Health Care Services Review Information - Notification (X216)

ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *240222*0119*^*00501*000000001*0*T*>~
GS*HI*SENDERGS*RECEIVERGS*20240222*011931*000000001*X*005010X216~
ST*278*0001*005010X216~
BHT*0007*CN*2004000345628*20040601*1410*NO~
HL*1**20*1~
NM1*1P*2*St JosephHospital*****46*0000012121~
REF*1J*162354~
HL*2*1*21*1~
NM1*X3*2*MarylandCapital InsuranceCompany*****46*789312~
HL*3*2*22*1~
NM1*IL*1*Smith*Joe****MI*12345678901~
DMG*D8*19580322*M~
HL*4*3*EV*0~
TRN*1*040601002349A*9000012121~
UM*AR*I*2*21>B~
HCR*A1*A0405295498~
DTP*435*D8*20040530~
HI*BF>410.90~
CL1*2~
NM1*SJ*2*St JosephHospital*****46*0000012121~
REF*1J*162354~
PER*IC**TE*6107771212~
SE*21*0001~
GE*1*000000001~
IEA*1*000000001~

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