2
705  DTM*472*20260720
706  CAS*CO*45*82**253*0.93
707  CAS*PR*2*11.6
708  REF*6R*RHP101148-1
709  AMT*B6*58
710  LX*53
711  CLP*RHP101149*1*576*188.16*48*HM*999031102053*11*1
712  NM1*QC*1*SYNTHETIC*PATIENT101149****MI*ZZ0101149
713  DTM*232*20260719
714  DTM*233*20260719
715  SVC*HC:64483*576*188.16**1
716  DTM*472*20260719
717  CAS*CO*45*336**253*3.84
718  CAS*PR*2*48
719  REF*6R*RHP101149-1
720  AMT*B6*240
721  LX*54
722  CLP*RHP101150*1*310*101.14*25.8*HM*999031102054*11*1
723  NM1*QC*1*SYNTHETIC*PATIENT101150****MI*ZZ0101150
724  DTM*232*20260718
725  DTM*233*20260718
726  SVC*HC:99213*221*72.13**1
727  DTM*472*20260718
728  CAS*CO*45*129**253*1.47
729  CAS*PR*2*18.4
730  REF*6R*RHP101150-1
731  AMT*B6*92
732  SVC*HC:90471*41*13.33**1
733  DTM*472*20260718
734  CAS*CO*45*24**253*0.27
735  CAS*PR*2*3.4
736  REF*6R*RHP101150-2
737  AMT*B6*17
738  SVC*HC:90686*48*15.68**1
739  DTM*472*20260718
740  CAS*CO*45*28**253*0.32
741  CAS*PR*2*4
742  REF*6R*RHP101150-3
743  AMT*B6*20
744  LX*55
745  CLP*RHP101151*1*338*110.54*28.2*HM*999031102055*11*1
746  NM1*QC*1*SYNTHETIC*PATIENT101151****MI*ZZ0101151
747  DTM*232*20260717
748  DTM*233*20260717
749  SVC*HC:99214*312*101.92**1
750  DTM*472*20260717
751  CAS*CO*45*182**253*2.08
752  CAS*PR*2*26
753  REF*6R*RHP101151-1
754  AMT*B6*130
755  SVC*HC:80053*26*8.62**1
756  DTM*472*20260717
757  CAS*CO*45*15**253*0.18
758  CAS*PR*2*2.2
759  REF*6R*RHP101151-2
760  AMT*B6*11
761  LX*56
762  CLP*RHP101152*1*228*74.48*19*HM*999031102056*11*1
763  NM1*QC*1*SYNTHETIC*PATIENT101152****MI*ZZ0101152
764  DTM*232*20260716
765  DTM*233*20260716
766  SVC*HC:99213*221*72.13**1
767  DTM*472*20260716
768  CAS*CO*45*129**253*1.47
769  CAS*PR*2*18.4
770  REF*6R*RHP101152-1
771  AMT*B6*92
772  SVC*HC:36415*7*2.35**1
773  DTM*472*20260716
774  CAS*CO*45*4**253*0.05
775  CAS*PR*2*0.6
776  REF*6R*RHP101152-2
777  AMT*B6*3
778  LX*57
779  CLP*RHP101153*1*1728*564.48*144*HM*999031102057*11*1
780  NM1*QC*1*SYNTHETIC*PATIENT101153****MI*ZZ0101153
781  DTM*232*20260715
782  DTM*233*20260715
783  SVC*HC:29881*1728*564.48**1
784  DTM*472*20260715
785  CAS*CO*45*1008**253*11.52
786  CAS*PR*2*144
787  REF*6R*RHP101153-1
788  AMT*B6*720
789  LX*58
790  CLP*RHP101154*1*319*104.27*26.6*HM*999031102058*11*1
791  NM1*QC*1*SYNTHETIC*PATIENT101154****MI*ZZ0101154
792  DTM*232*20260801
793  DTM*233*20260801
794  SVC*HC:99214*312*101.92**1
795  DTM*472*20260801
796  CAS*CO*45*182**253*2.08
797  CAS*PR*2*26
798  REF*6R*RHP101154-1
799  AMT*B6*130
800  SVC*HC:36415*7*2.35**1
801  DTM*472*20260801
802  CAS*CO*45*4**253*0.05
803  CAS*PR*2*0.6
804  REF*6R*RHP101154-2
805  AMT*B6*3
806  LX*59
807  CLP*RHP101155*1*624*203.84*52*HM*999031102059*11*1
808  NM1*QC*1*SYNTHETIC*PATIENT101155****MI*ZZ0101155
809  DTM*232*20260731
810  DTM*233*20260731
811  SVC*HC:73721*624*203.84**1
812  DTM*472*20260731
813  CAS*CO*45*364**253*4.16
814  CAS*PR*2*52
815  REF*6R*RHP101155-1
816  AMT*B6*260
817  LX*60
818  CLP*RHP101156*1*240*78.4*20*HM*999031102060*11*1
819  NM1*QC*1*SYNTHETIC*PATIENT101156****MI*ZZ0101156
820  DTM*232*20260730
821  DTM*233*20260730
822  SVC*HC:99213*221*72.13**1
823  DTM*472*20260730
824  CAS*CO*45*129**253*1.47
825  CAS*PR*2*18.4
826  REF*6R*RHP101156-1
827  AMT*B6*92
828  SVC*HC:85025*19*6.27**1
829  DTM*472*20260730
830  CAS*CO*45*11**253*0.13
831  CAS*PR*2*1.6
832  REF*6R*RHP101156-2
833  AMT*B6*8
834  LX*61
835  CLP*RHP101157*1*3480*1136.8*290*HM*999031102061*11*1
836  NM1*QC*1*SYNTHETIC*PATIENT101157****MI*ZZ0101157
837  DTM*232*20260729
838  DTM*233*20260729
839  SVC*HC:27447*3480*1136.8**1
840  DTM*472*20260729
841  CAS*CO*45*2030**253*23.2
842  CAS*PR*2*290
843  REF*6R*RHP101157-1
844  AMT*B6*1450
845  LX*62
846  CLP*RHP101158*1*439*143.47*36.6*HM*999031102062*11*1
847  NM1*QC*1*SYNTHETIC*PATIENT101158****MI*ZZ0101158
848  DTM*232*20260728
849  DTM*233*20260728
850  SVC*HC:99215*439*143.47**1
851  DTM*472*20260728
852  CAS*CO*45*256**253*2.93
853  CAS*PR*2*36.6
854  REF*6R*RHP101158-1
855  AMT*B6*183
856  LX*63
857  CLP*RHP101159*1*912*297.92*76*HM*999031102063*11*1
858  NM1*QC*1*SYNTHETIC*PATIENT101159****MI*ZZ0101159
859  DTM*232*20260727
860  DTM*233*20260727
861  SVC*HC:45380*912*297.92**1
862  DTM*472*20260727
863  CAS*CO*45*532**253*6.08
864  CAS*PR*2*76
865  REF*6R*RHP101159-1
866  AMT*B6*380
867  SE*865*0001
868  GE*1*101
869  IEA*1*000000101