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
	HS
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
	004010X092

ST- Transaction Set Header

01	143	Transaction Set Identifier Code	R
	270
02	329	Transaction Set Control Number	R

BHT- Beginning of Hierarchical Transaction

01	1005	Hierarchical Structure Code	R
	0022
02	353	Transaction Set Purpose Code	R
	01 13 36
03	127	Submitter Transaction Identifier	S
04	373	Transaction Set Creation Date	R
05	337	Transaction Set Creation Time	R
06	640	Transaction Type Code	S
	RT RU

HL- Information Source Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	N
03	735	Hierarchical Level Code	R
	20
04	736	Hierarchical Child Code	R
	1

NM1- Information Source Name

01	98	Entity Identifier Code	R
	2B 36 GP P5 PR
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Information Source Last or Organization Name	S
04	1036	Information Source First Name	S
05	1037	Information Source Middle Name	S
06	1038	Name Prefix	N
07	1039	Information Source Name Suffix	S
08	66	Identification Code Qualifier	R
	24 46 FI NI PI XV XX
09	67	Information Source Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

HL- Information Receiver Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	21
04	736	Hierarchical Child Code	R
	1

NM1- Information Receiver Name

01	98	Entity Identifier Code	R
	1P 2B 36 80 FA GP P5 PR
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Information Receiver Last or Organization Name	S
04	1036	Information Receiver First Name	S
05	1037	Information Receiver Middle Name	S
06	1038	Name Prefix	N
07	1039	Information Receiver Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 FI PI PP SV XX
09	67	Information Receiver Identification Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Information Receiver Additional Identification

01	128	Reference Identification Qualifier	R
	0B 1C 1D 1J 4A CT EL EO JD N5 N7 Q4 SY TJ HPI
02	127	Information Receiver Additional Identifier	R
03	352	License Number State Code	S
	External Source: states
N		C040	Reference Identifier

N3- Information Receiver Address

01	166	Information Receiver Address Line	R
02	166	Information Receiver Additional Address Line	S

N4- Information Receiver City/State/Zip Code

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

PER- Information Receiver Contact Information

01	366	Contact Function Code	R
	IC
02	93	Information Receiver Contact Name	S
03	365	Communication Number Qualifier	S
	ED EM FX TE
04	364	Information Receiver Communication Number	S
05	365	Communication Number Qualifier	S
	ED EM EX FX TE
06	364	Information Receiver Communication Number	S
07	365	Communication Number Qualifier	S
	ED EM EX FX TE
08	364	Information Receiver Communication Number	S
09	443	Contact Inquiry Reference	N

PRV- Information Receiver Provider Information

01	1221	Provider Code	R
	AD AT BI CO CV H HH LA OT P1 P2 PC PE R RF SB SK SU
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Receiver Provider Specialty Code	R
04	156	State or Province Code	N
	External Source: states
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

HL- Subscriber Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	22
04	736	Hierarchical Child Code	R
	0 1

TRN- Subscriber Trace Number

01	481	Trace Type Code	R
	1
02	127	Trace Number	R
03	509	Trace Assigning Entity Identifier	R
04	127	Trace Assigning Entity Additional Identifier	S

NM1- Subscriber Name

01	98	Entity Identifier Code	R
	IL
02	1065	Entity Type Qualifier	R
	1
03	1035	Subscriber Last Name	S
04	1036	Subscriber First Name	S
05	1037	Subscriber Middle Name	S
06	1038	Name Prefix	N
07	1039	Subscriber Name Suffix	S
08	66	Identification Code Qualifier	S
	MI ZZ
09	67	Subscriber Primary Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Subscriber Additional Identification

01	128	Reference Identification Qualifier	R
	18 1L 1W 49 6P A6 CT EA EJ F6 GH HJ IG N6 NQ SY
02	127	Subscriber Supplemental Identifier	R
03	352	Description	N
N		C040	Reference Identifier

N3- Subscriber Address

01	166	Subscriber Address Line 1	R
02	166	Subscriber Address Line 2	S

N4- Subscriber City/State/ZIP Code

01	19	Subscriber City Name	S
02	156	Subscriber State Code	S
	External Source: states
03	116	Subscriber Postal Zone or ZIP Code	S
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

PRV- Provider Information

01	1221	Provider Code	R
	AD AT BI CO CV H HH LA OT P1 P2 PC PE R RF SB SK SU
02	128	Reference Identification Qualifier	R
	9K D3 EI HPI SY TJ ZZ
03	127	Provider Identifier	R
04	156	State or Province Code	N
	External Source: states
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

DMG- Subscriber Demographic Information

01	1250	Date Time Period Format Qualifier	S
	D8
02	1251	Subscriber Birth Date	S
03	1068	Subscriber Gender Code	S
	F M
04	1067	Marital Status Code	N
05	1109	Race or Ethnicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
	External Source: country
08	659	Basis of Verification Code	N
09	380	Quantity	N

INS- Subscriber Relationship

01	1073	Insured Indicator	R
	Y
02	1069	Individual Relationship Code	R
	18
03	875	Maintenance Type Code	N
04	1203	Maintenance Reason Code	N
05	1216	Benefit Status Code	N
06	1218	Medicare Plan Code	N
07	1219	Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying	N
08	584	Employment Status Code	N
09	1220	Student Status Code	N
10	1073	Yes/No Condition or Response Code	N
11	1250	Date Time Period Format Qualifier	N
12	1251	Date Time Period	N
13	1165	Confidentiality Code	N
14	19	City Name	N
15	156	State or Province Code	N
	External Source: states
16	26	Country Code	N
	External Source: country
17	1470	Birth Sequence Number	R

DTP- Subscriber Date

01	374	Date Time Qualifier	R
	102 307 435 472
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Date Time Period	R

EQ- Subscriber Eligibility or Benefit Inquiry Information

01	1365	Service Type Code	S
	External Source: service_type
S		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD CJ HC ID IV ND ZZ
02	234	Procedure Code	R
03	1339	Procedure Modifier	S
04	1339	Procedure Modifier	S
05	1339	Procedure Modifier	S
06	1339	Procedure Modifier	S
07	352	Description	N
03	1207	Benefit Coverage Level Code	S
	CHD DEP ECH EMP ESP FAM IND SPC SPO
04	1336	Insurance Type Code	S
	AP C1 CO GP HM IP MA MB MC PR PS SP WC

AMT- Subscriber Spend Down Amount

01	522	Amount Qualifier Code	R
	R
02	782	Spend Down Amount	R
03	478	Credit/Debit Flag Code	N

III- Subscriber Eligibility or Benefit Additional Inquiry Information

01	1270	Code List Qualifier Code	R
	BF BK ZZ
02	1271	Industry Code	R
03	1136	Code Category	N
04	933	Free-Form Message Text	N
05	380	Quantity	N
N		C001	Composite Unit of Measure
07	752	Surface/Layer/Position Code	N
08	752	Surface/Layer/Position Code	N
09	752	Surface/Layer/Position Code	N

REF- Subscriber Additional Information

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Prior Authorization or Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

DTP- Subscriber Eligibility/Benefit Date

01	374	Date Time Qualifier	R
	307 435 472
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Date Time Period	R

HL- Dependent Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	23
04	736	Hierarchical Child Code	R
	0

TRN- Dependent Trace Number

01	481	Trace Type Code	R
	1
02	127	Trace Number	R
03	509	Trace Assigning Entity Identifier	R
04	127	Trace Assigning Entity Additional Identifier	S

NM1- Dependent Name

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

REF- Dependent Additional Identification

01	128	Reference Identification Qualifier	R
	18 1L 6P A6 CT EA EJ F6 GH HJ IF IG N6 SY
02	127	Dependent Supplemental Identifier	R
03	352	Description	N
N		C040	Reference Identifier

N3- Dependent Address

01	166	Dependent Address Line 1	R
02	166	Dependent Address Line 2	S

N4- Dependent City/State/ZIP Code

01	19	Dependent City Name	S
02	156	Dependent State Code	S
	External Source: states
03	116	Dependent Postal Zone or ZIP Code	S
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

PRV- Provider Information

01	1221	Provider Code	R
	AD AT BI CO CV H HH LA OT P1 P2 PC PE R RF SB SK SU
02	128	Reference Identification Qualifier	R
	9K D3 EI HPI SY TJ ZZ
03	127	Provider Identifier	R
04	156	State or Province Code	N
	External Source: states
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

DMG- Dependent Demographic Information

01	1250	Date Time Period Format Qualifier	S
	D8
02	1251	Dependent Birth Date	S
03	1068	Dependent Gender Code	S
	F M
04	1067	Marital Status Code	N
05	1109	Race or Ethnicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
	External Source: country
08	659	Basis of Verification Code	N
09	380	Quantity	N

INS- Dependent Relationship

01	1073	Insured Indicator	R
	N
02	1069	Individual Relationship Code	R
	01 19 34
03	875	Maintenance Type Code	N
04	1203	Maintenance Reason Code	N
05	1216	Benefit Status Code	N
06	1218	Medicare Plan Code	N
07	1219	Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying	N
08	584	Employment Status Code	N
09	1220	Student Status Code	N
10	1073	Yes/No Condition or Response Code	N
11	1250	Date Time Period Format Qualifier	N
12	1251	Date Time Period	N
13	1165	Confidentiality Code	N
14	19	City Name	N
15	156	State or Province Code	N
	External Source: states
16	26	Country Code	N
	External Source: country
17	1470	Birth Sequence Number	S

DTP- Dependent Date

01	374	Date Time Qualifier	R
	102 307 435 472
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Date Time Period	R

EQ- Dependent Eligibility or Benefit Inquiry Information

01	1365	Service Type Code	S
	External Source: service_type
S		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD CJ HC ID IV ND ZZ
02	234	Procedure Code	R
03	1339	Procedure Modifier	S
04	1339	Procedure Modifier	S
05	1339	Procedure Modifier	S
06	1339	Procedure Modifier	S
07	352	Description	N
03	1207	Benefit Coverage Level Code	S
	CHD DEP ECH EMP ESP FAM IND SPC SPO
04	1336	Insurance Type Code	S
	AP C1 CO GP HM HN IP MA MB MC PR PS SP WC

III- Dependent Eligibility or Benefit Additional Inquiry Information

01	1270	Code List Qualifier Code	R
	BF BK ZZ
02	1271	Industry Code	R
03	1136	Code Category	N
04	933	Free-Form Message Text	N
05	380	Quantity	N
N		C001	Composite Unit of Measure
07	752	Surface/Layer/Position Code	N
08	752	Surface/Layer/Position Code	N
09	752	Surface/Layer/Position Code	N

REF- Dependent Additional Information

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Prior Authorization or Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

DTP- Dependent Eligibility/Benefit Date

01	374	Date Time Qualifier	R
	307 435 472
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Date Time Period	R

SE- Transaction Set 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