001

ISA_LOOP - Interchange Control Header

020 GS_LOOP - Functional Group Header 020 ST_LOOP - Transaction Set Header 010 HEADER - Table 1 - Header 020 1000A - Submitter Name 020 1000B - Receiver Name 020 DETAIL - Table 2 - Detail 001 2000A - Billing/Pay-To Provider Hierarchical Level 015 2010AA - Billing Provider Name 015 2010AB - Pay-To Provider Name 020 2000B - Subscriber Hierarchichal Level 015 2010BA - Subscriber Name 015 2010BB - Credit/Debit Card Account Holder Name 015 2010BC - Payer Name 015 2010BD - Responsible Party Name 130 2300 - Claim Information 242 2305 - Home Health Care Plan Information 250 2310A - Attending Physician Name 250 2310B - Operating Physician Name 250 2310C - Other Provider Name 250 2310D - Referring Provider Name 250 2310E - Service Facility Name 290 2320 - Other Subscriber Information 325 2330A - Other Subscriber Name 325 2330B - Other Payer Name 325 2330C - Other Payer Patient Information 325 2330D - Other Payer Attending Provider 325 2330E - Other Payer Operating Provider 325 2330F - Other Payer Other Provider 325 2330G - Other Payer Referring Provider 325 2330H - Other Payer Service Facility Provider 365 2400 - Service Line Number 500 2420A - Attending Physician Name 500 2420B - Operating Physician Name 500 2420C - Other Provider Name 500 2420D - Referring Provider Name 540 2430 - Service Line Adjudication Information 140 2000C - Patient Hierarchical Level 015 2010CA - Patient Name 130 2300 - Claim Information 242 2305 - Home Health Care Plan Information 250 2310A - Attending Physician Name 250 2310B - Operating Physician Name 250 2310C - Other Provider Name 250 2310D - Referring Provider Name 250 2310E - Service Facility Name 290 2320 - Other Subscriber Information 325 2330A - Other Subscriber Name 325 2330B - Other Payer Name 325 2330C - Other Payer Patient Information 325 2330D - Other Payer Attending Provider 325 2330E - Other Payer Operating Provider 325 2330F - Other Payer Other Provider 325 2330G - Other Payer Referring Provider 325 2330H - Other Payer Service Facility Provider 365 2400 - Service Line Number 500 2420A - Attending Physician Name 500 2420B - Operating Physician Name 500 2420C - Other Provider Name 500 2420D - Referring Provider Name 540 2430 - Service Line Adjudication Information 030 FOOTER - Table 3 - Footer