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
RA
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
004010X061A1

ST- 820 Header
01 143 Transaction Set Identifier Code R
820
02 329 Transaction Set Control Number R

BPR- Financial Information
01 305 Transaction Handling Code R
C D I P U X
02 782 Total Premium Payment Amount R
03 478 Credit or Debit Flag Code R
C D
04 591 Payment Method Code R
ACH BOP CHK FWT SWT
05 812 Payment Format Code S
CCP CTX
06 506 Depository Financial Institution (DFI) Identification Number Qualifier S
01 04
07 507 Originating Depository Financial Institution (DFI) Identifier S
08 569 Account Number Qualifier S
DA ALC
09 508 Sender Bank Account Number S
10 509 Originating Company Identifier S
11 510 Originating Company Supplemental Code S
12 506 Depository Financial Institution (DFI) Identification Number Qualifier S
01 04
13 507 Receiving Depository Financial Institution (DFI) Identifier S
14 569 Account Number Qualifier S
DA SG
15 508 Receiver Bank Account Number S
16 373 Check Issue or EFT Effective Date R
17 1048 Business Function Code N
18 506 (DFI) ID Number Qualifier N
19 507 (DFI) Identification Number N
20 569 Account Number Qualifier N
21 508 Account Number N

TRN- Reassociation Key
01 481 Trace Type Code R
1 3
02 127 Check or EFT Trace Number R
03 509 Originating Company Identifier S
04 127 Originating Company Supplemental Code S

CUR- Non-US Dollars Currency
01 98 Entity Identifier Code R
2B PR
02 100 Currency Code R
MXP CAD USD
03 280 Exchange Rate S
04 98 Entity Identifier Code N
05 100 Currency Code N
06 669 Currency Market/Exchange Code N
07 374 Date/Time Qualifier N
08 373 Date N
09 337 Time N
10 374 Date/Time Qualifier N
11 373 Date N
12 337 Time N
13 374 Date/Time Qualifier N
14 373 Date N
15 337 Time N
16 374 Date/Time Qualifier N
17 373 Date N
18 337 Time N
19 374 Date/Time Qualifier N
20 373 Date N
21 337 Time N

REF- Premium Receivers Identification Key
01 128 Reference Identification Qualifier R
14 18 2F 38 72
02 127 Premium Receiver Reference Identifier R
03 352 Description N
N C040 Reference Identifier

DTM- Process Date
01 374 Date Time Qualifier R
009
02 373 Payer Process Date R
03 337 Time N
04 623 Time Code N
05 1250 Date Time Period Format Qualifier N
06 1251 Date Time Period N

DTM- Delivery Date
01 374 Date Time Qualifier R
035
02 373 Premium Delivery Date R
03 337 Time N
04 623 Time Code N
05 1250 Date Time Period Format Qualifier N
06 1251 Date Time Period N

DTM- Coverage Period
01 374 Date Time Qualifier R
582
02 373 Date N
03 337 Time N
04 623 Time Code N
05 1250 Date Time Period Format Qualifier R
RD8
06 1251 Coverage Period R

N1- Premium Receiver's Name
01 98 Entity Identifier Code R
PE
02 93 Information Receiver Last or Organization Name S
03 66 Identification Code Qualifier S
1 9 EQ FI XV
04 67 Receiver Identifier S
05 706 Entity Relationship Code N
06 98 Entity Identifier Code N

N2- Premium Receiver Additional Name
01 93 Receiver Additional Name R
02 93 Name N

N3- Premium Receiver's Address
01 166 Receiver Address Line R
02 166 Receiver Address Line S

N4- Premium Receiver's City, State, ZIP
01 19 Information Receiver City Name R
02 156 Information Receiver State Code R
External Source: states
03 116 Information Receiver Postal Zone or ZIP Code R
04 26 Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

N1- Premium Payer's Name
01 98 Entity Identifier Code R
PR
02 93 Premium Payer Name S
03 66 Identification Code Qualifier S
1 9 24 65 75 EQ FI PI
04 67 Premium Payer Identifier S
05 706 Entity Relationship Code N
06 98 Entity Identifier Code N

N2- Premium Payer Additional Name
01 93 Premium Payer Additional Name R
02 93 Name N

N3- Premium Payer's Address
01 166 Premium Payer Address Line R
02 166 Premium Payer Address Line S

N4- Premium Payer's City, State, ZIP
01 19 Premium Payer City Name R
02 156 Premium Payer State Code R
External Source: states
03 116 Premium Payer Postal Zone or ZIP Code R
04 26 Country Code S
External Source: country
05 309 Location Qualifier N
06 310 Location Identifier N

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

ENT- Organization Summary Remittance
01 554 Assigned Number R
02 98 Entity Identifier Code R
2L
03 66 Identification Code Qualifier S
1 9 FI
04 67 Organization Identification Code S
05 98 Entity Identifier Code N
06 66 Identification Code Qualifier N
07 67 Identification Code N
08 128 Reference Identification Qualifier N
09 127 Reference Identification N

RMR- Organization Summary Remittance Detail
01 128 Reference Identification Qualifier R
11 1L CT IK
02 127 Contract, Invoice, Account, Group, or Policy Number R
03 482 Payment Action Code S
PA PI PO PP
04 782 Detail Premium Payment Amount R
05 782 Billed Premium Amount S
06 782 Monetary Amount N
07 426 Adjustment Reason Code N
08 782 Monetary Amount N

IT1- Summary Line Item
01 350 Line Item Control Number R
02 358 Quantity Invoiced N
03 355 Unit or Basis for Measurement Code N
04 212 Unit Price N
05 639 Basis of Unit Price Code N
06 235 Product/Service ID Qualifier N
07 234 Product/Service ID N
08 235 Product/Service ID Qualifier N
09 234 Product/Service ID N
10 235 Product/Service ID Qualifier N
11 234 Product/Service ID N
12 235 Product/Service ID Qualifier N
13 234 Product/Service ID N
14 235 Product/Service ID Qualifier N
15 234 Product/Service ID N
16 235 Product/Service ID Qualifier N
17 234 Product/Service ID N
18 235 Product/Service ID Qualifier N
19 234 Product/Service ID N
20 235 Product/Service ID Qualifier N
21 234 Product/Service ID N
22 235 Product/Service ID Qualifier N
23 234 Product/Service ID N
24 235 Product/Service ID Qualifier N
25 234 Product/Service ID N

SLN- Member Count
01 350 Line Item Control Number R
02 350 Assigned Identification N
03 662 Information Only Indicator R
O
04 380 Head Count R
R C001 Composite Unit of Measure
01 355 Unit or Basis for Measurement Code R
10 IE PR
02 1018 Exponent N
03 649 Multiplier N
04 355 Unit or Basis for Measurement Code N
05 1018 Exponent N
06 649 Multiplier N
07 355 Unit or Basis for Measurement Code N
08 1018 Exponent N
09 649 Multiplier N
10 355 Unit or Basis for Measurement Code N
11 1018 Exponent N
12 649 Multiplier N
13 355 Unit or Basis for Measurement Code N
14 1018 Exponent N
15 649 Multiplier N
06 212 Unit Price N
07 639 Basis of Unit Price Code N
08 662 Relationship Code N
09 235 Product/Service ID Qualifier N
10 234 Product/Service ID N
11 235 Product/Service ID Qualifier N
12 234 Product/Service ID N
13 235 Product/Service ID Qualifier N
14 234 Product/Service ID N
15 235 Product/Service ID Qualifier N
16 234 Product/Service ID N
17 235 Product/Service ID Qualifier N
18 234 Product/Service ID N
19 235 Product/Service ID Qualifier N
20 234 Product/Service ID N
21 235 Product/Service ID Qualifier N
22 234 Product/Service ID N
23 235 Product/Service ID Qualifier N
24 234 Product/Service ID N
25 235 Product/Service ID Qualifier N
26 234 Product/Service ID N
27 235 Product/Service ID Qualifier N
28 234 Product/Service ID N

ADX- Organization Summary Remittance Level Adjustment
01 782 Adjustment Amount R
02 426 Adjustment Reason Code R
20 52 53 AA H1 H6 IA J3
03 128 Reference Identification Qualifier N
04 127 Reference Identification N

ENT- Individual Remittance
01 554 Assigned Number R
02 98 Entity Identifier Code R
2J
03 66 Identification Code Qualifier R
34 EI ZZ
04 67 Receiver's Individual Identifier R
05 98 Entity Identifier Code N
06 66 Identification Code Qualifier N
07 67 Identification Code N
08 128 Reference Identification Qualifier N
09 127 Reference Identification N

NM1- Individual Name
01 98 Entity Identifier Code R
EY QE
02 1065 Entity Type Qualifier R
1
03 1035 Individual Last Name S
04 1036 Individual First Name S
05 1037 Individual Middle Name S
06 1038 Individual Name Prefix S
07 1039 Individual Name Suffix S
08 66 Identification Code Qualifier S
34 EI N
09 67 Individual Identifier S
10 706 Entity Relationship Code N
11 98 Entity Identifier Code N

RMR- Individual Premium Remittance Detail
01 128 Reference Identification Qualifier R
11 9J AZ B7 CT ID IG IK KW
02 127 Insurance Remittance Reference Number R
03 482 Payment Action Code S
PI PP
04 782 Detail Premium Payment Amount R
05 782 Billed Premium Amount S
06 782 Monetary Amount N
07 426 Adjustment Reason Code N
08 782 Monetary Amount N

DTM- Individual Coverage Period
01 374 Date Time Qualifier R
582
02 373 Date N
03 337 Time N
04 623 Time Code N
05 1250 Date Time Period Format Qualifier R
RD8
06 1251 Coverage Period R

ADX- Individual Premium Adjustment
01 782 Adjustment Amount R
02 426 Adjustment Reason Code R
20 52 53 AA AX H1 H6 IA J3
03 128 Reference Identification Qualifier N
04 127 Reference Identification N

SE- 820 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