ISA*00*          *00*          *ZZ*SENDERID       *ZZ*RECEIVERID     *260829*1200*^*00501*000000001*0*T*:~
GS*HC*SENDER*RECEIVER*20260829*1200*1*X*005010X222A1~
ST*837*0001*005010X222A1~
BHT*0019*00*DEMO001*20260829*1200*CH~
NM1*41*2*SAMPLE SUBMITTER*****46*SUB123~
PER*IC*BILLING CONTACT*TE*6085550100~
NM1*40*2*SAMPLE RECEIVER*****46*RCV123~
HL*1**20*1~
NM1*85*2*SAMPLE MEDICAL GROUP*****XX*1234567893~
N3*123 SAMPLE ST~
N4*MADISON*WI*53703~
REF*EI*391234567~
HL*2*1*22*0~
SBR*P*18*******CI~
NM1*IL*1*PATIENT*TEST****MI*MEM123~
N3*1 MAIN ST~
N4*MADISON*WI*53703~
DMG*D8*19800101*M~
NM1*PR*2*SAMPLE HEALTH PLAN*****PI*842610001~
CLM*CLAIM001*225***11:B:1*Y*A*Y*I~
HI*ABK:I10*ABF:R079~
LX*1~
SV1*HC:99213*150*UN*1***1~
DTP*472*D8*20260820~
LX*2~
SV1*HC:93000*75*UN*1***2~
DTP*472*D8*20260820~
SE*26*0001~
GE*1*1~
IEA*1*000000001~