270 Requests Sent: ISA*00*1234567 *00* *ZZ*155214 *ZZ*OFFALLY *190228*1023*^*00501*000000001*0*T*:~ GS*HS*155214*OFFALLY*20190228*102331*2*X*005010X279A1~ ST*270*000000003*005010X279A1~ BHT*0022*13*PROVTest600*20190228*1023~ HL*1**20*1~ NM1*PR*2*TRICARE*****46*OFFALLY~ HL*2*1*21*1~ NM1*FA*2*Occupational Clinic, LLC*****FI*1044010401~ HL*3*2*22*0~ NM1*IL*1*Jones*RAYMOND*S***MI*796347724~ DMG*D8*19800925*M~ DTP*291*D8*20190227~ EQ*30~ SE*12*000000003~ GE*1*2~ IEA*1*000000001~ Patient : 44 271 X12: ISA*00* *00* *ZZ*571132733 *ZZ*571132733 *130312*1140*^*00501*499997000*0*T*>~ GS*HB*7GWZZL2SCS*7GWZZL2SCS*20130312*114005*6354*X*005010X279A1~ ST*271*000000010*005010X279A1~ BHT*0022*11*292001*20130312*11395812~ HL*1**20*1~ NM1*PR*2*TRICARE*****PI*571132733~ HL*2*1*21*1~ NM1*1P*2*MEMORIAL HOSPITAL*****XX*1044010401~ HL*3*2*22*0~ TRN*1*201211270000000038U*0571132733~ NM1*IL*1*JONES*RAYMOND*S***MI*796347724~ DMG*D8*19800925*M~ DTP*346*D8*20100422~ EB*1**47**PLAN 122 CHCBP~ EB*C*IND*30***22*50~ MSG*$50 MINIMUM COPAY~ EB*C*IND*30***29*50~ EB*C*FAM*30***22*100~ MSG*$100 MINIMUM COPAY~ EB*C*FAM*30***29*100~ EB*G*IND*30***22*1000~ EB*G*FAM*30***22*1000~ EB*B**47***7*17.35*****W~ MSG*$25 MINIMUM COPAY~ EB*A**47*****0****W~ SE*22*000000010~ GE*1*6354~ IEA*1*499997000~ 2100 LoopsArray ( [pid] => 44 [isa_sender_id] => 571132733 [isa_receiver_id] => 571132733 [isa_control_number] => 499997000 [payer_lname] => TRICARE [payer_fname] => [payer_mname] => [payer_member_id] => 571132733 [provider_lname] => MEMORIAL HOSPITAL [provider_fname] => [provider_mname] => [provider_member_id] => 1044010401 [subscriber_lname] => JONES [subscriber_fname] => RAYMOND [subscriber_mname] => S [subscriber_member_id] => 796347724 [subscriber_dob] => 19800925 [subscriber_sex] => M ) EB Segments: Array ( [0] => Array ( [active] => 1 [plan_begin] => 20100422 [plan_end] => [coverage_level] => [service_type] => 47 [ins_type] => [plan_desc] => PLAN 122 CHCBP [time_qualifier] => [amount] => [percent] => [network_ind] => [message] => ) [1] => Array ( [active] => C [plan_begin] => 20100422 [plan_end] => [coverage_level] => IND [service_type] => 30 [ins_type] => [plan_desc] => [time_qualifier] => 22 [amount] => 50 [percent] => [network_ind] => [message] => $50 MINIMUM COPAY ) [2] => Array ( [active] => C [plan_begin] => 20100422 [plan_end] => [coverage_level] => IND [service_type] => 30 [ins_type] => [plan_desc] => [time_qualifier] => 29 [amount] => 50 [percent] => [network_ind] => [message] => ) [3] => Array ( [active] => C [plan_begin] => 20100422 [plan_end] => [coverage_level] => FAM [service_type] => 30 [ins_type] => [plan_desc] => [time_qualifier] => 22 [amount] => 100 [percent] => [network_ind] => [message] => $100 MINIMUM COPAY ) [4] => Array ( [active] => C [plan_begin] => 20100422 [plan_end] => [coverage_level] => FAM [service_type] => 30 [ins_type] => [plan_desc] => [time_qualifier] => 29 [amount] => 100 [percent] => [network_ind] => [message] => ) [5] => Array ( [active] => G [plan_begin] => 20100422 [plan_end] => [coverage_level] => IND [service_type] => 30 [ins_type] => [plan_desc] => [time_qualifier] => 22 [amount] => 1000 [percent] => [network_ind] => [message] => ) [6] => Array ( [active] => G [plan_begin] => 20100422 [plan_end] => [coverage_level] => FAM [service_type] => 30 [ins_type] => [plan_desc] => [time_qualifier] => 22 [amount] => 1000 [percent] => [network_ind] => [message] => ) [7] => Array ( [active] => B [plan_begin] => 20100422 [plan_end] => [coverage_level] => [service_type] => 47 [ins_type] => [plan_desc] => [time_qualifier] => 7 [amount] => 17.35 [percent] => [network_ind] => W [message] => $25 MINIMUM COPAY ) [8] => Array ( [active] => A [plan_begin] => 20100422 [plan_end] => [coverage_level] => [service_type] => 47 [ins_type] => [plan_desc] => [time_qualifier] => [amount] => [percent] => 0 [network_ind] => W [message] => ) ) AAA Segments: Array ( )