001 ISA_LOOP - Interchange Control Header
010 ISA Interchange Control Header R 1
020 GS_LOOP - Functional Group Header
010 GS Functional Group Header R 1
020 ST_LOOP - Transaction Set Header
010 ST Transaction Set Header R 1
015 HEADER - Table 1 - Header
020 BPR Financial Information R 1
040 TRN Reassociation Trace Number R 1
050 CUR Foreign Currency Information S 1
060 REF Receiver Identification S 1
060 REF Version Identification S 1
070 DTM Production Date S 1
080 1000A - Payer Identification
080 N1 Payer Identification R 1
100 N3 Payer Address R 1
110 N4 Payer City, State, ZIP Code R 1
120 REF Additional Payer Identification S 4
130 PER Payer Contact Information S 1
080 1000B - Payee Identification
080 N1 Payee Identification R 1
100 N3 Payee Address S 1
110 N4 Payee City, State, ZIP Code S 1
120 REF Payee Additional Identification S >1
020 DETAIL - Table 2 - Detail
003 2000 - Header Number
003 LX Header Number R 1
005 TS3 Provider Summary Information S 1
007 TS2 Provider Supplemental Summary Information S 1
010 2100 - Claim Payment Information
010 CLP Claim Payment Information R 1
020 CAS Claim Adjustment S 99
030 NM1 Patient Name R 1
030 NM1 Insured Name S 1
030 NM1 Corrected Patient/Insured Name S 1
030 NM1 Service Provider Name S 1
030 NM1 Crossover Carrier Name S 1
030 NM1 Corrected Priority Payer Name S 2
033 MIA Inpatient Adjudication Information S 1
035 MOA Outpatient Adjudication Information S 1
040 REF Other Claim Related Identification S 5
040 REF Rendering Provider Identification S 10
050 DTM Claim Date S 4
060 PER Claim Contact Information S 3
062 AMT Claim Supplemental Information S 14
064 QTY Claim Supplemental Information Quantity S 15
070 2110 - Service Payment Information
070 SVC Service Payment Information R 1
080 DTM Service Date S 3
090 CAS Service Adjustment S 99
100 REF Service Identification S 7
100 REF Rendering Provider Information S 10
110 AMT Service Supplemental Amount S 12
120 QTY Service Supplemental Quantity S 6
130 LQ Health Care Remark Codes S 99
030 FOOTER - Table 3 - Footer
010 PLB Provider Adjustment S >1
050 SE Transaction Set Trailer R 1
030 GE Functional Group Trailer R 1
020 TA1 Interchange Acknowledgement S 1
030 IEA Interchange Control Trailer R 1