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
	HB
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
	271
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
	11
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	N

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
	0 1

AAA- Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	R
	04 41 42 79
04	889	Follow-up Action Code	R
	C N P R S Y

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

REF- Information Source Additional Identification

01	128	Reference Identification Qualifier	R
	18 55
02	127	Information Source Additional Plan Identifier	R
03	352	Plan Name	S
N	REF04	C040	Reference Identifier

PER- Information Source Contact Information

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

AAA- Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	R
	04 41 42 79 80 T4
04	889	Follow-up Action Code	R
	C N P R S W X Y

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
	0 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 XV 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	REF04	C040	Reference Identifier

AAA- Information Receiver Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	R
	15 41 43 44 45 46 47 48 50 51 79 97 T4
04	889	Follow-up Action Code	R
	C N R S W X Y

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 2
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	Subscriber Name Prefix	S
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 3H 49 6P A6 EA EJ F6 GH HJ IF IG ML N6 NQ Q4 SY
02	127	Subscriber Supplemental Identifier	R
03	352	Plan Sponsor Name	S
N	REF04	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	S
	CY FI
06	310	Location Identification Code	S

PER- Subscriber Contact Information

01	366	Contact Function Code	R
	IC
02	93	Subscriber Contact Name	S
03	365	Communication Number Qualifier	S
	HP TE WP
04	364	Subscriber Contact Number	S
05	365	Communication Number Qualifier	S
	EX HP TE WP
06	364	Subscriber Contact Number	S
07	365	Communication Number Qualifier	S
	EX HP TE WP
08	364	Subscriber Contact Number	S
09	443	Contact Inquiry Reference	N

AAA- Subscriber Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	R
	15 42 43 45 47 48 49 51 52 56 57 58 60 61 62 63 64 65 66 67 68 71 72 73 74 75 76 77 78
04	889	Follow-up Action Code	R
	C N R S W X Y

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 U
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	S
	001
04	1203	Maintenance Reason Code	S
	25
05	1216	Benefit Status Code	N
06	1218	Medicare Plan Code	N
07	1219	Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code	N
08	584	Employment Status Code	N
09	1220	Student Status Code	S
	F N P
10	1073	Handicap Indicator	S
	N Y
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- Subscriber Date

01	374	Date Time Qualifier	R
	102 152 291 307 318 340 341 342 343 346 347 356 357 382 435 442 458 472 539 540 636 771
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Date Time Period	R

EB- Subscriber Eligibility or Benefit Information

01	1390	Eligibility or Benefit Information	R
	1 2 3 4 5 6 7 8 A B C D E F G H I J K L M N O P Q R S T U V W X Y CB MC
02	1207	Benefit Coverage Level Code	S
	CHD DEP ECH EMP ESP FAM IND SPC SPO
03	1365	Service Type Code	S
	External Source: service_type
04	1336	Insurance Type Code	S
	D 12 13 14 15 16 41 42 43 47 AP C1 CO CP DB EP FF GP HM HN HS IN IP LC LD LI LT MA MB MC MH MI MP OT PE PL PP PR PS QM RP SP TF WC WU
05	1204	Plan Coverage Description	S
06	615	Time Period Qualifier	S
	6 7 13 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
07	782	Benefit Amount	S
08	954	Benefit Percent	S
09	673	Quantity Qualifier	S
	99 CA CE DB DY HS LA LE MN P6 QA S7 S8 VS YY
10	380	Benefit Quantity	S
11	1073	Authorization or Certification Indicator	S
	N U Y
12	1073	In Plan Network Indicator	S
	N U Y
S	EB13	C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD CJ HC ID 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

HSD- Health Care Services Delivery

01	673	Quantity Qualifier	S
	DY FL HS MN VS
02	380	Benefit Quantity	S
03	355	Unit or Basis for Measurement Code	S
	DA MO VS WK YR
04	1167	Sample Selection Modulus	S
05	615	Time Period Qualifier	S
	6 7 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
06	616	Period Count	S
07	678	Delivery Frequency Code	S
	1 2 3 4 5 6 7 8 9 A B C D E F G H J K L M N O P Q R S T U V W X Y Z SG SL SP SX SY SZ
08	679	Delivery Pattern Time Code	S
	A B C D E F G Y

REF- Subscriber Additional Identification

01	128	Reference Identification Qualifier	R
	18 1L 1W 49 6P 9F A6 F6 G1 IG N6 NQ
02	127	Subscriber Eligibility or Benefit Identifier	R
03	352	Plan Sponsor Name	S
N	REF04	C040	Reference Identifier

DTP- Subscriber Eligibility/Benefit Date

01	374	Date Time Qualifier	R
	193 194 198 290 292 295 304 307 318 348 349 356 357 435 472 636
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Eligibility or Benefit Date Time Period	R

AAA- Subscriber Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	R
	15 52 53 54 55 56 57 60 61 62 63 69 70
04	889	Follow-up Action Code	R
	C N R W X Y

MSG- Message Text

01	933	Free Form Message Text	R
02	934	Printer Carriage Control Code	N
03	1470	Number	N

III- Subscriber Eligibility or Benefit Additional 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	III06	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

LS- Loop Header

01	447	Loop Identifier Code	R
	2120

NM1- Subscriber Benefit Related Entity Name

01	98	Entity Identifier Code	R
	13 1P 2B 36 73 FA GP IL LR P3 P4 P5 PR VN X3 PRP SEP TTP
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Benefit Related Entity Last or Organization Name	S
04	1036	Benefit Related Entity First Name	S
05	1037	Benefit Related Entity Middle Name	S
06	1038	Name Prefix	N
07	1039	Benefit Related Entity Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 46 FA FI MI NI PI PP SV XV XX ZZ
09	67	Benefit Related Entity Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Subscriber Benefit Related Entity Address

01	166	Benefit Related Entity Address Line 1	R
02	166	Benefit Related Entity Address Line 2	S

N4- Subscriber Benefit Related City/State/ZIP Code

01	19	Benefit Related Entity City Name	S
02	156	Benefit Related Entity State Code	S
	External Source: states
03	116	Benefit Related Entity Postal Zone or ZIP Code	S
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	S
	RJ
06	310	Department of Defense Health Service Region Code	S

PER- Subscriber Benefit Related Entity Contact Information

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

PRV- Subscriber Benefit Related Provider Information

01	1221	Provider Code	R
	H R AT BI CO CV HH LA OT P1 P2 PC PE RF SK
02	128	Reference Identification Qualifier	R
	9K D3 EI SY TJ ZZ HPI
03	127	Provider Identifier	R
04	156	State or Province Code	N
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

LE- Loop Trailer

01	447	Loop Identifier Code	R
	2120

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 2
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	S
	MI ZZ
09	67	Dependent Primary Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Dependent Additional Identification

01	128	Reference Identification Qualifier	R
	18 1L 1W 49 6P EA EJ F6 GH HJ IF IG M7 N6 NQ Q4 SY
02	127	Dependent Supplemental Identifier	R
03	352	Plan Sponsor Name	S
N	REF04	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

PER- Dependent Contact Information

01	366	Contact Function Code	R
	IC
02	93	Dependent Contact Name	S
03	365	Communication Number Qualifier	S
	HP TE WP
04	364	Dependent Contact Number	S
05	365	Communication Number Qualifier	S
	EX HP TE WP
06	364	Dependent Contact Number	S
07	365	Communication Number Qualifier	S
	EX HP TE WP
08	364	Dependent Contact Number	S
09	443	Contact Inquiry Reference	N

AAA- Dependent Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	R
	15 42 43 45 47 48 49 51 52 56 57 58 60 61 62 63 64 65 66 67 68 71
04	889	Follow-up Action Code	R
	C N R S W X Y

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 U
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 21 34
03	875	Maintenance Type Code	S
	001
04	1203	Maintenance Reason Code	S
	25
05	1216	Benefit Status Code	N
06	1218	Medicare Plan Code	N
07	1219	Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code	N
08	584	Employment Status Code	N
09	1220	Student Status Code	S
	F N P
10	1073	Handicap Indicator	S
	N Y
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
	102 152 291 307 318 340 341 342 343 346 347 382 435 442 458 472 539 540 636
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Date Time Period	R

EB- Dependent Eligibility or Benefit Information

01	1390	Eligibility or Benefit Information	R
	1 2 3 4 5 6 7 8 A B C D E F G H I J K L M N O P Q R S T U V W X Y CB MC
02	1207	Benefit Coverage Level Code	S
	CHD DEP ECH ESP FAM IND SPC SPO
03	1365	Service Type Code	S
	External Source: service_type
04	1336	Insurance Type Code	S
	D 12 13 14 15 16 41 42 43 47 AP C1 CO CP DB EP FF GP HM HN HS IN IP LC LD LI LT MA MB MC MH MI MP OT PE PL PP PR PS QM RP SP TF WC WU
05	1204	Plan Coverage Description	S
06	615	Time Period Qualifier	S
	6 7 13 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
07	782	Benefit Amount	S
08	954	Benefit Percent	S
09	673	Quantity Qualifier	S
	99 CA CE DB DY HS LA LE MN P6 QA S7 S8 VS YY
10	380	Benefit Quantity	S
11	1073	Authorization or Certification Indicator	S
	N U Y
12	1073	In Plan Network Indicator	S
	N U Y
S	EB13	C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD CJ HC ID 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

HSD- Health Care Services Delivery

01	673	Quantity Qualifier	S
	DY FL HS MN VS
02	380	Benefit Quantity	S
03	355	Unit or Basis for Measurement Code	S
	DA MO VS WK YR
04	1167	Sample Selection Modulus	S
05	615	Qualifier	S
	6 7 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
06	616	Period Count	S
07	678	Delivery Frequency Code	S
	1 2 3 4 5 6 7 8 9 A B C D E F G H J K L M N O P Q R S T U V W X Y SG SL SP SX SY SZ
08	679	Delivery Pattern Time Code	S
	A B C D E F G Y

REF- Dependent Additional Identification

01	128	Reference Identification Qualifier	R
	18 1L 1W 49 6P 9F A6 F6 G1 IG N6 NQ
02	127	Dependent Eligibility or Benefit Identifier	R
03	352	Plan Sponsor Name	S
N	REF04	C040	Reference Identifier

DTP- Dependent Eligibility/Benefit Date

01	374	Date Time Qualifier	R
	193 194 198 290 292 295 304 307 318 348 349 356 357 435 472 636 771
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Eligibility or Benefit Date Time Period	R

AAA- Dependent Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	R
	15 52 53 54 55 56 57 60 61 62 63 69 70
04	889	Follow-up Action Code	R
	C N R W X Y

MSG- Message Text

01	933	Free Form Message Text	R
02	934	Printer Carriage Control Code	N
03	1470	Number	N

III- Dependent Eligibility or Benefit Additional 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	III06	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

LS- Dependent Eligibility or Benefit Information

01	447	Loop Identifier Code	R
	2120

NM1- Dependent Benefit Related Entity Name

01	98	Entity Identifier Code	R
	13 1P 2B 36 73 FA GP IL LR P3 P4 P5 PR VN X3 PRP SEP TTP
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Benefit Related Entity Last or Organization Name	S
04	1036	Benefit Related Entity First Name	S
05	1037	Benefit Related Entity Middle Name	S
06	1038	Name Prefix	N
07	1039	Benefit Related Entity Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 46 FA FI MI NI PI PP SV XV XX ZZ
09	67	Benefit Related Entity Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Dependent Benefit Related Entity Address

01	166	Benefit Related Entity Address Line 1	R
02	166	Benefit Related Entity Address Line 2	S

N4- Dependent Benefit Related Entity City/State/ZIP Code

01	19	Benefit Related Entity City Name	S
02	156	Benefit Related Entity State Code	S
	External Source: states
03	116	Benefit Related Entity Postal Zone or ZIP Code	S
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	S
	RJ
06	310	Department of Defense Health Service Region Code	S

PER- Dependent Benefit Related Entity Contact Information

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

PRV- Dependent Benefit Related Provider Information

01	1221	Provider Code	R
	H R AT BI CO CV HH LA OT P1 P2 PC PE RF SK
02	128	Reference Identification Qualifier	R
	9K D3 EI SY TJ ZZ HPI
03	127	Provider Identifier	R
04	156	State or Province Code	N
	External Source: states
N	PRV05	C035	Provider Specialty Information
06	1223	Provider Organization Code	N

LE- Loop Trailer

01	447	Loop Identifier Code	R
	2120

SE- Transaction Set Trailer

01	96	Transaction Segment Count	R
02	329	Transaction Set 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

GE- Functional Group Trailer

01	97	Number of Transaction Sets Included	R
02	28	Group Control Number	R

IEA- Interchange Control Trailer

01	I16	Number of Included Functional Groups	R
02	I12	Interchange Control Number	R