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
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
004010X093

ST- Transaction Set Header
01 143 Transaction Set Identifier Code R
277
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
08
03 127 Originator Application Transaction Identifier R
04 373 Transaction Set Creation Date R
05 337 Time N
06 640 Transaction Type Code R
DG

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 P0809 C1110
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
PI NI AD PP FI 21 XV
09 67 Payer Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N
External Source: entity_id

PER- Payer Contact Information P0304 P0506 P0708
01 366 Contact Function Code R
IC
02 93 Payer Contact Name S
03 365 Communication Number Qualifier R
ED EM TE
04 364 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 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 P0809 C1110
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 Information Receiver Name Prefix S
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 P0809 C1110
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 P0102
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 P0809 C1110
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
2
02 127 Trace Number R
03 509 Originating Company Identifier N
04 127 Reference Identification N

STC- Claim Level Status Information
R STC01 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
02 373 Status Information Effective Date R
03 306 Action Code N
04 782 Total Claim Charge Amount R
05 782 Claim Payment Amount R
06 373 Adjudication or Payment Date S
07 591 Payment Method Code S
ACH BOP CHK FWT NON
08 373 Check Issue or EFT Effective Date S
09 429 Check or EFT Trace Number S
S STC10 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
S STC11 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
12 933 Free-Form Message Text N

REF- Payer Claim Identification Number R0203
01 128 Reference Identification Qualifier R
1K
02 127 Payer Claim Control Number R
03 352 Description N
N REF04 C040 Reference Identifier

REF- Institutional Bill Type Identification R0203
01 128 Reference Identification Qualifier R
BLT
02 127 Bill Type Identifier R
03 352 Description N
N REF04 C040 Reference Identifier

REF- Medical Record Identification R0203
01 128 Reference Identification Qualifier R
EA
02 127 Medical Record Number R
03 352 Description N
N REF04 C040 Reference Identifier

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

SVC- Service Line Information
R SVC01 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 Line Item Provider Payment Amount R
04 234 Revenue Code S
05 380 Quantity N
N SVC06 C003 Composite Medical Procedure Identifier
07 380 Original Units of Service Count S

STC- Service Line Status Information
R STC01 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
02 373 Status Information Effective Date R
03 306 Action Code N
04 782 Line Item Charge Amount S
05 782 Line Item Provider Payment Amount S
06 373 Date N
07 591 Payment Method Code N
08 373 Date N
09 429 Check Number N
S STC10 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
S STC11 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
12 933 Free-Form Message Text N

REF- Service Line Item Identification R0203
01 128 Reference Identification Qualifier R
FJ
02 127 Line Item Control Number R
03 352 Description N
N REF04 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 P0102
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 P0809 C1110
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
2
02 127 Trace Number R
03 509 Originating Company Identifier N
04 127 Reference Identification N

STC- Claim Level Status Information
R STC01 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
02 373 Status Information Effective Date R
03 306 Action Code N
04 782 Total Claim Charge Amount R
05 782 Claim Payment Amount R
06 373 Adjudication or Payment Date S
07 591 Payment Method Code S
ACH BOP CHK FWT NON
08 373 Check Issue or EFT Effective Date S
09 429 Check or EFT Trace Number S
S STC10 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
S STC11 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
12 933 Free-Form Message Text N

REF- Payer Claim Identification Number R0203
01 128 Reference Identification Qualifier R
1K
02 127 Payer Claim Control Number R
03 352 Description N
N REF04 C040 Reference Identifier

REF- Institutional Bill Type Identification R0203
01 128 Reference Identification Qualifier R
BLT
02 127 Bill Type Identifier R
03 352 Description N
N REF04 C040 Reference Identifier

REF- Medical Record Identification R0203
01 128 Reference Identification Qualifier R
EA
02 127 Medical Record Number R
03 352 Description N
N REF04 C040 Reference Identifier

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 SVC01 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 Line Item Provider Payment Amount R
04 234 Revenue Code S
05 380 Quantity N
N SVC06 C003 Composite Medical Procedure Identifier
07 380 Original Units of Service Count S

STC- Service Line Status Information
R STC01 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
02 373 Status Information Effective Date R
03 306 Action Code N
04 782 Line Item Charge Amount S
05 782 Line Item Provider Payment Amount S
06 373 Date N
07 591 Payment Method Code N
08 373 Date N
09 429 Check Number N
S STC10 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
S STC11 C043 Health Care Claim Status
01 1271 Health Care Claim Status Category Code R
External Source: claim_status_cat
02 1271 Health Care Claim Status Code R
External Source: claim_status
03 98 Entity Identifier Code S
External Source: entity_id
12 933 Free-Form Message Text N

REF- Service Line Item Identification R0203
01 128 Reference Identification Qualifier R
FJ
02 127 Line Item Control Number R
03 352 Description N
N REF04 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