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
	HI
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
	004010X094A1

ST- Transaction Set Header

01	143	Transaction Set Identifier Code	R
	278
02	329	Transaction Set Control Number	R

BHT- Beginning of Hierarchical Transaction

01	1005	Hierarchical Structure Code	R
	0078
02	353	Transaction Set Purpose Code	R
	11
03	127	Submitter Transaction Identifier	R
04	373	Transaction Set Creation Date	R

05	337	Transaction Set Creation Time	R
06	640	Transaction Type Code	S
	18 19 AT

HL- Utilization Management Organization (UMO) 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

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 Y

NM1- Utilization Management Organization (UMO) Name

01	98	Entity Identifier Code	R
	X3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Utilization Management Organization (UMO) Last or Organization Name	S
04	1036	Utilization Management Organization (UMO) First Name	S
05	1037	Utilization Management Organization (UMO) Middle Name	S
06	1038	Name Prefix	N
07	1039	Utilization Management Organization (UMO) Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 46 PI XV XX
09	67	Utilization Management Organization (UMO) Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Utilization Management Organization (UMO) Contact Information

01	366	Contact Function Code	R
	IC
02	93	Utilization Management Organization (UMO) Contact Name	S
03	365	Communication Number Qualifier	S
	EM FX TE
04	364	Utilization Management Organization (UMO) Contact Communication Number	S
05	365	Communication Number Qualifier	S
	EM EX FX TE
06	364	Utilization Management Organization (UMO) Contact Communication Number	S
07	365	Communication Number Qualifier	S
	EM EX FX TE
08	364	Utilization Management Organization (UMO) Contact Communication Number	S
09	443	Contact Inquiry Reference	N

AAA- Utilization Management Organization (UMO) Request Validation

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

HL- Requester 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- Requester Name

01	98	Entity Identifier Code	R
	1P FA
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Requester Last or Organization Name	S
04	1036	Requester First Name	S
05	1037	Requester Middle Name	S
06	1038	Name Prefix	N
07	1039	Requester Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 46 XX
09	67	Requester Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Requester Supplemental Identification

01	128	Reference Identification Qualifier	R
	1G 1J CT EI N5 N7 SY ZH
02	127	Requester Supplemental Identifier	R
03	352	Description	N
N		C040	Reference Identifier

AAA- Requester Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	S
	35 41 43 44 45 46 47 49 50 51 79 97
04	889	Follow-up Action Code	S
	C N R

PRV- Requester Provider Information

01	1221	Provider Code	R
	AD AS AT CO CV OP OR OT PC PE RF
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
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
	1

TRN- Patient Event Tracking Number

01	481	Trace Type Code	R
	1 2
02	127	Patient Event Tracking Number	R
03	509	Trace Assigning Entity Number	R
04	127	Trace Assigning Entity Additional Identifier	S

AAA- Subscriber Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	S
	15 33 56
04	889	Follow-up Action Code	S
	C N

DTP- Accident Date

01	374	Date Time Qualifier	R
	439
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Accident Date	R

DTP- Last Menstrual Period Date

01	374	Date Time Qualifier	R
	484
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Menstrual Period Date	R

DTP- Estimated Date of Birth

01	374	Date Time Qualifier	R
	ABC
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Estimated Birth Date	R

DTP- Onset of Current Symptoms or Illness Date

01	374	Date Time Qualifier	R
	431
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Onset of Current Symptoms or Illness Date	R

HI- Subscriber Diagnosis

R		C022	Diagnosis 1
01	1270	Diagnosis Type Code	R
	BF BJ BK LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 2
01	1270	Diagnosis Type Code	R
	BF BJ LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 3
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 4
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 5
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 6
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 7
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 8
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 9
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 10
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 11
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 12
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

PWK- Additional Patient Information

01	755	Attachment Report Type Code	R
	03 04 05 06 07 08 09 10 11 13 15 21 48 55 59 77 A3 A4 AM AS AT B2 B3 BR BS BT CB CK D2 DA DB DG DJ DS FM HC HR I5 IR LA M1 NN OB OC OD OE OX P4 P5 P6 P7 PE PN PO PQ PY PZ QC QR RB RR RT RX SG V5 XP
02	756	Attachment Transmission Code	R
	BM EL EM FX VO
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	S
	AC
06	67	Attachment Control Number	S
07	352	Attachment Description	S
N		C002	Actions Indicated
09	1525	Request Category Code	N

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	R
	MI ZZ
09	67	Subscriber Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Subscriber Supplemental Identification

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

AAA- Subscriber Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	S
	15 58 64 65 66 67 68 71 72 73 74 75 76 77 78 79 95
04	889	Follow-up Action Code	S
	C N

DMG- Subscriber Demographic Information

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

NM1- Additional Patient Information Contact Name

01	98	Entity Identifier Code	R
	1P 2B ABG FA PR X3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Response Contact Last or Organization Name	S
04	1036	Response Contact First Name	S
05	1037	Response Contact Middle Name	S
06	1038	Name Prefix	N
07	1039	Response Contact Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 46 PI XV XX
09	67	Response Contact Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Additional Patient Information Contact Address

01	166	Response Contact Address Line	R
02	166	Response Contact Address Line	S

N4- Additional Patient Information Contact City/State/Zip Code

01	19	Response Contact City Name	S
02	156	Response Contact State or Province Code	S
	External Source: states
03	116	Response Contact Postal Zone or ZIP Code	S
04	26	Response Contact Country Code	S
	External Source: country
05	309	Location Qualifier	S
	B1 DP
06	310	Response Contact Specific Location	S

PER- Additional Patient Information Contact Information

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

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
	1

TRN- Patient Event Tracking Number

01	481	Trace Type Code	R
	1 2
02	127	Patient Event Tracking Number	R
03	509	Trace Assigning Entity Number	R
04	127	Trace Assigning Entity Additional Identifier	S

AAA- Dependent Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	S
	15 33 56
04	889	Follow-up Action Code	S
	C N

DTP- Accident Date

01	374	Date Time Qualifier	R
	439
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Accident Date	R

DTP- Last Menstrual Period Date

01	374	Date Time Qualifier	R
	484
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Last Menstrual Period Date	R

DTP- Estimated Date of Birth

01	374	Date Time Qualifier	R
	ABC
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Estimated Birth Date	R

DTP- Onset of Current Symptoms or Illness Date

01	374	Date Time Qualifier	R
	431
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Onset of Current Symptoms or Illness Date	R

HI- Dependent Diagnosis

R		C022	Diagnosis 1
01	1270	Diagnosis Type Code	R
	BF BJ BK LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 2
01	1270	Diagnosis Type Code	R
	BF BJ LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 3
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 4
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 5
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 6
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 7
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 8
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 9
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 10
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 11
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N
S		C022	Diagnosis 12
01	1270	Diagnosis Type Code	R
	BF LOI
02	1271	Diagnosis Code	R
03	1250	Date Time Period Format Qualifier	S
	D8
04	1251	Diagnosis Date	S
05	782	Monetary Amount	N
06	380	Quantity	N
07	799	Version Identifier	N

PWK- Additional Patient Information

01	755	Attachment Report Type Code	R
	03 04 05 06 07 08 09 10 11 13 15 21 48 55 59 77 A3 A4 AM AS AT B2 B3 BR BS BT CB CK D2 DA DB DG DJ DS FM HC HR I5 IR LA M1 NN OB OC OD OE OX P4 P5 P6 P7 PE PN PO PQ PY PZ QC QR RB RR RT RX SG V5 XP
02	756	Attachment Transmission Code	R
	BM EL EM FX VO
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	S
	AC
06	67	Attachment Control Number	S
07	352	Attachment Description	S
N		C002	Actions Indicated
09	1525	Request Category Code	N

NM1- Dependent Name

01	98	Entity Identifier Code	R
	QC
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 Supplemental Identification

01	128	Reference Identification Qualifier	R
	A6 EJ SY
02	127	Dependent Supplemental Identifier	R
03	352	Description	N
N		C040	Reference Identifier

AAA- Dependent Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	S
	15 33 58 64 65 66 67 68 71 77 95
04	889	Follow-up Action Code	S
	C N

DMG- Dependent Demographic Information

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

INS- Dependent Relationship

01	1073	Insured Indicator	R
	N
02	1069	Relationship to Insured	R
	01 04 05 07 09 10 15 17 19 20 21 22 23 24 29 32 33 34 39 40 41 43 53 G8
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 Event Code	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
16	26	Country Code	N
17	1470	Birth Sequence Number	S

NM1- Additional Patient Information Contact Name

01	98	Entity Identifier Code	R
	1P 2B ABG FA PR X3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Response Contact Last or Organization Name	S
04	1036	Response Contact First Name	S
05	1037	Response Contact Middle Name	S
06	1038	Name Prefix	N
07	1039	Response Contact Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 46 PI XV XX
09	67	Response Contact Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Additional Patient Information Contact Address

01	166	Response Contact Address Line	R
02	166	Response Contact Address Line	S

N4- Additional Patient Information Contact City/State/Zip Code

01	19	Response Contact City Name	S
02	156	Response Contact State or Province Code	S
	External Source: states
03	116	Response Contact Postal Zone or ZIP Code	S
04	26	Response Contact Country Code	S
	External Source: country
05	309	Location Qualifier	S
	B1 DP
06	310	Response Contact Specific Location	S

PER- Additional Patient Information Contact Information

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

MSG- Message Text

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

NM1- Service Provider Name

01	98	Entity Identifier Code	R
	1T FA SJ
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Service Provider Last or Organization Name	S
04	1036	Service Provider First Name	S
05	1037	Service Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Service Provider Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 46 XX
09	67	Service Provider Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Service Provider Supplemental Identification

01	128	Reference Identification Qualifier	R
	1G 1J EI N5 N7 SY ZH
02	127	Service Provider Supplemental Identifier	R
03	352	Description	N
N		C040	Reference Identifier

N3- Service Provider Address

01	166	Service Provider Address Line	R
02	166	Service Provider Address Line	S

N4- Service Provider City/State/ZIP Code

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

PER- Service Provider Contact Information

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

AAA- Service Provider Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	S
	15 33 35 41 43 44 45 46 47 49 51 52 79 97
04	889	Follow-up Action Code	S
	C N

PRV- Service Provider Information

01	1221	Provider Code	R
	AD AS AT CO CV OP OR OT PC PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

HL- Service Level

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

TRN- Service Trace Number

01	481	Trace Type Code	R
	1 2
02	127	Service Trace Number	R
03	509	Trace Assigning Entity Identifier	R
04	127	Trace Assigning Entity Additional Identifier	S

AAA- Service Request Validation

01	1073	Valid Request Indicator	R
	N Y
02	559	Agency Qualifier Code	N
03	901	Reject Reason Code	S
	15 33 52 57 60 61 62 T5
04	889	Follow-up Action Code	S
	C N

UM- Health Care Services Review Information

01	1525	Request Category Code	R
	AR HS SC
02	1322	Certification Type Code	R
	1 2 3 4 I R S
03	1365	Service Type Code	S
	1 2 3 4 5 6 7 8 12 14 15 16 17 18 20 21 23 24 25 26 27 28 33 34 35 36 37 38 39 40 42 44 45 46 48 50 51 52 53 54 56 57 58 59 61 62 63 64 65 67 68 69 70 71 72 73 74 75 76 77 78 79 80 82 83 84 85 86 93 94 95 98 99 A0 A1 A2 A3 A4 A6 A7 A8 A9 AB AC AD AE AF AG AI AJ AK AL AR BB BC BD BE BF BG BS
S		C023	Health Care Service Location Information
01	1331	Facility Type Code	R
02	1332	Facility Code Qualifier	R
	A B
03	1325	Claim Frequency Type Code	N
N		C024	Related Causes Information
06	1338	Level of Service Code	S
	03 U
07	1213	Current Health Condition Code	N
08	923	Prognosis Code	N
09	1363	Release of Information Code	N
10	1514	Delay Reason Code	N

HCR- Health Care Services Review

01	306	Certification Action Code	R
	A1 A3 A4 A6 CT NA
02	127	Certification Number	S
03	901	Reject Reason Code	S
	35 36 37 41 53 69 70 82 83 84 85 86 87 88 89 90 91 92 96 98 E8
04	1073	Second Surgical Opinion Indicator	S
	N Y

REF- Previous Certification Identification

01	128	Reference Identification Qualifier	R
	BB
02	127	Previous Certification Identifier	R
03	352	Description	N
N		C040	Reference Identifier

DTP- Service Date

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Proposed or Actual Service Date	R

DTP- Admission Date

01	374	Date Time Qualifier	R
	435
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Proposed or Actual Admission Date	R

DTP- Discharge Date

01	374	Date Time Qualifier	R
	096
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Proposed or Actual Discharge Date	R

DTP- Surgery Date

01	374	Date Time Qualifier	R
	456
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Proposed or Actual Surgery Date	R

DTP- Certification Issue Date

01	374	Date Time Qualifier	R
	102
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Certification Issue Date	R

DTP- Certification Expiration Date

01	374	Date Time Qualifier	R
	036
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Certification Expiration Date	R

DTP- Certification Effective Date

01	374	Date Time Qualifier	R
	007
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Certification Effective Date	R

HI- Procedures

R		C022	Procedure Code 1
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 2
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 3
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 4
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 5
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 6
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 7
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 8
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 9
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 10
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 11
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S
S		C022	Procedure Code 12
01	1270	Code List Qualifier Code	R
	ABR BO BQ JP LOI NDC ZZ
02	1271	Procedure Code	R
03	1250	Date Time Period Format Qualifier	S
	D8 RD8
04	1251	Procedure Date	S
05	782	Procedure Monetary Amount	S
06	380	Procedure Quantity	S
07	799	Version, Release, or Industry Identifier	S

HSD- Health Care Services Delivery

01	673	Quantity Qualifier	S
	DY FL HS MN VS
02	380	Service Unit Count	S
03	355	Unit or Basis for Measurement Code	S
	DA MO WK
04	1167	Sample Selection Modulus	S
05	615	Time Period Qualifier	S
	6 7 21 26 27 34 35
06	616	Period Count	S
07	678	Ship, Delivery or Calendar Pattern 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 SA SB SC SD SG SL SP SX SY SZ T U V W X Y
08	679	Delivery Pattern Time Code	S
	A B C D E F G Y

CL1- Institutional Claim Code

01	1315	Admission Type Code	S
02	1314	Admission Source Code	S
03	1352	Patient Status Code	S
04	1345	Nursing Home Residential Status Code	S
	1 2 3 4 5 6 7 8 9

CR1- Ambulance Transport Information

01	355	Unit or Basis for Measurement Code	N
02	81	Weight	N
03	1316	Ambulance Transport Code	R
	I R T X
04	1317	Ambulance Transport Reason Code	N
05	355	Unit or Basis for Measurement Code	S
	DH DK
06	380	Transport Distance	S
07	166	Ambulance Trip Origin Address	S
08	166	Ambulance Trip Destination Address	S
09	352	Description	N
10	352	Description	N

CR2- Spinal Manipulation Service Information

01	609	Treatment Series Number	S
02	380	Treatment Count	S
03	1367	Subluxation Level Code	S
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T10 T11 T12 T2 T3 T4 T5 T6 T7 T8 T9
04	1367	Subluxation Level Code	S
	C1 C2 C3 C4 C5 C6 C7 CO IL L1 L2 L3 L4 L5 OC SA T1 T10 T11 T12 T2 T3 T4 T5 T6 T7 T8 T9
05	355	Unit or Basis for Measurement Code	S
	DA MO WK YR
06	380	Treatment Period Count	S
07	380	Monthly Treatment Count	S
08	1342	Nature of Condition Code	N
09	1073	Yes/No Condition or Response Code	N
10	352	Description	N
11	352	Description	N
12	1073	Yes/No Condition or Response Code	N

CR5- Home Oxygen Therapy Information

01	1322	Certification Type Code	N
02	380	Quantity	N
03	1348	Oxygen Equipment Type Code	S
	A B C D E O
04	1348	Oxygen Equipment Type Code	S
	A B C D E O
05	352	Equipment Reason Description	S
06	380	Oxygen Flow Rate	R
07	380	Daily Oxygen Use Count	S
08	380	Oxygen Use Period Hour Count	S
09	352	Respiratory Therapist Order Text	S
10	380	Quantity	N
11	380	Quantity	N
12	1349	Oxygen Test Condition Code	N
13	1350	Oxygen Test Findings Code	N
14	1350	Oxygen Test Findings Code	N
15	1350	Oxygen Test Findings Code	N
16	380	Portable Oxygen System Flow Rate	S
17	1382	Oxygen Delivery System Code	R
	A B C D E
18	1348	Oxygen Equipment Type Code	S
	A B C D E O

CR6- Home Health Care Information

01	923	Prognosis Code	R
	1 2 3 4 5 6 7 8
02	373	Service From Date	R

03	1250	Date Time Period Format Qualifier	S
	RD8
04	1251	Home Health Certification Period	S
05	373	Date	N
06	1073	Yes/No Condition or Response Code	N
07	1073	Medicare Coverage Indicator	R
	N U Y
08	1322	Certification Type Code	R
	1 2 3 4 I R S
09	373	Date	N
10	235	Product/Service ID Qualifier	N
11	1137	Medical Code Value	N
12	373	Date	N
13	373	Date	N
14	373	Date	N
15	1250	Date Time Period Format Qualifier	N
16	1251	Date Time Period	N
17	1384	Patient Location Code	N
18	373	Date	N
19	373	Date	N
20	373	Date	N
21	373	Date	N

PWK- Additional Service Information

01	755	Attachment Report Type Code	R
	03 04 05 06 07 08 09 10 11 13 15 21 48 55 59 77 A3 A4 AM AS AT B2 B3 BR BS BT CB CK D2 DA DB DG DJ DS FM HC HR I5 IR LA M1 NN OB OC OD OE OX P4 P5 P6 P7 PE PN PO PQ PY PZ QC QR RB RR RT RX SG V5 XP
02	756	Attachment Transmission Code	R
	BM EL EM FX VO
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	S
	AC
06	67	Attachment Control Number	S
07	352	Attachment Description	S
N		C002	Actions Indicated
09	1525	Request Category Code	N

MSG- Message Text

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

NM1- Additional Service Information Contact Name

01	98	Entity Identifier Code	R
	1P 2B ABG FA PR X3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Response Contact Last or Organization Name	S
04	1036	Response Contact First Name	S
05	1037	Response Contact Middle Name	S
06	1038	Name Prefix	N
07	1039	Response Contact Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 46 PI XV XX
09	67	Response Contact Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Additional Service Information Contact Address

01	166	Response Contact Address Line	R
02	166	Response Contact Address Line	S

N4- Additional Service Information Contact City/State/Zip Code

01	19	Response Contact City Name	S
02	156	Response Contact State or Province Code	S
	External Source: states
03	116	Response Contact Postal Zone or ZIP Code	S
04	26	Response Contact Country Code	S
	External Source: country
05	309	Location Qualifier	S
	B1 DP
06	310	Response Contact Specific Location	S

PER- Additional Service Information Contact Information

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

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