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
	HN HR
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
	004010X093A1

ST- Transaction Set Header

01	143	Transaction Set Identifier Code	R
	276
02	329	Transaction Set Control Number	R

BHT- Beginning of Hierarchical Transaction

01	1005	Hierarchical Structure Code	R
	0010
02	353	Transaction Set Purpose Code	R
	13
03	127	Reference Identification	N
04	373	Transaction Set Creation Date	R

05	337	Time	N
06	640	Transaction Type Code	N

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- Payer Name

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Payer Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	21 AD FI NI PI PP XV
09	67	Payer Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Payer Contact Information

01	366	Contact Function Code	R
	IC
02	93	Payer Contact Name	S
03	365	Communication Number Qualifier	R
	ED EM TE
04	364	Payer Contact Communication Number	R
05	365	Communication Number Qualifier	S
	EX
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	EX FX
08	364	Payer Contact Communication Number	S
09	443	Contact Inquiry Reference	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
	41
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Information Receiver Last or Organization Name	R
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
	46 FI XX
09	67	Information Receiver Identification Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

HL- Service Provider Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	19
04	736	Hierarchical Child Code	R
	1

NM1- Provider Name

01	98	Entity Identifier Code	R
	1P
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Provider Last or Organization Name	R
04	1036	Provider First Name	S
05	1037	Provider Middle Name	S
06	1038	Provider Name Prefix	S
07	1039	Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	FI SV XX
09	67	Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier 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

DMG- Subscriber Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Subscriber Birth Date	R
03	1068	Subscriber Gender Code	R
	F M U
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

NM1- Subscriber Name

01	98	Entity Identifier Code	R
	IL QC
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Subscriber Last Name	R
04	1036	Subscriber First Name	S
05	1037	Subscriber Middle Name	S
06	1038	Subscriber Name Prefix	S
07	1039	Subscriber Name Suffix	S
08	66	Identification Code Qualifier	R
	24 MI ZZ
09	67	Subscriber Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

TRN- Claim Submitter Trace Number

01	481	Trace Type Code	R
	1
02	127	Trace Number	R
03	509	Originating Company Identifier	N
04	127	Reference Identification	N

REF- Payer Claim Identification Number

01	128	Reference Identification Qualifier	R
	1K
02	127	Payer Claim Control Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Institutional Bill Type Identification

01	128	Reference Identification Qualifier	R
	BLT
02	127	Bill Type Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Medical Record Identification

01	128	Reference Identification Qualifier	R
	EA
02	127	Medical Record Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Group Number

01	128	Reference Identification Qualifier	R
	LU
02	127	Group Number	R
03	352	Description	N
N		C040	Reference Identifier

AMT- Claim Submitted Charges

01	522	Amount Qualifier Code	R
	T3
02	782	Total Claim Charge Amount	R
03	478	Credit/Debit Flag Code	N

DTP- Claim Service Date

01	374	Date Time Qualifier	R
	232
02	1250	Date Time Period Format Qualifier	R
	RD8
03	1251	Claim Service Period	R

SVC- Service Line Information

R		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD CI HC ID IV N1 N2 N3 N4 ND NH NU RB
02	234	Service Identification 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
02	782	Line Item Charge Amount	R
03	782	Monetary Amount	N
04	234	Revenue Code	S
05	380	Quantity	N
N		C003	Composite Medical Procedure Identifier
07	380	Original Units of Service Count	S

REF- Service Line Item Identification

01	128	Reference Identification Qualifier	R
	FJ
02	127	Line Item Control Number	R
03	352	Description	N
N		C040	Reference Identifier

DTP- Service Line Date

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	RD8
03	1251	Service Line Date	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	N

DMG- Dependent Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Patient Birth Date	R
03	1068	Patient Gender Code	R
	F M U
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

NM1- Dependent Name

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

TRN- Claim Submitter Trace Number

01	481	Trace Type Code	R
	1
02	127	Trace Number	R
03	509	Originating Company Identifier	N
04	127	Reference Identification	N

REF- Payer Claim Identification Number

01	128	Reference Identification Qualifier	R
	1K
02	127	Payer Claim Control Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Institutional Bill Type Identification

01	128	Reference Identification Qualifier	R
	BLT
02	127	Bill Type Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Medical Record Identification

01	128	Reference Identification Qualifier	R
	EA
02	127	Medical Record Number	R
03	352	Description	N
N		C040	Reference Identifier

AMT- Claim Submitted Charges

01	522	Amount Qualifier Code	R
	T3
02	782	Total Claim Charge Amount	R
03	478	Credit/Debit Flag Code	N

DTP- Claim Service Date

01	374	Date Time Qualifier	R
	232
02	1250	Date Time Period Format Qualifier	R
	RD8
03	1251	Claim Service Period	R

SVC- Service Line Information

R		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD CI HC ID IV N1 N2 N3 N4 ND NH NU RB
02	234	Service Identification 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
02	782	Line Item Charge Amount	R
03	782	Monetary Amount	N
04	234	Revenue Code	S
05	380	Quantity	N
N		C003	Composite Medical Procedure Identifier
07	380	Original Units of Service Count	S

REF- Service Line Item Identification

01	128	Reference Identification Qualifier	R
	FJ
02	127	Line Item Control Number	R
03	352	Description	N
N		C040	Reference Identifier

DTP- Service Line Date

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	RD8
03	1251	Service Date	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