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
HI
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
004010X094A1

ST- Transaction Set Header
01 143 Transaction Set Identifier Code R
278
02 329 Transaction Set Control Number R

BHT- Beginning of Hierarchical Transaction
01 1005 Hierarchical Structure Code R
0078
02 353 Transaction Set Purpose Code R
11
03 127 Submitter Transaction Identifier R
04 373 Transaction Set Creation Date R
05 337 Transaction Set Creation Time R
06 640 Transaction Type Code S
18 19 AT

HL- Utilization Management Organization (UMO) 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

AAA- Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code R
04 41 42 79
04 889 Follow-up Action Code R
C N P Y

NM1- Utilization Management Organization (UMO) Name
01 98 Entity Identifier Code R
X3
02 1065 Entity Type Qualifier R
1 2
03 1035 Utilization Management Organization (UMO) Last or Organization Name S
04 1036 Utilization Management Organization (UMO) First Name S
05 1037 Utilization Management Organization (UMO) Middle Name S
06 1038 Name Prefix N
07 1039 Utilization Management Organization (UMO) Name Suffix S
08 66 Identification Code Qualifier R
24 34 46 PI XV XX
09 67 Utilization Management Organization (UMO) Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

AAA- Utilization Management Organization (UMO) Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code S
04 41 42 79 80 T4
04 889 Follow-up Action Code S
N P Y

HL- Requester 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- Requester Name
01 98 Entity Identifier Code R
1P FA
02 1065 Entity Type Qualifier R
1 2
03 1035 Requester Last or Organization Name S
04 1036 Requester First Name S
05 1037 Requester Middle Name S
06 1038 Name Prefix N
07 1039 Requester Name Suffix S
08 66 Identification Code Qualifier R
24 34 46 XX
09 67 Requester Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

REF- Requester Supplemental Identification
01 128 Reference Identification Qualifier R
1G 1J CT EI N5 N7 SY ZH
02 127 Requester Supplemental Identifier R
03 352 Description N
N C040 Reference Identifier

AAA- Requester Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code S
35 41 43 44 45 46 47 49 50 51 79 97
04 889 Follow-up Action Code S
C N R

PRV- Requester Provider Information
01 1221 Provider Code R
AD AS AT CO CV OP OR OT PC PE RF
02 128 Reference Identification Qualifier R
ZZ
03 127 Provider Taxonomy 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
1

TRN- Patient Event Tracking Number
01 481 Trace Type Code R
1 2
02 127 Patient Event Tracking Number R
03 509 Trace Assigning Entity Number R
04 127 Trace Assigning Entity Additional Identifier S

AAA- Subscriber Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code S
15 33 56
04 889 Follow-up Action Code S
C N

DTP- Accident Date
01 374 Date Time Qualifier R
439
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Accident Date R

DTP- Last Menstrual Period Date
01 374 Date Time Qualifier R
484
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Last Menstrual Period Date R

DTP- Estimated Date of Birth
01 374 Date Time Qualifier R
ABC
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Estimated Birth Date R

DTP- Onset of Current Symptoms or Illness Date
01 374 Date Time Qualifier R
431
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Onset of Current Symptoms or Illness Date R

HI- Subscriber Diagnosis
R C022 Diagnosis 1
01 1270 Diagnosis Type Code R
BF BJ BK LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 2
01 1270 Diagnosis Type Code R
BF BJ LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 3
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 4
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 5
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 6
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 7
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 8
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 9
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 10
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 11
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 12
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N

PWK- Additional Patient Information
01 755 Attachment Report Type Code R
03 04 05 06 07 08 09 10 11 13 15 21 48 55 59 77 A3 A4 AM AS AT B2 B3 BR BS BT CB CK D2 DA DB DG DJ DS FM HC HR I5 IR LA M1 NN OB OC OD OE OX P4 P5 P6 P7 PE PN PO PQ PY PZ QC QR RB RR RT RX SG V5 XP
02 756 Attachment Transmission Code R
BM EL EM FX VO
03 757 Report Copies Needed N
04 98 Entity Identifier Code N
05 66 Identification Code Qualifier S
AC
06 67 Attachment Control Number S
07 352 Attachment Description S
N C002 Actions Indicated
09 1525 Request Category Code N

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 R
MI ZZ
09 67 Subscriber Primary Identifier R
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

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

AAA- Subscriber Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code S
15 58 64 65 66 67 68 71 72 73 74 75 76 77 78 79 95
04 889 Follow-up Action Code S
C N

DMG- Subscriber Demographic Information
01 1250 Date Time Period Format Qualifier R
D8
02 1251 Subscriber Birth Date R
03 1068 Subscriber Gender Code S
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- Additional Patient Information Contact Name
01 98 Entity Identifier Code R
1P 2B ABG FA PR X3
02 1065 Entity Type Qualifier R
1 2
03 1035 Response Contact Last or Organization Name S
04 1036 Response Contact First Name S
05 1037 Response Contact Middle Name S
06 1038 Name Prefix N
07 1039 Response Contact Name Suffix S
08 66 Identification Code Qualifier S
24 34 46 PI XV XX
09 67 Response Contact Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Additional Patient Information Contact Address
01 166 Response Contact Address Line R
02 166 Response Contact Address Line S

N4- Additional Patient Information Contact City/State/Zip Code
01 19 Response Contact City Name S
02 156 Response Contact State or Province Code S
External Source: states
03 116 Response Contact Postal Zone or ZIP Code S
04 26 Response Contact Country Code S
External Source: country
05 309 Location Qualifier S
B1 DP
06 310 Response Contact Specific Location S

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

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
1

TRN- Patient Event Tracking Number
01 481 Trace Type Code R
1 2
02 127 Patient Event Tracking Number R
03 509 Trace Assigning Entity Number R
04 127 Trace Assigning Entity Additional Identifier S

AAA- Dependent Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code S
15 33 56
04 889 Follow-up Action Code S
C N

DTP- Accident Date
01 374 Date Time Qualifier R
439
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Accident Date R

DTP- Last Menstrual Period Date
01 374 Date Time Qualifier R
484
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Last Menstrual Period Date R

DTP- Estimated Date of Birth
01 374 Date Time Qualifier R
ABC
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Estimated Birth Date R

DTP- Onset of Current Symptoms or Illness Date
01 374 Date Time Qualifier R
431
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Onset of Current Symptoms or Illness Date R

HI- Dependent Diagnosis
R C022 Diagnosis 1
01 1270 Diagnosis Type Code R
BF BJ BK LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 2
01 1270 Diagnosis Type Code R
BF BJ LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 3
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 4
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 5
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 6
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 7
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 8
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 9
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 10
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 11
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N
S C022 Diagnosis 12
01 1270 Diagnosis Type Code R
BF LOI
02 1271 Diagnosis Code R
03 1250 Date Time Period Format Qualifier S
D8
04 1251 Diagnosis Date S
05 782 Monetary Amount N
06 380 Quantity N
07 799 Version Identifier N

PWK- Additional Patient Information
01 755 Attachment Report Type Code R
03 04 05 06 07 08 09 10 11 13 15 21 48 55 59 77 A3 A4 AM AS AT B2 B3 BR BS BT CB CK D2 DA DB DG DJ DS FM HC HR I5 IR LA M1 NN OB OC OD OE OX P4 P5 P6 P7 PE PN PO PQ PY PZ QC QR RB RR RT RX SG V5 XP
02 756 Attachment Transmission Code R
BM EL EM FX VO
03 757 Report Copies Needed N
04 98 Entity Identifier Code N
05 66 Identification Code Qualifier S
AC
06 67 Attachment Control Number S
07 352 Attachment Description S
N C002 Actions Indicated
09 1525 Request Category Code N

NM1- Dependent Name
01 98 Entity Identifier Code R
QC
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 S
MI ZZ
09 67 Dependent Primary Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

REF- Dependent Supplemental Identification
01 128 Reference Identification Qualifier R
A6 EJ SY
02 127 Dependent Supplemental Identifier R
03 352 Description N
N C040 Reference Identifier

AAA- Dependent Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code S
15 33 58 64 65 66 67 68 71 77 95
04 889 Follow-up Action Code S
C N

DMG- Dependent Demographic Information
01 1250 Date Time Period Format Qualifier R
D8
02 1251 Dependent Birth Date R
03 1068 Dependent Gender Code S
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

INS- Dependent Relationship
01 1073 Insured Indicator R
N
02 1069 Relationship to Insured R
01 04 05 07 09 10 15 17 19 20 21 22 23 24 29 32 33 34 39 40 41 43 53 G8
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 Event Code 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

NM1- Additional Patient Information Contact Name
01 98 Entity Identifier Code R
1P 2B ABG FA PR X3
02 1065 Entity Type Qualifier R
1 2
03 1035 Response Contact Last or Organization Name S
04 1036 Response Contact First Name S
05 1037 Response Contact Middle Name S
06 1038 Name Prefix N
07 1039 Response Contact Name Suffix S
08 66 Identification Code Qualifier S
24 34 46 PI XV XX
09 67 Response Contact Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Additional Patient Information Contact Address
01 166 Response Contact Address Line R
02 166 Response Contact Address Line S

N4- Additional Patient Information Contact City/State/Zip Code
01 19 Response Contact City Name S
02 156 Response Contact State or Province Code S
External Source: states
03 116 Response Contact Postal Zone or ZIP Code S
04 26 Response Contact Country Code S
External Source: country
05 309 Location Qualifier S
B1 DP
06 310 Response Contact Specific Location S

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

MSG- Message Text
01 933 Free Form Message Text R
02 934 Printer Carriage Control Code N
03 1470 Number N

NM1- Service Provider Name
01 98 Entity Identifier Code R
1T FA SJ
02 1065 Entity Type Qualifier R
1 2
03 1035 Service Provider Last or Organization Name S
04 1036 Service Provider First Name S
05 1037 Service Provider Middle Name S
06 1038 Name Prefix N
07 1039 Service Provider Name Suffix S
08 66 Identification Code Qualifier S
24 34 46 XX
09 67 Service Provider Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

REF- Service Provider Supplemental Identification
01 128 Reference Identification Qualifier R
1G 1J EI N5 N7 SY ZH
02 127 Service Provider Supplemental Identifier R
03 352 Description N
N C040 Reference Identifier

N3- Service Provider Address
01 166 Service Provider Address Line R
02 166 Service Provider Address Line S

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

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

AAA- Service Provider Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code S
15 33 35 41 43 44 45 46 47 49 51 52 79 97
04 889 Follow-up Action Code S
C N

PRV- Service Provider Information
01 1221 Provider Code R
AD AS AT CO CV OP OR OT PC PE
02 128 Reference Identification Qualifier R
ZZ
03 127 Provider Taxonomy Code R
04 156 State or Province Code N
N C035 Provider Specialty Information
06 1223 Provider Organization Code N

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

TRN- Service Trace Number
01 481 Trace Type Code R
1 2
02 127 Service Trace Number R
03 509 Trace Assigning Entity Identifier R
04 127 Trace Assigning Entity Additional Identifier S

AAA- Service Request Validation
01 1073 Valid Request Indicator R
N Y
02 559 Agency Qualifier Code N
03 901 Reject Reason Code S
15 33 52 57 60 61 62 T5
04 889 Follow-up Action Code S
C N

UM- Health Care Services Review Information
01 1525 Request Category Code R
AR HS SC
02 1322 Certification Type Code R
1 2 3 4 I R S
03 1365 Service Type Code S
1 2 3 4 5 6 7 8 12 14 15 16 17 18 20 21 23 24 25 26 27 28 33 34 35 36 37 38 39 40 42 44 45 46 48 50 51 52 53 54 56 57 58 59 61 62 63 64 65 67 68 69 70 71 72 73 74 75 76 77 78 79 80 82 83 84 85 86 93 94 95 98 99 A0 A1 A2 A3 A4 A6 A7 A8 A9 AB AC AD AE AF AG AI AJ AK AL AR BB BC BD BE BF BG BS
S C023 Health Care Service Location Information
01 1331 Facility Type Code R
02 1332 Facility Code Qualifier R
A B
03 1325 Claim Frequency Type Code N
N C024 Related Causes Information
06 1338 Level of Service Code S
03 U
07 1213 Current Health Condition Code N
08 923 Prognosis Code N
09 1363 Release of Information Code N
10 1514 Delay Reason Code N

HCR- Health Care Services Review
01 306 Certification Action Code R
A1 A3 A4 A6 CT NA
02 127 Certification Number S
03 901 Reject Reason Code S
35 36 37 41 53 69 70 82 83 84 85 86 87 88 89 90 91 92 96 98 E8
04 1073 Second Surgical Opinion Indicator S
N Y

REF- Previous Certification Identification
01 128 Reference Identification Qualifier R
BB
02 127 Previous Certification Identifier R
03 352 Description N
N C040 Reference Identifier

DTP- Service Date
01 374 Date Time Qualifier R
472
02 1250 Date Time Period Format Qualifier R
D8 RD8
03 1251 Proposed or Actual Service Date R

DTP- Admission Date
01 374 Date Time Qualifier R
435
02 1250 Date Time Period Format Qualifier R
D8 RD8
03 1251 Proposed or Actual Admission Date R

DTP- Discharge Date
01 374 Date Time Qualifier R
096
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Proposed or Actual Discharge Date R

DTP- Surgery Date
01 374 Date Time Qualifier R
456
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Proposed or Actual Surgery Date R

DTP- Certification Issue Date
01 374 Date Time Qualifier R
102
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Certification Issue Date R

DTP- Certification Expiration Date
01 374 Date Time Qualifier R
036
02 1250 Date Time Period Format Qualifier R
D8
03 1251 Certification Expiration Date R

DTP- Certification Effective Date
01 374 Date Time Qualifier R
007
02 1250 Date Time Period Format Qualifier R
D8 RD8
03 1251 Certification Effective Date R

HI- Procedures
R C022 Procedure Code 1
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 2
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 3
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 4
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 5
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 6
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 7
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 8
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 9
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 10
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 11
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S
S C022 Procedure Code 12
01 1270 Code List Qualifier Code R
ABR BO BQ JP LOI NDC ZZ
02 1271 Procedure Code R
03 1250 Date Time Period Format Qualifier S
D8 RD8
04 1251 Procedure Date S
05 782 Procedure Monetary Amount S
06 380 Procedure Quantity S
07 799 Version, Release, or Industry Identifier S

HSD- Health Care Services Delivery
01 673 Quantity Qualifier S
DY FL HS MN VS
02 380 Service Unit Count S
03 355 Unit or Basis for Measurement Code S
DA MO WK
04 1167 Sample Selection Modulus S
05 615 Time Period Qualifier S
6 7 21 26 27 34 35
06 616 Period Count S
07 678 Ship, Delivery or Calendar Pattern Code S
1 2 3 4 5 6 7 8 9 A B C D E F G H J K L M N O P Q R S SA SB SC SD SG SL SP SX SY SZ T U V W X Y
08 679 Delivery Pattern Time Code S
A B C D E F G Y

CL1- Institutional Claim Code
01 1315 Admission Type Code S
02 1314 Admission Source Code S
03 1352 Patient Status Code S
04 1345 Nursing Home Residential Status Code S
1 2 3 4 5 6 7 8 9

CR1- Ambulance Transport Information
01 355 Unit or Basis for Measurement Code N
02 81 Weight N
03 1316 Ambulance Transport Code R
I R T X
04 1317 Ambulance Transport Reason Code N
05 355 Unit or Basis for Measurement Code S
DH DK
06 380 Transport Distance S
07 166 Ambulance Trip Origin Address S
08 166 Ambulance Trip Destination Address S
09 352 Description N
10 352 Description N

CR2- Spinal Manipulation Service Information
01 609 Treatment Series Number S
02 380 Treatment Count S
03 1367 Subluxation Level Code S
C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T10 T11 T12 T2 T3 T4 T5 T6 T7 T8 T9
04 1367 Subluxation Level Code S
C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T10 T11 T12 T2 T3 T4 T5 T6 T7 T8 T9
05 355 Unit or Basis for Measurement Code S
DA MO WK YR
06 380 Treatment Period Count S
07 380 Monthly Treatment Count S
08 1342 Nature of Condition Code N
09 1073 Yes/No Condition or Response Code N
10 352 Description N
11 352 Description N
12 1073 Yes/No Condition or Response Code N

CR5- Home Oxygen Therapy Information
01 1322 Certification Type Code N
02 380 Quantity N
03 1348 Oxygen Equipment Type Code S
A B C D E O
04 1348 Oxygen Equipment Type Code S
A B C D E O
05 352 Equipment Reason Description S
06 380 Oxygen Flow Rate R
07 380 Daily Oxygen Use Count S
08 380 Oxygen Use Period Hour Count S
09 352 Respiratory Therapist Order Text S
10 380 Quantity N
11 380 Quantity N
12 1349 Oxygen Test Condition Code N
13 1350 Oxygen Test Findings Code N
14 1350 Oxygen Test Findings Code N
15 1350 Oxygen Test Findings Code N
16 380 Portable Oxygen System Flow Rate S
17 1382 Oxygen Delivery System Code R
A B C D E
18 1348 Oxygen Equipment Type Code S
A B C D E O

CR6- Home Health Care Information
01 923 Prognosis Code R
1 2 3 4 5 6 7 8
02 373 Service From Date R
03 1250 Date Time Period Format Qualifier S
RD8
04 1251 Home Health Certification Period S
05 373 Date N
06 1073 Yes/No Condition or Response Code N
07 1073 Medicare Coverage Indicator R
N U Y
08 1322 Certification Type Code R
1 2 3 4 I R S
09 373 Date N
10 235 Product/Service ID Qualifier N
11 1137 Medical Code Value N
12 373 Date N
13 373 Date N
14 373 Date N
15 1250 Date Time Period Format Qualifier N
16 1251 Date Time Period N
17 1384 Patient Location Code N
18 373 Date N
19 373 Date N
20 373 Date N
21 373 Date N

PWK- Additional Service Information
01 755 Attachment Report Type Code R
03 04 05 06 07 08 09 10 11 13 15 21 48 55 59 77 A3 A4 AM AS AT B2 B3 BR BS BT CB CK D2 DA DB DG DJ DS FM HC HR I5 IR LA M1 NN OB OC OD OE OX P4 P5 P6 P7 PE PN PO PQ PY PZ QC QR RB RR RT RX SG V5 XP
02 756 Attachment Transmission Code R
BM EL EM FX VO
03 757 Report Copies Needed N
04 98 Entity Identifier Code N
05 66 Identification Code Qualifier S
AC
06 67 Attachment Control Number S
07 352 Attachment Description S
N C002 Actions Indicated
09 1525 Request Category Code N

MSG- Message Text
01 933 Free Form Message Text R
02 934 Printer Carriage Control Code N
03 1470 Number N

NM1- Additional Service Information Contact Name
01 98 Entity Identifier Code R
1P 2B ABG FA PR X3
02 1065 Entity Type Qualifier R
1 2
03 1035 Response Contact Last or Organization Name S
04 1036 Response Contact First Name S
05 1037 Response Contact Middle Name S
06 1038 Name Prefix N
07 1039 Response Contact Name Suffix S
08 66 Identification Code Qualifier S
24 34 46 PI XV XX
09 67 Response Contact Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

N3- Additional Service Information Contact Address
01 166 Response Contact Address Line R
02 166 Response Contact Address Line S

N4- Additional Service Information Contact City/State/Zip Code
01 19 Response Contact City Name S
02 156 Response Contact State or Province Code S
External Source: states
03 116 Response Contact Postal Zone or ZIP Code S
04 26 Response Contact Country Code S
External Source: country
05 309 Location Qualifier S
B1 DP
06 310 Response Contact Specific Location S

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

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