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 - Utilization Management Organization (UMO) Level 010 HL Utilization Management Organization (UMO) Level R 1 170 2010A - Utilization Management Organizational (UMO) Name 170 NM1 Utilization Management Organizational (UMO) Name R 1 180 2000B - Requester Level 010 HL Requester Level R 1 170 2010B - Requester Name 170 NM1 Requester Name R 1 180 REF Requester Supplemental Identification S 8 200 N3 Requester Address S 1 210 N4 Requester City/State/ZIP Code S 1 220 PER Requester Contact Information S 1 240 PRV Requester Provider Information S 1 180 2000C - Subscriber Level 010 HL Subscriber Level R 1 020 TRN Patient Event Tracking Number S 2 070 DTP Accident Date S 1 070 DTP Last Menstrual Period Date S 1 070 DTP Estimated Date of Birth S 1 070 DTP Onset of Current Symptoms or Illness Date S 1 080 HI Subscriber Diagnosis S 1 155 PWK Additional Patient Information S 10 170 2010CA - Subscriber Name 170 NM1 Subscriber Name R 1 180 REF Subscriber Supplemental Identification S 9 250 DMG Subscriber Demographic Information S 1 180 2000D - Dependent Level 010 HL Dependent Level R 1 020 TRN Patient Event Tracking Number S 2 070 DTP Accident Date S 1 070 DTP Last Menstrual Period Date S 1 070 DTP Estimated Date of Birth S 1 070 DTP Onset of Current Symptoms or Illness Date S 1 080 HI Dependent Diagnosis S 1 155 PWK Additional Patient Information S 10 170 2010DA - Dependent Name 170 NM1 Dependent Name R 1 180 REF Dependent Supplemental Identification S 3 250 DMG Dependent Demographic Information S 1 260 INS Dependent Relationship S 1 180 2000E - Service Provider Level 010 HL Service Provider Level R 1 160 MSG Message Text S 1 170 2010E - Service Provider Name 170 NM1 Service Provider Name R 1 180 REF Service Provider Supplemental Identification S 7 200 N3 Service Provider Address S 1 210 N4 Service Provider City/State/ZIP Code S 1 220 PER Service Provider Contact Information S 1 240 PRV Service Provider Information S 1 180 2000F - Service Level 010 HL Service Level R 1 020 TRN Service Trace Number S 2 040 UM Health Care Services Review Information R 1 060 REF Previous Certification Identification S 1 070 DTP Service Date S 1 070 DTP Admission Date S 1 070 DTP Discharge Date S 1 070 DTP Surgery Date S 1 080 HI Procedures S 1 090 HSD Health Care Services Delivery S 1 100 CRC Patient Condition Information S 6 110 CL1 Institutional Claim Code S 1 120 CR1 Ambulance Transport Information S 1 130 CR2 Spinal Manipulation Service Information S 1 140 CR5 Home Oxygen Therapy Information S 1 150 CR6 Home Health Care Information S 1 155 PWK Additional Service Information S 10 160 MSG Message Text S 1 030 FOOTER - Table 3 - Footer 280 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