ISA- Interchange Control Header

01	I01	Authorization Information Qualifier	R
	00 03
02	I02	Authorization Information	R
03	I03	Security Information Qualifier	R
	00 01
04	I04	Security Information	R
05	I05	Interchange ID Qualifier	R
	01 14 20 27 28 29 30 33 ZZ
06	I06	Interchange Sender ID	R
07	I05	Interchange ID Qualifier	R
	01 14 20 27 28 29 30 33 ZZ
08	I07	Interchange Receiver ID	R
09	I08	Interchange Date	R

10	I09	Interchange Time	R

11	I10	Interchange Control Standards Identifier	R
	U
12	I11	Interchange Control Version Number	R
	00401
13	I12	Interchange Control Number	R
14	I13	Acknowledgment Requested	R
	0 1
15	I14	Usage Indicator	R
	P T
16	I15	Component Element Separator	R

GS- Functional Group Header

01	479	Functional Identifier Code	R
	HC
02	142	Application Sender's Code	R
03	124	Application Receiver's Code	R
04	373	Date	R

05	337	Time	R

06	28	Group Control Number	R
07	455	Responsible Agency Code	R
	X
08	480	Version / Release / Industry Identifier Code	R
	004010X097A1

ST- Transaction Set Header

01	143	Transaction Set Identifier Code	R
	837
02	329	Transaction Set Control Number	R

BHT- Beginning of Hierarchical Transaction

01	1005	Hierarchical Structure Code	R
	0019
02	353	Transaction Set Purpose Code	R
	00 18
03	127	Originator Application Transaction Identifier	R
04	373	Transaction Set Creation Date	R

05	337	Transaction Set Creation Time	R
06	640	Claim or Encounter Identifier	R
	CH RP

REF- Transmission Type Identification

01	128	Reference Identification Qualifier	R
	87
02	127	Transmission Type Code	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Submitter Name

01	98	Entity Identifier Code	R
	41
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Submitter Last or Organization Name	R
04	1036	Submitter First Name	S
05	1037	Submitter Middle Name	S
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	46
09	67	Submitter Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Submitter Contact Information

01	366	Contact Function Code	R
	IC
02	93	Submitter Contact Name	R
03	365	Communication Number Qualifier	R
	ED EM FX TE
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	ED EM EX FX TE
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	ED EM EX FX TE
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

NM1- Receiver Name

01	98	Entity Identifier Code	R
	40
02	1065	Entity Type Qualifier	R
	2
03	1035	Receiver Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	46
09	67	Receiver Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

HL- Billing/Pay-To Provider Hierarchical Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	N
03	735	Hierarchical Level Code	R
	20
04	736	Hierarchical Child Code	R
	1

PRV- Billing/Pay-To Provider Specialty Information

01	1221	Provider Code	R
	BI PT
02	128	Referefence Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
05	C035	Provider Specialty Information	N
06	1223	Provider Organization Code	N

CUR- Foreign Currency Information

01	98	Entity Identifier Code	R
	85
02	100	Currency Code	R
	External Source: currency
03	280	Exchange Rate	N
04	98	Entity Identifier Code	N
05	100	Currency Code	N
06	669	Currency Market/Exchange Code	N
07	374	Date/Time Qualifier	N
08	373	Date	N
09	337	Time	N
10	374	Date/Time Qualifier	N
11	373	Date	N
12	337	Time	N
13	374	Date/Time Qualifier	N
14	373	Date	N
15	337	Time	N
16	374	Date/Time Qualifier	N
17	373	Date	N
18	337	Time	N
19	374	Date/Time Qualifier	N
20	373	Date	N
21	337	Time	N

NM1- Billing Provider Name

01	98	Entity Identifier Code	R
	85
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Billing Provider Last or Organizational Name	R
04	1036	Billing Provider First Name	S
05	1037	Billing Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Billing Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Billing Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Billing Provider Address

01	166	Billing Provider Address 1	R
02	166	Billing Provider Address 2	S

N4- Billing Provider City/State/ZIP Code

01	19	Billing Provider City Name	R
02	156	Billing Provider State or Province Code	R
	External Source: states
03	116	Billing Provider Postal Zone or ZIP Code	R
04	26	Billing Provider Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Billing Provider Secondary Identification Number

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Billing Provider Additional Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Claim Submitter Credit/Debit Card Information

01	128	Reference Identification Qualifier	R
	06 8U EM IJ LU RB ST TT
02	127	Billing Provider Credit Card Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Pay-To Provider's Name

01	98	Entity Identifier Code	R
	87
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Pay-To Provider Last or Organizational Name	R
04	1036	Pay-To Provider First Name	S
05	1037	Pay-To Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Pay-To Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Pay-To Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Pay-To Provider's Address

01	166	Pay-To Provider Address 1	R
02	166	Pay-To Provider Address 2	S

N4- Pay-To Provider City/State/ZIP

01	19	Pay-To Provider City Name	R
02	156	Pay-To Provider State Code	R
	External Source: states
03	116	Pay-To Provider Postal Zone or ZIP Code	R
04	26	Pay-To Provider Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Pay-To Provider Secondary Identification Number

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Pay-To Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

HL- Subscriber Hierarchical Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	22
04	736	Hierarchical Child Code	R
	0 1

SBR- Subscriber Information

01	1138	Payer Responsibility Sequence Number Code	R
	P S T
02	1069	Individual Relationship Code	S
	18
03	127	Insured Group or Policy Number	S
04	93	Insured Group Name	S
05	1336	Insurance Type Code	N
06	1143	Coordination of Benefits Code	R
	1 6
07	1073	Yes/No Condition or Response Code	N
08	584	Employment Status Code	N
09	1032	Claim Filing Indicator Code	S
	09 11 12 13 14 15 16 17 BL CH CI DS FI HM LM MB MC MH OF SA VA WC ZZ

NM1- Subscriber Name

01	98	Entity Identifier Code	R
	IL
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Subscriber Last Name	R
04	1036	Subscriber First Name	S
05	1037	Subscriber Middle Name	S
06	1038	Name Prefix	N
07	1039	Subscriber Name Suffix	S
08	66	Identification Code Qualifier	S
	MI ZZ
09	67	Subscriber Primary Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Subscriber Address

01	166	Subscriber Address 1	R
02	166	Subscriber Address 2	S

N4- Subscriber City/State/ZIP Code

01	19	Subscriber City Name	R
02	156	Subscriber State Code	R
	External Source: states
03	116	Subscriber Postal Zone or ZIP Code	R
04	26	Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

DMG- Subscriber Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Subscriber Birth Date	R
03	1068	Subscriber Gender Code	R
	F M U
04	1067	Marital Status Code	N
05	1109	Race or Ethnicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
08	659	Basis of Verification Code	N
09	380	Quantity	N

REF- Subscriber Secondary Identification

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Subscriber Supplemental Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Property and Casualty Claim Number

01	128	Reference Identification Qualifier	R
	Y4
02	127	Property Casualty Claim Number	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Payer Name

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Payer Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	PI XV
09	67	Payer Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Payer Address

01	166	Payer Address 1	R
02	166	Payer Address 2	S

N4- Payer City/State/ZIP Code

01	19	Payer City Name	R
02	156	Payer State Code	R
	External Source: states
03	116	Payer Postal Zone or ZIP Code	R
04	26	Payer Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Payer Secondary Identification Number

01	128	Payer Secondary Identification Number	R
	2U FY NF TJ
02	127	Payer Additional Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Credit/Debit Card Holder Name

01	98	Location Qualifier	R
	AO
02	1065	Loop Identifier Code	R
	1 2
03	1035	Credit or Debit Card Holder Last or Organizational Name	R
04	1036	Entity Type Qualifier	S
05	1037	Credit or Debit Card Holder Middle Name	S
06	1038	Name Prefix	N
07	1039	Credit or Debit Card Holder Name Suffix	S
08	66	Identification Code Qualifier	R
	MI
09	67	Credit or Debit Card Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Credit/Debit Card Information

01	128	Reference Identification Qualifier	R
	BB
02	127	Credit or Debit Card Authorization Number	R
03	352	Description	N
N		C040	Reference Identifier

CLM- Claim Information

01	1028	Patient Account Number	R
02	782	Total Claim Charge Amount	R
03	1032	Claim Filing Indicator Code	N
04	1343	Non-Institutional Claim Type Code	N
R		C023	Place of Service Code
01	1331	Facility Type Code	R
	External Source: pos
02	1332	Facility Code Qualifier	N
03	1325	Claim Submission Reason Code	R
06	1073	Provider or Supplier Signature Indicator	R
	N Y
07	1359	Medicare Assignment Code	S
	A C P
08	1073	Benefits Assignment Certification Indicator	R
	N Y
09	1363	Release of Information Code	R
	N Y
10	1351	Patient Signature Source Code	N
S		C024	Related Causes Information
01	1362	Related Causes Code	R
	AA EM OA
02	1362	Related Causes Code	S
	AA EM OA
03	1362	Related Causes Code	S
	AA EM OA
04	156	Auto Accident State or Province Code	S
	External Source: states
05	26	Country Code	S
	External Source: country
12	1366	Special Program Indicator	S
	01 02 03 05
13	1073	Yes/No Condition or Response Code	N
14	1338	Level of Service Code	N
15	1073	Yes/No Condition or Response Code	N
16	1360	Provider Agreement Code	N
17	1029	Claim Status Code	N
18	1073	Yes/No Condition or Response Code	N
19	1383	Predetermination of Benefits Code	S
	PB
20	1514	Delay Reason Code	S
	1 2 3 4 5 6 7 8 9 10 11

DTP- Date - Admission

01	374	Date Time Qualifier	R
	435
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Related Hospitalization Admission Date	R

DTP- Date - Discharge

01	374	Date Time Qualifier	R
	096
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Discharge or End Of Care Date	R

DTP- Date - Referral

01	374	Date Time Qualifier	R
	330
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Referral Date	R

DTP- Date - Accident

01	374	Date Time Qualifier	R
	439
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Accident Date	R

DTP- Date - Appliance Placement

01	374	Date Time Qualifier	R
	452
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Orthodontic Banding Date	R

DTP- Date - Service

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Service Date	R

DN1- Orthodontic Total Months of Treatment

01	380	Orthodontic Treatment Months Count	S
02	380	Orthodontic Treatment Months Remaining Count	S
03	1073	Question Response	S
	Y
04	352	Description	N

DN2- Tooth Status

01	127	Tooth Number	R
02	1368	Tooth Status Code	R
	E I M
03	380	Quantity	N
04	1250	Date Time Period Format Qualifier	N
05	1251	Date Time Period	N

PWK- Claim Supplemental Information

01	755	Attachment Report Type Code	R
	B4 DA DG EB OB OZ P6 RB RR
02	756	Attachment Transmission Code	R
	AA BM EL EM FX
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	S
	AC
06	67	Attachment Control Number	S
07	352	Description	N
N		C002	Actions Indicated
09	1525	Request Category Code	N

AMT- Patient Amount Paid

01	522	Amount Qualifier Code	R
	F5
02	782	Patient Amount Paid	R
03	478	Credit/Debit Flag Code	N

AMT- Credit/Debit Card - Maximum Amount

01	522	Amount Qualifier Code	R
	MA
02	782	Credit or Debit Card Maximum Amount	R
03	478	Credit/Debit Flag Code	N

REF- Predetermination Identification

01	128	Reference Identification Qualifier	R
	G3
02	127	Predetermination of Benefits Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Service Authorization Exception Code

01	128	Reference Identification Qualifier	R
	4N
02	127	Service Authorization Exception Code	R
	1 2 3 4 5 6 7
03	352	Description	N
N		C040	Reference Identifier

REF- Original Reference Number (ICN/DCN)

01	128	Reference Identification Qualifier	R
	F8
02	127	Claim Original Reference Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Claim Identification Number for Clearinghouses and Other Transmission Intermediaries

01	128	Reference Identification Qualifier	R
	D9
02	127	Value Added Network Trace Number	R
03	352	Description	N
N		C040	Reference Identifier

NTE- Claim Note

01	363	Note Reference Code	R
	ADD
02	352	Claim Note Text	R

NM1- Referring Provider Name

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Referring Provider Last Name	R
04	1036	Referring Provider First Name	S
05	1037	Referring Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Referring Provider Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 XX
09	67	Referring Provider Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Referring Provider Specialty Information

01	1221	Provider Code	R
	RF
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Referring Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Referring Provider Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Rendering Provider Name

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider Last or Organization Name	R
04	1036	Rendering Provider First Name	S
05	1037	Rendering Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Rendering Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Rendering Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Rendering Provider Specialty Information

01	1221	Provider Code	R
	PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Rendering Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Rendering Provider Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Service Facility Location

01	98	Entity Identifier Code	R
	FA
02	1065	Entity Type Qualifier	R
	2
03	1035	Laboratory or Facility Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Laboratory or Facility Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Service Facility Location Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H G2 LU TJ X4 X5
02	127	Laboratory or Facility Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Assistant Surgeon Name

01	98	Entity Identifier Code	R
	DD
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Assistant Last or Organazation Name	R
04	1036	Assistant Surgeon First Name	S
05	1037	Assistant Surgeon Middle Name	S
06	1038	Name Prefix	N
07	1039	Assistant Surgeon Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Assistant Surgeon Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Assistant Surgeon Specialty Information

01	1221	Provider Code	R
	AS
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Assistant Surgeon Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Assistant Surgeon Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

SBR- Other Subscriber Information

01	1138	Payer Responsibility Sequence Number Code	R
	P S T
02	1069	Individual Relationship Code	R
	01 18 19 20 21 22 29 76
03	127	Insured Group or Policy Number	S
04	93	Policy Name	S
05	1336	Insurance Type Code	N
06	1143	Coordination of Benefits Code	N
07	1073	Yes/No Condition or Response Code	N
08	584	Employment Status Code	N
09	1032	Claim Filing Indicator Code	S
	09 11 12 13 14 15 16 17 BL CH CI DS FI HM LM MB MC MH OF SA VA WC ZZ

CAS- Claim Adjustment

01	1033	Claim Adjustment Group Code	R
	CO CR OA PI PR
02	1034	Adjustment Reason Code	R
	External Source: adjustment_reason
03	782	Adjustment Amount	R
04	380	Adjustment Quantity	S
05	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
06	782	Adjustment Amount	S
07	380	Adjustment Quantity	S
08	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
09	782	Adjustment Amount	S
10	380	Adjustment Quantity	S
11	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
12	782	Adjustment Amount	S
13	380	Adjustment Quantity	S
14	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
15	782	Adjustment Amount	S
16	380	Adjustment Quantity	S
17	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
18	782	Adjustment Amount	S
19	380	Adjustment Quantity	S

AMT- Coordination of Benefits (COB) Payer Paid Amount

01	522	Amount Qualifier Code	R
	D
02	782	Payer Paid Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Approved Amount

01	522	Amount Qualifier Code	R
	AAE
02	782	Approved Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Allowed Amount

01	522	Amount Qualifier Code	R
	B6
02	782	Allowed Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Patient Responsibility Amount

01	522	Amount Qualifier Code	R
	F2
02	782	Patient Responsibility Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Covered Amount

01	522	Amount Qualifier Code	R
	AU
02	782	Covered Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Discount Amount

01	522	Amount Qualifier Code	R
	D8
02	782	Other Payer Discount Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Patient Paid Amount

01	522	Amount Qualifier Code	R
	F5
02	782	Other Payer Patient Paid Amount	R
03	478	Credit/Debit Flag Code	N

DMG- Other Insured Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Other Insured Birth Date	R
03	1068	Other Insured Gender Code	R
	F M U
04	1067	Marital Status Code	N
05	1109	Race or Ethnicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
08	659	Basis of Verification Code	N
09	380	Quantity	N

OI- Other Insurance Coverage Information

01	1032	Claim Filing Indicator Code	N
02	1383	Claim Submission Reason Code	N
03	1073	Benefits Assignment Certification Indicator	R
	N Y
04	1351	Patient Signature Source Code	N
05	1360	Provider Agreement Code	N
06	1363	Release of Information	R
	N Y

NM1- Other Subscriber Name

01	98	Entity Identifier Code	R
	IL
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Other Insured Last Name	R
04	1036	Other Insured First Name	R
05	1037	Other Insured Middle Name	S
06	1038	Name Prefix	N
07	1039	Other Insured Name Suffix	S
08	66	Identification Code Qualifier	R
	24 MI ZZ
09	67	Other Insured Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Other Subscriber Address

01	166	Other Insured's Address 1	R
02	166	Other Insured's Address 2	S

N4- Other Subscriber City/State/ZIP Code

01	19	Other Insured City Name	R
02	156	Other Insured State Code	R
	External Source: states
03	116	Other Insured Postal Zone or ZIP Code	R
04	26	Other Insured's Country	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Other Subscriber Secondary Identification

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Insured Additional Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Name

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Other Payer Last or Organization Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	PI XV
09	67	Other Payer Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Other Payer Contact Information

01	366	Contact Function Code	R
	IC
02	93	Other Payer Contact Name	R
03	365	Communication Number Qualifier	R
	ED EM FX TE
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	ED EM EX FX TE
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	ED EM EX FX TE
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

DTP- Claim Paid Date

01	374	Date Time Qualifier	R
	573
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Date Claim Paid	R

REF- Other Payer Secondary Identifier

01	128	Reference Identification Qualifier	R
	2U D8 F8 FY NF TJ
02	127	Other Payer Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Other Payer Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Other Payer Prior Authorization or Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Other Payer Claim Adjustment Indicator

01	128	Reference Identification Qualifier	R
	T4
02	127	Other Payer Claim Adjustment Indicator	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Patient Information

01	98	Entity Identifier Code	R
	QC
02	1065	Entity Type Qualifier	R
	1
03	1035	Other Payer Patient Last Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	MI
09	67	Other Payer Patient Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Patient Identification

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Payer Patient Primary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Referring Provider

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Referring Provider Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Other Payer Referring Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Rendering Provider

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Rendering Provider Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Other Payer Rendering Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

LX- Line Counter

554

Line Counter

SV3- Dental Service

R		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD
02	234	Procedure Code	R
03	1339	Procedure Code Modifier	S
04	1339	Procedure Code Modifier	S
05	1339	Procedure Code Modifier	S
06	1339	Procedure Code Modifier	S
07	352	Description	N
02	782	Line Item Charge Amount	R
03	1331	Facility Type Code	S
	External Source: pos
S		C006	Oral Cavity Designation
01	1361	Oral Cavity Designation Code	R
	L R 00 01 02 09 10 20 30 40
02	1361	Oral Cavity Designation Code	S
	L R 00 01 02 09 10 20 30 40
03	1361	Oral Cavity Designation Code	S
	L R 00 01 02 09 10 20 30 40
04	1361	Oral Cavity Designation Code	S
	L R 00 01 02 09 10 20 30 40
05	1361	Oral Cavity Designation Code	S
	L R 00 01 02 09 10 20 30 40
05	1358	Prosthesis, Crown, or Inlay Code	S
	I R
06	380	Procedure Count	R
07	352	Description	N
08	1327	Copay Status Code	N
09	1360	Provider Agreement Code	N
10	1073	Yes/No Condition or Response Code	N
N		C004	Composite Diagnosis Code Pointer

TOO- Tooth Information

01	1270	Code List Qualifier Code	R
	JP
02	1271	Tooth Code	S
S		C005	Tooth Surface
01	1369	Tooth Surface Code	R
	B D F I L M O
02	1369	Tooth Surface Code	S
	B D F I L M O
03	1369	Tooth Surface Code	S
	B D F I L M O
04	1369	Tooth Surface Code	S
	B D F I L M O
05	1369	Tooth Surface Code	S
	B D F I L M O

DTP- Date - Service

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Service Date	R

DTP- Date - Prior Placement

01	374	Date Time Qualifier	R
	441
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Prior Placement Date	R

DTP- Date - Appliance Placement

01	374	Date Time Qualifier	R
	452
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Orthodontic Banding Date	R

DTP- Date - Replacement

01	374	Date Time Qualifier	R
	446
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Replacement Date	R

QTY- Anesthesia Quantity

01	673	Quantity Qualifier	R
	BF EM HM HO HP P3 P4 P5 SG
02	380	Anesthesia Unit Count	R
N		C001	Composite Unit of Measure
04	61	Free-Form Message	N

REF- Service Predetermination Identification

01	128	Reference Identification Qualifier	R
	G3
02	127	Predetermination of Benefits Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Line Item Control Number

01	128	Reference Identification Qualifier	R
	6R
02	127	Line Item Control Number	R
03	352	Description	N
N		C040	Reference Identifier

AMT- Approved Amount

01	522	Amount Qualifier Code	R
	AAE
02	782	Approved Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Sales Tax Amount

01	522	Amount Qualifier Code	R
	T
02	782	Sales Tax Amount	R
03	478	Credit/Debit Flag Code	N

NTE- Line Note

01	363	Note Reference Code	R
02	352	Claim Note Text	R

NM1- Rendering Provider Name

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider Last or Organization Name	R
04	1036	Rendering Provider First Name	S
05	1037	Rendering Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Rendering Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Rendering Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Rendering Provider Specialty Information

01	1221	Provider Code	R
	PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Rendering Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Rendering Provider Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Prior Authorization or Referral Number

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Other Payer Last or Organization Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	PI XV
09	67	Other Payer Referral Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Other Payer Prior Authorization or Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Assistant Surgeon Name

01	98	Entity Identifier Code	R
	DD
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Assistant Surgeon Last or Organization Name	R
04	1036	Assistant Surgeon First Name	S
05	1037	Assistant Surgeon Middle Name	S
06	1038	Name Prefix	N
07	1039	Assistant Surgeon Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Assistant Surgeon Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Assistant Surgeon Specialty Information

01	1221	Provider Code	R
	AS
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Assistant Surgeon Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 LU TJ X4 X5
02	127	Assistant Surgeon Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

SVD- Line Adjudication Information

01	67	Other Payer Primary Identifier	R
02	782	Service Line Paid Amount	R
R		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD ZZ
02	234	Procedure Code	R
03	1339	Procedure Modifier	S
04	1339	Procedure Modifier	S
05	1339	Procedure Modifier	S
06	1339	Procedure Modifier	S
07	352	Procedure Code Description	S
04	234	Product/Service ID	N
05	380	Paid Service Unit Count	R
06	554	Bundled or Unbundled Line Number	S

CAS- Service Adjustment

01	1033	Adjustment Group Code	R
	CO CR OA PI PR
02	1034	Adjustment Reason Code	R
	External Source: adjustment_reason
03	782	Adjustment Amount	R
04	380	Adjustment Quantity	S
05	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
06	782	Adjustment Amount	S
07	380	Adjustment Quantity	S
08	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
09	782	Adjustment Amount	S
10	380	Adjustment Quantity	S
11	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
12	782	Adjustment Amount	S
13	380	Adjustment Quantity	S
14	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
15	782	Adjustment Amount	S
16	380	Adjustment Quantity	S
17	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
18	782	Adjustment Amount	S
19	380	Adjustment Quantity	S

DTP- Line Adjudication Date

01	374	Date Time Qualifier	R
	573
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Adjudication or Payment Date	R

HL- Patient Hierarchical Level

01	628	Hierarchical ID Number	R
02	734	Hierarchical Parent ID Number	R
03	735	Hierarchical Level Code	R
	23
04	736	Hierarchical Child Code	R
	0

PAT- Patient Information

01	1069	Patient's Relationship to Insured	R
	01 19 20 22 29 41 53 76
02	1384	Patient Location Code	N
03	584	Employment Status Code	N
04	1220	Student Status Code	S
	F N P
05	1250	Date Time Period Format Qualifier	N
06	1251	Date Time Period	N
07	355	Unit or Basis for Measurement Code	N
08	81	Weight	N
09	1073	Yes/No Condition or Response Code	N

NM1- Patient Name

01	98	Entity Identifier Code	R
	QC
02	1065	Entity Type Qualifier	R
	1
03	1035	Patient Last Name	R
04	1036	Patient First Name	R
05	1037	Patient Middle Name	S
06	1038	Name Prefix	N
07	1039	Patient Name Suffix	S
08	66	Identification Code Qualifier	S
	MI ZZ
09	67	Patient Primary Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Patient Address

01	166	Patient's Address 1	R
02	166	Patient's Address 2	S

N4- Patient City/State/ZIP Code

01	19	Patient City Name	R
02	156	Patient State Code	R
	External Source: states
03	116	Patient Postal Zone or ZIP Code	R
04	26	Patient Country Code	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

DMG- Patient Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Patient Birth Date	R
03	1068	Patient Gender Code	R
	F M U
04	1067	Marital Status Code	N
05	1109	Race or Ethnicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
08	659	Basis of Verification Code	N
09	380	Quantity	N

REF- Patient Secondary Identification

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Patient Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Property and Casualty Claim Number

01	128	Reference Identification Qualifier	R
	Y4
02	127	Property Casualty Claim Number	R
03	352	Description	N
N		C040	Reference Identifier

CLM- Claim Information

01	1028	Patient Account Number	R
02	782	Total Claim Charge Amount	R
03	1032	Claim Filing Indicator Code	N
04	1343	Non-Institutional Claim Type Code	N
R		C023	Place of Service Code
01	1331	Facility Type Code	R
	External Source: pos
02	1332	Facility Code Qualifier	N
03	1325	Claim Submission Reason Code	R
06	1073	Provider or Supplier Signature Indicator	R
	N Y
07	1359	Medicare Assignment Code	S
	A C P
08	1073	Benefits Assignment Certification Indicator	R
	N Y
09	1363	Release of Information Code	R
	N Y
10	1351	Patient Signature Source Code	N
S		C024	Related Causes Information
01	1362	Related Causes Code	R
	AA EM OA
02	1362	Related Causes Code	S
	AA EM OA
03	1362	Related Causes Code	S
	AA EM OA
04	156	Auto Accident State or Province Code	S
	External Source: states
05	26	Country Code	S
	External Source: country
12	1366	Special Program Indicator	S
	01 02 03 05
13	1073	Yes/No Condition or Response Code	N
14	1338	Level of Service Code	N
15	1073	Yes/No Condition or Response Code	N
16	1360	Provider Agreement Code	N
17	1029	Claim Status Code	N
18	1073	Yes/No Condition or Response Code	N
19	1383	Predetermination of Benefits Code	S
	PB
20	1514	Delay Reason Code	S
	1 2 3 4 5 6 7 8 9 10 11

DTP- Date - Admission

01	374	Date Time Qualifier	R
	435
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Related Hospitalization Admission Date	R

DTP- Date - Discharge

01	374	Date Time Qualifier	R
	096
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Discharge or End Of Care Date	R

DTP- Date - Referral

01	374	Date Time Qualifier	R
	330
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Referral Date	R

DTP- Date - Accident

01	374	Date Time Qualifier	R
	439
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Accident Date	R

DTP- Date - Appliance Placement

01	374	Date Time Qualifier	R
	452
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Orthodontic Banding Date	R

DTP- Date - Service

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	D8 RD8
03	1251	Service Date	R

DN1- Orthodontic Total Months of Treatment

01	380	Orthodontic Treatment Months Count	S
02	380	Orthodontic Treatment Months Remaining Count	S
03	1073	Question Response	S
	Y
04	352	Description	N

DN2- Tooth Status

01	127	Tooth Number	R
02	1368	Tooth Status Code	R
	E I M
03	380	Quantity	N
04	1250	Date Time Period Format Qualifier	N
05	1251	Date Time Period	N

PWK- Claim Supplemental Information

01	755	Attachment Report Type Code	R
	B4 DA DG EB OB OZ P6 RB RR
02	756	Attachment Transmission Code	R
	AA BM EL EM FX
03	757	Report Copies Needed	N
04	98	Entity Identifier Code	N
05	66	Identification Code Qualifier	S
	AC
06	67	Attachment Control Number	S
07	352	Description	N
N		C002	Actions Indicated
09	1525	Request Category Code	N

AMT- Patient Amount Paid

01	522	Amount Qualifier Code	R
	F5
02	782	Patient Amount Paid	R
03	478	Credit/Debit Flag Code	N

AMT- Credit/Debit Card - Maximum Amount

01	522	Amount Qualifier Code	R
	MA
02	782	Credit or Debit Card Maximum Amount	R
03	478	Credit/Debit Flag Code	N

REF- Predetermination Identification

01	128	Reference Identification Qualifier	R
	G3
02	127	Predetermination of Benefits Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Service Authorization Exception Code

01	128	Reference Identification Qualifier	R
	4N
02	127	Service Authorization Exception Code	R
	1 2 3 4 5 6 7
03	352	Description	N
N		C040	Reference Identifier

REF- Original Reference Number (ICN/DCN)

01	128	Reference Identification Qualifier	R
	F8
02	127	Claim Original Reference Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Claim Identification Number for Clearinghouses and Other Transmission Intermediaries

01	128	Reference Identification Qualifier	R
	D9
02	127	Value Added Network Trace Number	R
03	352	Description	N
N		C040	Reference Identifier

NTE- Claim Note

01	363	Note Reference Code	R
	ADD
02	352	Claim Note Text	R

NM1- Referring Provider Name

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Referring Provider Last Name	R
04	1036	Referring Provider First Name	S
05	1037	Referring Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Referring Provider Name Suffix	S
08	66	Identification Code Qualifier	S
	24 34 XX
09	67	Referring Provider Identifier	S
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Referring Provider Specialty Information

01	1221	Provider Code	R
	RF
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Referring Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Referring Provider Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Rendering Provider Name

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider Last or Organization Name	R
04	1036	Rendering Provider First Name	S
05	1037	Rendering Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Rendering Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Rendering Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Rendering Provider Specialty Information

01	1221	Provider Code	R
	PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Rendering Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Rendering Provider Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Service Facility Location

01	98	Entity Identifier Code	R
	FA
02	1065	Entity Type Qualifier	R
	2
03	1035	Laboratory or Facility Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Laboratory or Facility Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Service Facility Location Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1G 1H G2 LU TJ X4 X5
02	127	Laboratory or Facility Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Assistant Surgeon Name

01	98	Entity Identifier Code	R
	DD
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Assistant Last or Organazation Name	R
04	1036	Assistant Surgeon First Name	S
05	1037	Assistant Surgeon Middle Name	S
06	1038	Name Prefix	N
07	1039	Assistant Surgeon Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Assistant Surgeon Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Assistant Surgeon Specialty Information

01	1221	Provider Code	R
	AS
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Assistant Surgeon Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H G2 LU TJ X4 X5
02	127	Assistant Surgeon Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

SBR- Other Subscriber Information

01	1138	Payer Responsibility Sequence Number Code	R
	P S T
02	1069	Individual Relationship Code	R
	01 18 19 20 21 22 29 76
03	127	Insured Group or Policy Number	S
04	93	Policy Name	S
05	1336	Insurance Type Code	N
06	1143	Coordination of Benefits Code	N
07	1073	Yes/No Condition or Response Code	N
08	584	Employment Status Code	N
09	1032	Claim Filing Indicator Code	S
	09 11 12 13 14 15 16 17 BL CH CI DS FI HM LM MB MC MH OF SA VA WC ZZ

CAS- Claim Adjustment

01	1033	Claim Adjustment Group Code	R
	CO CR OA PI PR
02	1034	Adjustment Reason Code	R
	External Source: adjustment_reason
03	782	Adjustment Amount	R
04	380	Adjustment Quantity	S
05	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
06	782	Adjustment Amount	S
07	380	Adjustment Quantity	S
08	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
09	782	Adjustment Amount	S
10	380	Adjustment Quantity	S
11	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
12	782	Adjustment Amount	S
13	380	Adjustment Quantity	S
14	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
15	782	Adjustment Amount	S
16	380	Adjustment Quantity	S
17	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
18	782	Adjustment Amount	S
19	380	Adjustment Quantity	S

AMT- Coordination of Benefits (COB) Payer Paid Amount

01	522	Amount Qualifier Code	R
	D
02	782	Payer Paid Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Approved Amount

01	522	Amount Qualifier Code	R
	AAE
02	782	Approved Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Allowed Amount

01	522	Amount Qualifier Code	R
	B6
02	782	Allowed Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Patient Responsibility Amount

01	522	Amount Qualifier Code	R
	F2
02	782	Patient Responsibility Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Covered Amount

01	522	Amount Qualifier Code	R
	AU
02	782	Covered Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Discount Amount

01	522	Amount Qualifier Code	R
	D8
02	782	Other Payer Discount Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Coordination of Benefits (COB) Patient Paid Amount

01	522	Amount Qualifier Code	R
	F5
02	782	Other Payer Patient Paid Amount	R
03	478	Credit/Debit Flag Code	N

DMG- Other Insured Demographic Information

01	1250	Date Time Period Format Qualifier	R
	D8
02	1251	Other Insured Birth Date	R
03	1068	Other Insured Gender Code	R
	F M U
04	1067	Marital Status Code	N
05	1109	Race or Ethnicity Code	N
06	1066	Citizenship Status Code	N
07	26	Country Code	N
08	659	Basis of Verification Code	N
09	380	Quantity	N

OI- Other Insurance Coverage Information

01	1032	Claim Filing Indicator Code	N
02	1383	Claim Submission Reason Code	N
03	1073	Benefits Assignment Certification Indicator	R
	N Y
04	1351	Patient Signature Source Code	N
05	1360	Provider Agreement Code	N
06	1363	Release of Information	R
	N Y

NM1- Other Subscriber Name

01	98	Entity Identifier Code	R
	IL
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Other Insured Last Name	R
04	1036	Other Insured First Name	R
05	1037	Other Insured Middle Name	S
06	1038	Name Prefix	N
07	1039	Other Insured Name Suffix	S
08	66	Identification Code Qualifier	R
	24 MI ZZ
09	67	Other Insured Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

N3- Other Subscriber Address

01	166	Other Insured's Address 1	R
02	166	Other Insured's Address 2	S

N4- Other Subscriber City/State/ZIP Code

01	19	Other Insured City Name	R
02	156	Other Insured State Code	R
	External Source: states
03	116	Other Insured Postal Zone or ZIP Code	R
04	26	Other Insured's Country	S
	External Source: country
05	309	Location Qualifier	N
06	310	Location Identifier	N

REF- Other Subscriber Secondary Identification

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Insured Additional Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Name

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Other Payer Last or Organization Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	PI XV
09	67	Other Payer Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PER- Other Payer Contact Information

01	366	Contact Function Code	R
	IC
02	93	Other Payer Contact Name	R
03	365	Communication Number Qualifier	R
	ED EM FX TE
04	364	Communication Number	R
05	365	Communication Number Qualifier	S
	ED EM EX FX TE
06	364	Communication Number	S
07	365	Communication Number Qualifier	S
	ED EM EX FX TE
08	364	Communication Number	S
09	443	Contact Inquiry Reference	N

DTP- Claim Paid Date

01	374	Date Time Qualifier	R
	573
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Date Claim Paid	R

REF- Other Payer Secondary Identifier

01	128	Reference Identification Qualifier	R
	2U D8 F8 FY NF TJ
02	127	Other Payer Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Other Payer Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Other Payer Prior Authorization or Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Other Payer Claim Adjustment Indicator

01	128	Reference Identification Qualifier	R
	T4
02	127	Other Payer Claim Adjustment Indicator	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Patient Information

01	98	Entity Identifier Code	R
	QC
02	1065	Entity Type Qualifier	R
	1
03	1035	Other Payer Patient Last Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	MI
09	67	Other Payer Patient Primary Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Patient Identification

01	128	Reference Identification Qualifier	R
	1W 23 IG SY
02	127	Other Payer Patient Primary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Referring Provider

01	98	Entity Identifier Code	R
	DN P3
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Referring Provider Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Other Payer Referring Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Rendering Provider

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Name Last or Organization Name	N
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	N
09	67	Identification Code	N
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Rendering Provider Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Other Payer Rendering Provider Identifier	R
03	352	Description	N
N		C040	Reference Identifier

LX- Line Counter

554

Line Counter

SV3- Dental Service

R		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD
02	234	Procedure Code	R
03	1339	Procedure Code Modifier	S
04	1339	Procedure Code Modifier	S
05	1339	Procedure Code Modifier	S
06	1339	Procedure Code Modifier	S
07	352	Description	N
02	782	Line Item Charge Amount	R
03	1331	Facility Type Code	S
	External Source: pos
S		C006	Oral Cavity Designation
01	1361	Oral Cavity Designation Code	R
	L R 00 01 02 09 10 20 30 40
02	1361	Oral Cavity Designation Code	S
	L R 00 01 02 09 10 20 30 40
03	1361	Oral Cavity Designation Code	S
	L R 00 01 02 09 10 20 30 40
04	1361	Oral Cavity Designation Code	S
	L R 00 01 02 09 10 20 30 40
05	1361	Oral Cavity Designation Code	S
	L R 00 01 02 09 10 20 30 40
05	1358	Prosthesis, Crown, or Inlay Code	S
	I R
06	380	Procedure Count	R
07	352	Description	N
08	1327	Copay Status Code	N
09	1360	Provider Agreement Code	N
10	1073	Yes/No Condition or Response Code	N
N		C004	Composite Diagnosis Code Pointer

TOO- Tooth Information

01	1270	Code List Qualifier Code	R
	JP
02	1271	Tooth Code	S
S		C005	Tooth Surface
01	1369	Tooth Surface Code	R
	B D F I L M O
02	1369	Tooth Surface Code	S
	B D F I L M O
03	1369	Tooth Surface Code	S
	B D F I L M O
04	1369	Tooth Surface Code	S
	B D F I L M O
05	1369	Tooth Surface Code	S
	B D F I L M O

DTP- Date - Service

01	374	Date Time Qualifier	R
	472
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Service Date	R

DTP- Date - Prior Placement

01	374	Date Time Qualifier	R
	441
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Prior Placement Date	R

DTP- Date - Appliance Placement

01	374	Date Time Qualifier	R
	452
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Orthodontic Banding Date	R

DTP- Date - Replacement

01	374	Date Time Qualifier	R
	446
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Replacement Date	R

QTY- Anesthesia Quantity

01	673	Quantity Qualifier	R
	BF EM HM HO HP P3 P4 P5 SG
02	380	Anesthesia Unit Count	R
N		C001	Composite Unit of Measure
04	61	Free-Form Message	N

REF- Service Predetermination Identification

01	128	Reference Identification Qualifier	R
	G3
02	127	Predetermination of Benefits Identifier	R
03	352	Description	N
N		C040	Reference Identifier

REF- Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

REF- Line Item Control Number

01	128	Reference Identification Qualifier	R
	6R
02	127	Line Item Control Number	R
03	352	Description	N
N		C040	Reference Identifier

AMT- Approved Amount

01	522	Amount Qualifier Code	R
	AAE
02	782	Approved Amount	R
03	478	Credit/Debit Flag Code	N

AMT- Sales Tax Amount

01	522	Amount Qualifier Code	R
	T
02	782	Sales Tax Amount	R
03	478	Credit/Debit Flag Code	N

NTE- Line Note

01	363	Note Reference Code	R
02	352	Claim Note Text	R

NM1- Rendering Provider Name

01	98	Entity Identifier Code	R
	82
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Rendering Provider Last or Organization Name	R
04	1036	Rendering Provider First Name	S
05	1037	Rendering Provider Middle Name	S
06	1038	Name Prefix	N
07	1039	Rendering Provider Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Rendering Provider Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Rendering Provider Specialty Information

01	1221	Provider Code	R
	PE
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Rendering Provider Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H EI G2 G5 LU SY TJ
02	127	Rendering Provider Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Other Payer Prior Authorization or Referral Number

01	98	Entity Identifier Code	R
	PR
02	1065	Entity Type Qualifier	R
	2
03	1035	Other Payer Last or Organization Name	R
04	1036	Name First	N
05	1037	Name Middle	N
06	1038	Name Prefix	N
07	1039	Name Suffix	N
08	66	Identification Code Qualifier	R
	PI XV
09	67	Other Payer Referral Number	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

REF- Other Payer Prior Authorization or Referral Number

01	128	Reference Identification Qualifier	R
	9F G1
02	127	Other Payer Prior Authorization or Referral Number	R
03	352	Description	N
N		C040	Reference Identifier

NM1- Assistant Surgeon Name

01	98	Entity Identifier Code	R
	DD
02	1065	Entity Type Qualifier	R
	1 2
03	1035	Assistant Surgeon Last or Organization Name	R
04	1036	Assistant Surgeon First Name	S
05	1037	Assistant Surgeon Middle Name	S
06	1038	Name Prefix	N
07	1039	Assistant Surgeon Name Suffix	S
08	66	Identification Code Qualifier	R
	24 34 XX
09	67	Assistant Surgeon Identifier	R
10	706	Entity Relationship Code	N
11	98	Entity Identifier Code	N

PRV- Assistant Surgeon Specialty Information

01	1221	Provider Code	R
	AS
02	128	Reference Identification Qualifier	R
	ZZ
03	127	Provider Taxonomy Code	R
04	156	State or Province Code	N
N		C035	Provider Specialty Information
06	1223	Provider Organization Code	N

REF- Assistant Surgeon Secondary Identification

01	128	Reference Identification Qualifier	R
	0B 1A 1B 1C 1D 1E 1H G2 LU TJ X4 X5
02	127	Assistant Surgeon Secondary Identifier	R
03	352	Description	N
N		C040	Reference Identifier

SVD- Line Adjudication Information

01	67	Other Payer Primary Identifier	R
02	782	Service Line Paid Amount	R
R		C003	Composite Medical Procedure Identifier
01	235	Product or Service ID Qualifier	R
	AD ZZ
02	234	Procedure Code	R
03	1339	Procedure Modifier	S
04	1339	Procedure Modifier	S
05	1339	Procedure Modifier	S
06	1339	Procedure Modifier	S
07	352	Procedure Code Description	S
04	234	Product/Service ID	N
05	380	Paid Service Unit Count	R
06	554	Bundled or Unbundled Line Number	S

CAS- Service Adjustment

01	1033	Adjustment Group Code	R
	CO CR OA PI PR
02	1034	Adjustment Reason Code	R
	External Source: adjustment_reason
03	782	Adjustment Amount	R
04	380	Adjustment Quantity	S
05	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
06	782	Adjustment Amount	S
07	380	Adjustment Quantity	S
08	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
09	782	Adjustment Amount	S
10	380	Adjustment Quantity	S
11	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
12	782	Adjustment Amount	S
13	380	Adjustment Quantity	S
14	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
15	782	Adjustment Amount	S
16	380	Adjustment Quantity	S
17	1034	Adjustment Reason Code	S
	External Source: adjustment_reason
18	782	Adjustment Amount	S
19	380	Adjustment Quantity	S

DTP- Line Adjudication Date

01	374	Date Time Qualifier	R
	573
02	1250	Date Time Period Format Qualifier	R
	D8
03	1251	Adjudication or Payment Date	R

SE- Transaction Set Trailer

01	96	Transaction Segment Count	R
02	329	Transaction Set Control Number	R

GE- Functional Group Trailer

01	97	Number of Transaction Sets Included	R
02	28	Group Control Number	R

TA1- Interchange Acknowledgement

01	I12	Interchange Control Number	R
02	I08	Interchange Date	R
03	I09	Interchange Time	R
04	I17	Interchange Acknowledgement Code	R
	A E R
05	I18	Interchange Note Code	R
	000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031

IEA- Interchange Control Trailer

01	I16	Number of Included Functional Groups	R
02	I12	Interchange Control Number	R