Remittances / EFT9990000498

Tallow Creek Health Plan

Payment EFT9990000498, electronic funds transfer dated Sep 21, 2026. From TCH_835_B.x12, imported Sep 22, 2026 by Dana Whitfield.

Balances to the cent

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Payments dated Sep 21, 2026 to Sep 21, 2026, as of Oct 6, 2026. Whole organization, every site.

Payment

$19,074.92

Electronic funds transfer

Claims

67 matched to billed claims

Claim payments

$19,096.15

Before provider adjustments

Provider adjustments

-$21.23

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
RHP100103 Superseded by a later result	Claim number matched exactly	Reversal	-$449.00	-$223.65	-$223.65	$0.00
RHP100103	Claim number matched exactly	Paid as expected	$449.00	$243.10	$243.10	$0.00
RHP100107	Claim number matched exactly	Paid as expected	$221.00	$119.60	$95.68 patient $23.92	$23.92
RHP100141	Claim number matched exactly	Paid as expected	$312.00	$169.00	$139.00 patient $30.00	$30.00
RHP100142	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.80 patient $24.70	$24.70
RHP100143	Claim number matched exactly	Denied	$156.00	$0.00	$0.00	$0.00	$84.50
RHP100241	Claim number matched exactly	Paid as expected	$967.00	$523.90	$419.12 patient $104.78	$104.78
RHP100700	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08
RHP100701	Claim number matched exactly	Paid as expected	$576.00	$312.00	$262.00 patient $50.00	$50.00
RHP100702	Claim number matched exactly	Paid as expected	$310.00	$167.70	$167.70	$0.00
RHP100703	Claim number matched exactly	Paid as expected	$338.00	$183.30	$83.30 patient $100.00	$100.00
RHP100704	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.50 patient $25.00	$25.00
RHP100705	Claim number matched exactly	Denied	$1,728.00	$0.00	$0.00	$0.00	$936.00
RHP100706	Claim number matched exactly	Paid as expected	$319.00	$172.90	$138.32 patient $34.58	$34.58
RHP100707	Claim number matched exactly	Paid as expected	$624.00	$338.00	$188.00 patient $150.00	$150.00
RHP100708	Claim number matched exactly	Paid as expected	$240.00	$130.00	$130.00	$0.00
RHP100709	Claim number matched exactly	Paid as expected	$3,480.00	$1,885.00	$1,696.50 patient $188.50	$188.50
RHP100710	Claim number matched exactly	Paid as expected	$439.00	$237.90	$214.11 patient $23.79	$23.79
RHP100711	Claim number matched exactly	Paid as expected	$912.00	$494.00	$494.00	$0.00
RHP100712	Claim number matched exactly	Paid as expected	$269.00	$145.60	$105.60 patient $40.00	$40.00
RHP100713	Claim number matched exactly	Paid as expected	$528.00	$286.00	$228.80 patient $57.20	$57.20
RHP100714	Claim number matched exactly	Paid as expected	$449.00	$243.10	$243.10	$0.00
RHP100715	Claim number matched exactly	Paid as expected	$2,520.00	$1,365.00	$1,092.00 patient $273.00	$273.00
RHP100716	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08
RHP100717	Claim number matched exactly	Paid as expected	$576.00	$312.00	$262.00 patient $50.00	$50.00
RHP100718	Claim number matched exactly	Denied	$310.00	$0.00	$0.00	$0.00	$167.70
RHP100719	Claim number matched exactly	Paid as expected	$338.00	$183.30	$83.30 patient $100.00	$100.00
RHP100720	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.50 patient $25.00	$25.00
RHP100721	Claim number matched exactly	Paid as expected	$1,728.00	$936.00	$748.80 patient $187.20	$187.20
RHP100722	Claim number matched exactly	Paid as expected	$319.00	$172.90	$138.32 patient $34.58	$34.58
RHP100723	Claim number matched exactly	Paid as expected	$624.00	$338.00	$188.00 patient $150.00	$150.00
RHP100724	Claim number matched exactly	Paid as expected	$240.00	$130.00	$130.00	$0.00
RHP100725	Claim number matched exactly	Paid as expected	$3,480.00	$1,885.00	$1,696.50 patient $188.50	$188.50
RHP100726	Claim number matched exactly	Paid as expected	$439.00	$237.90	$214.11 patient $23.79	$23.79
RHP100727	Claim number matched exactly	Paid as expected	$912.00	$494.00	$494.00	$0.00
RHP100728	Claim number matched exactly	Paid as expected	$269.00	$145.60	$105.60 patient $40.00	$40.00
RHP100729	Claim number matched exactly	Paid as expected	$528.00	$286.00	$228.80 patient $57.20	$57.20
RHP100730	Claim number matched exactly	Paid as expected	$449.00	$243.10	$243.10	$0.00
RHP100731	Claim number matched exactly	Denied	$2,520.00	$0.00	$0.00	$0.00	$1,365.00
RHP100732	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08
RHP100733	Claim number matched exactly	Paid as expected	$576.00	$312.00	$262.00 patient $50.00	$50.00
RHP100734	Claim number matched exactly	Paid as expected	$310.00	$167.70	$167.70	$0.00
RHP100735	Claim number matched exactly	Paid as expected	$338.00	$183.30	$83.30 patient $100.00	$100.00
RHP100736	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.50 patient $25.00	$25.00
RHP100737	Claim number matched exactly	Paid as expected	$1,728.00	$936.00	$748.80 patient $187.20	$187.20
RHP100738	Claim number matched exactly	Paid as expected	$319.00	$172.90	$138.32 patient $34.58	$34.58
RHP100739	Claim number matched exactly	Paid as expected	$624.00	$338.00	$188.00 patient $150.00	$150.00
RHP100740	Claim number matched exactly	Paid as expected	$240.00	$130.00	$130.00	$0.00
RHP100741	Claim number matched exactly	Paid as expected	$3,480.00	$1,885.00	$1,696.50 patient $188.50	$188.50
RHP100742	Claim number matched exactly	Paid as expected	$439.00	$237.90	$214.11 patient $23.79	$23.79
RHP100743	Claim number matched exactly	Paid as expected	$912.00	$494.00	$494.00	$0.00
RHP100744	Claim number matched exactly	Denied	$269.00	$0.00	$0.00	$0.00	$145.60
RHP100745	Claim number matched exactly	Paid as expected	$528.00	$286.00	$228.80 patient $57.20	$57.20
RHP100746	Claim number matched exactly	Paid as expected	$449.00	$243.10	$243.10	$0.00
RHP100747	Claim number matched exactly	Paid as expected	$2,520.00	$1,365.00	$1,092.00 patient $273.00	$273.00
RHP100748	Claim number matched exactly	Paid as expected	$140.00	$75.40	$60.32 patient $15.08	$15.08
RHP100749	Claim number matched exactly	Paid as expected	$576.00	$312.00	$262.00 patient $50.00	$50.00
RHP100750	Claim number matched exactly	Paid as expected	$310.00	$167.70	$167.70	$0.00
RHP100751	Claim number matched exactly	Paid as expected	$338.00	$183.30	$83.30 patient $100.00	$100.00
RHP100752	Claim number matched exactly	Paid as expected	$228.00	$123.50	$98.50 patient $25.00	$25.00
RHP100753	Claim number matched exactly	Paid as expected	$1,728.00	$936.00	$748.80 patient $187.20	$187.20
RHP100754	Claim number matched exactly	Paid as expected	$319.00	$172.90	$138.32 patient $34.58	$34.58
RHP100755	Claim number matched exactly	Paid as expected	$624.00	$338.00	$188.00 patient $150.00	$150.00
RHP100756	Claim number matched exactly	Paid as expected	$240.00	$130.00	$130.00	$0.00
RHP100757	Claim number matched exactly	Denied	$3,480.00	$0.00	$0.00	$0.00	$1,885.00
RHP100758	Claim number matched exactly	Paid as expected	$439.00	$237.90	$214.11 patient $23.79	$23.79
RHP100759	Claim number matched exactly	Paid as expected	$912.00	$494.00	$494.00	$0.00

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Provider adjustments

Provider adjustments change the whole payment, not one claim: WO is money the payer takes back for an earlier overpayment, and L6 is interest the payer adds for paying late. Positive amounts reduce the payment.

Reason	Reference	Amount
WO Overpayment recovery (money taken back)	RHP100109	$25.35
L6 Interest owed to the practice	INT0498	-$4.12

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The payer's remittance file (835)

Payer ID 99901. Payee RIDGELINE HEALTH PARTNERS, NPI 9999999001. Transaction 0001, 887 segments.

Show the raw file (891 segments)

1  ISA*00*          *00*          *ZZ*PAYER99901     *ZZ*RIDGELINE999   *260920*0800*^*00501*000000107*0*T*:
2  GS*HP*PAYER99901*RIDGELINE999*20260920*0800*107*X*005010X221A1
3  ST*835*0001
4  BPR*I*19074.92*C*ACH*CCP*01*999999992*DA*000111222*1999999999**01*999999993*DA*000333444*20260921
5  TRN*1*EFT9990000498*1999999901
6  DTM*405*20260920
7  N1*PR*TALLOW CREEK HEALTH PLAN
8  REF*2U*99901
9  N1*PE*RIDGELINE HEALTH PARTNERS*XX*9999999001
10  REF*TJ*999999999
11  LX*1
12  CLP*RHP100103*22*-449*-223.65*0*CI*999010498001R*11*8
13  NM1*QC*1*SYNTHETIC*PATIENT100103****MI*ZZ0100103
14  DTM*232*20260801
15  DTM*233*20260801
16  SVC*HC:99204*-408*-203.32**1
17  DTM*472*20260801
18  CAS*CO*45*-204.68
19  REF*6R*RHP100103-1
20  AMT*B6*-203.32
21  SVC*HC:93000*-41*-20.33**1
22  DTM*472*20260801
23  CAS*CO*45*-20.67
24  REF*6R*RHP100103-2
25  AMT*B6*-20.33
26  LX*2
27  CLP*RHP100103*1*449*243.1*0*CI*999010498002C*11*1
28  NM1*QC*1*SYNTHETIC*PATIENT100103****MI*ZZ0100103
29  DTM*232*20260801
30  DTM*233*20260801
31  SVC*HC:99204*408*221**1
32  DTM*472*20260801
33  CAS*CO*45*187
34  REF*6R*RHP100103-1
35  AMT*B6*221
36  SVC*HC:93000*41*22.1**1
37  DTM*472*20260801
38  CAS*CO*45*18.9
39  REF*6R*RHP100103-2
40  AMT*B6*22.1
41  LX*3
42  CLP*RHP100107*1*221*95.68*23.92*CI*999010498003D*11*1
43  NM1*QC*1*SYNTHETIC*PATIENT100107****MI*ZZ0100107
44  DTM*232*20260805
45  DTM*233*20260805
46  SVC*HC:99213*221*95.68**1
47  DTM*472*20260805
48  CAS*CO*45*101.4
49  CAS*PR*2*23.92
50  REF*6R*RHP100107-1
51  AMT*B6*119.6
52  LX*4
53  CLP*RHP100141*1*312*139*30*CI*999010498004*11*1
54  NM1*QC*1*SYNTHETIC*PATIENT100141****MI*ZZ0100141
55  DTM*232*20260829
56  DTM*233*20260829
57  SVC*HC:99214*312*139**1
58  DTM*472*20260829
59  CAS*CO*45*143
60  CAS*PR*3*30
61  REF*6R*RHP100141-1
62  AMT*B6*169
63  LX*5
64  CLP*RHP100142*1*228*98.8*24.7*CI*999010498005*11*1
65  NM1*QC*1*SYNTHETIC*PATIENT100142****MI*ZZ0100142
66  DTM*232*20260830
67  DTM*233*20260830
68  SVC*HC:99213*221*95.68**1
69  DTM*472*20260830
70  CAS*CO*45*101.4
71  CAS*PR*2*23.92
72  REF*6R*RHP100142-1
73  AMT*B6*119.6
74  SVC*HC:36415*7*3.12**1
75  DTM*472*20260830
76  CAS*CO*45*3.1
77  CAS*PR*2*0.78
78  REF*6R*RHP100142-2
79  AMT*B6*3.9
80  LX*6
81  CLP*RHP100143*4*156*0*0*CI*999010498006*11*1
82  NM1*QC*1*SYNTHETIC*PATIENT100143****MI*ZZ0100143
83  DTM*232*20260831
84  DTM*233*20260831
85  SVC*HC:20610*156*0**1
86  DTM*472*20260831
87  CAS*CO*197*156
88  REF*6R*RHP100143-1
89  AMT*B6*0
90  LX*7
91  CLP*RHP100241*1*967*419.12*104.78*CI*999010498007C*11*1
92  NM1*QC*1*SYNTHETIC*PATIENT100241****MI*ZZ0100241
93  DTM*232*20260809
94  DTM*233*20260809
95  SVC*HC:99215*439*190.32**1
96  DTM*472*20260809
97  CAS*CO*45*201.1
98  CAS*PR*2*47.58
99  REF*6R*RHP100241-1
100  AMT*B6*237.9
101  SVC*HC:93306*528*228.8**1
102  DTM*472*20260809
103  CAS*CO*45*242
104  CAS*PR*2*57.2
105  REF*6R*RHP100241-2
106  AMT*B6*286
107  LX*8
108  CLP*RHP100700*1*140*60.32*15.08*CI*999010498008*11*1
109  NM1*QC*1*SYNTHETIC*PATIENT100700****MI*ZZ0100700
110  DTM*232*20260909
111  DTM*233*20260909
112  SVC*HC:97110*140*60.32**2
113  DTM*472*20260909
114  CAS*CO*45*64.6
115  CAS*PR*2*15.08
116  REF*6R*RHP100700-1
117  AMT*B6*75.4
118  LX*9
119  CLP*RHP100701*1*576*262*50*CI*999010498009*11*1
120  NM1*QC*1*SYNTHETIC*PATIENT100701****MI*ZZ0100701
121  DTM*232*20260908
122  DTM*233*20260908
123  SVC*HC:64483*576*262**1
124  DTM*472*20260908
125  CAS*CO*45*264
126  CAS*PR*3*50
127  REF*6R*RHP100701-1
128  AMT*B6*312
129  LX*10
130  CLP*RHP100702*1*310*167.7*0*CI*999010498010*11*1
131  NM1*QC*1*SYNTHETIC*PATIENT100702****MI*ZZ0100702
132  DTM*232*20260907
133  DTM*233*20260907
134  SVC*HC:99213*221*119.6**1
135  DTM*472*20260907
136  CAS*CO*45*101.4
137  REF*6R*RHP100702-1
138  AMT*B6*119.6
139  SVC*HC:90471*41*22.1**1
140  DTM*472*20260907
141  CAS*CO*45*18.9
142  REF*6R*RHP100702-2
143  AMT*B6*22.1
144  SVC*HC:90686*48*26**1
145  DTM*472*20260907
146  CAS*CO*45*22
147  REF*6R*RHP100702-3
148  AMT*B6*26
149  LX*11
150  CLP*RHP100703*1*338*83.3*100*CI*999010498011*11*1
151  NM1*QC*1*SYNTHETIC*PATIENT100703****MI*ZZ0100703
152  DTM*232*20260906
153  DTM*233*20260906
154  SVC*HC:99214*312*69**1
155  DTM*472*20260906
156  CAS*CO*45*143
157  CAS*PR*1*100
158  REF*6R*RHP100703-1
159  AMT*B6*169
160  SVC*HC:80053*26*14.3**1
161  DTM*472*20260906
162  CAS*CO*45*11.7
163  REF*6R*RHP100703-2
164  AMT*B6*14.3
165  LX*12
166  CLP*RHP100704*1*228*98.5*25*CI*999010498012*11*1
167  NM1*QC*1*SYNTHETIC*PATIENT100704****MI*ZZ0100704
168  DTM*232*20260905
169  DTM*233*20260905
170  SVC*HC:99213*221*94.6**1
171  DTM*472*20260905
172  CAS*CO*45*101.4
173  CAS*PR*3*25
174  REF*6R*RHP100704-1
175  AMT*B6*119.6
176  SVC*HC:36415*7*3.9**1
177  DTM*472*20260905
178  CAS*CO*45*3.1
179  REF*6R*RHP100704-2
180  AMT*B6*3.9
181  LX*13
182  CLP*RHP100705*4*1728*0*0*CI*999010498013*11*1
183  NM1*QC*1*SYNTHETIC*PATIENT100705****MI*ZZ0100705
184  DTM*232*20260904
185  DTM*233*20260904
186  SVC*HC:29881*1728*0**1
187  DTM*472*20260904
188  CAS*CO*50*1728
189  REF*6R*RHP100705-1
190  AMT*B6*0
191  LQ*HE*N130
192  LX*14
193  CLP*RHP100706*1*319*138.32*34.58*CI*999010498014*11*1
194  NM1*QC*1*SYNTHETIC*PATIENT100706****MI*ZZ0100706
195  DTM*232*20260903
196  DTM*233*20260903
197  SVC*HC:99214*312*135.2**1
198  DTM*472*20260903
199  CAS*CO*45*143
200  CAS*PR*2*33.8
201  REF*6R*RHP100706-1
202  AMT*B6*169
203  SVC*HC:36415*7*3.12**1
204  DTM*472*20260903
205  CAS*CO*45*3.1
206  CAS*PR*2*0.78
207  REF*6R*RHP100706-2
208  AMT*B6*3.9
209  LX*15
210  CLP*RHP100707*1*624*188*150*CI*999010498015*11*1
211  NM1*QC*1*SYNTHETIC*PATIENT100707****MI*ZZ0100707
212  DTM*232*20260902
213  DTM*233*20260902
214  SVC*HC:73721*624*188**1
215  DTM*472*20260902
216  CAS*CO*45*286
217  CAS*PR*1*150
218  REF*6R*RHP100707-1
219  AMT*B6*338
220  LX*16
221  CLP*RHP100708*1*240*130*0*CI*999010498016*11*1
222  NM1*QC*1*SYNTHETIC*PATIENT100708****MI*ZZ0100708
223  DTM*232*20260901
224  DTM*233*20260901
225  SVC*HC:99213*221*119.6**1
226  DTM*472*20260901
227  CAS*CO*45*101.4
228  REF*6R*RHP100708-1
229  AMT*B6*119.6
230  SVC*HC:85025*19*10.4**1
231  DTM*472*20260901
232  CAS*CO*45*8.6
233  REF*6R*RHP100708-2
234  AMT*B6*10.4
235  LX*17
236  CLP*RHP100709*1*3480*1696.5*188.5*CI*999010498017*11*1
237  NM1*QC*1*SYNTHETIC*PATIENT100709****MI*ZZ0100709
238  DTM*232*20260831
239  DTM*233*20260831
240  SVC*HC:27447*3480*1696.5**1
241  DTM*472*20260831
242  CAS*CO*45*1595
243  CAS*PR*2*188.5
244  REF*6R*RHP100709-1
245  AMT*B6*1885
246  LX*18
247  CLP*RHP100710*1*439*214.11*23.79*CI*999010498018*11*1
248  NM1*QC*1*SYNTHETIC*PATIENT100710****MI*ZZ0100710
249  DTM*232*20260830
250  DTM*233*20260830
251  SVC*HC:99215*439*214.11**1
252  DTM*472*20260830
253  CAS*CO*45*201.1
254  CAS*PR*2*23.79
255  REF*6R*RHP100710-1
256  AMT*B6*237.9
257  LX*19
258  CLP*RHP100711*1*912*494*0*CI*999010498019*11*1
259  NM1*QC*1*SYNTHETIC*PATIENT100711****MI*ZZ0100711
260  DTM*232*20260829
261  DTM*233*20260829
262  SVC*HC:45380*912*494**1
263  DTM*472*20260829
264  CAS*CO*45*418
265  REF*6R*RHP100711-1
266  AMT*B6*494
267  LX*20
268  CLP*RHP100712*1*269*105.6*40*CI*999010498020*11*1
269  NM1*QC*1*SYNTHETIC*PATIENT100712****MI*ZZ0100712
270  DTM*232*20260828
271  DTM*233*20260828
272  SVC*HC:99203*269*105.6**1
273  DTM*472*20260828
274  CAS*CO*45*123.4
275  CAS*PR*3*40
276  REF*6R*RHP100712-1
277  AMT*B6*145.6
278  LX*21
279  CLP*RHP100713*1*528*228.8*57.2*CI*999010498021*11*1
280  NM1*QC*1*SYNTHETIC*PATIENT100713****MI*ZZ0100713
281  DTM*232*20260827
282  DTM*233*20260827
283  SVC*HC:93306*528*228.8**1
284  DTM*472*20260827
285  CAS*CO*45*242
286  CAS*PR*2*57.2
287  REF*6R*RHP100713-1
288  AMT*B6*286
289  LX*22
290  CLP*RHP100714*1*449*243.1*0*CI*999010498022*11*1
291  NM1*QC*1*SYNTHETIC*PATIENT100714****MI*ZZ0100714
292  DTM*232*20260826
293  DTM*233*20260826
294  SVC*HC:99204*408*221**1
295  DTM*472*20260826
296  CAS*CO*45*187
297  REF*6R*RHP100714-1
298  AMT*B6*221
299  SVC*HC:93000*41*22.1**1
300  DTM*472*20260826
301  CAS*CO*45*18.9
302  REF*6R*RHP100714-2
303  AMT*B6*22.1
304  LX*23
305  CLP*RHP100715*1*2520*1092*273*CI*999010498023*11*1
306  NM1*QC*1*SYNTHETIC*PATIENT100715****MI*ZZ0100715
307  DTM*232*20260825
308  DTM*233*20260825
309  SVC*HC:29827*2520*1092**1
310  DTM*472*20260825
311  CAS*CO*45*1155
312  CAS*PR*2*273
313  REF*6R*RHP100715-1
314  AMT*B6*1365
315  LX*24
316  CLP*RHP100716*1*140*60.32*15.08*CI*999010498024*11*1
317  NM1*QC*1*SYNTHETIC*PATIENT100716****MI*ZZ0100716
318  DTM*232*20260824
319  DTM*233*20260824
320  SVC*HC:97110*140*60.32**2
321  DTM*472*20260824
322  CAS*CO*45*64.6
323  CAS*PR*2*15.08
324  REF*6R*RHP100716-1
325  AMT*B6*75.4
326  LX*25
327  CLP*RHP100717*1*576*262*50*CI*999010498025*11*1
328  NM1*QC*1*SYNTHETIC*PATIENT100717****MI*ZZ0100717
329  DTM*232*20260823
330  DTM*233*20260823
331  SVC*HC:64483*576*262**1
332  DTM*472*20260823
333  CAS*CO*45*264
334  CAS*PR*3*50
335  REF*6R*RHP100717-1
336  AMT*B6*312
337  LX*26
338  CLP*RHP100718*4*310*0*0*CI*999010498026*11*1
339  NM1*QC*1*SYNTHETIC*PATIENT100718****MI*ZZ0100718
340  DTM*232*20260909
341  DTM*233*20260909
342  SVC*HC:99213*221*0**1
343  DTM*472*20260909
344  CAS*CO*22*221
345  REF*6R*RHP100718-1
346  AMT*B6*0
347  SVC*HC:90471*41*0**1
348  DTM*472*20260909
349  CAS*CO*22*41
350  REF*6R*RHP100718-2
351  AMT*B6*0
352  SVC*HC:90686*48*0**1
353  DTM*472*20260909
354  CAS*CO*22*48
355  REF*6R*RHP100718-3
356  AMT*B6*0
357  LX*27
358  CLP*RHP100719*1*338*83.3*100*CI*999010498027*11*1
359  NM1*QC*1*SYNTHETIC*PATIENT100719****MI*ZZ0100719
360  DTM*232*20260908
361  DTM*233*20260908
362  SVC*HC:99214*312*69**1
363  DTM*472*20260908
364  CAS*CO*45*143
365  CAS*PR*1*100
366  REF*6R*RHP100719-1
367  AMT*B6*169
368  SVC*HC:80053*26*14.3**1
369  DTM*472*20260908
370  CAS*CO*45*11.7
371  REF*6R*RHP100719-2
372  AMT*B6*14.3
373  LX*28
374  CLP*RHP100720*1*228*98.5*25*CI*999010498028*11*1
375  NM1*QC*1*SYNTHETIC*PATIENT100720****MI*ZZ0100720
376  DTM*232*20260907
377  DTM*233*20260907
378  SVC*HC:99213*221*94.6**1
379  DTM*472*20260907
380  CAS*CO*45*101.4
381  CAS*PR*3*25
382  REF*6R*RHP100720-1
383  AMT*B6*119.6
384  SVC*HC:36415*7*3.9**1
385  DTM*472*20260907
386  CAS*CO*45*3.1
387  REF*6R*RHP100720-2
388  AMT*B6*3.9
389  LX*29
390  CLP*RHP100721*1*1728*748.8*187.2*CI*999010498029*11*1
391  NM1*QC*1*SYNTHETIC*PATIENT100721****MI*ZZ0100721
392  DTM*232*20260906
393  DTM*233*20260906
394  SVC*HC:29881*1728*748.8**1
395  DTM*472*20260906
396  CAS*CO*45*792
397  CAS*PR*2*187.2
398  REF*6R*RHP100721-1
399  AMT*B6*936
400  LX*30
401  CLP*RHP100722*1*319*138.32*34.58*CI*999010498030*11*1
402  NM1*QC*1*SYNTHETIC*PATIENT100722****MI*ZZ0100722
403  DTM*232*20260905
404  DTM*233*20260905
405  SVC*HC:99214*312*135.2**1
406  DTM*472*20260905
407  CAS*CO*45*143
408  CAS*PR*2*33.8
409  REF*6R*RHP100722-1
410  AMT*B6*169
411  SVC*HC:36415*7*3.12**1
412  DTM*472*20260905
413  CAS*CO*45*3.1
414  CAS*PR*2*0.78
415  REF*6R*RHP100722-2
416  AMT*B6*3.9
417  LX*31
418  CLP*RHP100723*1*624*188*150*CI*999010498031*11*1
419  NM1*QC*1*SYNTHETIC*PATIENT100723****MI*ZZ0100723
420  DTM*232*20260904
421  DTM*233*20260904
422  SVC*HC:73721*624*188**1
423  DTM*472*20260904
424  CAS*CO*45*286
425  CAS*PR*1*150
426  REF*6R*RHP100723-1
427  AMT*B6*338
428  LX*32
429  CLP*RHP100724*1*240*130*0*CI*999010498032*11*1
430  NM1*QC*1*SYNTHETIC*PATIENT100724****MI*ZZ0100724
431  DTM*232*20260903
432  DTM*233*20260903
433  SVC*HC:99213*221*119.6**1
434  DTM*472*20260903
435  CAS*CO*45*101.4
436  REF*6R*RHP100724-1
437  AMT*B6*119.6
438  SVC*HC:85025*19*10.4**1
439  DTM*472*20260903
440  CAS*CO*45*8.6
441  REF*6R*RHP100724-2
442  AMT*B6*10.4
443  LX*33
444  CLP*RHP100725*1*3480*1696.5*188.5*CI*999010498033*11*1
445  NM1*QC*1*SYNTHETIC*PATIENT100725****MI*ZZ0100725
446  DTM*232*20260902
447  DTM*233*20260902
448  SVC*HC:27447*3480*1696.5**1
449  DTM*472*20260902
450  CAS*CO*45*1595
451  CAS*PR*2*188.5
452  REF*6R*RHP100725-1
453  AMT*B6*1885
454  LX*34
455  CLP*RHP100726*1*439*214.11*23.79*CI*999010498034*11*1
456  NM1*QC*1*SYNTHETIC*PATIENT100726****MI*ZZ0100726
457  DTM*232*20260901
458  DTM*233*20260901
459  SVC*HC:99215*439*214.11**1
460  DTM*472*20260901
461  CAS*CO*45*201.1
462  CAS*PR*2*23.79
463  REF*6R*RHP100726-1
464  AMT*B6*237.9
465  LX*35
466  CLP*RHP100727*1*912*494*0*CI*999010498035*11*1
467  NM1*QC*1*SYNTHETIC*PATIENT100727****MI*ZZ0100727
468  DTM*232*20260831
469  DTM*233*20260831
470  SVC*HC:45380*912*494**1
471  DTM*472*20260831
472  CAS*CO*45*418
473  REF*6R*RHP100727-1
474  AMT*B6*494
475  LX*36
476  CLP*RHP100728*1*269*105.6*40*CI*999010498036*11*1
477  NM1*QC*1*SYNTHETIC*PATIENT100728****MI*ZZ0100728
478  DTM*232*20260830
479  DTM*233*20260830
480  SVC*HC:99203*269*105.6**1
481  DTM*472*20260830
482  CAS*CO*45*123.4
483  CAS*PR*3*40
484  REF*6R*RHP100728-1
485  AMT*B6*145.6
486  LX*37
487  CLP*RHP100729*1*528*228.8*57.2*CI*999010498037*11*1
488  NM1*QC*1*SYNTHETIC*PATIENT100729****MI*ZZ0100729
489  DTM*232*20260829
490  DTM*233*20260829
491  SVC*HC:93306*528*228.8**1
492  DTM*472*20260829
493  CAS*CO*45*242
494  CAS*PR*2*57.2
495  REF*6R*RHP100729-1
496  AMT*B6*286
497  LX*38
498  CLP*RHP100730*1*449*243.1*0*CI*999010498038*11*1
499  NM1*QC*1*SYNTHETIC*PATIENT100730****MI*ZZ0100730
500  DTM*232*20260828
501  DTM*233*20260828
502  SVC*HC:99204*408*221**1
503  DTM*472*20260828
504  CAS*CO*45*187
505  REF*6R*RHP100730-1
506  AMT*B6*221
507  SVC*HC:93000*41*22.1**1
508  DTM*472*20260828
509  CAS*CO*45*18.9
510  REF*6R*RHP100730-2
511  AMT*B6*22.1
512  LX*39
513  CLP*RHP100731*4*2520*0*0*CI*999010498039*11*1
514  NM1*QC*1*SYNTHETIC*PATIENT100731****MI*ZZ0100731
515  DTM*232*20260827
516  DTM*233*20260827
517  SVC*HC:29827*2520*0**1
518  DTM*472*20260827
519  CAS*CO*197*2520
520  REF*6R*RHP100731-1
521  AMT*B6*0
522  LX*40
523  CLP*RHP100732*1*140*60.32*15.08*CI*999010498040*11*1
524  NM1*QC*1*SYNTHETIC*PATIENT100732****MI*ZZ0100732
525  DTM*232*20260826
526  DTM*233*20260826
527  SVC*HC:97110*140*60.32**2
528  DTM*472*20260826
529  CAS*CO*45*64.6
530  CAS*PR*2*15.08
531  REF*6R*RHP100732-1
532  AMT*B6*75.4
533  LX*41
534  CLP*RHP100733*1*576*262*50*CI*999010498041*11*1
535  NM1*QC*1*SYNTHETIC*PATIENT100733****MI*ZZ0100733
536  DTM*232*20260825
537  DTM*233*20260825
538  SVC*HC:64483*576*262**1
539  DTM*472*20260825
540  CAS*CO*45*264
541  CAS*PR*3*50
542  REF*6R*RHP100733-1
543  AMT*B6*312
544  LX*42
545  CLP*RHP100734*1*310*167.7*0*CI*999010498042*11*1
546  NM1*QC*1*SYNTHETIC*PATIENT100734****MI*ZZ0100734
547  DTM*232*20260824
548  DTM*233*20260824
549  SVC*HC:99213*221*119.6**1
550  DTM*472*20260824
551  CAS*CO*45*101.4
552  REF*6R*RHP100734-1
553  AMT*B6*119.6
554  SVC*HC:90471*41*22.1**1
555  DTM*472*20260824
556  CAS*CO*45*18.9
557  REF*6R*RHP100734-2
558  AMT*B6*22.1
559  SVC*HC:90686*48*26**1
560  DTM*472*20260824
561  CAS*CO*45*22
562  REF*6R*RHP100734-3
563  AMT*B6*26
564  LX*43
565  CLP*RHP100735*1*338*83.3*100*CI*999010498043*11*1
566  NM1*QC*1*SYNTHETIC*PATIENT100735****MI*ZZ0100735
567  DTM*232*20260823
568  DTM*233*20260823
569  SVC*HC:99214*312*69**1
570  DTM*472*20260823
571  CAS*CO*45*143
572  CAS*PR*1*100
573  REF*6R*RHP100735-1
574  AMT*B6*169
575  SVC*HC:80053*26*14.3**1
576  DTM*472*20260823
577  CAS*CO*45*11.7
578  REF*6R*RHP100735-2
579  AMT*B6*14.3
580  LX*44
581  CLP*RHP100736*1*228*98.5*25*CI*999010498044*11*1
582  NM1*QC*1*SYNTHETIC*PATIENT100736****MI*ZZ0100736
583  DTM*232*20260909
584  DTM*233*20260909
585  SVC*HC:99213*221*94.6**1
586  DTM*472*20260909
587  CAS*CO*45*101.4
588  CAS*PR*3*25
589  REF*6R*RHP100736-1
590  AMT*B6*119.6
591  SVC*HC:36415*7*3.9**1
592  DTM*472*20260909
593  CAS*CO*45*3.1
594  REF*6R*RHP100736-2
595  AMT*B6*3.9
596  LX*45
597  CLP*RHP100737*1*1728*748.8*187.2*CI*999010498045*11*1
598  NM1*QC*1*SYNTHETIC*PATIENT100737****MI*ZZ0100737
599  DTM*232*20260908
600  DTM*233*20260908
601  SVC*HC:29881*1728*748.8**1
602  DTM*472*20260908
603  CAS*CO*45*792
604  CAS*PR*2*187.2
605  REF*6R*RHP100737-1
606  AMT*B6*936
607  LX*46
608  CLP*RHP100738*1*319*138.32*34.58*CI*999010498046*11*1
609  NM1*QC*1*SYNTHETIC*PATIENT100738****MI*ZZ0100738
610  DTM*232*20260907
611  DTM*233*20260907
612  SVC*HC:99214*312*135.2**1
613  DTM*472*20260907
614  CAS*CO*45*143
615  CAS*PR*2*33.8
616  REF*6R*RHP100738-1
617  AMT*B6*169
618  SVC*HC:36415*7*3.12**1
619  DTM*472*20260907
620  CAS*CO*45*3.1
621  CAS*PR*2*0.78
622  REF*6R*RHP100738-2
623  AMT*B6*3.9
624  LX*47
625  CLP*RHP100739*1*624*188*150*CI*999010498047*11*1
626  NM1*QC*1*SYNTHETIC*PATIENT100739****MI*ZZ0100739
627  DTM*232*20260906
628  DTM*233*20260906
629  SVC*HC:73721*624*188**1
630  DTM*472*20260906
631  CAS*CO*45*286
632  CAS*PR*1*150
633  REF*6R*RHP100739-1
634  AMT*B6*338
635  LX*48
636  CLP*RHP100740*1*240*130*0*CI*999010498048*11*1
637  NM1*QC*1*SYNTHETIC*PATIENT100740****MI*ZZ0100740
638  DTM*232*20260905
639  DTM*233*20260905
640  SVC*HC:99213*221*119.6**1
641  DTM*472*20260905
642  CAS*CO*45*101.4
643  REF*6R*RHP100740-1
644  AMT*B6*119.6
645  SVC*HC:85025*19*10.4**1
646  DTM*472*20260905
647  CAS*CO*45*8.6
648  REF*6R*RHP100740-2
649  AMT*B6*10.4
650  LX*49
651  CLP*RHP100741*1*3480*1696.5*188.5*CI*999010498049*11*1
652  NM1*QC*1*SYNTHETIC*PATIENT100741****MI*ZZ0100741
653  DTM*232*20260904
654  DTM*233*20260904
655  SVC*HC:27447*3480*1696.5**1
656  DTM*472*20260904
657  CAS*CO*45*1595
658  CAS*PR*2*188.5
659  REF*6R*RHP100741-1
660  AMT*B6*1885
661  LX*50
662  CLP*RHP100742*1*439*214.11*23.79*CI*999010498050*11*1
663  NM1*QC*1*SYNTHETIC*PATIENT100742****MI*ZZ0100742
664  DTM*232*20260903
665  DTM*233*20260903
666  SVC*HC:99215*439*214.11**1
667  DTM*472*20260903
668  CAS*CO*45*201.1
669  CAS*PR*2*23.79
670  REF*6R*RHP100742-1
671  AMT*B6*237.9
672  LX*51
673  CLP*RHP100743*1*912*494*0*CI*999010498051*11*1
674  NM1*QC*1*SYNTHETIC*PATIENT100743****MI*ZZ0100743
675  DTM*232*20260902
676  DTM*233*20260902
677  SVC*HC:45380*912*494**1
678  DTM*472*20260902
679  CAS*CO*45*418
680  REF*6R*RHP100743-1
681  AMT*B6*494
682  LX*52
683  CLP*RHP100744*4*269*0*0*CI*999010498052*11*1
684  NM1*QC*1*SYNTHETIC*PATIENT100744****MI*ZZ0100744
685  DTM*232*20260901
686  DTM*233*20260901
687  SVC*HC:99203*269*0**1
688  DTM*472*20260901
689  CAS*CO*4*269
690  REF*6R*RHP100744-1
691  AMT*B6*0
692  LX*53
693  CLP*RHP100745*1*528*228.8*57.2*CI*999010498053*11*1
694  NM1*QC*1*SYNTHETIC*PATIENT100745****MI*ZZ0100745
695  DTM*232*20260831
696  DTM*233*20260831
697  SVC*HC:93306*528*228.8**1
698  DTM*472*20260831
699  CAS*CO*45*242
700  CAS*PR*2*57.2
701  REF*6R*RHP100745-1
702  AMT*B6*286
703  LX*54
704  CLP*RHP100746*1*449*243.1*0*CI*999010498054*11*1
705  NM1*QC*1*SYNTHETIC*PATIENT100746****MI*ZZ0100746
706  DTM*232*20260830
707  DTM*233*20260830
708  SVC*HC:99204*408*221**1
709  DTM*472*20260830
710  CAS*CO*45*187
711  REF*6R*RHP100746-1
712  AMT*B6*221
713  SVC*HC:93000*41*22.1**1
714  DTM*472*20260830
715  CAS*CO*45*18.9
716  REF*6R*RHP100746-2
717  AMT*B6*22.1
718  LX*55
719  CLP*RHP100747*1*2520*1092*273*CI*999010498055*11*1
720  NM1*QC*1*SYNTHETIC*PATIENT100747****MI*ZZ0100747
721  DTM*232*20260829
722  DTM*233*20260829
723  SVC*HC:29827*2520*1092**1
724  DTM*472*20260829
725  CAS*CO*45*1155
726  CAS*PR*2*273
727  REF*6R*RHP100747-1
728  AMT*B6*1365
729  LX*56
730  CLP*RHP100748*1*140*60.32*15.08*CI*999010498056*11*1
731  NM1*QC*1*SYNTHETIC*PATIENT100748****MI*ZZ0100748
732  DTM*232*20260828
733  DTM*233*20260828
734  SVC*HC:97110*140*60.32**2
735  DTM*472*20260828
736  CAS*CO*45*64.6
737  CAS*PR*2*15.08
738  REF*6R*RHP100748-1
739  AMT*B6*75.4
740  LX*57
741  CLP*RHP100749*1*576*262*50*CI*999010498057*11*1
742  NM1*QC*1*SYNTHETIC*PATIENT100749****MI*ZZ0100749
743  DTM*232*20260827
744  DTM*233*20260827
745  SVC*HC:64483*576*262**1
746  DTM*472*20260827
747  CAS*CO*45*264
748  CAS*PR*3*50
749  REF*6R*RHP100749-1
750  AMT*B6*312
751  LX*58
752  CLP*RHP100750*1*310*167.7*0*CI*999010498058*11*1
753  NM1*QC*1*SYNTHETIC*PATIENT100750****MI*ZZ0100750
754  DTM*232*20260826
755  DTM*233*20260826
756  SVC*HC:99213*221*119.6**1
757  DTM*472*20260826
758  CAS*CO*45*101.4
759  REF*6R*RHP100750-1
760  AMT*B6*119.6
761  SVC*HC:90471*41*22.1**1
762  DTM*472*20260826
763  CAS*CO*45*18.9
764  REF*6R*RHP100750-2
765  AMT*B6*22.1
766  SVC*HC:90686*48*26**1
767  DTM*472*20260826
768  CAS*CO*45*22
769  REF*6R*RHP100750-3
770  AMT*B6*26
771  LX*59
772  CLP*RHP100751*1*338*83.3*100*CI*999010498059*11*1
773  NM1*QC*1*SYNTHETIC*PATIENT100751****MI*ZZ0100751
774  DTM*232*20260825
775  DTM*233*20260825
776  SVC*HC:99214*312*69**1
777  DTM*472*20260825
778  CAS*CO*45*143
779  CAS*PR*1*100
780  REF*6R*RHP100751-1
781  AMT*B6*169
782  SVC*HC:80053*26*14.3**1
783  DTM*472*20260825
784  CAS*CO*45*11.7
785  REF*6R*RHP100751-2
786  AMT*B6*14.3
787  LX*60
788  CLP*RHP100752*1*228*98.5*25*CI*999010498060*11*1
789  NM1*QC*1*SYNTHETIC*PATIENT100752****MI*ZZ0100752
790  DTM*232*20260824
791  DTM*233*20260824
792  SVC*HC:99213*221*94.6**1
793  DTM*472*20260824
794  CAS*CO*45*101.4
795  CAS*PR*3*25
796  REF*6R*RHP100752-1
797  AMT*B6*119.6
798  SVC*HC:36415*7*3.9**1
799  DTM*472*20260824
800  CAS*CO*45*3.1
801  REF*6R*RHP100752-2
802  AMT*B6*3.9
803  LX*61
804  CLP*RHP100753*1*1728*748.8*187.2*CI*999010498061*11*1
805  NM1*QC*1*SYNTHETIC*PATIENT100753****MI*ZZ0100753
806  DTM*232*20260823
807  DTM*233*20260823
808  SVC*HC:29881*1728*748.8**1
809  DTM*472*20260823
810  CAS*CO*45*792
811  CAS*PR*2*187.2
812  REF*6R*RHP100753-1
813  AMT*B6*936
814  LX*62
815  CLP*RHP100754*1*319*138.32*34.58*CI*999010498062*11*1
816  NM1*QC*1*SYNTHETIC*PATIENT100754****MI*ZZ0100754
817  DTM*232*20260909
818  DTM*233*20260909
819  SVC*HC:99214*312*135.2**1
820  DTM*472*20260909
821  CAS*CO*45*143
822  CAS*PR*2*33.8
823  REF*6R*RHP100754-1
824  AMT*B6*169
825  SVC*HC:36415*7*3.12**1
826  DTM*472*20260909
827  CAS*CO*45*3.1
828  CAS*PR*2*0.78
829  REF*6R*RHP100754-2
830  AMT*B6*3.9
831  LX*63
832  CLP*RHP100755*1*624*188*150*CI*999010498063*11*1
833  NM1*QC*1*SYNTHETIC*PATIENT100755****MI*ZZ0100755
834  DTM*232*20260908
835  DTM*233*20260908
836  SVC*HC:73721*624*188**1
837  DTM*472*20260908
838  CAS*CO*45*286
839  CAS*PR*1*150
840  REF*6R*RHP100755-1
841  AMT*B6*338
842  LX*64
843  CLP*RHP100756*1*240*130*0*CI*999010498064*11*1
844  NM1*QC*1*SYNTHETIC*PATIENT100756****MI*ZZ0100756
845  DTM*232*20260907
846  DTM*233*20260907
847  SVC*HC:99213*221*119.6**1
848  DTM*472*20260907
849  CAS*CO*45*101.4
850  REF*6R*RHP100756-1
851  AMT*B6*119.6
852  SVC*HC:85025*19*10.4**1
853  DTM*472*20260907
854  CAS*CO*45*8.6
855  REF*6R*RHP100756-2
856  AMT*B6*10.4
857  LX*65
858  CLP*RHP100757*4*3480*0*0*CI*999010498065*11*1
859  NM1*QC*1*SYNTHETIC*PATIENT100757****MI*ZZ0100757
860  DTM*232*20260906
861  DTM*233*20260906
862  SVC*HC:27447*3480*0**1
863  DTM*472*20260906
864  CAS*CO*27*3480
865  REF*6R*RHP100757-1
866  AMT*B6*0
867  LX*66
868  CLP*RHP100758*1*439*214.11*23.79*CI*999010498066*11*1
869  NM1*QC*1*SYNTHETIC*PATIENT100758****MI*ZZ0100758
870  DTM*232*20260905
871  DTM*233*20260905
872  SVC*HC:99215*439*214.11**1
873  DTM*472*20260905
874  CAS*CO*45*201.1
875  CAS*PR*2*23.79
876  REF*6R*RHP100758-1
877  AMT*B6*237.9
878  LX*67
879  CLP*RHP100759*1*912*494*0*CI*999010498067*11*1
880  NM1*QC*1*SYNTHETIC*PATIENT100759****MI*ZZ0100759
881  DTM*232*20260904
882  DTM*233*20260904
883  SVC*HC:45380*912*494**1
884  DTM*472*20260904
885  CAS*CO*45*418
886  REF*6R*RHP100759-1
887  AMT*B6*494
888  PLB*9999999001*20261231*WO:RHP100109*25.35*L6:INT0498*-4.12
889  SE*887*0001
890  GE*1*107
891  IEA*1*000000107