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
	BE
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
	004010X095A1

ST- Transaction Set Header

01	143	Transaction Set Identifier Code	R
	834
02	329	Transaction Set Control Number	R

BGN- Beginning Segment C0504

01	353	Transaction Set Purpose Code	R
	00 15 22
02	127	Transaction Set Identifier Code	R
03	373	Transaction Set Creation Date	R
04	337	Transaction Set Creation Time	R
05	623	Time Zone Code	S
	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 AD AS AT CD CS CT ED ES ET GM HD HS HT LT MD MS MT ND NS NT PD PS PT TD TS TT UT
06	127	Transaction Set Identifier Code	S
07	640	Transaction Type Code	N
08	306	Action Code	R
	2 4
09	786	Security Level Code	N

REF- Transaction Set Policy Number R0203

01	128	Reference Identification Qualifier	R
	38
02	127	Master Policy Number	R
03	352	Description	N
N		C040	Reference Identifier

DTP- File Effective Date

01	374	Date Time Qualifier	R
	007 303 382 388
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Date Time Period	R

N1- Sponsor Name R0203 P0304

01	98	Entity Identifier Code	R
	P5
02	93	Plan Sponsor Name	S
03	66	Identification Code Qualifier	R
	FI ZZ
04	67	Sponsor Identifier	R
05	706	Entity Relationship Code	N
06	98	Entity Identifier Code	N

N1- Payer R0203 P0304

01	98	Entity Identifier Code	R
	IN
02	93	Insurer Name	S
03	66	Identification Code Qualifier	R
	FI XV
04	67	Insurer Identification Code	R
05	706	Entity Relationship Code	N
06	98	Entity Identifier Code	N

N1- TPA/Broker Name R0203 P0304

01	98	Entity Identifier Code	R
	BO TV
02	93	TPA or Broker Name	R
03	66	Identification Code Qualifier	R
	94 FI XV
04	67	TPA or Broker Identification Code	R
05	706	Entity Relationship Code	N
06	98	Entity Identifier Code	N

ACT- TPA/Broker Account Information P0304 C0506 C0705

01	508	TPA or Broker Account Number	R
02	93	Name	N
03	66	Identification Code Qualifier	N
04	67	Identification Code	N
05	569	Account Number Qualifier	N
06	508	TPA or Broker Account Number	S
07	352	Description	N
08	107	Payment Method Code	N
09	1216	Benefit Status Code	N

INS- Member Level Detail P1112

01	1073	Insured Indicator	R
	N Y
02	1069	Individual Relationship Code	R
	01 03 04 05 06 07 08 09 10 11 12 13 14 15 17 18 19 23 24 25 26 31 32 33 38 48 49 53
03	875	Maintenance Type Code	R
	001 021 024 025 030
04	1203	Maintenance Reason Code	S
	01 02 03 04 05 06 07 08 09 10 11 14 15 16 17 18 20 21 22 25 26 27 28 29 31 32 33 37 38 39 40 41 43 AI XN XT
05	1216	Benefit Status Code	R
	A C S T
06	1218	Medicare Plan Code	S
	A B C D E
07	1219	Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code	S
	1 2 3 4 5 6 7 8
08	584	Employment Status Code	S
	AO AU FT L1 PT RT TE
09	1220	Student Status Code	S
	F N P
10	1073	Handicap Indicator	S
	N Y
11	1250	Date Time Period Format Qualifier	S
	D8
12	1251	Insured Individual Death Date	S
13	1165	Confidentiality Code	N
14	19	City Name	N
15	156	State or Province Code	N
16	26	Country Code	N
17	1470	Birth Sequence Number	S

REF- Subscriber Number R0203

01	128	Reference Identification Qualifier	R
	0F
02	127	Subscriber Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Member Policy Number R0203

01	128	Reference Identification Qualifier	R
	1L
02	127	Insured Group or Policy Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Member Identification Number R0203

01	128	Reference Identification Qualifier	R
	17 23 3H 6O DX F6 Q4 ZZ
02	127	Subscriber Supplemental Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Prior Coverage Months R0203

01	128	Reference Identification Qualifier	R
	QQ
02	127	Prior Coverage Month Count	R
03	352	Description	N
N		C040	Reference Identifier

DTP- Member Level Dates

01	374	Date Time Qualifier	R
	286 296 297 300 301 303 336 337 338 339 340 341 350 351 356 357 383 393 394 473 474
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Status Information Effective Date	R

NM1- Member Name P0809 C1110

01	98	Entity Identifier Code	R
	74 IL
02	1065	Entity Type Qualifier	R
	1
03	1035	Subscriber Last Name	R
04	1036	Subscriber First Name	R
05	1037	Subscriber Middle Name	S
06	1038	Subscriber Name Prefix	S
07	1039	Subscriber Name Suffix	S
08	66	Identification Code Qualifier	S
	34 ZZ
09	67	Subscriber Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Member Communications Numbers P0304 P0506 P0708

01	366	Contact Function Code	R
	IP
02	93	Name	N
03	365	Communication Number Qualifier	R
	EM EX FX HP TE WP
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	EM EX FX HP TE WP
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	EM EX FX HP TE WP
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

N3- Member Residence Street Address

01	166	Subscriber Address Line	R
02	166	Subscriber Address Line	S

N4- Member Residence City, State, Zip Code C0605

01	19	Subscriber City Name	R
02	156	Subscriber State Code	R
	External Source: states
03	116	Subscriber Postal Zone or ZIP Code	R
04	26	Country Code	S
05	309	Location Qualifier	S
	60 CY
06	310	Location Identification Code	S

DMG- Member Demographics P0102

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Member Birth Date	R
03	1068	Gender Code	R
	F M U
04	1067	Marital Status Code	S
	B D I M R S U W X
05	1109	Race or Ethnicity Code	S
	7 8 A B C D E F G H I J N O P Z
06	1066	Citizenship Status Code	S
	1 2 3 4 5 6 7
07	26	Country Code	N
08	659	Basis of Verification Code	N
09	380	Quantity	N

ICM- Member Income

01	594	Frequency Code	R
	1 2 3 4 6 7 8 9 B C H Q S U
02	782	Wage Amount	R
03	380	Work Hours Count	S
04	310	Location Identification Code	S
05	1214	Salary Grade Code	S
06	100	Currency Code	N

AMT- Member Policy Amounts

01	522	Amount Qualifier Code	R
	B9 C1 D2 P3
02	782	Contract Amount	R
03	478	Credit/Debit Flag Code	N

HLH- Member Health Information

01	1212	Health Related Code	S
	N S T U X
02	65	Member Height	S
03	81	Member Weight	S
04	81	Weight	N
05	352	Description	N
06	1213	Current Health Condition Code	N
07	352	Description	N

LUI- Member Language P0102 L040203

01	66	Identification Code Qualifier	S
	LD LE
02	67	Language Code	S
03	352	Language Description	S
04	1303	Language Use Indicator	S
	5 7 8
05	1476	Language Proficiency Indicator	N

NM1- Incorrect Member Name P0809 C1110

01	98	Entity Identifier Code	R
	70
02	1065	Entity Type Qualifier	R
	1
03	1035	Prior Incorrect Insured Last Name	R
04	1036	Prior Incorrect Insured First Name	R
05	1037	Prior Incorrect Insured Middle Name	S
06	1038	Prior Incorrect Insured Name Prefix	S
07	1039	Prior Incorrect Insured Name Suffix	S
08	66	Identification Code Qualifier	S
	34 ZZ
09	67	Prior Incorrect Insured Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

DMG- Incorrect Member Demographics P0102

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Prior Incorrect Insured Birth Date	R
03	1068	Prior Incorrect Insured Gender Code	R
	F M U
04	1067	Marital Status Code	N
05	1109	Race or Ethnicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
08	659	Basis of Verification Code	N
09	380	Quantity	N

NM1- Member Mailing Address P0809 C1110

01	98	Entity Identifier Code	R
	31
02	1065	Entity Type Qualifier	R
	1
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Member Mail Street Address

01	166	Subscriber Address Line	R
02	166	Subscriber Address Line	S

N4- Member Mail City, State, Zip C0605

01	19	Subscriber City Name	R
02	156	Subscriber State Code	R
	External Source: states
03	116	Subscriber Postal Zone or ZIP Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

NM1- Member Employer P0809 C1110

01	98	Entity Identifier Code	R
	ES
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Insured Employer Name	S
04	1036	Insured Employer First Name	S
05	1037	Insured Employer Middle Name	S
06	1038	Name Prefix	N
07	1039	Insured Employer Name Suffix	S
08	66	Identification Code Qualifier	S
	ZZ
09	67	Insured Employer Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Member Employer Communications Numbers P0304 P0506 P0708

01	366	Contact Function Code	R
	EP
02	93	Name	N
03	365	Communication Number Qualifier	R
	EM EX FX TE
04	364	Communication Number	R
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

N3- Member Employer Street Address

01	166	Insured Employer Address Line	R
02	166	Insured Employer Address Line	S

N4- Member Employer City, State, Zip C0605

01	19	Insured Employer City Name	R
02	156	Insured Employer State Code	R
	External Source: states
03	116	Insured Employer Postal Zone or ZIP Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

NM1- Member School P0809 C1110

01	98	Entity Identifier Code	R
	M8
02	1065	Entity Type Qualifier	R
	2
03	1035	School Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Member School Communications Numbers P0304 P0506 P0708

01	366	Contact Function Code	R
	SK
02	93	Name	N
03	365	Communication Number Qualifier	R
	EM EX FX TE
04	364	Communication Number	R
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

N3- Member School Street Address

01	166	School Address Line	R
02	166	School Address Line	S

N4- Member School City, State, Zip C0605

01	19	School City Name	R
02	156	School State Code	R
	External Source: states
03	116	School Postal Zone or ZIP Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

NM1- Custodial Parent P0809 C1110

01	98	Entity Identifier Code	R
	S3
02	1065	Entity Type Qualifier	R
	1
03	1035	Custodial Parent Last Name	R
04	1036	Custodial Parent First Name	R
05	1037	Custodial Parent Middle Name	S
06	1038	Custodial Parent Name Prefix	S
07	1039	Custodial Parent Name Suffix	S
08	66	Identification Code Qualifier	S
	34 ZZ
09	67	Custodial Parent Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Custodial Parent Communications Numbers P0304 P0506 P0708

01	366	Contact Function Code	R
	PQ
02	93	Name	N
03	365	Communication Number Qualifier	R
	EM EX FX HP TE WP
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	EM EX FX HP TE WP
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	EM EX HP TE WP
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

N3- Custodial Parent Street Address

01	166	Custodial Parent Address Line	R
02	166	Custodial Parent Address Line	S

N4- Custodial Parent City, State, Zip C0605

01	19	Custodial Parent City Name	R
02	156	Custodial Parent State Code	R
	External Source: states
03	116	Custodial Parent Postal Zone or ZIP Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

NM1- Responsible Person P0809 C1110

01	98	Entity Identifier Code	R
	E1 EI EXS GD J6 QD
02	1065	Entity Type Qualifier	R
	1
03	1035	Responsible Party Last or Organization Name	R
04	1036	Responsible Party First Name	R
05	1037	Responsible Party Middle Name	S
06	1038	Responsible Party Name Prefix	S
07	1039	Responsible Party Suffix Name	S
08	66	Identification Code Qualifier	S
	34 ZZ
09	67	Responsible Party Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Responsible Person Communications Numbers P0304 P0506 P0708

01	366	Contact Function Code	R
	RP
02	93	Name	N
03	365	Communication Number Qualifier	R
	EM EX FX HP TE WP
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	EM EX FX HP TE WP
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	EM EX FX HP TE WP
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

N3- Responsible Person Street Address

01	166	Responsible Party Address Line	R
02	166	Responsible Party Address Line	S

N4- Responsible Person City, State, Zip C0605

01	19	Responsible Party City Name	R
02	156	Responsible Party State Code	R
	External Source: states
03	116	Responsible Party Postal Zone or ZIP Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

DSB- Disability Information P0708

01	1146	Disability Type Code	R
	1 2 3 4
02	380	Quantity	N
03	1149	Occupation Code	N
04	1154	Work Intensity Code	N
05	1161	Product Option Code	N
06	782	Monetary Amount	N
07	235	Product or Service ID Qualifier	S
	DX
08	1137	Diagnosis Code	S

DTP- Disability Eligibility Dates

01	374	Date Time Qualifier	R
	360 361
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Disability Eligibility Date	R

HD- Health Coverage

01	875	Maintenance Type Code	R
	001 002 021 024 025 026 030 032
02	1203	Maintenance Reason Code	N
03	1205	Insurance Line Code	R
	AG AH AJ AK HE MM UR DCP DEN EPO FAC HE HLT HMO LTC LTD MM MOD PDG POS PPO PRA STD UR VIS
04	1204	Plan Coverage Description	S
05	1207	Coverage Level Code	S
	CHD DEP E1D E2D E3D E5D E6D E7D E8D E9D ECH EMP ESP FAM IND SPC SPO TWO
06	609	Count	N
07	609	Count	N
08	1209	Underwriting Decision Code	N
09	1073	Yes/No Condition or Response Code	N
10	1211	Drug House Code	N
11	1073	Yes/No Condition or Response Code	N

DTP- Health Coverage Dates

01	374	Date Time Qualifier	R
	303 348 349 543
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Coverage Period	R

AMT- Health Coverage Policy

01	522	Amount Qualifier Code	R
	B9 C1 D2 P3
02	782	Contract Amount	R
03	478	Credit/Debit Flag Code	N

REF- Health Coverage Policy Number R0203

01	128	Reference Identification Qualifier	R
	17 1L ZZ
02	127	Insured Group or Policy Number	R
03	352	Description	N
N		C040	Reference Identifier

IDC- Identification Card

01	1204	Plan Coverage Description	R
02	1215	Identification Card Type Code	R
	D H P
03	380	Identification Card Count	S
04	306	Action Code	S
	1 2 RX

LX- Provider Information

554

Assigned Number

NM1- Provider Name P0809 C1110

01	98	Entity Identifier Code	R
	3D OD P3 QA QN Y2
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Provider Last or Organization Name	S
04	1036	Provider First Name	S
05	1037	Provider Middle Name	S
06	1038	Provider Name Prefix	S
07	1039	Provider Name Suffix	S
08	66	Identification Code Qualifier	S
	34 FI SV XX
09	67	Provider Identifier	S
10	706	Entity Relationship Code	R
	25 26 72
11	98	Entity Identifier Code	N

N4- Provider City, State, Zip Code C0605

01	19	Member City Name	R
02	156	Member State Code	R
	External Source: states
03	116	Member Postal Zone or Zip Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	S
	60 CY RJ
06	310	Location Identification Code	S

PER- Provider Communications Numbers P0304 P0506 P0708

01	366	Contact Function Code	R
	IC
02	93	Name	N
03	365	Communication Number Qualifier	R
	EM EX FX HP TE WP
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	EM EX FX HP TE WP
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	EM EX FX HP TE WP
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

PLA- PCP Change Reason

01	306	Action Code	R
	2
02	98	Entity Identifier Code	R
	1P
03	373	Provider Effective Date	R

04	337	Time	N
05	1203	Maintenance Reason Code	R
	14 22 46 AA AB AC AD AE AF AG AH AI AJ

COB- Coordination of Benefits

01	1138	Payer Responsibility Sequence Number Code	R
	P S T U
02	127	Insured Group or Policy Number	S
03	1143	Coordination of Benefits Code	R
	1 5 6

REF- Additional Coordination of Benefits Identifiers R0203

01	128	Reference Identification Qualifier	R
	60 6P A6 SY ZZ
02	127	Insured Group or Policy Number	R
03	352	Description	N
N		C040	Reference Identifier

N1- Other Insurance Company Name R0203 P0304

01	98	Entity Identifier Code	R
	IN
02	93	Insurer Name	S
03	66	Identification Code Qualifier	S
	FI NI XV
04	67	Insured Group or Policy Number	S
05	706	Entity Relationship Code	N
06	98	Entity Identifier Code	N

DTP- Coordination of Benefits Eligibility Dates

01	374	Date Time Qualifier	R
	344 345
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Coordination of Benefits Date	R

SE- Transaction Set 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