001

ISA_LOOP - Interchange Control Header

020 GS_LOOP - Functional Group Header 020 ST_LOOP - Transaction Set Header 010 HEADER - Table 1 - Header 070 1000A - Sponsor Name 070 1000B - Payer 070 1000C - TPA/Broker Name 120 1100C - TPA/Broker Account Information 020 DETAIL - Table 2 - Detail 010 2000 - Member Level Detail 030 2100A - Member Name 030 2100B - Incorrect Member Name 030 2100C - Member Mailing Address 030 2100D - Member Employer 030 2100E - Member School 030 2100F - Custodial Parent 030 2100G - Responsible Person 200 2200 - Disability Information 260 2300 - Health Coverage 310 2310 - Provider Information 400 2320 - Coordination of Benefits 030 FOOTER - Table 3 - Footer