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
005 ST Transaction Set Header R 1
010 HEADER - Table 1 - Header
020 BGN Beginning Segment R 1
030 REF Transaction Set Policy Number S 1
040 DTP File Effective Date S >1
070 1000A - Sponsor Name
070 N1 Sponsor Name R 1
070 1000B - Payer
070 N1 Payer R 1
070 1000C - TPA/Broker Name
070 N1 TPA/Broker Name R 1
120 1100C - TPA/Broker Account Information
120 ACT TPA/Broker Account Information R 1
020 DETAIL - Table 2 - Detail
010 2000 - Member Level Detail
010 INS Member Level Detail R 1
020 REF Subscriber Number R 1
020 REF Member Policy Number S 1
020 REF Member Identification Number S 5
020 REF Prior Coverage Months S 1
025 DTP Member Level Dates S 20
030 2100A - Member Name
030 NM1 Member Name R 1
040 PER Member Communications Numbers S 1
050 N3 Member Residence Street Address S 1
060 N4 Member Residence City, State, Zip Code S 1
080 DMG Member Demographics S 1
110 ICM Member Income S 1
120 AMT Member Policy Amounts S 4
130 HLH Member Health Information S 1
150 LUI Member Language S 5
030 2100B - Incorrect Member Name
030 NM1 Incorrect Member Name R 1
080 DMG Incorrect Member Demographics S 1
030 2100C - Member Mailing Address
030 NM1 Member Mailing Address R 1
050 N3 Member Mail Street Address S 1
060 N4 Member Mail City, State, Zip S 1
030 2100D - Member Employer
030 NM1 Member Employer R 1
040 PER Member Employer Communications Numbers S 1
050 N3 Member Employer Street Address S 1
060 N4 Member Employer City, State, Zip S 1
030 2100E - Member School
030 NM1 Member School R 1
040 PER Member School Communications Numbers S 1
050 N3 Member School Street Address S 1
060 N4 Member School City, State, Zip S 1
030 2100F - Custodial Parent
030 NM1 Custodial Parent R 1
040 PER Custodial Parent Communications Numbers S 1
050 N3 Custodial Parent Street Address S 1
060 N4 Custodial Parent City, State, Zip S 1
030 2100G - Responsible Person
030 NM1 Responsible Person R 1
040 PER Responsible Person Communications Numbers S 1
050 N3 Responsible Person Street Address S 1
060 N4 Responsible Person City, State, Zip S 1
200 2200 - Disability Information
200 DSB Disability Information R 1
210 DTP Disability Eligibility Dates S 2
260 2300 - Health Coverage
260 HD Health Coverage R 1
270 DTP Health Coverage Dates R 4
280 AMT Health Coverage Policy S 4
290 REF Health Coverage Policy Number S 2
300 IDC Identification Card S 10
310 2310 - Provider Information
310 LX Provider Information R 1
320 NM1 Provider Name R 1
360 N4 Provider City, State, Zip Code S 1
370 PER Provider Communications Numbers S 2
395 PLA PCP Change Reason S 1
400 2320 - Coordination of Benefits
400 COB Coordination of Benefits R 1
405 REF Additional Coordination of Benefits Identifiers S 5
410 N1 Other Insurance Company Name S 1
450 DTP Coordination of Benefits Eligibility Dates S 2
030 FOOTER - Table 3 - Footer
690 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