001 ISA_LOOP - Interchange Control Header
010 ISA Interchange Control Header R
020 GS_LOOP - Functional Group Header
010 GS Functional Group Header R
020 ST_LOOP - Transaction Set Header
010 ST Transaction Set Header R
015 HEADER - Table 1 - Header
020 BHT Beginning of Hierarchical Transaction R
020 DETAIL - Table 2 - Detail
010 2000A - Information Source Level >1
010 HL Information Source Level R
050 2100A - Payer Name >1
050 NM1 Payer Name R
080 PER Payer Contact Information S
060 2000B - Information Receiver Level >1
010 HL Information Receiver Level R
050 2100B - Information Receiver Name >1
050 NM1 Information Receiver Name R
060 2000C - Service Provider Level >1
010 HL Service Provider Level R
050 2100C - Provider Name >1
050 NM1 Provider Name R
060 2000D - Subscriber Level >1
010 HL Subscriber Level R
040 DMG Subscriber Demographic Information S
050 2100D - Subscriber Name >1
050 NM1 Subscriber Name R
090 2200D - Claim Submitter Trace Number >1
090 TRN Claim Submitter Trace Number R
100 REF Payer Claim Identification Number S
100 REF Institutional Bill Type Identification S
100 REF Medical Record Identification S
110 AMT Claim Submitted Charges S
120 DTP Claim Service Date S
130 2210D - Service Line Information >1
130 SVC Service Line Information S
140 REF Service Line Item Identification S
150 DTP Service Line Date R
100 2000E - Dependent Level >1
010 HL Dependent Level S
040 DMG Dependent Demographic Information R
050 2100E - Dependent Name >1
050 NM1 Dependent Name R
090 2200E - Claim Submitter Trace Number >1
090 TRN Claim Submitter Trace Number R
100 REF Payer Claim Identification Number S
100 REF Institutional Bill Type Identification S
100 REF Medical Record Identification S
110 AMT Claim Submitted Charges S
120 DTP Claim Service Date S
130 2210E - Service Line Information >1
130 SVC Service Line Information S
140 REF Service Line Item Identification S
150 DTP Service Line Date S
030 FOOTER - Table 3 - Footer
270 SE Transaction Set Trailer R
030 GE Functional Group Trailer R
020 TA1 Interchange Acknowledgement S
030 IEA Interchange Control Trailer R