Entire Segment |
ST|835|0001 |
BPR|I|112357.08|C|ACH|CCP|01|075911603|DA|00000004556640373|1811725341||01|12 |
TRN|1|001551354|1811725341 |
REF|EV|1710582184 |
DTM|405|20220128 |
N1|PR|COTXIX|XV|7912900843 |
N3|P.O. BOX 30 |
N4|DENVER|CO|80201 |
PER|CX|MEDICAID PROVIDER SERVICES|TE|8442352387 |
PER|BL|MEDICAID PROVIDER SERVICES|TE|8442352387 |
N1|PE|TEAM SELECT HOME CARE|XX|1710582184 |
REF|TJ|611611357 |
LX|1 |
CLP|91163953|4|587.2|0||MC|2022024015421 |
CAS|PI|208|587.2 |
NM1|QC|1|HART|EARL||||MR|P576096 |
REF|EA|91163953 |
DTM|232|20211231 |
DTM|233|20211231 |
CLP|91157961|4|2396.68|0||MC|2022024015427 |
CAS|PI|208|2396.68 |
NM1|QC|1|LEVERING|EDMUND||||MR|N499248 |
REF|EA|91157961 |
DTM|232|20211120 |
DTM|233|20211201 |
CLP|91115300|4|1259.72|0||MC|2022024015425 |
CAS|PI|208|1259.72 |
NM1|QC|1|MILLER|JODY||||MR|P215665 |
REF|EA|91115300 |
DTM|232|20211206 |
DTM|233|20211210 |
CLP|359731|1|676.24|541.52||MC|2022026035667|32|2 |
NM1|QC|1|ANDERSON|GEORGINA||||MR|Q000224 |
REF|EA|LN200007959101 |
DTM|232|20220116 |
DTM|233|20220122 |
SVC|HC^S9122|90|77.36|0571|2 |
DTM|472|20220116 |
CAS|CO|45|12.64 |
REF|G1|6212660033 |
REF|6R|5528721387Z1 |
AMT|B6|77.36 |
LQ|HE|N381 |
SVC|HC^S9122|90|77.36|0571|2 |
DTM|472|20220117 |
CAS|CO|45|12.64 |
REF|G1|6212660033 |
REF|6R|5528721387Z2 |
AMT|B6|77.36 |
LQ|HE|N381 |
SVC|HC^S9122|90|77.36|0571|2 |
DTM|472|20220118 |
CAS|CO|45|12.64 |
REF|G1|6212660033 |
REF|6R|5528721387Z3 |
AMT|B6|77.36 |
LQ|HE|N381 |
SVC|HC^S9122|90|77.36|0571|2 |
DTM|472|20220119 |
CAS|CO|45|12.64 |
REF|G1|6212660033 |
REF|6R|5528721387Z4 |
AMT|B6|77.36 |
LQ|HE|N381 |
SVC|HC^S9122|90|77.36|0571|2 |
DTM|472|20220120 |
CAS|CO|45|12.64 |
REF|G1|6212660033 |
REF|6R|5528721387Z5 |
AMT|B6|77.36 |
LQ|HE|N381 |
SVC|HC^S9122|90|77.36|0571|2 |
DTM|472|20220121 |
CAS|CO|45|12.64 |
REF|G1|6212660033 |
REF|6R|5528721387Z6 |
AMT|B6|77.36 |
LQ|HE|N381 |
SVC|HC^G0156|23.12|0|0579|0||2 |
DTM|472|20220121 |
CAS|PI|15|23.12 |
REF|6R|5528721387Z7 |
LQ|HE|M62 |
SVC|HC^S9122|90|77.36|0571|2 |
DTM|472|20220122 |
CAS|CO|45|12.64 |
REF|G1|6212660033 |
REF|6R|5528721387Z8 |
AMT|B6|77.36 |
LQ|HE|N381 |
SVC|HC^G0156|23.12|0|0579|0||2 |
DTM|472|20220122 |
CAS|PI|15|23.12 |
REF|6R|5528721387Z9 |
LQ|HE|M62 |
CLP|359940|1|1340.92|1163.96||MC|2022026036544 |
NM1|QC|1|APODACA|KRYSTA||||MR|Y458323 |
REF|EA|LN200006102401 |
DTM|232|20220116 |
DTM|233|20220122 |
SVC|HC^S9122|180|154.72|0571|4 |
DTM|472|20220116 |
CAS|CO|45|25.28 |
REF|G1|6213230008 |
REF|6R|5528721423Z1 |
AMT|B6|154.72 |
LQ|HE|N381 |
SVC|HC^G0156|11.56|11.56|0579|1 |
DTM|472|20220116 |
REF|G1|6213230008 |
REF|6R|5528721423Z2 |
AMT|B6|11.56 |
SVC|HC^S9122|180|154.72|0571|4 |
DTM|472|20220117 |
CAS|CO|45|25.28 |
REF|G1|6213230008 |
REF|6R|5528721423Z3 |
AMT|B6|154.72 |
LQ|HE|N381 |
SVC|HC^G0156|11.56|11.56|0579|1 |
DTM|472|20220117 |
REF|G1|6213230008 |
REF|6R|5528721423Z4 |
AMT|B6|11.56 |
SVC|HC^S9122|180|154.72|0571|4 |
DTM|472|20220118 |
CAS|CO|45|25.28 |
REF|G1|6213230008 |
REF|6R|5528721423Z5 |
AMT|B6|154.72 |
LQ|HE|N381 |
SVC|HC^G0156|11.56|11.56|0579|1 |
DTM|472|20220118 |
REF|G1|6213230008 |
REF|6R|5528721423Z6 |
AMT|B6|11.56 |
SVC|HC^S9122|180|154.72|0571|4 |
DTM|472|20220119 |
CAS|CO|45|25.28 |
REF|G1|6213230008 |
REF|6R|5528721423Z7 |
AMT|B6|154.72 |
LQ|HE|N381 |
SVC|HC^G0156|11.56|11.56|0579|1 |
DTM|472|20220119 |
REF|G1|6213230008 |
REF|6R|5528721423Z8 |
AMT|B6|11.56 |
SVC|HC^S9122|180|154.72|0571|4 |
DTM|472|20220120 |
CAS|CO|45|25.28 |
REF|G1|6213230008 |
REF|6R|5528721423Z9 |
AMT|B6|154.72 |
LQ|HE|N381 |
SVC|HC^G0156|11.56|11.56|0579|1 |
DTM|472|20220120 |
REF|G1|6213230008 |
REF|6R|5528721423Z10 |
AMT|B6|11.56 |
SVC|HC^S9122|180|154.72|0571|4 |
DTM|472|20220121 |
CAS|CO|45|25.28 |
REF|G1|6213230008 |
REF|6R|5528721423Z11 |
AMT|B6|154.72 |
LQ|HE|N381 |
SVC|HC^G0156|11.56|11.56|0579|1 |
DTM|472|20220121 |
REF|G1|6213230008 |
REF|6R|5528721423Z12 |
AMT|B6|11.56 |
SVC|HC^S9122|180|154.72|0571|4 |
DTM|472|20220122 |
CAS|CO|45|25.28 |
REF|G1|6213230008 |
REF|6R|5528721423Z13 |
AMT|B6|154.72 |
LQ|HE|N381 |
SVC|HC^G0156|11.56|11.56|0579|1 |
DTM|472|20220122 |
REF|G1|6213230008 |
REF|6R|5528721423Z14 |
AMT|B6|11.56 |
CLP|359816|1|710.92|622.44||MC|2022026035978 |
NM1|QC|1|ARIO|ROD||||MR|O445183 |
REF|EA|LN200006921401 |
DTM|232|20220116 |
DTM|233|20220122 |
SVC|HC^S9122|90|77.36|0571|2 |
DTM|472|20220116 |
CAS|CO|45|12.64 |
REF|6R|5528721402Z1 |
AMT|B6|77.36 |
LQ|HE|N381 |
SVC|HC^G0156|11.56|11.56|0579|1 |
DTM|472|20220116 |
REF|6R|5528721402Z2 |
AMT|B6|11.56 |