ISA- Interchange Control Header
01 I01 Authorization Information Qualifier R
00 03
02 I02 Authorization Information R
03 I03 Security Information Qualifier R
00 01
04 I04 Security Information R
05 I05 Interchange ID Qualifier R
01 14 20 27 28 29 30 33 ZZ
06 I06 Interchange Sender ID R
07 I05 Interchange ID Qualifier R
01 14 20 27 28 29 30 33 ZZ
08 I07 Interchange Receiver ID R
09 I08 Interchange Date R
10 I09 Interchange Time R
11 I10 Interchange Control Standards Identifier R
U
12 I11 Interchange Control Version Number R
00401
13 I12 Interchange Control Number R
14 I13 Acknowledgment Requested R
0 1
15 I14 Usage Indicator R
P T
16 I15 Component Element Separator R

GS- Functional Group Header
01 479 Functional Identifier Code R
HS
02 142 Application Sender's Code R
03 124 Application Receiver's Code R
04 373 Date R
05 337 Time R
06 28 Group Control Number R
07 455 Responsible Agency Code R
X
08 480 Version / Release / Industry Identifier Code R
004010X092A1

ST- Transaction Set Header
01 143 Transaction Set Identifier Code R
270
02 329 Transaction Set Control Number R

BHT- Beginning of Hierarchical Transaction
01 1005 Hierarchical Structure Code R
0022
02 353 Transaction Set Purpose Code R
01 13 36
03 127 Submitter Transaction Identifier S
04 373 Transaction Set Creation Date R
05 337 Transaction Set Creation Time R
06 640 Transaction Type Code S
RT RU

HL- Information Source Level
01 628 Hierarchical ID Number R
02 734 Hierarchical Parent ID Number N
03 735 Hierarchical Level Code R
20
04 736 Hierarchical Child Code R
1

NM1- Information Source Name
01 98 Entity Identifier Code R
2B 36 GP P5 PR
02 1065 Entity Type Qualifier R
1 2
03 1035 Information Source Last or Organization Name S
04 1036 Information Source First Name S
05 1037 Information Source Middle Name S
06 1038 Name Prefix N
07 1039 Information Source Name Suffix S
08 66 Identification Code Qualifier R
24 46 FI NI PI XV XX
09 67 Information Source Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

HL- Information Receiver Level
01 628 Hierarchical ID Number R
02 734 Hierarchical Parent ID Number R
03 735 Hierarchical Level Code R
21
04 736 Hierarchical Child Code R
1

NM1- Information Receiver Name
01 98 Entity Identifier Code R
1P 2B 36 80 FA GP P5 PR
02 1065 Entity Type Qualifier R
1 2
03 1035 Information Receiver Last or Organization Name S
04 1036 Information Receiver First Name S
05 1037 Information Receiver Middle Name S
06 1038 Name Prefix N
07 1039 Information Receiver Name Suffix S
08 66 Identification Code Qualifier R
24 34 FI PI PP SV XV XX
09 67 Information Receiver Identification Number R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

REF- Information Receiver Additional Identification
01 128 Reference Identification Qualifier R
0B 1C 1D 1J 4A CT EL EO JD N5 N7 Q4 SY TJ HPI
02 127 Information Receiver Additional Identifier R
03 352 License Number State Code S
External Source: states
N C040 Reference Identifier

N3- Information Receiver Address
01 166 Information Receiver Address Line R
02 166 Information Receiver Additional Address Line S

N4- Information Receiver City/State/Zip Code
01 19 Information Receiver City Name R
02 156 Information Receiver State Code R
External Source: states
03 116 Information Receiver Postal Zone or ZIP Code R
04 26 Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

PER- Information Receiver Contact Information
01 366 Contact Function Code R
IC
02 93 Information Receiver Contact Name S
03 365 Communication Number Qualifier S
ED EM FX TE
04 364 Information Receiver Communication Number S
05 365 Communication Number Qualifier S
ED EM EX FX TE
06 364 Information Receiver Communication Number S
07 365 Communication Number Qualifier S
ED EM EX FX TE
08 364 Information Receiver Communication Number S
09 443 Contact Inquiry Reference N

PRV- Information Receiver Provider Information
01 1221 Provider Code R
AD AT BI CO CV H HH LA OT P1 P2 PC PE R RF SB SK SU
02 128 Reference Identification Qualifier R
ZZ
03 127 Receiver Provider Specialty Code R
04 156 State or Province Code N
N C035 Provider Specialty Information
06 1223 Provider Organization Code N

HL- Subscriber Level
01 628 Hierarchical ID Number R
02 734 Hierarchical Parent ID Number R
03 735 Hierarchical Level Code R
22
04 736 Hierarchical Child Code R
0 1

TRN- Subscriber Trace Number
01 481 Trace Type Code R
1
02 127 Trace Number R
03 509 Trace Assigning Entity Identifier R
04 127 Trace Assigning Entity Additional Identifier S

NM1- Subscriber Name
01 98 Entity Identifier Code R
IL
02 1065 Entity Type Qualifier R
1
03 1035 Subscriber Last Name S
04 1036 Subscriber First Name S
05 1037 Subscriber Middle Name S
06 1038 Name Prefix N
07 1039 Subscriber Name Suffix S
08 66 Identification Code Qualifier S
MI ZZ
09 67 Subscriber Primary Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

REF- Subscriber Additional Identification
01 128 Reference Identification Qualifier R
18 1L 1W 49 6P A6 CT EA EJ F6 GH HJ IG N6 NQ SY
02 127 Subscriber Supplemental Identifier R
03 352 Description N
N C040 Reference Identifier

N3- Subscriber Address
01 166 Subscriber Address Line 1 R
02 166 Subscriber Address Line 2 S

N4- Subscriber City/State/ZIP Code
01 19 Subscriber City Name S
02 156 Subscriber State Code S
External Source: states
03 116 Subscriber Postal Zone or ZIP Code S
04 26 Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

PRV- Provider Information
01 1221 Provider Code R
AD AT BI CO CV H HH LA OT P1 P2 PC PE R RF SB SK SU
02 128 Reference Identification Qualifier R
9K D3 EI HPI SY TJ ZZ
03 127 Provider Identifier R
04 156 State or Province Code N
N C035 Provider Specialty Information
06 1223 Provider Organization Code N

DMG- Subscriber Demographic Information
01 1250 Date Time Period Format Qualifier S
D8
02 1251 Subscriber Birth Date S
03 1068 Subscriber Gender Code S
F M
04 1067 Marital Status Code N
05 1109 Race or Ethnicity Code N
06 1066 Citizenship Status Code N
07 26 Country Code N
08 659 Basis of Verification Code N
09 380 Quantity N

INS- Subscriber Relationship
01 1073 Insured Indicator R
Y
02 1069 Individual Relationship Code R
18
03 875 Maintenance Type Code N
04 1203 Maintenance Reason Code N
05 1216 Benefit Status Code N
06 1218 Medicare Plan Code N
07 1219 Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying N
08 584 Employment Status Code N
09 1220 Student Status Code N
10 1073 Yes/No Condition or Response Code N
11 1250 Date Time Period Format Qualifier N
12 1251 Date Time Period N
13 1165 Confidentiality Code N
14 19 City Name N
15 156 State or Province Code N
16 26 Country Code N
17 1470 Birth Sequence Number R

DTP- Subscriber Date
01 374 Date Time Qualifier R
102 307 435 472
02 1250 Date Time Period Format Qualifier R
D8 RD8
03 1251 Date Time Period R

EQ- Subscriber Eligibility or Benefit Inquiry Information
01 1365 Service Type Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 30 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 A0 A1 A2 A3 A4 A5 A6 A7 A8 A9 AA AB AC AD AE AF AG AH AI AJ AK AL AM AN AO AQ AR BA BB BC BD BE BF BG BH BI BJ BK BL BM BN BP BQ BR BS
S C003 Composite Medical Procedure Identifier
01 235 Product or Service ID Qualifier R
AD CJ HC ID IV N4 ZZ
02 234 Procedure Code R
03 1339 Procedure Modifier S
04 1339 Procedure Modifier S
05 1339 Procedure Modifier S
06 1339 Procedure Modifier S
07 352 Description N
03 1207 Benefit Coverage Level Code S
CHD DEP ECH EMP ESP FAM IND SPC SPO
04 1336 Insurance Type Code S
AP C1 CO GP HM HN IP MA MB MC PR PS SP WC

AMT- Subscriber Spend Down Amount
01 522 Amount Qualifier Code R
R
02 782 Spend Down Amount R
03 478 Credit/Debit Flag Code N

III- Subscriber Eligibility or Benefit Additional Inquiry Information
01 1270 Code List Qualifier Code R
BF BK ZZ
02 1271 Industry Code R
03 04 05 06 07 08 11 12 15 20 21 22 23 24 25 26 31 32 33 34 41 42 50 51 52 53 54 55 56 60 61 62 65 71 72 81 99
03 1136 Code Category N
04 933 Free-Form Message Text N
05 380 Quantity N
N C001 Composite Unit of Measure
07 752 Surface/Layer/Position Code N
08 752 Surface/Layer/Position Code N
09 752 Surface/Layer/Position Code N

REF- Subscriber Additional Information
01 128 Reference Identification Qualifier R
9F G1
02 127 Prior Authorization or Referral Number R
03 352 Description N
N C040 Reference Identifier

DTP- Subscriber Eligibility/Benefit Date
01 374 Date Time Qualifier R
307 435 472
02 1250 Date Time Period Format Qualifier R
D8 RD8
03 1251 Date Time Period R

HL- Dependent Level
01 628 Hierarchical ID Number R
02 734 Hierarchical Parent ID Number R
03 735 Hierarchical Level Code R
23
04 736 Hierarchical Child Code R
0

TRN- Dependent Trace Number
01 481 Trace Type Code R
1
02 127 Trace Number R
03 509 Trace Assigning Entity Identifier R
04 127 Trace Assigning Entity Additional Identifier S

NM1- Dependent Name
01 98 Entity Identifier Code R
03
02 1065 Entity Type Qualifier R
1
03 1035 Dependent Last Name S
04 1036 Dependent First Name S
05 1037 Dependent Middle Name S
06 1038 Name Prefix N
07 1039 Dependent Name Suffix S
08 66 Identification Code Qualifier N
09 67 Identification Code N
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

REF- Dependent Additional Identification
01 128 Reference Identification Qualifier R
18 1L 6P A6 CT EA EJ F6 GH HJ IF IG N6 SY
02 127 Dependent Supplemental Identifier R
03 352 Description N
N C040 Reference Identifier

N3- Dependent Address
01 166 Dependent Address Line 1 R
02 166 Dependent Address Line 2 S

N4- Dependent City/State/ZIP Code
01 19 Dependent City Name S
02 156 Dependent State Code S
External Source: states
03 116 Dependent Postal Zone or ZIP Code S
04 26 Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

PRV- Provider Information
01 1221 Provider Code R
AD AT BI CO CV H HH LA OT P1 P2 PC PE R RF SB SK SU
02 128 Reference Identification Qualifier R
9K D3 EI HPI SY TJ ZZ
03 127 Provider Identifier R
04 156 State or Province Code N
N C035 Provider Specialty Information
06 1223 Provider Organization Code N

DMG- Dependent Demographic Information
01 1250 Date Time Period Format Qualifier S
D8
02 1251 Dependent Birth Date S
03 1068 Dependent Gender Code S
F M
04 1067 Marital Status Code N
05 1109 Race or Ethnicity Code N
06 1066 Citizenship Status Code N
07 26 Country Code N
08 659 Basis of Verification Code N
09 380 Quantity N

INS- Dependent Relationship
01 1073 Insured Indicator R
N
02 1069 Individual Relationship Code R
01 19 34
03 875 Maintenance Type Code N
04 1203 Maintenance Reason Code N
05 1216 Benefit Status Code N
06 1218 Medicare Plan Code N
07 1219 Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying N
08 584 Employment Status Code N
09 1220 Student Status Code N
10 1073 Yes/No Condition or Response Code N
11 1250 Date Time Period Format Qualifier N
12 1251 Date Time Period N
13 1165 Confidentiality Code N
14 19 City Name N
15 156 State or Province Code N
16 26 Country Code N
17 1470 Birth Sequence Number S

DTP- Dependent Date
01 374 Date Time Qualifier R
102 307 435 472
02 1250 Date Time Period Format Qualifier R
D8 RD8
03 1251 Date Time Period R

EQ- Dependent Eligibility or Benefit Inquiry Information
01 1365 Service Type Code S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 30 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 A0 A1 A2 A3 A4 A5 A6 A7 A8 A9 AA AB AC AD AE AF AG AH AI AJ AK AL AM AN AO AQ AR BA BB BC BD BE BF BG BH BI BJ BK BL BM BN BP BQ BR BS
S C003 Composite Medical Procedure Identifier
01 235 Product or Service ID Qualifier R
AD CJ HC ID IV N4 ZZ
02 234 Procedure Code R
03 1339 Procedure Modifier S
04 1339 Procedure Modifier S
05 1339 Procedure Modifier S
06 1339 Procedure Modifier S
07 352 Description N
03 1207 Benefit Coverage Level Code S
CHD DEP ECH EMP ESP FAM IND SPC SPO
04 1336 Insurance Type Code S
AP C1 CO GP HM IP MA MB MC PR PS SP WC

III- Dependent Eligibility or Benefit Additional Inquiry Information
01 1270 Code List Qualifier Code R
BF BK ZZ
02 1271 Industry Code R
03 04 05 06 07 08 11 12 15 20 21 22 23 24 25 26 31 32 33 34 41 42 50 51 52 53 54 55 56 60 61 62 65 71 72 81 99
03 1136 Code Category N
04 933 Free-Form Message Text N
05 380 Quantity N
N C001 Composite Unit of Measure
07 752 Surface/Layer/Position Code N
08 752 Surface/Layer/Position Code N
09 752 Surface/Layer/Position Code N

REF- Dependent Additional Information
01 128 Reference Identification Qualifier R
9F G1
02 127 Prior Authorization or Referral Number R
03 352 Description N
N C040 Reference Identifier

DTP- Dependent Eligibility/Benefit Date
01 374 Date Time Qualifier R
307 435 472
02 1250 Date Time Period Format Qualifier R
D8 RD8
03 1251 Date Time Period R

SE- Transaction Set Trailer
01 96 Transaction Segment Count R
02 329 Transaction Set Control Number R

GE- Functional Group Trailer
01 97 Number of Transaction Sets Included R
02 28 Group Control Number R

TA1- Interchange Acknowledgement
01 I12 Interchange Control Number R
02 I08 Interchange Date R
03 I09 Interchange Time R
04 I17 Interchange Acknowledgement Code R
A E R
05 I18 Interchange Note Code R
000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031

IEA- Interchange Control Trailer
01 I16 Number of Included Functional Groups R
02 I12 Interchange Control Number R