Health Care Services Review Information - Acknowledgment (X216)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240222*0119*^*00501*000000001*0*T*>~
GS*HI*SENDERGS*RECEIVERGS*20240222*011952*000000001*X*005010X216~
ST*278*0034*005010X216~
BHT*0007*53*2004000345628*20050602*0420~
HL*1**20*1~
NM1*X3*2*MarylandCapital InsuranceCompany*****46*789312~
HL*2*1*21*1~
NM1*1P*2*St JosephHospital*****46*0000012121~
HL*3*2*22*1~
NM1*IL*1*Smith*Joe****MI*12345678901~
DMG*D8*19580322*M~
HL*4*3*EV*0~
TRN*2*040601002349A*9000012121~
UM*AR*I*2*21>B~
HCR*A1*A0405295498~
DTP*435*D8*20040530~
HI*BF>410.90~
NM1*SJ*2*St JosephHospital*****46*0000012121~
REF*1J*162354~
SE*18*0034~
GE*1*000000001~
IEA*1*000000001~

X12 278 Health Care Services Review Information - Acknowledgment (X216)