| 020 |
|
ST_LOOP - Transaction Set Header |
|
|
| 010 |
ST |
820 Header |
R |
1 |
|
| 015 |
|
HEADER - Table 1 - Header |
|
|
| 020 |
BPR |
Financial Information |
R |
1 |
|
| 035 |
TRN |
Reassociation Key |
R |
1 |
|
| 040 |
CUR |
Non-US Dollars Currency |
S |
1 |
|
| 050 |
REF |
Premium Receivers Identification Key |
S |
>1 |
|
| 060 |
DTM |
Process Date |
S |
1 |
|
| 060 |
DTM |
Delivery Date |
S |
1 |
|
| 060 |
DTM |
Coverage Period |
S |
1 |
|
| 070 |
|
1000A - Premium Receiver's Name |
|
1 |
| 070 |
N1 |
Premium Receiver's Name |
R |
1 |
|
| 080 |
N2 |
Premium Receiver Additional Name |
S |
1 |
|
| 090 |
N3 |
Premium Receiver's Address |
S |
1 |
|
| 100 |
N4 |
Premium Receiver's City, State, ZIP |
S |
1 |
|
|
| 070 |
|
1000B - Premium Payer's Name |
|
1 |
| 070 |
N1 |
Premium Payer's Name |
R |
1 |
|
| 080 |
N2 |
Premium Payer Additional Name |
S |
1 |
|
| 090 |
N3 |
Premium Payer's Address |
S |
1 |
|
| 100 |
N4 |
Premium Payer's City, State, ZIP |
S |
1 |
|
| 120 |
PER |
Premium Payer's Administrative Contact |
S |
>1 |
|
|
|
| 020 |
|
DETAIL - Table 2 - Detail |
|
|
| 010 |
|
2000A - Organization Summary Remittance |
|
1 |
| 010 |
ENT |
Organization Summary Remittance |
R |
1 |
|
| 150 |
|
2300A - Organization Summary Remittance Detail |
|
>1 |
| 150 |
RMR |
Organization Summary Remittance Detail |
R |
1 |
|
| 190 |
|
2310A - Summary Line Item |
|
1 |
| 190 |
IT1 |
Summary Line Item |
R |
1 |
|
| 204 |
|
2315A - Member Count |
|
>1 |
| 204 |
SLN |
Member Count |
R |
1 |
|
|
|
| 210 |
|
2320A - Organization Summary Remittance Level Adjustment |
|
>1 |
| 210 |
ADX |
Organization Summary Remittance Level Adjustment |
R |
1 |
|
|
|
|
| 160 |
|
2000B - Individual Remittance |
|
>1 |
| 010 |
ENT |
Individual Remittance |
R |
1 |
|
| 020 |
|
2100B - Individual Name |
|
>1 |
| 020 |
NM1 |
Individual Name |
R |
1 |
|
|
| 150 |
|
2300B - Individual Premium Remittance Detail |
|
>1 |
| 150 |
RMR |
Individual Premium Remittance Detail |
R |
1 |
|
| 180 |
DTM |
Individual Coverage Period |
S |
1 |
|
| 210 |
|
2320B - Individual Premium Adjustment |
|
>1 |
| 210 |
ADX |
Individual Premium Adjustment |
R |
1 |
|
|
|
|
|
| 030 |
|
FOOTER - Table 3 - Footer |
|
|
|
| 010 |
SE |
820 Trailer |
R |
1 |
|