Example line of billing data in the billing submission flat file:
12211229212123456789012BUNNYB123456729FTB0002 0206000191200083 04
| Field Name | Columns | Characters | Example |
| Service Month & Year | 1-4 | 4 | 1221 |
| Invoice Date | 5-10 | 6 | 1229 |
| The Number "2" | 11 | 1 | 2 |
| Medicaid Number | 12-23 | 12 | 123456789012 |
| Last Name | 24-28 | 5 | BUNNY |
| First Initial | 29 | 1 | B |
| Company Contract | 30-36 | 7 | 1234567 |
| Service Date (Day) | 37-38 | 2 | 29 |
| Service Code | 39-41 | 3 | FTB |
| Billing Units | 42-45 | 4 | 0002 |
| Special Billing | 46 | 1 | Blank or "S" |
| Blanks or Patient Liability | 47-53 | 7 | |
| Group Size | 54-55 | 2 | 2 |
| County Number | 56-57 | 2 | 06 |
| Billing Rate | 58-64 | 7 | 0001912 |
| Blanks or Competency AddOn | 65-73 | 9 | 00083---- |
| Staff Size | 74-75 | 2 | 04 |