<X12>
	<ISA>
		<ISA01-AuthorizationInformationQualifier><!--I01-->00<!--No Authorization Information Present (No Meaningful Information in I02)--></ISA01-AuthorizationInformationQualifier>
		<ISA02-AuthorizationInformation><!--I02-->          </ISA02-AuthorizationInformation>
		<ISA03-SecurityInformationQualifier><!--I03-->00<!--No Security Information Present (No Meaningful Information in I04)--></ISA03-SecurityInformationQualifier>
		<ISA04-SecurityInformation><!--I04-->          </ISA04-SecurityInformation>
		<ISA05-InterchangeIdQualifier><!--I05-->ZZ<!--Mutually Defined--></ISA05-InterchangeIdQualifier>
		<ISA06-InterchangeSenderId><!--I06-->431420764000000</ISA06-InterchangeSenderId>
		<ISA07-InterchangeIdQualifier><!--I05-->ZZ<!--Mutually Defined--></ISA07-InterchangeIdQualifier>
		<ISA08-InterchangeReceiverId><!--I07-->6232           </ISA08-InterchangeReceiverId>
		<ISA09-InterchangeDate><!--I08-->070219<!--2007&#x2D;02&#x2D;19--></ISA09-InterchangeDate>
		<ISA10-InterchangeTime><!--I09-->1302</ISA10-InterchangeTime>
		<ISA11-InterchangeControlStandards><!--I10-->U<!--U.S. EDI Community of ASC X12, TDCC, and UCS--></ISA11-InterchangeControlStandards>
		<ISA12-InterchangeControlVersion><!--I11-->00401<!--Draft Standards for Trial Use Approved for Publication by ASC X12 Procedures Review Board through October 1997--></ISA12-InterchangeControlVersion>
		<ISA13-InterchangeControlNumber><!--I12-->000862650</ISA13-InterchangeControlNumber>
		<ISA14-AcknowledgmentRequested><!--I13-->0<!--No Acknowledgment Requested--></ISA14-AcknowledgmentRequested>
		<ISA15-UsageIndicator><!--I14-->P<!--Production Data--></ISA15-UsageIndicator>
		<ISA16-ComponentElementSeparator><!--I15-->:</ISA16-ComponentElementSeparator>
	</ISA>
	<GS>
		<GS01-FunctionalIdentifierCode><!--479-->HP<!--Health Care Claim Payment/Advice (835)--></GS01-FunctionalIdentifierCode>
		<GS02-ApplicationSenderSCode><!--142-->431420764</GS02-ApplicationSenderSCode>
		<GS03-ApplicationReceiverSCode><!--124-->6232</GS03-ApplicationReceiverSCode>
		<GS04-Date><!--373-->20070219<!--2007&#x2D;02&#x2D;19--></GS04-Date>
		<GS05-Time><!--337-->1302</GS05-Time>
		<GS06-GroupControlNumber><!--28-->1</GS06-GroupControlNumber>
		<GS07-ResponsibleAgencyCode><!--455-->X<!--Accredited Standards Committee X12--></GS07-ResponsibleAgencyCode>
		<GS08-VersionReleaseIndustry><!--480-->004010X091A1<!--Draft Standards Approved for Publication by ASC X12 Procedures Review Board through October 1997 &#x2D; X091A1--></GS08-VersionReleaseIndustry>
	</GS>
	<TS_835>
		<ST>
			<ST01-TransactionSetIdentifierCode><!--143-->835<!--Health Care Claim Payment/Advice--></ST01-TransactionSetIdentifierCode>
			<ST02-TransactionSetControlNumber><!--329-->000000001</ST02-TransactionSetControlNumber>
		</ST>
		<BPR>
			<BPR01-TransactionHandlingCode><!--305-->H<!--Notification Only--></BPR01-TransactionHandlingCode>
			<BPR02-MonetaryAmount><!--782-->0</BPR02-MonetaryAmount>
			<BPR03-CreditDebitFlagCode><!--478-->C<!--Credit--></BPR03-CreditDebitFlagCode>
			<BPR04-PaymentMethodCode><!--591-->NON<!--Non&#x2D;Payment Data--></BPR04-PaymentMethodCode>
			<BPR16-Date><!--373-->20070209<!--2007&#x2D;02&#x2D;09--></BPR16-Date>
		</BPR>
		<TRN>
			<TRN01-TraceTypeCode><!--481-->1<!--Current Transaction Trace Numbers--></TRN01-TraceTypeCode>
			<TRN02-ReferenceIdentification><!--127-->Z70403AD8871SYS</TRN02-ReferenceIdentification>
			<TRN03-OriginatingCompanyIdentifier><!--509-->1351840597</TRN03-OriginatingCompanyIdentifier>
		</TRN>
		<REF>
			<REF01-ReferenceIdentificationQualifier><!--128-->EV<!--Receiver Identification Number--></REF01-ReferenceIdentificationQualifier>
			<REF02-ReferenceIdentification><!--127-->D08605524</REF02-ReferenceIdentification>
		</REF>
		<REF>
			<REF01-ReferenceIdentificationQualifier><!--128-->F2<!--Version Code &#x2D; Local--></REF01-ReferenceIdentificationQualifier>
			<REF02-ReferenceIdentification><!--127-->2001274</REF02-ReferenceIdentification>
		</REF>
		<DTM>
			<DTM01-DateTimeQualifier><!--374-->405<!--Production--></DTM01-DateTimeQualifier>
			<DTM02-Date><!--373-->20070209<!--2007&#x2D;02&#x2D;09--></DTM02-Date>
		</DTM>
		<GROUP_1>
			<N1>
				<N101-EntityIdentifierCode><!--98-->PR<!--Payer--></N101-EntityIdentifierCode>
				<N102-Name><!--93-->ADMINASTAR FEDERAL- REGION B DMERC</N102-Name>
				<N103-IdentificationCodeQualifier><!--66-->XV<!--Health Care Financing Administration National Payer Identification Number (PAYERID)--></N103-IdentificationCodeQualifier>
				<N104-IdentificationCode><!--67-->00635</N104-IdentificationCode>
			</N1>
			<N3>
				<N301-AddressInformation><!--166-->8115 KNUE ROAD</N301-AddressInformation>
			</N3>
			<N4>
				<N401-CityName><!--19-->INDIANAPOLIS</N401-CityName>
				<N402-StateOrProvinceCode><!--156-->IN</N402-StateOrProvinceCode>
				<N403-PostalCode><!--116-->46250</N403-PostalCode>
			</N4>
			<REF>
				<REF01-ReferenceIdentificationQualifier><!--128-->2U<!--Payer Identification Number--></REF01-ReferenceIdentificationQualifier>
				<REF02-ReferenceIdentification><!--127-->17003</REF02-ReferenceIdentification>
			</REF>
			<PER>
				<PER01-ContactFunctionCode><!--366-->CX<!--Payers Claim Office--></PER01-ContactFunctionCode>
				<PER02-Name><!--93-->EDI HELPDESK</PER02-Name>
				<PER03-CommunicationNumberQualifier><!--365-->TE<!--Telephone--></PER03-CommunicationNumberQualifier>
				<PER04-CommunicationNumber><!--364-->8772734334</PER04-CommunicationNumber>
			</PER>
		</GROUP_1>
		<GROUP_1>
			<N1>
				<N101-EntityIdentifierCode><!--98-->PE<!--Payee--></N101-EntityIdentifierCode>
				<N102-Name><!--93-->EYRCR ASSOC OF BLUFFTON</N102-Name>
				<N103-IdentificationCodeQualifier><!--66-->FI<!--Federal Taxpayer's Identification Number--></N103-IdentificationCodeQualifier>
				<N104-IdentificationCode><!--67-->351471499</N104-IdentificationCode>
			</N1>
			<N3>
				<N301-AddressInformation><!--166-->PO BOX 396</N301-AddressInformation>
			</N3>
			<N4>
				<N401-CityName><!--19-->BLUFFTON</N401-CityName>
				<N402-StateOrProvinceCode><!--156-->IN</N402-StateOrProvinceCode>
				<N403-PostalCode><!--116-->467140396</N403-PostalCode>
			</N4>
			<REF>
				<REF01-ReferenceIdentificationQualifier><!--128-->1C<!--Medicare Provider Number--></REF01-ReferenceIdentificationQualifier>
				<REF02-ReferenceIdentification><!--127-->0356760001</REF02-ReferenceIdentification>
			</REF>
		</GROUP_1>
		<GROUP_2>
			<LX>
				<LX01-AssignedNumber><!--554-->1</LX01-AssignedNumber>
			</LX>
			<GROUP_3>
				<CLP>
					<CLP01-ClaimSubmitterSIdentifier><!--1028-->2005429</CLP01-ClaimSubmitterSIdentifier>
					<CLP02-ClaimStatusCode><!--1029-->4<!--Denied--></CLP02-ClaimStatusCode>
					<CLP03-MonetaryAmount><!--782-->137.00</CLP03-MonetaryAmount>
					<CLP04-MonetaryAmount><!--782-->0</CLP04-MonetaryAmount>
					<CLP06-ClaimFilingIndicatorCode><!--1032-->MB<!--Medicare Part B--></CLP06-ClaimFilingIndicatorCode>
					<CLP07-ReferenceIdentification><!--127-->07026220582010</CLP07-ReferenceIdentification>
					<CLP08-FacilityCodeValue><!--1331-->12</CLP08-FacilityCodeValue>
				</CLP>
				<NM1>
					<NM101-EntityIdentifierCode><!--98-->QC<!--Patient--></NM101-EntityIdentifierCode>
					<NM102-EntityTypeQualifier><!--1065-->1<!--Person--></NM102-EntityTypeQualifier>
					<NM103-NameLastOrOrganizationName><!--1035-->BROWN</NM103-NameLastOrOrganizationName>
					<NM104-NameFirst><!--1036-->LAVONNE</NM104-NameFirst>
					<NM108-IdentificationCodeQualifier><!--66-->HN<!--Health Insurance Claim (HIC) Number--></NM108-IdentificationCodeQualifier>
					<NM109-IdentificationCode><!--67-->312327124A</NM109-IdentificationCode>
				</NM1>
				<MOA>
					<MOA03-ReferenceIdentification><!--127-->MA130</MOA03-ReferenceIdentification>
					<MOA04-ReferenceIdentification><!--127-->MA13</MOA04-ReferenceIdentification>
				</MOA>
				<DTM>
					<DTM01-DateTimeQualifier><!--374-->050<!--Received--></DTM01-DateTimeQualifier>
					<DTM02-Date><!--373-->20070126<!--2007&#x2D;01&#x2D;26--></DTM02-Date>
				</DTM>
				<GROUP_4>
					<SVC>
						<SVC01-CompositeMedicalProcedureIdentifier>
							<SVC0101-ProductServiceIdQualifier><!--235-->HC<!--Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes--></SVC0101-ProductServiceIdQualifier>
							<SVC0102-ProductServiceId><!--234-->V2300</SVC0102-ProductServiceId>
						</SVC01-CompositeMedicalProcedureIdentifier>
						<SVC02-MonetaryAmount><!--782-->137.00</SVC02-MonetaryAmount>
						<SVC03-MonetaryAmount><!--782-->0</SVC03-MonetaryAmount>
						<SVC05-Quantity><!--380-->0</SVC05-Quantity>
						<SVC07-Quantity><!--380-->2</SVC07-Quantity>
					</SVC>
					<DTM>
						<DTM01-DateTimeQualifier><!--374-->472<!--Service--></DTM01-DateTimeQualifier>
						<DTM02-Date><!--373-->20070109<!--2007&#x2D;01&#x2D;09--></DTM02-Date>
					</DTM>
					<CAS>
						<CAS01-ClaimAdjustmentGroupCode><!--1033-->CO<!--Contractual Obligations--></CAS01-ClaimAdjustmentGroupCode>
						<CAS02-ClaimAdjustmentReasonCode><!--1034-->16</CAS02-ClaimAdjustmentReasonCode>
						<CAS03-MonetaryAmount><!--782-->137.00</CAS03-MonetaryAmount>
					</CAS>
					<REF>
						<REF01-ReferenceIdentificationQualifier><!--128-->LU<!--Location Number--></REF01-ReferenceIdentificationQualifier>
						<REF02-ReferenceIdentification><!--127-->12</REF02-ReferenceIdentification>
					</REF>
				</GROUP_4>
			</GROUP_3>
		</GROUP_2>
		<SE>
			<SE01-NumberOfIncludedSegments><!--96-->25</SE01-NumberOfIncludedSegments>
			<SE02-TransactionSetControlNumber><!--329-->000000001</SE02-TransactionSetControlNumber>
		</SE>
	</TS_835>
	<GE>
		<GE01-NumberOfTransactionSets><!--97-->1</GE01-NumberOfTransactionSets>
		<GE02-GroupControlNumber><!--28-->1</GE02-GroupControlNumber>
	</GE>
	<IEA>
		<IEA01-NumberOfIncludedFunctional><!--I16-->1</IEA01-NumberOfIncludedFunctional>
		<IEA02-InterchangeControlNumber><!--I12-->000862650</IEA02-InterchangeControlNumber>
	</IEA>
</X12>
