| 020 |
ST_LOOP - Transaction Set Header |
| 015 |
HEADER - Table 1 - Header |
| 080 |
1000A - Payer Identification |
|
| 080 |
1000B - Payee Identification |
|
|
| 020 |
DETAIL - Table 2 - Detail |
| 003 |
2000 - Header Number |
| 010 |
2100 - Claim Payment Information |
| 070 |
2110 - Service Payment Information |
|
|
|
|
| 030 |
FOOTER - Table 3 - Footer |
|