ISA- Interchange Control Header

GS- Functional Group Header

ST- Transaction Set Header

BHT- Beginning of Hierarchical Transaction

REF- Transmission Type Identification

NM1- Submitter Name

N2- Additional Submitter Name Information

PER- Submitter EDI Contact Information

NM1- Receiver Name

N2- Receiver Additional Name Information

HL- Billing/Pay-To Provider Hierarchical Level

PRV- Billing/Pay-To Provider Specialty Information

CUR- Foreign Currency Information

NM1- Billing Provider Name

N2- Additional Billing Provider Name Information

N3- Billing Provider Address

N4- Billing Provider City/State/ZIP Code

REF- Billing Provider Secondary Identification

REF- Credit/Debit Card Billing Information

PER- Billing Provider Contact Information

NM1- Pay-To Provider Name

N2- Additional Pay-To Provider Name Information

N3- Pay-To Provider Address

N4- Pay-To Provider City/State/ZIP Code

REF- Pay-To Provider Secondary Identification

HL- Subscriber Hierarchical Level

SBR- Subscriber Information

PAT- Patient Information

NM1- Subscriber Name

N2- Additional Subscriber Name Information

N3- Subscriber Address

N4- Subscriber City/State/ZIP Code

DMG- Subscriber Demographic Information

REF- Subscriber Secondary Identification

REF- Property and Casualty Claim Number

NM1- Payer Name

N2- Additional Payer Name Information

N3- Payer Address

N4- Payer City/State/ZIP Code

REF- Payer Secondary Identification

NM1- Responsible Party Name

N2- Additional Responsible Party Name Information

N3- Responsible Party Address

N4- Responsible Party City/State/ZIP Code

NM1- Credit/Debit Card Holder Name

N2- Additional Credit/Debit Card Holder Name Information

REF- Credit/Debit Card Information

CLM- Claim Information

DTP- Date - Order Date

DTP- Date - Initial Treatment

DTP- Date - Referral Date

DTP- Date - Date Last Seen

DTP- Date - Onset of Current Illness/Symptom

DTP- Date - Acute Manifestation

DTP- Date - Similar Illness/Symptom Onset

DTP- Date - Accident

DTP- Date - Last Menstrual Period

DTP- Date - Last X-Ray

DTP- Date - Estimated Date of Birth

DTP- Date - Hearing and Vision Prescription Date

DTP- Date - Disability Begin

DTP- Date - Disability End

DTP- Date - Last Worked

DTP- Date - Authorized Return to Work

DTP- Date - Admission

DTP- Date - Discharge

DTP- Date - Assumed and Relinquished Care Dates

PWK- Claim Supplemental Information

CN1- Contract Information

AMT- Credit/Debit Card Maximum Amount

AMT- Patient Amount Paid

AMT- Total Purchased Service Amount

REF- Service Authorization Exception Code

REF- Mandatory Medicare (Section 4081) Crossover Indicator

REF- Mammography Certification Number

REF- Prior Authorization or Referral Number

REF- Original Reference Number (ICN/DCN)

REF- Clinical Laboratory Improvement Amendment (CLIA) Number

REF- Repriced Claim Number

REF- Adjusted Repriced Claim Number

REF- Investigational Device Exemption Number

REF- Claim Identification Number for Clearing Houses and Other Transmission Intermediaries

REF- Ambulatory Patient Group (APG)

REF- Medical Record Number

REF- Demonstration Project Identifier

K3- File Information

NTE- Claim Note

CR1- Ambulance Transport Information

CR2- Spinal Manipulation Service Information

CRC- Ambulance Certification

CRC- Patient Condition Information: Vision

CRC- Homebound Indicator

HI- Health Care Diagnosis Code

HCP- Claim Pricing/Repricing Information

CR7- Home Health Care Plan Information

HSD- Health Care Services Delivery

NM1- Referring Provider Name

PRV- Referring Provider Specialty Information

N2- Additional Referring Provider Name Information

REF- Referring Provider Secondary Identification

NM1- Rendering Provider Name

PRV- Rendering Provider Specialty Information

N2- Additional Rendering Provider Name Information

REF- Rendering Provider Secondary Identification

NM1- Purchased Service Provider Name

REF- Purchased Service Provider Secondary Identification

NM1- Service Facility Location

N2- Additional Service Facility Location Name Information

N3- Service Facility Location Address

N4- Service Facility Location City/State/ZIP

REF- Service Facility Location Secondary Identification

NM1- Supervising Provider Name

N2- Additional Supervising Provider Name Information

REF- Supervising Provider Secondary Identification

SBR- Other Subscriber Information

CAS- Claim Level Adjustments

AMT- Coordination of Benefits (COB) Payer Paid Amount

AMT- Coordination of Benefits (COB) Approved Amount

AMT- Coordination of Benefits (COB) Allowed Amount

AMT- Coordination of Benefits (COB) Patient Responsibility Amount

AMT- Coordination of Benefits (COB) Covered Amount

AMT- Coordination of Benefits (COB) Discount Amount

AMT- Coordination of Benefits (COB) Per Day Limit Amount

AMT- Coordination of Benefits (COB) Patient Paid Amount

AMT- Coordination of Benefits (COB) Tax Amount

AMT- Coordination of Benefits (COB) Total Claim Before Taxes Amount

DMG- Subscriber Demographic Information

OI- Other Insurance Coverage Information

MOA- Medicare Outpatient Adjudication Information

NM1- Other Subscriber Name

N2- Additional Other Subscriber Name Information

N3- Other Subscriber Address

N4- Other Subscriber City/State/ZIP Code

REF- Other Subscriber Secondary Identification

NM1- Other Payer Name

N2- Additional Other Payer Name Information

PER- Other Payer Contact Information

DTP- Claim Adjudication Date

REF- Other Payer Secondary Identifier

REF- Other Payer Prior Authorization or Referral Number

REF- Other Payer Claim Adjustment Indicator

NM1- Other Payer Patient Information

REF- Other Payer Patient Identification

NM1- Other Payer Referring Provider

REF- Other Payer Referring Provider Identification

NM1- Other Payer Rendering Provider

REF- Other Payer Rendering Provider Secondary Identification

NM1- Other Payer Purchased Service Provider

REF- Other Payer Purchased Service Provider Identification

NM1- Other Payer Service Facility Location

REF- Other Payer Service Facility Location Identification