| Entire Segment |
| ST*835*000000001 |
| BPR*I*12433.47*C*ACH*CCP*01*041203824*DA*9653481425*1203174593**01*111000614* |
| TRN*1*0927974940*1203174593 |
| REF*EV*999999999999999 |
| DTM*405*20251014 |
| N1*PR*AMBETTER |
| N3*7700 FORSYTH |
| N4*ST LOUIS*MO*63105 |
| PER*CX*EDI SUPPORT DESK*TE*8002252573 |
| PER*BL*EDI HELPDESK*TE*8002252573 |
| N1*PE*SENIOR CARE PROVIDERS*XX*1841824489 |
| N3*21396 PROVINCIAL BLVD |
| N4*KATY*TX*77450 |
| REF*TJ*843959949 |
| LX*1 |
| CLP*4043215652*1*490*244.26*38.44*MC*Y279MPEY4417**1 |
| NM1*QC*1*AKTER*ATIFA****MI*U9368349702 |
| NM1*IL*1*KADER*MOHAMMAD****MI*U9368349701 |
| NM1*82*1*MANSOUR*MOHAMED****XX*1871809442 |
| REF*EA*000000413589 |
| AMT*AU*282.7 |
| SVC*HC:99214:25*160*128.96 |
| DTM*472*20251003 |
| CAS*CO*45*31.04 |
| REF*6R*995730944L1365980181 |
| AMT*B6*128.96 |
| SVC*HC:93923*250*95.14 |
| DTM*472*20251003 |
| CAS*CO*45*123.14 |
| CAS*PR*2*31.72*1 |
| REF*6R*995730944L1365980182 |
| AMT*B6*126.86 |
| SVC*HC:94010*80*20.16 |
| DTM*472*20251003 |
| CAS*CO*45*53.12 |
| CAS*PR*2*6.72*1 |
| REF*6R*995730944L1365980183 |
| AMT*B6*26.88 |
| LX*2 |
| CLP*4043215610*1*130*62.45**MC*Y279MPEY4818**1 |
| NM1*QC*1*AL FARAH*HABIB****MI*U9135075602 |
| NM1*IL*1*SWEIS*AMAL****MI*U9135075601 |
| NM1*82*1*MANSOUR*MOHAMED****XX*1871809442 |
| REF*EA*000000413590 |
| AMT*AU*62.45 |
| SVC*HC:99490*130*62.45 |
| DTM*472*20250731 |
| CAS*CO*45*67.55 |
| REF*6R*995731690L1365981790 |
| AMT*B6*62.45 |
| LX*3 |
| CLP*4044843474*1*160*128.96**MC*Y280MPEM8996**1 |
| NM1*QC*1*AL RSHAIDAT*EMAD****MI*U9529443501 |
| NM1*IL*1*AL RSHAIDAT*EMAD****MI*U9529443501 |
| NM1*82*1*MANSOUR*MOHAMED****XX*1871809442 |
| REF*EA*000000413592 |
| AMT*AU*128.96 |
| SVC*HC:99214*160*128.96 |
| DTM*472*20250930 |
| CAS*CO*45*31.04 |
| REF*6R*995731628L1366385674 |
| AMT*B6*128.96 |
| LX*4 |
| CLP*4043215492*1*200*135.24**MC*Y279MPEY4453**1 |
| NM1*QC*1*BROOKS*LATERRIA****MI*UZ099513601 |
| NM1*IL*1*BROOKS*LATERRIA****MI*UZ099513601 |
| NM1*82*1*AL HADAD*SUDAD K****XX*1558922625 |
| REF*EA*000000413653 |
| AMT*AU*135.24 |
| SVC*HC:99487*200*135.24 |
| DTM*472*20250831 |
| CAS*CO*45*64.76 |
| REF*6R*995731687L1365981787 |
| AMT*B6*135.24 |
| LX*5 |
| CLP*4043215585*1*450*208.94**MC*Y279MPEY4510**1 |
| NM1*QC*1*DUNN*VERLONDA****MI*U9660978801 |
| NM1*IL*1*DUNN*VERLONDA****MI*U9660978801 |
| NM1*82*1*AL HADAD*SUDAD K****XX*1558922625 |
| REF*EA*000000413655 |
| AMT*AU*208.94 |
| SVC*HC:99204:25*200*84.22 |
| DTM*472*20250930 |
| CAS*CO*45*115.78 |
| REF*6R*995731637L1365981710 |
| AMT*B6*84.22 |
| SVC*HC:99396*250*124.72 |
| DTM*472*20250930 |
| CAS*CO*45*125.28 |
| REF*6R*995731637L1365981711 |
| AMT*B6*124.72 |
| LX*6 |
| CLP*4043215558*1*150*42.42*20*MC*Y279MPEY3697**1 |
| NM1*QC*1*FLORES-RIBON*ERIKA****MI*UZ111631101 |
| NM1*IL*1*FLORES-RIBON*ERIKA****MI*UZ111631101 |
| NM1*82*1*AL HADAD*SUDAD K****XX*1558922625 |
| REF*EA*000000413656 |
| AMT*AU*62.42 |
| SVC*HC:99402*150*42.42 |
| DTM*472*20251003 |
| CAS*CO*45*87.58 |
| CAS*PR*3*20*1 |
| REF*6R*995730939L1365980171 |
| AMT*B6*62.42 |
| LX*7 |
| CLP*4043215495*1*160*128.96**MC*Y279MPEY4994**1 |
| NM1*QC*1*ALLEN*ERIC****MI*UZ060687001 |
| NM1*IL*1*ALLEN*ERIC****MI*UZ060687001 |
| NM1*82*1*MANSOUR*MOHAMED****XX*1871809442 |
| REF*EA*000000413594 |
| AMT*AU*128.96 |
| SVC*HC:99214*160*128.96 |
| DTM*472*20251001 |
| CAS*CO*45*31.04 |
| REF*6R*995730981L1365980252 |
| AMT*B6*128.96 |
| LX*8 |
| CLP*4043215534*1*160*128.96**MC*Y279MPEY4351**1 |
| NM1*QC*1*ARELLANO*MARIA****MI*U9614735901 |
| NM1*IL*1*ARELLANO*MARIA****MI*U9614735901 |
| NM1*82*1*MANSOUR*MOHAMED****XX*1871809442 |
| REF*EA*000000413595 |
| AMT*AU*128.96 |
| SVC*HC:99214*160*128.96 |
| DTM*472*20251006 |
| CAS*CO*45*31.04 |
| REF*6R*995730933L1365980164 |
| AMT*B6*128.96 |
| LX*9 |
| CLP*4043215650*1*200*135.24**MC*Y279MPEY4761**1 |
| NM1*QC*1*ILORI-OLADELE*OLABIYI****MI*UZ122324301 |
| NM1*IL*1*ILORI-OLADELE*OLABIYI****MI*UZ122324301 |
| NM1*82*1*AL HADAD*SUDAD K****XX*1558922625 |
| REF*EA*000000413657 |
| AMT*AU*135.24 |
| SVC*HC:99487*200*135.24 |
| DTM*472*20250930 |
| CAS*CO*45*64.76 |
| REF*6R*995731645L1365981726 |
| AMT*B6*135.24 |
| LX*10 |
| CLP*4043215531*1*160*128.96**MC*Y279MPEY5512**1 |
| NM1*QC*1*ILORI-OLADELE*OLABIYI****MI*UZ122324301 |
| NM1*IL*1*ILORI-OLADELE*OLABIYI****MI*UZ122324301 |
| NM1*82*1*AL HADAD*SUDAD K****XX*1558922625 |
| REF*EA*000000413658 |
| AMT*AU*128.96 |
| SVC*HC:99214*160*128.96 |
| DTM*472*20251002 |
| CAS*CO*45*31.04 |
| REF*6R*995730961L1365980211 |
| AMT*B6*128.96 |
| LX*11 |
| CLP*4043215526*1*450*186.53*15*MC*Y279MPEY5110**1 |
| NM1*QC*1*KHANAM*TOHURA****MI*U9241768402 |
| NM1*IL*1*MUZTABA*AHMED****MI*U9241768401 |
| NM1*82*1*AL HADAD*SUDAD K****XX*1558922625 |
| REF*EA*000000413660 |
| AMT*AU*201.53 |
| SVC*HC:99204:25*200*69.22 |
| DTM*472*20250930 |
| CAS*CO*45*115.78 |
| CAS*PR*3*15*1 |
| REF*6R*995731643L1365981723 |
| AMT*B6*84.22 |
| SVC*HC:99395*250*117.31 |
| DTM*472*20250930 |
| CAS*CO*45*132.69 |
| REF*6R*995731643L1365981724 |
| AMT*B6*117.31 |
| LX*12 |
| CLP*4043215631*1*410*181.79**MC*Y279MPEY4962**1 |
| NM1*QC*1*CASTILLO*ANTHONY****MI*UZ141708601 |
| NM1*IL*1*CASTILLO*ANTHONY****MI*UZ141708601 |
| NM1*82*1*MANSOUR*MOHAMED****XX*1871809442 |
| REF*EA*000000413597 |
| AMT*AU*181.79 |
| SVC*HC:99214:25*160*64.48 |
| DTM*472*20251001 |
| CAS*CO*45*95.52 |
| REF*6R*995730980L1365980246 |
| AMT*B6*64.48 |
| SVC*HC:99395*250*117.31 |
| DTM*472*20251001 |
| CAS*CO*45*132.69 |
| REF*6R*995730980L1365980247 |
| AMT*B6*117.31 |
| LX*13 |
| CLP*4043215505*1*160*98.96*30*MC*Y279MPEY4202**1 |
| NM1*QC*1*DANIELS*DONDRE****MI*U9822915301 |
| NM1*IL*1*DANIELS*DONDRE****MI*U9822915301 |
| NM1*82*1*MANSOUR*MOHAMED****XX*1871809442 |
| REF*EA*000000413599 |
| AMT*AU*128.96 |
| SVC*HC:99214*160*98.96 |
| DTM*472*20251003 |
| CAS*CO*45*31.04 |
| CAS*PR*3*30*1 |
| REF*6R*995730942L1365980177 |