| 020 |
ST_LOOP - Transaction Set Header |
| 015 |
HEADER - Table 1 - Header |
| 070 |
1000A - Premium Receiver's Name |
|
| 070 |
1000B - Premium Payer's Name |
|
|
| 020 |
DETAIL - Table 2 - Detail |
| 010 |
2000A - Organization Summary Remittance |
| 150 |
2300A - Organization Summary Remittance Detail |
| 190 |
2310A - Summary Line Item |
|
|
| 210 |
2320A - Organization Summary Remittance Level Adjustment |
|
|
|
| 160 |
2000B - Individual Remittance |
| 020 |
2100B - Individual Name |
|
| 150 |
2300B - Individual Premium Remittance Detail |
| 210 |
2320B - Individual Premium Adjustment |
|
|
|
|
| 030 |
FOOTER - Table 3 - Footer |
|