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
010 BHT Beginning of Hierarchical Transaction R 1
015 REF Transmission Type Identification R 1
020 1000A - Submitter Name 1
020 NM1 Submitter Name R 1
025 N2 Additional Submitter Name Information S 1
045 PER Submitter Contact Information R 2
020 1000B - Receiver Name 1
020 NM1 Receiver Name R 1
025 N2 Receiver Additional Name Information S 1
020 DETAIL - Table 2 - Detail
001 2000A - Billing/Pay-To Provider Hierarchical Level >1
001 HL Billing/Pay-To Provider Hierarchical Level R 1
003 PRV Billing/Pay-To Provider Specialty Information S 1
010 CUR Foreign Currency Information S 1
015 2010AA - Billing Provider Name 1
015 NM1 Billing Provider Name R 1
020 N2 Additional Billing Provider Name Information S 1
025 N3 Billing Provider Address R 1
030 N4 Billing Provider City/State/ZIP Code R 1
035 REF Billing Provider Secondary Identification Number S 5
035 REF Credit/Debit Card Information S 8
015 2010AB - Pay-To Provider's Name 1
015 NM1 Pay-To Provider's Name R 1
020 N2 Additional Pay-To Provider Name Information S 1
025 N3 Pay-To Provider's Address R 1
030 N4 Pay-To Provider City/State/ZIP R 1
035 REF Pay-To Provider Secondary Identification Number S 5
001 2000B - Subscriber Hierarchical Level >1
001 HL Subscriber Hierarchical Level R 1
005 SBR Subscriber Information R 1
015 2010BA - Subscriber Name 1
015 NM1 Subscriber Name R 1
020 N2 Additional Subscriber Name Information S 1
025 N3 Subscriber Address S 1
030 N4 Subscriber City/State/ZIP Code S 1
032 DMG Subscriber Demographic Information S 1
035 REF Subscriber Secondary Identification S 4
035 REF Property and Casualty Claim Number S 1
015 2010BB - Payer Name 1
015 NM1 Payer Name R 1
020 N2 Additional Payer Name Information S 1
025 N3 Payer Address S 1
030 N4 Payer City/State/ZIP Code S 1
035 REF Payer Secondary Identification Number S 3
015 2010BC - Credit/Debit Card Holder Name 1
015 NM1 Credit/Debit Card Holder Name R 1
020 N2 Additional Credit/Debit Card Holder Name Information S 1
035 REF Credit/Debit Card Information S 3
130 2300 - Claim Information 100
130 CLM Claim Information R 1
135 DTP Date - Admission S 1
135 DTP Date - Discharge S 1
135 DTP Date - Referral S 1
135 DTP Date - Accident S 1
135 DTP Date - Appliance Placement S 5
135 DTP Date - Service S 1
145 DN1 Orthodontic Total Months of Treatment S 1
150 DN2 Tooth Status S 35
155 PWK Claim Supplemental Information S 10
175 AMT Patient Amount Paid S 1
175 AMT Credit/Debit Card - Maximum Amount S 1
180 REF Predetermination Identification S 5
180 REF Service Authorization Exception Code S 1
180 REF Original Reference Number (ICN/DCN) S 1
180 REF Referral Identification S 1
180 REF Claim Identification Number for Clearinghouses and Other Transmission Intermediaries S 1
190 NTE Claim Note S 20
250 2310A - Referring Provider Name 2
250 NM1 Referring Provider Name R 1
255 PRV Referring Provider Specialty Information S 1
260 N2 Additional Referring Provider Name Information S 1
271 REF Referring Provider Secondary Identification S 5
250 2310B - Rendering Provider Name 1
250 NM1 Rendering Provider Name R 1
255 PRV Rendering Provider Specialty Information R 1
260 N2 Additional Rendering Provider Name Information S 1
271 REF Rendering Provider Secondary Identification S 5
250 2310C - Service Facility Location 1
250 NM1 Service Facility Location R 1
260 N2 Additional Service Facility Location Name Information S 1
271 REF Service Facility Location Secondary Identification S 5
290 2320 - Other Subscriber Information 10
290 SBR Other Subscriber Information R 1
295 CAS Claim Adjustment S 5
300 AMT Coordination of Benefits (COB) Payer Paid Amount S 1
300 AMT Coordination of Benefits (COB) Approved Amount S 1
300 AMT Coordination of Benefits (COB) Allowed Amount S 1
300 AMT Coordination of Benefits (COB) Patient Responsibility Amount S 1
300 AMT Coordination of Benefits (COB) Covered Amount S 1
300 AMT Coordination of Benefits (COB) Discount Amount S 1
300 AMT Coordination of Benefits (COB) Patient Paid Amount S 1
305 DMG Other Insured Demographic Information S 1
310 OI Other Insurance Coverage Information R 1
325 2330A - Other Subscriber Name 1
325 NM1 Other Subscriber Name R 1
330 N2 Additional Other Subscriber Name Information S 1
332 N3 Other Subscriber Address S 1
340 N4 Other Subscriber City/State/ZIP Code S 1
355 REF Other Subscriber Secondary Identification S 3
325 2330B - Other Payer Name 1
325 NM1 Other Payer Name R 1
330 N2 Additional Other Payer Name Information S 1
345 PER Other Payer Contact Information S 2
350 DTP Claim Paid Date S 1
355 REF Other Payer Secondary Identifier S 3
355 REF Other Payer Referral Number S 1
355 REF Other Payer Claim Adjustment Indicator S 1
325 2330C - Other Payer Patient Information 1
325 NM1 Other Payer Patient Information R 1
355 REF Other Payer Patient Identification S 3
325 2330D - Other Payer Referring Provider 1
325 NM1 Other Payer Referring Provider R 1
355 REF Other Payer Referring Provider Identification S 3
325 2330E - Other Payer Rendering Provider 1
325 NM1 Other Payer Rendering Provider R 1
355 REF Other Payer Rendering Provider Identification S 3
365 2400 - Line Counter 50
365 LX Line Counter R 1
380 SV3 Dental Service R 1
382 TOO Tooth Information S 32
455 DTP Date - Service S 1
455 DTP Date - Prior Placement S 1
455 DTP Date - Appliance Placement S 1
455 DTP Date - Replacement S 1
460 QTY Anesthesia Quantity S 5
470 REF Service Predetermination Identification S 1
470 REF Referral Number S 1
470 REF Line Item Control Number S 1
475 AMT Approved Amount S 1
485 NTE Line Note S 10
500 2420A - Rendering Provider Name 1
500 NM1 Rendering Provider Name R 1
505 PRV Rendering Provider Specialty Information R 1
510 N2 Additional Rendering Provider Name Information S 1
525 REF Rendering Provider Secondary Identification S 5
500 2420B - Other Payer Referral Number 1
500 NM1 Other Payer Referral Number R 1
525 REF Other Payer Referral Number S 1
540 2430 - Line Adjudication Information 25
540 SVD Line Adjudication Information R 1
545 CAS Service Adjustment S 99
550 DTP Line Adjudication Date R 1
001 2000C - Patient Hierarchical Level >1
001 HL Patient Hierarchical Level R 1
007 PAT Patient Information R 1
015 2010CA - Patient Name 1
015 NM1 Patient Name R 1
020 N2 Additional Name Information S 1
025 N3 Patient Address R 1
030 N4 Patient City/State/ZIP Code R 1
032 DMG Patient Demographic Information R 1
035 REF Patient Secondary Identification S 5
035 REF Property and Casualty Claim Number S 1
130 2300 - Claim Information 100
130 CLM Claim Information R 1
135 DTP Date - Admission S 1
135 DTP Date - Discharge S 1
135 DTP Date - Referral S 1
135 DTP Date - Accident S 1
135 DTP Date - Appliance Placement S 5
135 DTP Date - Service S 1
145 DN1 Orthodontic Total Months of Treatment S 1
150 DN2 Tooth Status S 35
155 PWK Claim Supplemental Information S 10
175 AMT Patient Amount Paid S 1
175 AMT Credit/Debit Card - Maximum Amount S 1
180 REF Predetermination Identification S 5
180 REF Service Authorization Exception Code S 1
180 REF Original Reference Number (ICN/DCN) S 1
180 REF Referral Identification S 1
180 REF Claim Identification Number for Clearinghouses and Other Transmission Intermediaries S 1
190 NTE Claim Note S 20
250 2310A - Referring Provider Name 2
250 NM1 Referring Provider Name R 1
255 PRV Referring Provider Specialty Information S 1
260 N2 Additional Referring Provider Name Information S 1
271 REF Referring Provider Secondary Identification S 5
250 2310B - Rendering Provider Name 1
250 NM1 Rendering Provider Name R 1
255 PRV Rendering Provider Specialty Information R 1
260 N2 Additional Rendering Provider Name Information S 1
271 REF Rendering Provider Secondary Identification S 5
250 2310C - Service Facility Location 1
250 NM1 Service Facility Location R 1
260 N2 Additional Service Facility Location Name Information S 1
271 REF Service Facility Location Secondary Identification S 5
290 2320 - Other Subscriber Information 10
290 SBR Other Subscriber Information R 1
295 CAS Claim Adjustment S 5
300 AMT Coordination of Benefits (COB) Payer Paid Amount S 1
300 AMT Coordination of Benefits (COB) Approved Amount S 1
300 AMT Coordination of Benefits (COB) Allowed Amount S 1
300 AMT Coordination of Benefits (COB) Patient Responsibility Amount S 1
300 AMT Coordination of Benefits (COB) Covered Amount S 1
300 AMT Coordination of Benefits (COB) Discount Amount S 1
300 AMT Coordination of Benefits (COB) Patient Paid Amount S 1
305 DMG Other Insured Demographic Information S 1
310 OI Other Insurance Coverage Information R 1
325 2330A - Other Subscriber Name 1
325 NM1 Other Subscriber Name R 1
330 N2 Additional Other Subscriber Name Information S 1
332 N3 Other Subscriber Address S 1
340 N4 Other Subscriber City/State/ZIP Code S 1
355 REF Other Subscriber Secondary Identification S 3
325 2330B - Other Payer Name 1
325 NM1 Other Payer Name R 1
330 N2 Additional Other Payer Name Information S 1
345 PER Other Payer Contact Information S 2
350 DTP Claim Paid Date S 1
355 REF Other Payer Secondary Identifier S 3
355 REF Other Payer Referral Number S 1
355 REF Other Payer Claim Adjustment Indicator S 1
325 2330C - Other Payer Patient Information 1
325 NM1 Other Payer Patient Information R 1
355 REF Other Payer Patient Identification S 3
325 2330D - Other Payer Referring Provider 1
325 NM1 Other Payer Referring Provider R 1
355 REF Other Payer Referring Provider Identification S 3
325 2330E - Other Payer Rendering Provider 1
325 NM1 Other Payer Rendering Provider R 1
355 REF Other Payer Rendering Provider Identification S 3
365 2400 - Line Counter 50
365 LX Line Counter R 1
380 SV3 Dental Service R 1
382 TOO Tooth Information S 32
455 DTP Date - Service S 1
455 DTP Date - Prior Placement S 1
455 DTP Date - Appliance Placement S 1
455 DTP Date - Replacement S 1
460 QTY Anesthesia Quantity S 5
470 REF Service Predetermination Identification S 1
470 REF Referral Number S 1
470 REF Line Item Control Number S 1
475 AMT Approved Amount S 1
485 NTE Line Note S 10
500 2420A - Rendering Provider Name 1
500 NM1 Rendering Provider Name R 1
505 PRV Rendering Provider Specialty Information R 1
510 N2 Additional Rendering Provider Name Information S 1
525 REF Rendering Provider Secondary Identification S 5
500 2420B - Other Payer Referral Number 1
500 NM1 Other Payer Referral Number R 1
525 REF Other Payer Referral Number S 1
540 2430 - Line Adjudication Information 25
540 SVD Line Adjudication Information R 1
545 CAS Service Adjustment S 99
550 DTP Line Adjudication Date R 1
030 FOOTER - Table 3 - Footer
555 SE Transaction Set Trailer R 1
030 GE Functional Group Trailer R 1
020 TA1 Interchange Acknowledgement S
030 IEA Interchange Control Trailer R 1