| BPS CLAIM | DATE RESPONSE RECEIVED | RESPONSES | VERSION/RELEASE NUMBER | TRANSACTION CODE | TRANSACTION COUNT | MEDICAID ID NUMBER | MEDICAID AGENCY NUMBER | SERVICE PROVIDER ID | SERV PROVIDER ID QUALIFIER | GROUP ID | CARDHOLDER ID | DATE OF BIRTH | PATIENT FIRST NAME | PATIENT LAST NAME | DATE OF SERVICE | HEADER RESPONSE STATUS | MESSAGE | PLAN ID | NETWORK REIMBURSEMENT ID | PAYER/HEALTH PLAN ID QUALIFIER | PAYER/HEALTH PLAN ID | RAW DATA RECEIVED |
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