ISA*00*          *00*          *ZZ*TEST-PAYER     *30*TEST-PAYEE     *260316*0855*+*00501*000059660*0*P*:~GS*RA*TEST-PAYER*TEST-PAYEE*20260316*085500*44273*X*005010X218~ST*820*0001*005010X218~BPR*I*91977.81*C*NON******68-0317191******20260312~TRN*3*TESTTRN02000001~REF*14*0000245023~N1*PE*TEST PAYEE ORGANIZATION~N3*123 TEST STREET~N4*TESTCITY*CA*00000~N1*PR*TEST PAYER AGENCY~N3*123 TEST STREET~N4*TESTCITY*CA*00000~ENT*1*2J*EI*999999999~NM1*IL*1*LASTNAME01*FIRSTNAME01****N*TESTMBR000000001~RMR*IK*TESTPLAN-SREGLR-2602200043000P**5555.82~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Dual-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**454.72*5555.82~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Dual-State Only~DTM*582****RD8*20260101-20260131~ADX*-5101.10*53~ENT*2*2J*EI*999999999~NM1*IL*1*LASTNAME02*FIRSTNAME02****N*TESTMBR000000002~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*3*2J*EI*999999999~NM1*IL*1*LASTNAME03*FIRSTNAME03****N*TESTMBR000000003~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*4*2J*EI*999999999~NM1*IL*1*LASTNAME13*FIRSTNAME13****N*TESTMBR000000013~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ENT*5*2J*EI*999999999~NM1*IL*1*LASTNAME04*FIRSTNAME04****N*TESTMBR000000004~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*6*2J*EI*999999999~NM1*IL*1*LASTNAME05*FIRSTNAME05****N*TESTMBR000000005~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*7*2J*EI*999999999~NM1*IL*1*LASTNAME06*FIRSTNAME06****N*TESTMBR000000006~RMR*IK*TESTPLAN-SREGLR-2602200043000P**-8086.53~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ENT*8*2J*EI*999999999~NM1*IL*1*LASTNAME07*FIRSTNAME07****N*TESTMBR000000007~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*9*2J*EI*999999999~NM1*IL*1*LASTNAME08*FIRSTNAME08****N*TESTMBR000000008~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*10*2J*EI*999999999~NM1*IL*1*LASTNAME09*FIRSTNAME09****N*TESTMBR000000009~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*11*2J*EI*999999999~NM1*IL*1*LASTNAME10*FIRSTNAME10****N*TESTMBR000000010~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*1H;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*12*2J*EI*999999999~NM1*IL*1*LASTNAME11*FIRSTNAME11****N*TESTMBR000000011~RMR*IK*TESTPLAN-SREGLR-2602200043000P**8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260201-20260228~RMR*IK*TESTPLAN-SREGLR-2602200043000P**401.72*8488.25~REF*18*957~REF*ZZ*M1;2~REF*ZZ*Medi-Cal Only-State Only~DTM*582****RD8*20260101-20260131~ADX*-8086.53*53~ENT*13*2J*EI*999999999~NM1*IL*1*LASTNAME12*FIRSTNAME12****N*TESTMBR000000012~RMR*IK*TESTPLAN-SREGLR-2602200043000P**5555.82~REF*18*957~REF*ZZ*17;2~REF*ZZ*Dual-State Only~DTM*582****RD8*20260101-20260131~SE*162*0001~GE*1*44273~IEA*1*000059660~
