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 |
|
|
RA |
| 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 |
|
|
004010X061 |
ST-
820 Header
| 01 |
143 |
Transaction Set Identifier Code |
R |
|
|
820 |
| 02 |
329 |
Transaction Set Control Number |
R |
|
BPR-
Financial Information
| 01 |
305 |
Transaction Handling Code |
R |
|
|
C D I P U X |
| 02 |
782 |
Total Premium Payment Amount |
R |
|
| 03 |
478 |
Credit or Debit Flag Code |
R |
|
|
C D |
| 04 |
591 |
Payment Method Code |
R |
|
|
ACH BOP CHK FWT SWT |
| 05 |
812 |
Payment Format Code |
S |
|
|
CCP CTX |
| 06 |
506 |
Depository Financial Institution (DFI) Identification Number Qualifier |
S |
|
|
01 04 |
| 07 |
507 |
Originating Depository Financial Institution (DFI) Identifier |
S |
|
| 08 |
569 |
Account Number Qualifier |
S |
|
|
DA ALC |
| 09 |
508 |
Sender Bank Account Number |
S |
|
| 10 |
509 |
Originating Company Identifier |
S |
|
| 11 |
510 |
Originating Company Supplemental Code |
S |
|
| 12 |
506 |
Depository Financial Institution (DFI) Identification Number Qualifier |
S |
|
|
01 04 |
| 13 |
507 |
Receiving Depository Financial Institution (DFI) Identifier |
S |
|
| 14 |
569 |
Account Number Qualifier |
S |
|
|
DA SG |
| 15 |
508 |
Receiver Bank Account Number |
S |
|
| 16 |
373 |
Check Issue or EFT Effective Date |
R |
|
|
|
| 17 |
1048 |
Business Function Code |
N |
|
| 18 |
506 |
(DFI) ID Number Qualifier |
N |
|
| 19 |
507 |
(DFI) Identification Number |
N |
|
| 20 |
569 |
Account Number Qualifier |
N |
|
| 21 |
508 |
Account Number |
N |
|
TRN-
Reassociation Key
| 01 |
481 |
Trace Type Code |
R |
|
|
1 3 |
| 02 |
127 |
Check or EFT Trace Number |
R |
|
| 03 |
509 |
Originating Company Identifier |
S |
|
| 04 |
127 |
Originating Company Supplemental Code |
S |
|
CUR-
Non-US Dollars Currency
| 01 |
98 |
Entity Identifier Code |
R |
|
|
2B PR |
| 02 |
100 |
Currency Code |
R |
|
|
MXP CAD USD |
| 03 |
280 |
Exchange Rate |
S |
|
| 04 |
98 |
Entity Identifier Code |
N |
|
| 05 |
100 |
Currency Code |
N |
|
| 06 |
669 |
Currency Market/Exchange Code |
N |
|
| 07 |
374 |
Date/Time Qualifier |
N |
|
| 08 |
373 |
Date |
N |
|
| 09 |
337 |
Time |
N |
|
| 10 |
374 |
Date/Time Qualifier |
N |
|
| 11 |
373 |
Date |
N |
|
| 12 |
337 |
Time |
N |
|
| 13 |
374 |
Date/Time Qualifier |
N |
|
| 14 |
373 |
Date |
N |
|
| 15 |
337 |
Time |
N |
|
| 16 |
374 |
Date/Time Qualifier |
N |
|
| 17 |
373 |
Date |
N |
|
| 18 |
337 |
Time |
N |
|
| 19 |
374 |
Date/Time Qualifier |
N |
|
| 20 |
373 |
Date |
N |
|
| 21 |
337 |
Time |
N |
|
REF-
Premium Receivers Identification Key
| 01 |
128 |
Reference Identification Qualifier |
R |
|
|
14 18 2F 38 72 |
| 02 |
127 |
Premium Receiver Reference Identifier |
R |
|
| 03 |
352 |
Description |
N |
|
| N |
|
C040 |
Reference Identifier |
|
DTM-
Process Date
| 01 |
374 |
Date Time Qualifier |
R |
|
|
009 |
| 02 |
373 |
Payer Process Date |
R |
|
|
|
| 03 |
337 |
Time |
N |
|
| 04 |
623 |
Time Code |
N |
|
| 05 |
1250 |
Date Time Period Format Qualifier |
N |
|
| 06 |
1251 |
Date Time Period |
N |
|
DTM-
Delivery Date
| 01 |
374 |
Date Time Qualifier |
R |
|
|
035 |
| 02 |
373 |
Premium Delivery Date |
R |
|
|
|
| 03 |
337 |
Time |
N |
|
| 04 |
623 |
Time Code |
N |
|
| 05 |
1250 |
Date Time Period Format Qualifier |
N |
|
| 06 |
1251 |
Date Time Period |
N |
|
DTM-
Coverage Period
| 01 |
374 |
Date Time Qualifier |
R |
|
|
582 |
| 02 |
373 |
Date |
N |
|
| 03 |
337 |
Time |
N |
|
| 04 |
623 |
Time Code |
N |
|
| 05 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
| 06 |
1251 |
Coverage Period |
R |
|
N1-
Premium Receiver's Name
| 01 |
98 |
Entity Identifier Code |
R |
|
|
PE |
| 02 |
93 |
Information Receiver Last or Organization Name |
S |
|
| 03 |
66 |
Identification Code Qualifier |
S |
|
|
1 9 EQ FI XV |
| 04 |
67 |
Receiver Identifier |
S |
|
| 05 |
706 |
Entity Relationship Code |
N |
|
| 06 |
98 |
Entity Identifier Code |
N |
|
N2-
Premium Receiver Additional Name
| 01 |
93 |
Receiver Additional Name |
R |
|
| 02 |
93 |
Name |
N |
|
N3-
Premium Receiver's Address
| 01 |
166 |
Receiver Address Line |
R |
|
| 02 |
166 |
Receiver Address Line |
S |
|
N4-
Premium Receiver's City, State, ZIP
| 01 |
19 |
Information Receiver City Name |
R |
|
| 02 |
156 |
Information Receiver State Code |
R |
|
|
External Source: states |
| 03 |
116 |
Information Receiver Postal Zone or ZIP Code |
R |
|
| 04 |
26 |
Country Code |
S |
|
|
External Source: country |
| 05 |
309 |
Location Qualifier |
N |
|
| 06 |
310 |
Location Identifier |
N |
|
N1-
Premium Payer's Name
| 01 |
98 |
Entity Identifier Code |
R |
|
|
PR |
| 02 |
93 |
Premium Payer Name |
S |
|
| 03 |
66 |
Identification Code Qualifier |
S |
|
|
1 9 24 75 EQ FI PI |
| 04 |
67 |
Premium Payer Identifier |
S |
|
| 05 |
706 |
Entity Relationship Code |
N |
|
| 06 |
98 |
Entity Identifier Code |
N |
|
N2-
Premium Payer Additional Name
| 01 |
93 |
Premium Payer Additional Name |
R |
|
| 02 |
93 |
Name |
N |
|
N3-
Premium Payer's Address
| 01 |
166 |
Premium Payer Address Line |
R |
|
| 02 |
166 |
Premium Payer Address Line |
S |
|
N4-
Premium Payer's City, State, ZIP
| 01 |
19 |
Premium Payer City Name |
R |
|
| 02 |
156 |
Premium Payer State Code |
R |
|
|
External Source: states |
| 03 |
116 |
Premium Payer Postal Zone or ZIP Code |
R |
|
| 04 |
26 |
Country Code |
S |
|
|
External Source: country |
| 05 |
309 |
Location Qualifier |
N |
|
| 06 |
310 |
Location Identifier |
N |
|
PER-
Premium Payer's Administrative Contact
| 01 |
366 |
Contact Function Code |
R |
|
|
IC |
| 02 |
93 |
Premium Payer Contact Name |
R |
|
| 03 |
365 |
Communication Number Qualifier |
S |
|
|
EM FX TE |
| 04 |
364 |
Communication Number |
S |
|
| 05 |
365 |
Communication Number Qualifier |
S |
|
|
EM EX FX TE |
| 06 |
364 |
Communication Number |
S |
|
| 07 |
365 |
Communication Number Qualifier |
S |
|
|
EM EX FX TE |
| 08 |
364 |
Communication Number |
S |
|
| 09 |
443 |
Contact Inquiry Reference |
N |
|
ENT-
Organization Summary Remittance
| 01 |
554 |
Assigned Number |
R |
|
| 02 |
98 |
Entity Identifier Code |
R |
|
|
2L |
| 03 |
66 |
Identification Code Qualifier |
S |
|
|
1 9 FI |
| 04 |
67 |
Organization Identification Code |
S |
|
| 05 |
98 |
Entity Identifier Code |
N |
|
| 06 |
66 |
Identification Code Qualifier |
N |
|
| 07 |
67 |
Identification Code |
N |
|
| 08 |
128 |
Reference Identification Qualifier |
N |
|
| 09 |
127 |
Reference Identification |
N |
|
RMR-
Organization Summary Remittance Detail
| 01 |
128 |
Reference Identification Qualifier |
R |
|
|
11 1L CT IK |
| 02 |
127 |
Contract, Invoice, Account, Group, or Policy Number |
R |
|
| 03 |
482 |
Payment Action Code |
S |
|
|
PA PI PO PP |
| 04 |
782 |
Detail Premium Payment Amount |
R |
|
| 05 |
782 |
Billed Premium Amount |
S |
|
| 06 |
782 |
Monetary Amount |
N |
|
| 07 |
426 |
Adjustment Reason Code |
N |
|
| 08 |
782 |
Monetary Amount |
N |
|
IT1-
Summary Line Item
| 01 |
350 |
Line Item Control Number |
R |
|
| 02 |
358 |
Quantity Invoiced |
N |
|
| 03 |
355 |
Unit or Basis for Measurement Code |
N |
|
| 04 |
212 |
Unit Price |
N |
|
| 05 |
639 |
Basis of Unit Price Code |
N |
|
| 06 |
235 |
Product/Service ID Qualifier |
N |
|
| 07 |
234 |
Product/Service ID |
N |
|
| 08 |
235 |
Product/Service ID Qualifier |
N |
|
| 09 |
234 |
Product/Service ID |
N |
|
| 10 |
235 |
Product/Service ID Qualifier |
N |
|
| 11 |
234 |
Product/Service ID |
N |
|
| 12 |
235 |
Product/Service ID Qualifier |
N |
|
| 13 |
234 |
Product/Service ID |
N |
|
| 14 |
235 |
Product/Service ID Qualifier |
N |
|
| 15 |
234 |
Product/Service ID |
N |
|
| 16 |
235 |
Product/Service ID Qualifier |
N |
|
| 17 |
234 |
Product/Service ID |
N |
|
| 18 |
235 |
Product/Service ID Qualifier |
N |
|
| 19 |
234 |
Product/Service ID |
N |
|
| 20 |
235 |
Product/Service ID Qualifier |
N |
|
| 21 |
234 |
Product/Service ID |
N |
|
| 22 |
235 |
Product/Service ID Qualifier |
N |
|
| 23 |
234 |
Product/Service ID |
N |
|
| 24 |
235 |
Product/Service ID Qualifier |
N |
|
| 25 |
234 |
Product/Service ID |
N |
|
SLN-
Member Count
| 01 |
350 |
Line Item Control Number |
R |
|
| 02 |
350 |
Assigned Identification |
N |
|
| 03 |
662 |
Information Only Indicator |
R |
|
|
O |
| 04 |
380 |
Head Count |
R |
|
| R |
|
C001 |
Composite Unit of Measure |
|
| 01 |
355 |
Unit or Basis for Measurement Code |
R |
|
|
10 IE PR |
| 02 |
1018 |
Exponent |
N |
|
| 03 |
649 |
Multiplier |
N |
|
| 04 |
355 |
Unit or Basis for Measurement Code |
N |
|
| 05 |
1018 |
Exponent |
N |
|
| 06 |
649 |
Multiplier |
N |
|
| 07 |
355 |
Unit or Basis for Measurement Code |
N |
|
| 08 |
1018 |
Exponent |
N |
|
| 09 |
649 |
Multiplier |
N |
|
| 10 |
355 |
Unit or Basis for Measurement Code |
N |
|
| 11 |
1018 |
Exponent |
N |
|
| 12 |
649 |
Multiplier |
N |
|
| 13 |
355 |
Unit or Basis for Measurement Code |
N |
|
| 14 |
1018 |
Exponent |
N |
|
| 15 |
649 |
Multiplier |
N |
|
| 06 |
212 |
Unit Price |
N |
|
| 07 |
639 |
Basis of Unit Price Code |
N |
|
| 08 |
662 |
Relationship Code |
N |
|
| 09 |
235 |
Product/Service ID Qualifier |
N |
|
| 10 |
234 |
Product/Service ID |
N |
|
| 11 |
235 |
Product/Service ID Qualifier |
N |
|
| 12 |
234 |
Product/Service ID |
N |
|
| 13 |
235 |
Product/Service ID Qualifier |
N |
|
| 14 |
234 |
Product/Service ID |
N |
|
| 15 |
235 |
Product/Service ID Qualifier |
N |
|
| 16 |
234 |
Product/Service ID |
N |
|
| 17 |
235 |
Product/Service ID Qualifier |
N |
|
| 18 |
234 |
Product/Service ID |
N |
|
| 19 |
235 |
Product/Service ID Qualifier |
N |
|
| 20 |
234 |
Product/Service ID |
N |
|
| 21 |
235 |
Product/Service ID Qualifier |
N |
|
| 22 |
234 |
Product/Service ID |
N |
|
| 23 |
235 |
Product/Service ID Qualifier |
N |
|
| 24 |
234 |
Product/Service ID |
N |
|
| 25 |
235 |
Product/Service ID Qualifier |
N |
|
| 26 |
234 |
Product/Service ID |
N |
|
| 27 |
235 |
Product/Service ID Qualifier |
N |
|
| 28 |
234 |
Product/Service ID |
N |
|
ADX-
Organization Summary Remittance Level Adjustment
| 01 |
782 |
Adjustment Amount |
R |
|
| 02 |
426 |
Adjustment Reason Code |
R |
|
|
20 52 53 AA H1 H6 IA J3 |
| 03 |
128 |
Reference Identification Qualifier |
N |
|
| 04 |
127 |
Reference Identification |
N |
|
ENT-
Individual Remittance
| 01 |
554 |
Assigned Number |
R |
|
| 02 |
98 |
Entity Identifier Code |
R |
|
|
2J |
| 03 |
66 |
Identification Code Qualifier |
R |
|
|
34 EI ZZ |
| 04 |
67 |
Receiver's Individual Identifier |
R |
|
| 05 |
98 |
Entity Identifier Code |
N |
|
| 06 |
66 |
Identification Code Qualifier |
N |
|
| 07 |
67 |
Identification Code |
N |
|
| 08 |
128 |
Reference Identification Qualifier |
N |
|
| 09 |
127 |
Reference Identification |
N |
|
NM1-
Individual Name
| 01 |
98 |
Entity Identifier Code |
R |
|
|
EY QE |
| 02 |
1065 |
Entity Type Qualifier |
R |
|
|
1 |
| 03 |
1035 |
Individual Last Name |
S |
|
| 04 |
1036 |
Individual First Name |
S |
|
| 05 |
1037 |
Individual Middle Name |
S |
|
| 06 |
1038 |
Individual Name Prefix |
S |
|
| 07 |
1039 |
Individual Name Suffix |
S |
|
| 08 |
66 |
Identification Code Qualifier |
S |
|
|
34 EI N |
| 09 |
67 |
Individual Identifier |
S |
|
| 10 |
706 |
Entity Relationship Code |
N |
|
| 11 |
98 |
Entity Identifier Code |
N |
|
RMR-
Individual Premium Remittance Detail
| 01 |
128 |
Reference Identification Qualifier |
R |
|
|
11 9J AZ B7 CT ID IG IK KW |
| 02 |
127 |
Insurance Remittance Reference Number |
R |
|
| 03 |
482 |
Payment Action Code |
S |
|
|
PI PP |
| 04 |
782 |
Detail Premium Payment Amount |
R |
|
| 05 |
782 |
Billed Premium Amount |
S |
|
| 06 |
782 |
Monetary Amount |
N |
|
| 07 |
426 |
Adjustment Reason Code |
N |
|
| 08 |
782 |
Monetary Amount |
N |
|
DTM-
Individual Coverage Period
| 01 |
374 |
Date Time Qualifier |
R |
|
|
582 |
| 02 |
373 |
Date |
N |
|
| 03 |
337 |
Time |
N |
|
| 04 |
623 |
Time Code |
N |
|
| 05 |
1250 |
Date Time Period Format Qualifier |
R |
|
|
RD8 |
| 06 |
1251 |
Coverage Period |
R |
|
ADX-
Individual Premium Adjustment
| 01 |
782 |
Adjustment Amount |
R |
|
| 02 |
426 |
Adjustment Reason Code |
R |
|
|
20 52 53 AA AX H1 H6 IA J3 |
| 03 |
128 |
Reference Identification Qualifier |
N |
|
| 04 |
127 |
Reference Identification |
N |
|
SE-
820 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 |
|