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
	HN HR
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
	004010X093A1

ST- Transaction Set Header

01	143	Transaction Set Identifier Code	R
	277
02	329	Transaction Set Control Number	R

BHT- Beginning of Hierarchical Transaction

01	1005	Hierarchical Structure Code	R
	0010
02	353	Transaction Set Purpose Code	R
	08
03	127	Originator Application Transaction Identifier	R
04	373	Transaction Set Creation Date	R

05	337	Time	N
06	640	Transaction Type Code	R
	DG

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- Payer Name

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Payer Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	21 AD FI NI PI PP XV
09	67	Payer Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Payer Contact Information

01	366	Contact Function Code	R
	IC
02	93	Payer Contact Name	S
03	365	Communication Number Qualifier	R
	ED EM TE
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	EX
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	EX FX
08	364	Communication Number	S
09	443	Contact Inquiry Reference	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
	41
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Information Receiver Last or Organization Name	R
04	1036	Information Receiver First Name	S
05	1037	Information Receiver Middle Name	S
06	1038	Information Receiver Name Prefix	S
07	1039	Information Receiver Name Suffix	S
08	66	Identification Code Qualifier	R
	46 FI XX
09	67	Information Receiver Identification Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

HL- Service Provider Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	19
04	736	Hierarchical Child Code	R
	1

NM1- Provider Name

01	98	Entity Identifier Code	R
	1P
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Provider Last or Organization Name	R
04	1036	Provider First Name	S
05	1037	Provider Middle Name	S
06	1038	Provider Name Prefix	S
07	1039	Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	FI SV XX
09	67	Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier 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

DMG- Subscriber Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Subscriber Birth Date	R
03	1068	Subscriber Gender Code	R
	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
08	659	Basis of Verification Code	N
09	380	Quantity	N

NM1- Subscriber Name

01	98	Entity Identifier Code	R
	IL QC
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Subscriber Last Name	R
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	R
	24 MI ZZ
09	67	Subscriber Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

TRN- Claim Submitter Trace Number

01	481	Trace Type Code	R
	2
02	127	Trace Number	R
03	509	Originating Company Identifier	N
04	127	Reference Identification	N

STC- Claim Level Status Information

R		C043	Health Care Claim Status
01	1271	Health Care Claim Status Category Code	R
	External Source: claim_status_cat
02	1271	Health Care Claim Status Code	R
	External Source: claim_status
03	98	Entity Identifier Code	S
	External Source: entity_id
02	373	Status Information Effective Date	R

03	306	Action Code	N
04	782	Total Claim Charge Amount	R
05	782	Claim Payment Amount	R
06	373	Adjudication or Payment Date	S

07	591	Payment Method Code	S
	ACH BOP CHK FWT NON
08	373	Check Issue or EFT Effective Date	S

09	429	Check or EFT Trace Number	S
S		C043	Health Care Claim Status
01	1271	Health Care Claim Status Category Code	R
	External Source: claim_status_cat
02	1271	Health Care Claim Status Code	R
	External Source: claim_status
03	98	Entity Identifier Code	S
	External Source: entity_id
S		C043	Health Care Claim Status
01	1271	Health Care Claim Status Category Code	R
	External Source: claim_status_cat
02	1271	Health Care Claim Status Code	R
	External Source: claim_status
03	98	Entity Identifier Code	S
	External Source: entity_id
12	933	Free-Form Message Text	N

REF- Payer Claim Identification Number

01	128	Reference Identification Qualifier	R
	1K
02	127	Payer Claim Control Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Institutional Bill Type Identification

01	128	Reference Identification Qualifier	R
	BLT
02	127	Bill Type Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Medical Record Identification

01	128	Reference Identification Qualifier	R
	EA
02	127	Medical Record Number	R
03	352	Description	N
N		C040	Reference Identifier

DTP- Claim Service Date

01	374	Date Time Qualifier	R
	232
02	1250	Date Time Period Format Qualifier	R
	RD8
03	1251	Claim Service Date	R

SVC- Service Line Information

R		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD CI HC ID IV N1 N2 N3 N4 ND NH NU RB
02	234	Service Identification 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
02	782	Line Item Charge Amount	R
03	782	Line Item Provider Payment Amount	R
04	234	Revenue Code	S
05	380	Quantity	N
N		C003	Composite Medical Procedure Identifier
07	380	Original Units of Service Count	S

STC- Service Line Status Information

R		C043	Health Care Claim Status
01	1271	Health Care Claim Status Category Code	R
	External Source: claim_status_cat
02	1271	Health Care Claim Status Code	R
	External Source: claim_status
03	98	Entity Identifier Code	S
	External Source: entity_id
02	373	Status Information Effective Date	R

03	306	Action Code	N
04	782	Line Item Charge Amount	S
05	782	Line Item Provider Payment Amount	S
06	373	Date	N
07	591	Payment Method Code	N
08	373	Date	N
09	429	Check Number	N
S		C043	Health Care Claim Status
01	1271	Health Care Claim Status Category Code	R
	External Source: claim_status_cat
02	1271	Health Care Claim Status Code	R
	External Source: claim_status
03	98	Entity Identifier Code	S
	External Source: entity_id
S		C043	Health Care Claim Status
01	1271	Health Care Claim Status Category Code	R
	External Source: claim_status_cat
02	1271	Health Care Claim Status Code	R
	External Source: claim_status
03	98	Entity Identifier Code	S
	External Source: entity_id
12	933	Free-Form Message Text	N

REF- Service Line Item Identification

01	128	Reference Identification Qualifier	R
	FJ
02	127	Line Item Control Number	R
03	352	Description	N
N		C040	Reference Identifier

DTP- Service Line Date

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	RD8
03	1251	Service Line Date	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	N

DMG- Dependent Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Patient Birth Date	R
03	1068	Patient Gender Code	R
	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
08	659	Basis of Verification Code	N
09	380	Quantity	N

NM1- Dependent Name

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