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
010 ST Transaction Set Header R 1
015 HEADER - Table 1 - Header
020 BHT Beginning of Hierarchical Transaction R 1
020 DETAIL - Table 2 - Detail
010 2000A - Information Source Level
010 HL Information Source Level R 1
050 2100A - Payer Name
050 NM1 Payer Name R 1
080 PER Payer Contact Information S 1
060 2000B - Information Receiver Level
010 HL Information Receiver Level R 1
050 2100B - Information Receiver Name
050 NM1 Information Receiver Name R 1
060 2000C - Service Provider Level
010 HL Service Provider Level R 1
050 2100C - Provider Name
050 NM1 Provider Name R 1
060 2000D - Subscriber Level
010 HL Subscriber Level R 1
040 DMG Subscriber Demographic Information S 1
050 2100D - Subscriber Name
050 NM1 Subscriber Name R 1
090 2200D - Claim Submitter Trace Number
090 TRN Claim Submitter Trace Number R 1
100 REF Payer Claim Identification Number S 1
100 REF Institutional Bill Type Identification S 1
100 REF Medical Record Identification S 1
100 REF Group Number S 1
110 AMT Claim Submitted Charges S 1
120 DTP Claim Service Date S 1
130 2210D - Service Line Information
130 SVC Service Line Information R 1
140 REF Service Line Item Identification S 1
150 DTP Service Line Date R 1
100 2000E - Dependent Level
010 HL Dependent Level R 1
040 DMG Dependent Demographic Information R 1
050 2100E - Dependent Name
050 NM1 Dependent Name R 1
090 2200E - Claim Submitter Trace Number
090 TRN Claim Submitter Trace Number R 1
100 REF Payer Claim Identification Number S 1
100 REF Institutional Bill Type Identification S 1
100 REF Medical Record Identification S 1
110 AMT Claim Submitted Charges S 1
120 DTP Claim Service Date S 1
130 2210E - Service Line Information
130 SVC Service Line Information R 1
140 REF Service Line Item Identification S 1
150 DTP Service Line Date S 1
030 FOOTER - Table 3 - Footer
270 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