List of 1 Requests Sent: *** 270 Request Message 1 of 1 ISA*00*0000000 *00*0000000000*ZZ*account# *ZZ*OFFALLY *190302*1946*^*00501*000000001*0*T*:~ GS*HS*account#*OFFALLY*20190302*194618*2*X*005010X279A1~ ST*270*000000003*005010X279A1~ BHT*0022*13*PROVTest600*20190302*1946~ HL*1**20*1~ NM1*PR*2*UNITED HEALTHCARE MEDICARE SOLUTIONS*****46*87726~ HL*2*1*21*1~ NM1*1P*2*Occupational Clinic, LLC*****XX*123456789~ HL*3*2*22*0~ NM1*IL*1*LNAME*FNAME****MI*111111111~ REF*EJ*44~ DMG*D8*19460506*F~ DTP*291*D8*20190301~ EQ*30~ SE*13*000000003~ GE*1*2~ IEA*1*000000001~ 271 Response: ISA*00* *00* *ZZ*OFFALLY *ZZ*account# *190302*1746*^*00501*061174621*0*P*:~ GS*HB*OFFALLY*account#*20190302*1746*1*X*005010X279A1~ ST*271*000000001*005010X279A1~ BHT*0022*11*326662121*20190302*184621~ HL*1**20*1~ NM1*PR*2*UNITEDHEALTHCARE*****PI*87726~ PER*IC**UR*WWW.UNITEDHEALTHCAREONLINE.COM~ HL*2*1*21*1~ NM1*1P*2*Occupational Clinic, LLC*****XX*123456789~ HL*3*2*22*0~ TRN*2*226662121*9OFFICALLY~ NM1*IL*1*LNAME*FNAME*A***MI*111111111~ REF*EJ*44~ N3*822 SOME AVE APT A~ N4*ALBANY*GA*31701~ DMG*D8*19500101*F~ EB*1**30*PR*RPPO-UNITEDHEALTHCARE DUAL COMPLETE CHOICE (REGION~ REF*1L*99981~ DTP*346*D8*20190301~ LS*2120~ NM1*PR*2*UNITEDHEALTHCARE*****PI*87726~ N3*UNITEDHEALTHCARE*P.O. BOX 30436~ N4*SALT LAKE CITY*UT*84130~ PER*IC**UR*WWW.UNITEDHEALTHCAREONLINE.COM~ LE*2120~ EB*C*FAM*30***22*0*****W~ DTP*346*D8*20190301~ EB*C*IND*30***22*0*****W~ DTP*346*D8*20190301~ EB*G*FAM*30*PR**22*99999.99*****W~ DTP*346*D8*20190301~ EB*G*IND*30*PR**22*6700*****W~ DTP*346*D8*20190301~ EB*C*FAM*30***24*0*****W~ DTP*346*D8*20190301~ EB*C*IND*30***24*0*****W~ DTP*346*D8*20190301~ EB*G*FAM*30*PR**24*0*****W~ DTP*346*D8*20190301~ EB*G*IND*30*PR**24*0*****W~ DTP*346*D8*20190301~ EB*C*FAM*30***29*0*****W~ DTP*346*D8*20190301~ EB*C*IND*30***29*0*****W~ DTP*346*D8*20190301~ EB*G*FAM*30*PR**29*99999.99*****W~ DTP*346*D8*20190301~ EB*G*IND*30*PR**29*6700*****W~ DTP*346*D8*20190301~ EB*L~ LS*2120~ NM1*P3*2*NON PAR PCP SELECTED~ N3*9900 BREN RD E~ N4*MINNETONKA*MN*55343~ PER*IC**TE*9999999999*FX*0000000000~ LE*2120~ EB*1**1^33^47^48^86^98^MH^PT^UC*********W~ DTP*346*D8*20190301~ EB*1**50*********W~ DTP*346*D8*20190301~ MSG*OUTPATIENT SURGERY~ EB*1**96*********W~ DTP*346*D8*20190301~ MSG*OFFICE VISIT SPECIALIST~ EB*1**AL*********W~ DTP*346*D8*20190301~ MSG*ROUTINE EYE EXAM~ EB*1**50*********W~ DTP*346*D8*20190301~ MSG*OUTPATIENT HOSPITAL~ EB*A*IND*50***7**.2****W~ DTP*346*D8*20190301~ MSG*OUTPATIENT HOSPITAL~ EB*A*IND*9***27**0****W~ DTP*346*D8*20190301~ MSG*VIRTUAL VISITS/TELEMEDICINE~ EB*A*IND*96***27**0****W~ DTP*346*D8*20190301~ MSG*OFFICE VISIT SPECIALIST~ EB*A*IND*50***7**.2****W~ DTP*346*D8*20190301~ MSG*OUTPATIENT SURGERY~ EB*A*IND*86^UC***7**0****W~ DTP*346*D8*20190301~ EB*A*IND*33^48^98^PT***27**0****W~ DTP*346*D8*20190301~ EB*B*IND*33^48^98^PT***27*0*****W~ DTP*346*D8*20190301~ EB*B*IND*96***27*0*****W~ DTP*346*D8*20190301~ MSG*OFFICE VISIT SPECIALIST~ EB*B*IND*UC***7*65*****W~ DTP*346*D8*20190301~ EB*B*IND*9***27*0*****W~ DTP*346*D8*20190301~ MSG*VIRTUAL VISITS/TELEMEDICINE~ EB*B*IND*86***7*90*****W~ DTP*346*D8*20190301~ EB*B*IND*50***7*0*****W~ DTP*346*D8*20190301~ MSG*OUTPATIENT SURGERY~ EB*B*IND*50***7*0*****W~ DTP*346*D8*20190301~ MSG*OUTPATIENT HOSPITAL~ EB*1**30**SPECTERA VISION PLAN~ DTP*346*RD8*20190301-20191231~ LS*2120~ NM1*PR*2*UNITEDHEALTHCARE*****PI*87726~ N3*PO BOX 30978~ N4*SALT LAKE CITY*UT*841300978~ LE*2120~ EB*C*IND*30***23*0*****W~ DTP*346*RD8*20190301-20191231~ EB*C*FAM*30***23*0*****W~ DTP*346*RD8*20190301-20191231~ EB*G*IND*30***23*0*****W~ DTP*346*RD8*20190301-20191231~ EB*G*FAM*30***23*0*****W~ DTP*346*RD8*20190301-20191231~ EB*1**AL~ DTP*346*RD8*20190301-20191231~ EB*U**35~ LS*2120~ NM1*VN*2*UNITEDHEALTHCARE DENTAL~ PER*IC**UR*WWW.DBP.COM~ LE*2120~ EB*U**88~ LS*2120~ NM1*VN*2*OPTUMRX~ PER*IC**UR*PROFESSIONALS.OPTUMRX.COM~ LE*2120~ EB*X~ LS*2120~ NM1*1P*2*Occupational Clinic, LLC*****XX*123456789~ LE*2120~ SE*134*000000001~ GE*1*1~ IEA*1*061174621~ Subscribers Loop Array ( [0] => Array ( [pid] => 44 [isa_sender_id] => OFFALLY [isa_receiver_id] => account# [isa_control_number] => 061174621 [payer_org] => UNITEDHEALTHCARE [payer_member_id] => 87726 [provider_org] => Occupational Clinic, LLC [provider_member_id] => 123456789 [trace] => 0 [subscriber_lname] => LNAME [subscriber_fname] => FNAME [subscriber_mname] => A [subscriber_member_id] => 111111111 [subscriber_dob] => 19460506 [subscriber_sex] => F [benefits] => Array ( [0] => Array ( [type] => 1 [benefit_type] => Code(1) Active Coverage [start_date] => 20190301 [end_date] => [coverage_level] => [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => Code(PR) PPO [plan_desc] => RPPO-UNITEDHEALTHCARE DUAL COMPLETE CHOICE (REGION [coverage_period] => [amount] => [percent] => [network_ind] => [message] => ) [1] => Array ( [type] => C [benefit_type] => Code(C) Deductible [start_date] => 20190301 [end_date] => [coverage_level] => FAM [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(22) Service Year [amount] => 0 [percent] => [network_ind] => W [message] => ) [2] => Array ( [type] => C [benefit_type] => Code(C) Deductible [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(22) Service Year [amount] => 0 [percent] => [network_ind] => W [message] => ) [3] => Array ( [type] => G [benefit_type] => Code(G) Out of pocket [start_date] => 20190301 [end_date] => [coverage_level] => FAM [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => Code(PR) PPO [plan_desc] => [coverage_period] => Code(22) Service Year [amount] => 99999.99 [percent] => [network_ind] => W [message] => ) [4] => Array ( [type] => G [benefit_type] => Code(G) Out of pocket [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => Code(PR) PPO [plan_desc] => [coverage_period] => Code(22) Service Year [amount] => 6700 [percent] => [network_ind] => W [message] => ) [5] => Array ( [type] => C [benefit_type] => Code(C) Deductible [start_date] => 20190301 [end_date] => [coverage_level] => FAM [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(24) [amount] => 0 [percent] => [network_ind] => W [message] => ) [6] => Array ( [type] => C [benefit_type] => Code(C) Deductible [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(24) [amount] => 0 [percent] => [network_ind] => W [message] => ) [7] => Array ( [type] => G [benefit_type] => Code(G) Out of pocket [start_date] => 20190301 [end_date] => [coverage_level] => FAM [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => Code(PR) PPO [plan_desc] => [coverage_period] => Code(24) [amount] => 0 [percent] => [network_ind] => W [message] => ) [8] => Array ( [type] => G [benefit_type] => Code(G) Out of pocket [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => Code(PR) PPO [plan_desc] => [coverage_period] => Code(24) [amount] => 0 [percent] => [network_ind] => W [message] => ) [9] => Array ( [type] => C [benefit_type] => Code(C) Deductible [start_date] => 20190301 [end_date] => [coverage_level] => FAM [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(29) [amount] => 0 [percent] => [network_ind] => W [message] => ) [10] => Array ( [type] => C [benefit_type] => Code(C) Deductible [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(29) [amount] => 0 [percent] => [network_ind] => W [message] => ) [11] => Array ( [type] => G [benefit_type] => Code(G) Out of pocket [start_date] => 20190301 [end_date] => [coverage_level] => FAM [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => Code(PR) PPO [plan_desc] => [coverage_period] => Code(29) [amount] => 99999.99 [percent] => [network_ind] => W [message] => ) [12] => Array ( [type] => G [benefit_type] => Code(G) Out of pocket [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => Code(PR) PPO [plan_desc] => [coverage_period] => Code(29) [amount] => 6700 [percent] => [network_ind] => W [message] => ) [13] => Array ( [type] => L [benefit_type] => Code(L) Primary Care Provider [start_date] => [end_date] => [coverage_level] => [coverage_type] => [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => [message] => ) [14] => Array ( [type] => 1 [benefit_type] => Code(1) Active Coverage [start_date] => 20190301 [end_date] => [coverage_level] => [coverage_type] => Code(1^33^47^48^86^98^MH^PT^UC) [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => W [message] => ) [15] => Array ( [type] => 1 [benefit_type] => Code(1) Active Coverage [start_date] => 20190301 [end_date] => [coverage_level] => [coverage_type] => Code(50) Hospital Outpatient [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => W [message] => OUTPATIENT SURGERY ) [16] => Array ( [type] => 1 [benefit_type] => Code(1) Active Coverage [start_date] => 20190301 [end_date] => [coverage_level] => [coverage_type] => Code(96) [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => W [message] => OFFICE VISIT SPECIALIST ) [17] => Array ( [type] => 1 [benefit_type] => Code(1) Active Coverage [start_date] => 20190301 [end_date] => [coverage_level] => [coverage_type] => Code(AL) Vision [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => W [message] => ROUTINE EYE EXAM ) [18] => Array ( [type] => 1 [benefit_type] => Code(1) Active Coverage [start_date] => 20190301 [end_date] => [coverage_level] => [coverage_type] => Code(50) Hospital Outpatient [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => W [message] => OUTPATIENT HOSPITAL ) [19] => Array ( [type] => A [benefit_type] => Code(A) Co-insurance [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(50) Hospital Outpatient [plan_type] => [plan_desc] => [coverage_period] => Code(7) Co-Insurance Days Co-Payment Amount [amount] => [percent] => .2 [network_ind] => W [message] => OUTPATIENT HOSPITAL ) [20] => Array ( [type] => A [benefit_type] => Code(A) Co-insurance [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(9) [plan_type] => [plan_desc] => [coverage_period] => Code(27) Visit [amount] => [percent] => 0 [network_ind] => W [message] => VIRTUAL VISITS/TELEMEDICINE ) [21] => Array ( [type] => A [benefit_type] => Code(A) Co-insurance [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(96) [plan_type] => [plan_desc] => [coverage_period] => Code(27) Visit [amount] => [percent] => 0 [network_ind] => W [message] => OFFICE VISIT SPECIALIST ) [22] => Array ( [type] => A [benefit_type] => Code(A) Co-insurance [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(50) Hospital Outpatient [plan_type] => [plan_desc] => [coverage_period] => Code(7) Co-Insurance Days Co-Payment Amount [amount] => [percent] => .2 [network_ind] => W [message] => OUTPATIENT SURGERY ) [23] => Array ( [type] => A [benefit_type] => Code(A) Co-insurance [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(86^UC) [plan_type] => [plan_desc] => [coverage_period] => Code(7) Co-Insurance Days Co-Payment Amount [amount] => [percent] => 0 [network_ind] => W [message] => ) [24] => Array ( [type] => A [benefit_type] => Code(A) Co-insurance [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(33^48^98^PT) [plan_type] => [plan_desc] => [coverage_period] => Code(27) Visit [amount] => [percent] => 0 [network_ind] => W [message] => ) [25] => Array ( [type] => B [benefit_type] => Code(B) Co-payment [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(33^48^98^PT) [plan_type] => [plan_desc] => [coverage_period] => Code(27) Visit [amount] => 0 [percent] => [network_ind] => W [message] => ) [26] => Array ( [type] => B [benefit_type] => Code(B) Co-payment [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(96) [plan_type] => [plan_desc] => [coverage_period] => Code(27) Visit [amount] => 0 [percent] => [network_ind] => W [message] => OFFICE VISIT SPECIALIST ) [27] => Array ( [type] => B [benefit_type] => Code(B) Co-payment [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(UC) Urgent Care [plan_type] => [plan_desc] => [coverage_period] => Code(7) Co-Insurance Days Co-Payment Amount [amount] => 65 [percent] => [network_ind] => W [message] => ) [28] => Array ( [type] => B [benefit_type] => Code(B) Co-payment [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(9) [plan_type] => [plan_desc] => [coverage_period] => Code(27) Visit [amount] => 0 [percent] => [network_ind] => W [message] => VIRTUAL VISITS/TELEMEDICINE ) [29] => Array ( [type] => B [benefit_type] => Code(B) Co-payment [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(86) Emergency Services [plan_type] => [plan_desc] => [coverage_period] => Code(7) Co-Insurance Days Co-Payment Amount [amount] => 90 [percent] => [network_ind] => W [message] => ) [30] => Array ( [type] => B [benefit_type] => Code(B) Co-payment [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(50) Hospital Outpatient [plan_type] => [plan_desc] => [coverage_period] => Code(7) Co-Insurance Days Co-Payment Amount [amount] => 0 [percent] => [network_ind] => W [message] => OUTPATIENT SURGERY ) [31] => Array ( [type] => B [benefit_type] => Code(B) Co-payment [start_date] => 20190301 [end_date] => [coverage_level] => IND [coverage_type] => Code(50) Hospital Outpatient [plan_type] => [plan_desc] => [coverage_period] => Code(7) Co-Insurance Days Co-Payment Amount [amount] => 0 [percent] => [network_ind] => W [message] => OUTPATIENT HOSPITAL ) [32] => Array ( [type] => 1 [benefit_type] => Code(1) Active Coverage [start_date] => 20190301 [end_date] => 20191231 [coverage_level] => [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => SPECTERA VISION PLAN [coverage_period] => [amount] => [percent] => [network_ind] => [message] => ) [33] => Array ( [type] => C [benefit_type] => Code(C) Deductible [start_date] => 20190301 [end_date] => 20191231 [coverage_level] => IND [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(23) [amount] => 0 [percent] => [network_ind] => W [message] => ) [34] => Array ( [type] => C [benefit_type] => Code(C) Deductible [start_date] => 20190301 [end_date] => 20191231 [coverage_level] => FAM [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(23) [amount] => 0 [percent] => [network_ind] => W [message] => ) [35] => Array ( [type] => G [benefit_type] => Code(G) Out of pocket [start_date] => 20190301 [end_date] => 20191231 [coverage_level] => IND [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(23) [amount] => 0 [percent] => [network_ind] => W [message] => ) [36] => Array ( [type] => G [benefit_type] => Code(G) Out of pocket [start_date] => 20190301 [end_date] => 20191231 [coverage_level] => FAM [coverage_type] => Code(30) Health Plan Benefit Coverage [plan_type] => [plan_desc] => [coverage_period] => Code(23) [amount] => 0 [percent] => [network_ind] => W [message] => ) [37] => Array ( [type] => 1 [benefit_type] => Code(1) Active Coverage [start_date] => 20190301 [end_date] => 20191231 [coverage_level] => [coverage_type] => Code(AL) Vision [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => [message] => ) [38] => Array ( [type] => U [benefit_type] => Code(U) [start_date] => [end_date] => [coverage_level] => [coverage_type] => Code(35) Dental [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => [message] => ) [39] => Array ( [type] => U [benefit_type] => Code(U) [start_date] => [end_date] => [coverage_level] => [coverage_type] => Code(88) Pharmacy [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => [message] => ) [40] => Array ( [type] => X [benefit_type] => Code(X) Beneficiary is Medicare entitled [start_date] => [end_date] => [coverage_level] => [coverage_type] => [plan_type] => [plan_desc] => [coverage_period] => [amount] => [percent] => [network_ind] => [message] => ) ) ) )