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's Name 020 2000B - Subscriber Hierarchical Level 015 2010BA - Subscriber Name 015 2010BB - Payer Name 015 2010BC - Credit/Debit Card Holder Name 130 2300 - Claim Information 250 2310A - Referring Provider Name 250 2310B - Rendering Provider Name 250 2310C - Service Facility Location 250 2310D - Assistant Surgeon 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 Referring Provider 325 2330E - Other Payer Rendering Provider 365 2400 - Line Counter 500 2420A - Rendering Provider Name 500 2420B - Other Payer Prior Authorization or Referral Number 500 2420C - Assistant Surgeon Name 540 2430 - Line Adjudication Information 140 2000C - Patient Hierarchical Level 015 2010CA - Patient Name 130 2300 - Claim Information 250 2310A - Referring Provider Name 250 2310B - Rendering Provider Name 250 2310C - Service Facility Location 250 2310D - Assistant Surgeon 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 Referring Provider 325 2330E - Other Payer Rendering Provider 365 2400 - Line Counter 500 2420A - Rendering Provider Name 500 2420B - Other Payer Prior Authorization or Referral Number 500 2420C - Assistant Surgeon Name 540 2430 - Line Adjudication Information 030 FOOTER - Table 3 - Footer