ISA*00*          *00*          *ZZ*Z12345         *ZZ*NYSDOH-APD     *191021*1705*>*00501*000000010*0*T*:~
GS*BE*57165*NYSDOH-APD*20191021*1705*00004*X*005010X318~
ST*834*12345*005010X318~
BGN*00*124567*20191021*1200*ES***RX~
DTP*007*D8*20171021~
N1*41*SUBMITTERNAME*46*Z12345~
N1*40*NYDOH-APD*46*OSDS~
N1*ACV*INFOSRCNAME*94*57165~
INS*Y*18*021*28*A***FT~
REF*0F*2024433308~
REF*SY*065488888~
NM1*IL*1*SMITH*JEAN****MI*2024433308~
PER*IP**EM*JSMITH@AOL.COM*TE*5188109999~
N3*99 TEST RESIDENCE RD*APT 3~
N4*MELROSE*NY*121211712**CY*36083~
DMG*D8*19800918*M*I*:RET:R5~
EC*02~
HLH*N~
LUI*LD*123**8~
NM1*31*1~
N3*TEST MAIL STREET*TEST ADDR 2~
N4*MELROSE*NY*121210001~
NM1*36*2*MEMBER EMPLOYER NAME~
NM1*QD*1*RESPONSIBLE*PERSON~
PER*RP**TE*8105551212~
N3*10 RESPONSIBLE STREET~
N4*KANSAS CITY*MO*64108~
DSB*2******ZZ*N181~
DTP*360*D8*20171231~
DTP*361*D8*20181031~
HD*021**HMO*FAM~
DTP*303*D8*20191021~
DTP*348*D8*20190601~
DTP*349*D8*20190731~
AMT*D2*350~
AMT*P3*20~
REF*1L*888888~
LX*1~
NM1*P3*1*JONES*PCP****XX*1700813623~
N3*50 PCP STREET~
N4*ALBANY*NY*122070001~
PER*IC**WP*80155504321~
PRV*OT*PXC*2086H0002X~
PLA*ND*P3*20190601~
COB*P**6~
NM1*IN*2*INFOSRCNAME~
N3*INS PRIMARY DR~
N4*KANSAS CITY*MO*64108~
COB*S**1~
NM1*IN*2*SECONDARY INS CO*****FI*99999999~
N3*INS SECONDARY DR~
N4*KANSAS CITY*MO*64108~
HD*021**DEN*FAM~
DTP*303*D8*20190601~
DTP*348*D8*20190601~
DTP*349*D8*20190731~
AMT*D2*150~
AMT*P3*20~
REF*1L*999999~
LX*1~
NM1*P3*1*JONES*DENTIST****XX*1700814443~
N3*55 SOUTH PEARL STREET~
N4*ALBANY*NY*122070001~
PER*IC**WP*80155505555~
PRV*OT*PXC*1223X0008X~
PLA*ND*QN*20190601~
LS*2700~
LX*1~
N1*IAE*ISSUER_PLAN_PRODUCT_ID~
REF*18*57165NY001000100~
INS*Y*18*021*41*A***FT~
REF*0F*2024433308~
REF*SY*065488888~
NM1*IL*1*SMITH*JEAN****MI*2024433308~
PER*IP**EM*JSMITH@AOL.COM*TE*5188109999~
N3*99 TEST RESIDENCE RD*APT 3~
N4*MELROSE*NY*121211712**CY*36083~
DMG*D8*19800918*M*I*:RET:R5~
EC*02~
HLH*N~
LUI*LD*123**8~
NM1*31*1~
N3*TEST MAIL STREET*TEST ADDR 2~
N4*MELROSE*NY*121210001~
NM1*36*2*MEMBER EMPLOYER NAME~
NM1*QD*1*RESPONSIBLE*PERSON~
PER*RP**TE*8105551212~
N3*10 RESPONSIBLE STREET~
N4*KANSAS CITY*MO*64108~
DSB*2******ZZ*N181~
DTP*360*D8*20171231~
DTP*361*D8*20181031~
HD*021**HMO*FAM~
DTP*303*D8*20190901~
DTP*348*D8*20190901~
AMT*D2*250~
AMT*P3*10~
REF*1L*777777~
LX*1~
NM1*P3*1*JONES*PCP****XX*1700813623~
N3*50 PCP STREET~
N4*ALBANY*NY*122070001~
PER*IC**WP*80155504321~
PRV*OT*PXC*2086H0002X~
PLA*ND*P3*20190901~
COB*P**6~
NM1*IN*2*INFOSRCNAME~
N3*INS PRIMARY DR~
N4*KANSAS CITY*MO*64108~
COB*S**1~
NM1*IN*2*SECONDARY INS CO*****FI*99999999~
N3*INS SECONDARY DR~
N4*KANSAS CITY*MO*64108~
HD*021**DEN*FAM~
DTP*303*D8*20190901~
DTP*348*D8*20190901~
AMT*D2*50~
AMT*P3*15~
REF*1L*666666~
LX*1~
NM1*P3*1*JONES*DENTIST****XX*1700814443~
N3*55 DENTIST STREET~
N4*ALBANY*NY*122070001~
PER*IC**WP*80155505555~
PRV*OT*PXC*1223X0008X~
PLA*ND*QN*20190801~
LS*2700~
LX*1~
N1*IAE*ISSUER_PLAN_PRODUCT_ID~
REF*18*57165NY001000100~
SE*129*12345~
GE*1*00004~
IEA*1*000000010~