HIPAA_835::Base Transaction Set Header ST*835*1234~ Financial Information BPR*C*150000*C*ACH*CTX*01*999999992*DA*123456*1512345678**01*999988880*DA*98765*20020913~ Reassociation Trace Number TRN*1*12345*1512345678~ Production Date DTM*405*20020916~ HIPAA_835::L1000A - Payer Identification Payer Identification N1*PR*INSURANCE COMPANY OF TIMBUCKTU~ Payer Address N3*1 MAIN STREET~ Payer City, State, ZIP Code N4*TIMBUCKTU*AK*89111~ Additional Payer Identification REF*2U*999~ HIPAA_835::L1000B - Payee Identification Payee Identification N1*PE*REGIONAL HOPE HOSPITAL*XX*6543210903~ HIPAA_835::L2000 - Header Number Header Number LX*110212~ Provider Summary Information TS3*6543210903*11*20021231*1*211366.97****138018.4**73348.57~ Provider Supplemental Summary Information TS2*2178.45*1919.71**56.82*197.69*4.23~ HIPAA_835::L2100 - Claim Payment Information Claim Payment Information CLP*666123*1*211366.97*138018.4**MA*1999999444444*11*1~ Claim Adjustment CAS*CO*45*73348.57~ Patient Name NM1*QC*1*JONES*SAM*O***HN*666666666A~ Inpatient Adjudication Information MIA*0***138018.4~ Statement From or To Date DTM*232*20020816~DTM*233*20020824~ Claim Supplemental Information Quantity QTY*CA*8~ Header Number LX*130212~ Provider Summary Information TS3*6543210909*13*19961231*1*15000****11980.33**3019.67~ HIPAA_835::L2100 - Claim Payment Information Claim Payment Information CLP*777777*1*15000*11980.33**MB*1999999444445*13*1~ Claim Adjustment CAS*CO*45*3019.67~ Patient Name NM1*QC*1*BORDER*LIZ*E***HN*996669999B~ Outpatient Adjudication Information MOA***MA02~ Statement From or To Date DTM*232*20020512~ Provider Adjustment PLB*6543210903*20021231*CV:CP*-1.27~ Transaction Set Trailer SE*28*1234~