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 005 ST Transaction Set Header R 1 010 HEADER - Table 1 - Header 010 BHT Beginning of Hierarchical Transaction R 1 015 REF Transaction Type Identification R 1 020 1000A - Submitter Name 1 020 NM1 Submitter Name R 1 045 PER Submitter EDI Contact Information R 2 020 1000B - Receiver Name 1 020 NM1 Receiver Name R 1 020 DETAIL - Table 2 - Detail 001 2000A - Billing/Pay-To Provider Hierarchical Level >1 001 HL Billing/Pay-To Provider Hierarchical Level R 1 003 PRV Billing/Pay-To Provider Specialty Information S 1 010 CUR Foreign Currency Information S 1 015 2010AA - Billing Provider Name 1 015 NM1 Billing Provider Name R 1 025 N3 Billing Provider Address R 1 030 N4 Billing Provider City/State/ZIP Code R 1 035 REF Billing Provider Secondary Identification S 8 035 REF Credit/Debit Card Billing Information S 8 040 PER Billing Provider Contact Information S 2 015 2010AB - Pay-To Provider Name 1 015 NM1 Pay-To Provider Name R 1 025 N3 Pay-To Provider Address R 1 030 N4 Pay-To Provider City/State/ZIP Code R 1 035 REF Pay-To Provider Secondary Identification S 5 020 2000B - Subscriber Hierarchichal Level >1 001 HL Subscriber Hierarchical Level R 1 005 SBR Subscriber Information R 1 007 PAT Patient Information S 1 015 2010BA - Subscriber Name 1 015 NM1 Subscriber Name R 1 025 N3 Subscriber Address S 1 030 N4 Subscriber City/State/ZIP Code S 1 032 DMG Subscriber Demographic Information S 1 035 REF Subscriber Secondary Identification S 4 035 REF Property and Casualty Claim Number S 1 015 2010BB - Credit/Debit Card Account Holder Name 1 015 NM1 Credit/Debit Card Account Holder Name R 1 035 REF Credit/Debit Card Information S 2 015 2010BC - Payer Name 1 015 NM1 Payer Name R 1 025 N3 Payer Address S 1 030 N4 Payer City/State/ZIP Code S 1 035 REF Payer Secondary Identification S 3 015 2010BD - Responsible Party Name 1 015 NM1 Responsible Party Name R 1 025 N3 Responsible Party Address R 1 030 N4 Responsible Party City/State/ZIP Code R 1 130 2300 - Claim Information 100 130 CLM Claim Information R 1 135 DTP Discharge Hour S 1 135 DTP Statement Dates R 1 135 DTP Admission Date/Hour S 1 140 CL1 Institutional Claim Code S 1 155 PWK Claim Supplemental Information S 10 160 CN1 Contract Information S 1 175 AMT Payer Estimated Amount Due S 1 175 AMT Patient Estimated Amount Due S 1 175 AMT Patient Paid Amount S 1 175 AMT Credit/Debit Card Maximum Amount S 1 180 REF Adjusted Repriced Claim Number S 1 180 REF Repriced Claim Number S 1 180 REF Claim Identification Number For Clearinghouses and Other Transmission Intermediaries S 1 180 REF Document Identification Code S 1 180 REF Original Reference Number (ICN/DCN) S 1 180 REF Investigational Device Exemption Number S 1 180 REF Service Authorization Exception Code S 1 180 REF Peer Review Organization (PRO) Approval Number S 1 180 REF Prior Authorization or Referral Number S 2 180 REF Medical Record Number S 1 180 REF Demonstration Project Identifier S 1 185 K3 File Information S 10 190 NTE Claim Note S 10 190 NTE Billing Note S 1 216 CR6 Home Health Care Information S 1 220 CRC Home Health Functional Limitations S 3 220 CRC Home Health Activities Permitted S 3 220 CRC Home Health Mental Status S 2 231 HI Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information R 1 231 HI Diagnosis Related Group (DRG) Information S 1 231 HI Other Diagnosis Information S 2 231 HI Principal Procedure Information S 1 231 HI Other Procedure Information S 2 231 HI Occurrence Span Information S 2 231 HI Occurrence Information S 2 231 HI Value Information S 2 231 HI Condition Information S 2 231 HI Treatment Code Information S 2 240 QTY Claim Quantity S 4 241 HCP Claim Pricing/Repricing Information S 1 242 2305 - Home Health Care Plan Information 6 242 CR7 Home Health Care Plan Information R 1 243 HSD Health Care Services Delivery S 12 250 2310A - Attending Physician Name 1 250 NM1 Attending Physician Name R 1 255 PRV Attending Physician Specialty Information R 1 271 REF Attending Physician Secondary Identification S 5 250 2310B - Operating Physician Name 1 250 NM1 Operating Physician Name R 1 255 PRV Operating Physician Specialty Information S 1 271 REF Operating Physician Secondary Identification S 5 250 2310C - Other Provider Name 1 250 NM1 Other Provider Name R 1 255 PRV Other Provider Specialty Information R 1 271 REF Other Provider Secondary Identification S 5 250 2310D - Referring Provider Name 2 250 NM1 Referring Provider Name R 1 255 PRV Referring Provider Specialty Information S 1 271 REF Referring Provider Secondary Identification S 5 250 2310E - Service Facility Name 1 250 NM1 Service Facility Name R 1 255 PRV Service Facility Specialty Information S 1 265 N3 Service Facility Address R 1 270 N4 Service Facility City/State/Zip Code R 1 271 REF Service Facility Secondary Identification S 5 290 2320 - Other Subscriber Information 10 290 SBR Other Subscriber Information R 1 295 CAS Claim Level Adjustment S 5 300 AMT Payer Prior Payment S 1 300 AMT Coordination of Benefits (COB) Total Allowed Amount S 1 300 AMT Coordination of Benefits (COB) Total Submitted Charges S 1 300 AMT Diagnostic Related Group (DRG) Outlier Amount S 1 300 AMT Coordination of Benefits (COB) Total Medicare Paid Amount S 1 300 AMT dicare Paid Amount - 100% S 1 300 AMT Medicare Paid Amount - 80% S 1 300 AMT Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount S 1 300 AMT Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount S 1 300 AMT Coordination of Benefits (COB) Total Non-Covered Amount S 1 300 AMT Coordination of Benefits (COB) Total Denied Amount S 1 305 DMG Other Subscriber Demographic Information S 1 310 OI Other Insurance Coverage Information R 1 315 MIA Medicare Inpatient Adjudication Information S 1 320 MOA Medicare Outpatient Adjudication Information S 1 325 2330A - Other Subscriber Name 1 325 NM1 Other Subscriber Name R 1 332 N3 Other Subscriber Address S 1 340 N4 Other Subscriber City/State/ZIP Code S 1 355 REF Other Subscriber Secondary Identification S 3 325 2330B - Other Payer Name 1 325 NM1 Other Payer Name R 1 332 N3 Other Payer Address S 1 340 N4 Other Payer City/State/ZIP Code S 1 350 DTP Claim Adjudication Date S 1 355 REF Other Payer Secondary Identification and Reference Number S 2 355 REF Other Payer Prior Authorization or Referral Number S 1 325 2330C - Other Payer Patient Information 1 325 NM1 Other Payer Patient Information R 1 355 REF Other Payer identification Number S 3 325 2330D - Other Payer Attending Provider 1 325 NM1 Other Payer Attending Provider R 1 355 REF Other Payer Attending Provider Identification R 3 325 2330E - Other Payer Operating Provider 1 325 NM1 Other Payer Operating Provider R 1 355 REF Other Payer Operating Provider Identification R 3 325 2330F - Other Payer Other Provider 1 325 NM1 Other Payer Other Provider R 1 355 REF Other Payer Other Provider Identification R 3 325 2330G - Other Payer Referring Provider 2 325 NM1 Other Payer Referring Provider R 1 355 REF Other Payer Referring Provider Identification R 3 325 2330H - Other Payer Service Facility Provider 1 325 NM1 Other Payer Service Facility Provider R 1 355 REF Other Payer Service Facility Provider Identification R 3 365 2400 - Service Line Number 999 365 LX Service Line Number R 1 375 SV2 Institutional Service Line R 1 385 SV4 Prescription Number S 1 420 PWK Line Supplemental Information S 5 455 DTP Service Line Date S 1 455 DTP Assessment Date S 1 475 AMT Service Tax Amount S 1 475 AMT Facility Tax Amount S 1 500 2420A - Attending Physician Name 1 500 NM1 Attending Physician Name R 1 505 PRV Attending Physician Specialty Information R 1 525 REF Attending Physician Secondary Identification S 1 500 2420B - Operating Physician Name 1 500 NM1 Operating Physician Name R 1 505 PRV Operating Physician Specialty Information S 1 525 REF Operating Physician Secondary Identification S 1 500 2420C - Other Provider Name 1 500 NM1 Other Provider Name R 1 505 PRV Other Provider Specialty Information S 1 525 REF Other Provider Secondary Identification S 1 500 2420D - Referring Provider Name 1 500 NM1 Referring Provider Name R 1 505 PRV Referring Provider Specialty Information S 1 525 REF Referring Provider Secondary Identification S 1 540 2430 - Service Line Adjudication Information 25 540 SVD Service Line Adjudication Information R 1 545 CAS Service Line Adjustment S 99 550 DTP Service Adjudication Date S 1 140 2000C - Patient Hierarchical Level >1 001 HL Patient Hierarchical Level R 1 007 PAT Patient Information R 1 015 2010CA - Patient Name 1 015 NM1 Patient Name R 1 025 N3 Patient Address R 1 030 N4 Patient City/State/ZIP Code R 1 032 DMG Patient Demographic Information R 1 035 REF Patient Secondary Identification Number S 5 035 REF Property and Casualty Claim Number S 1 130 2300 - Claim Information 100 130 CLM Claim Information R 1 135 DTP Discharge Hour S 1 135 DTP Statement Dates R 1 135 DTP Admission Date/Hour S 1 140 CL1 Institutional Claim Code S 1 155 PWK Claim Supplemental Information S 10 160 CN1 Contract Information S 1 175 AMT Payer Estimated Amount Due S 1 175 AMT Patient Estimated Amount Due S 1 175 AMT Patient Paid Amount S 1 175 AMT Credit/Debit Card Maximum Amount S 1 180 REF Adjusted Repriced Claim Number S 1 180 REF Repriced Claim Number S 1 180 REF Claim Identification Number For Clearinghouses and Other Transmission Intermediaries S 1 180 REF Document Identification Code S 1 180 REF Original Reference Number (ICN/DCN) S 1 180 REF Investigational Device Exemption Number S 1 180 REF Service Authorization Exception Code S 1 180 REF Peer Review Organization (PRO) Approval Number S 1 180 REF Prior Authorization or Referral Number S 2 180 REF Medical Record Number S 1 180 REF Demonstration Project Identifier S 1 185 K3 File Information S 10 190 NTE Claim Note S 10 190 NTE Billing Note S 1 216 CR6 Home Health Care Information S 1 220 CRC Home Health Functional Limitations S 3 220 CRC Home Health Activities Permitted S 3 220 CRC Home Health Mental Status S 2 231 HI Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information R 1 231 HI Diagnosis Related Group (DRG) Information S 1 231 HI Other Diagnosis Information S 2 231 HI Principal Procedure Information S 1 231 HI Other Procedure Information S 2 231 HI Occurrence Span Information S 2 231 HI Occurrence Information S 2 231 HI Value Information S 2 231 HI Condition Information S 2 231 HI Treatment Code Information S 2 240 QTY Claim Quantity S 4 241 HCP Claim Pricing/Repricing Information S 1 242 2305 - Home Health Care Plan Information 6 242 CR7 Home Health Care Plan Information R 1 243 HSD Health Care Services Delivery S 12 250 2310A - Attending Physician Name 1 250 NM1 Attending Physician Name R 1 255 PRV Attending Physician Specialty Information R 1 271 REF Attending Physician Secondary Identification S 5 250 2310B - Operating Physician Name 1 250 NM1 Operating Physician Name R 1 255 PRV Operating Physician Specialty Information S 1 271 REF Operating Physician Secondary Identification S 5 250 2310C - Other Provider Name 1 250 NM1 Other Provider Name R 1 255 PRV Other Provider Specialty Information R 1 271 REF Other Provider Secondary Identification S 5 250 2310D - Referring Provider Name 2 250 NM1 Referring Provider Name R 1 255 PRV Referring Provider Specialty Information S 1 271 REF Referring Provider Secondary Identification S 5 250 2310E - Service Facility Name 1 250 NM1 Service Facility Name R 1 255 PRV Service Facility Specialty Information S 1 265 N3 Service Facility Address R 1 270 N4 Service Facility City/State/Zip Code R 1 271 REF Service Facility Secondary Identification S 5 290 2320 - Other Subscriber Information 10 290 SBR Other Subscriber Information R 1 295 CAS Claim Level Adjustment S 5 300 AMT Payer Prior Payment S 1 300 AMT Coordination of Benefits (COB) Total Allowed Amount S 1 300 AMT Coordination of Benefits (COB) Total Submitted Charges S 1 300 AMT Diagnostic Related Group (DRG) Outlier Amount S 1 300 AMT Coordination of Benefits (COB) Total Medicare Paid Amount S 1 300 AMT Medicare Paid Amount - 100% S 1 300 AMT Medicare Paid Amount - 80% S 1 300 AMT Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount S 1 300 AMT Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount S 1 300 AMT Coordination of Benefits (COB) Total Non-Covered Amount S 1 300 AMT Coordination of Benefits (COB) Total Denied Amount S 1 305 DMG Other Subscriber Demographic Information S 1 310 OI Other Insurance Coverage Information R 1 315 MIA Medicare Inpatient Adjudication Information S 1 320 MOA Medicare Outpatient Adjudication Information S 1 325 2330A - Other Subscriber Name 1 325 NM1 Other Subscriber Name R 1 332 N3 Other Subscriber Address S 1 340 N4 Other Subscriber City/State/ZIP Code S 1 355 REF Other Subscriber Secondary Identification S 3 325 2330B - Other Payer Name 1 325 NM1 Other Payer Name R 1 332 N3 Other Payer Address S 1 340 N4 Other Payer City/State/ZIP Code S 1 350 DTP Claim Adjudication Date S 1 355 REF Other Payer Secondary Identification and Reference Number S 2 355 REF Other Payer Prior Authorization or Referral Number S 1 325 2330C - Other Payer Patient Information 1 325 NM1 Other Payer Patient Information R 1 355 REF Other Payer Patient Identification Number S 3 325 2330D - Other Payer Attending Provider 1 325 NM1 Other Payer Attending Provider R 1 355 REF Other Payer Attending Provider Identification R 3 325 2330E - Other Payer Operating Provider 1 325 NM1 Other Payer Operating Provider R 1 355 REF Other Payer Operating Provider Identification R 3 325 2330F - Other Payer Other Provider 1 325 NM1 Other Payer Other Provider R 1 355 REF Other Payer Other Provider Identification R 3 325 2330G - Other Payer Referring Provider 2 325 NM1 Other Payer Referring Provider R 1 355 REF Other Payer Referring Provider Identification R 3 325 2330H - Other Payer Service Facility Provider 1 325 NM1 Other Payer Service Facility Provider R 1 355 REF Other Payer Service Facility Provider Identification R 3 365 2400 - Service Line Number 999 365 LX Service Line Number R 1 375 SV2 Institutional Service Line R 1 385 SV4 Prescription Number S 1 420 PWK Line Supplemental Information S 5 455 DTP Service Line Date S 1 455 DTP Assessment Date S 1 475 AMT Service Tax Amount S 1 475 AMT Facility Tax Amount S 1 500 2420A - Attending Physician Name 1 500 NM1 Attending Physician Name R 1 505 PRV Attending Physician Specialty Information R 1 525 REF Attending Physician Secondary Identification S 1 500 2420B - Operating Physician Name 1 500 NM1 Operating Physician Name R 1 505 PRV Operating Physician Specialty Information S 1 525 REF Operating Physician Secondary Identification S 1 500 2420C - Other Provider Name 1 500 NM1 Other Provider Name R 1 505 PRV Other Provider Specialty Information S 1 525 REF Other Provider Secondary Identification S 1 500 2420D - Referring Provider Name 1 500 NM1 Referring Provider Name R 1 505 PRV Referring Provider Specialty Information S 1 525 REF Referring Provider Secondary Identification S 1 540 2430 - Service Line Adjudication Information 25 540 SVD Service Line Adjudication Information R 1 545 CAS Service Line Adjustment S 99 550 DTP Service Adjudication Date S 1 030 FOOTER - Table 3 - Footer 555 SE Transaction Set Trailer R 1 030 GE Functional Group Trailer R 1
020	TA1	Interchange Acknowledgement	S
030	IEA	Interchange Control Trailer	R	1