001 ISA_LOOP - Interchange Control Header
010 ISA Interchange Control Header R 1
020 GS_LOOP - Functional Group Header
010 GS Functional Group Header R 1
020 ST_LOOP - Transaction Set Header
010 ST Transaction Set Header R 1
015 HEADER - Table 1 - Header
020 BHT Beginning of Hierarchical Transaction R 1
020 DETAIL - Table 2 - Detail
010 2000A - Utilization Management Organization (UMO) Level
010 HL Utilization Management Organization (UMO) Level R 1
030 AAA Request Validation S 9
170 2010A - Utilization Management Organization (UMO) Name
170 NM1 Utilization Management Organization (UMO) Name R 1
220 PER Utilization Management Organization (UMO) Contact Information S 1
230 AAA Utilization Management Organization (UMO) Request Validation S 9
180 2000B - Requester Level
010 HL Requester Level R 1
170 2010B - Requester Name
170 NM1 Requester Name R 1
180 REF Requester Supplemental Identification S 8
230 AAA Requester Request Validation S 9
240 PRV Requester Provider Information S 1
180 2000C - Subscriber Level
010 HL Subscriber Level R 1
020 TRN Patient Event Tracking Number S 3
030 AAA Subscriber Request Validation S 9
070 DTP Accident Date S 1
070 DTP Last Menstrual Period Date S 1
070 DTP Estimated Date of Birth S 1
070 DTP Onset of Current Symptoms or Illness Date S 1
080 HI Subscriber Diagnosis S 1
155 PWK Additional Patient Information S 10
170 2010CA - Subscriber Name
170 NM1 Subscriber Name R 1
180 REF Subscriber Supplemental Identification S 9
230 AAA Subscriber Request Validation S 9
250 DMG Subscriber Demographic Information S 1
170 2010CB - Additional Patient Information Contact Name
170 NM1 Additional Patient Information Contact Name R 1
200 N3 Additional Patient Information Contact Address S 1
210 N4 Additional Patient Information Contact City/State/Zip Code S 1
220 PER Additional Patient Information Contact Information S 3
180 2000D - Dependent Level
010 HL Dependent Level R 1
020 TRN Patient Event Tracking Number S 3
030 AAA Dependent Request Validation S 9
070 DTP Accident Date S 1
070 DTP Last Menstrual Period Date S 1
070 DTP Estimated Date of Birth S 1
070 DTP Onset of Current Symptoms or Illness Date S 1
080 HI Dependent Diagnosis S 1
155 PWK Additional Patient Information S 10
170 2010DA - Dependent Name
170 NM1 Dependent Name R 1
180 REF Dependent Supplemental Identification S 3
230 AAA Dependent Request Validation S 9
250 DMG Dependent Demographic Information S 1
260 INS Dependent Relationship S 1
170 2010DB - Additional Patient Information Contact Name
170 NM1 Additional Patient Information Contact Name R 1
200 N3 Additional Patient Information Contact Address S 1
210 N4 Additional Patient Information Contact City/State/Zip Code S 1
220 PER Additional Patient Information Contact Information S 3
180 2000E - Service Provider Level
010 HL Service Provider Level R 1
160 MSG Message Text S 1
170 2010E - Service Provider Name
170 NM1 Service Provider Name R 1
180 REF Service Provider Supplemental Identification S 7
200 N3 Service Provider Address S 1
210 N4 Service Provider City/State/ZIP Code S 1
220 PER Service Provider Contact Information S 1
230 AAA Service Provider Request Validation S 9
240 PRV Service Provider Information S 1
180 2000F - Service Level
010 HL Service Level R 1
020 TRN Service Trace Number S 3
030 AAA Service Request Validation S 9
040 UM Health Care Services Review Information R 1
050 HCR Health Care Services Review S 1
060 REF Previous Certification Identification S 1
070 DTP Service Date S 1
070 DTP Admission Date S 1
070 DTP Discharge Date S 1
070 DTP Surgery Date S 1
070 DTP Certification Issue Date S 1
070 DTP Certification Expiration Date S 1
070 DTP Certification Effective Date S 1
080 HI Procedures S 1
090 HSD Health Care Services Delivery S 1
110 CL1 Institutional Claim Code S 1
120 CR1 Ambulance Transport Information S 1
130 CR2 Spinal Manipulation Service Information S 1
140 CR5 Home Oxygen Therapy Information S 1
150 CR6 Home Health Care Information S 1
155 PWK Additional Service Information S 10
160 MSG Message Text S 1
170 2010F - Additional Service Information Contact Name
170 NM1 Additional Service Information Contact Name S >1
200 N3 Additional Service Information Contact Address S 1
210 N4 Additional Service Information Contact City/State/Zip Code S 1
220 PER Additional Service Information Contact Information S 3
030 FOOTER - Table 3 - Footer
280 SE Transaction Set Trailer R 1
030 GE Functional Group Trailer R 1
020 TA1 Interchange Acknowledgement S 1
030 IEA Interchange Control Trailer R 1