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 Transmission Type Identification R 1 020 1000A - Submitter Name 020 NM1 Submitter Name R 1 045 PER Submitter Contact Information R 2 020 1000B - Receiver Name 020 NM1 Receiver Name R 1 020 DETAIL - Table 2 - Detail 001 2000A - Billing/Pay-To Provider Hierarchical Level 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 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 Number S 5 035 REF Claim Submitter Credit/Debit Card Information S 8 015 2010AB - Pay-To Provider's Name 015 NM1 Pay-To Provider's Name R 1 025 N3 Pay-To Provider's Address R 1 030 N4 Pay-To Provider City/State/ZIP R 1 035 REF Pay-To Provider Secondary Identification Number S 5 020 2000B - Subscriber Hierarchical Level 001 HL Subscriber Hierarchical Level R 1 005 SBR Subscriber Information R 1 015 2010BA - Subscriber Name 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 - Payer Name 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 Number S 3 015 2010BC - Credit/Debit Card Holder Name 015 NM1 Credit/Debit Card Holder Name R 1 035 REF Credit/Debit Card Information S 3 130 2300 - Claim Information 130 CLM Claim Information R 1 135 DTP Date - Admission S 1 135 DTP Date - Discharge S 1 135 DTP Date - Referral S 1 135 DTP Date - Accident S 1 135 DTP Date - Appliance Placement S 5 135 DTP Date - Service S 1 145 DN1 Orthodontic Total Months of Treatment S 1 150 DN2 Tooth Status S 35 155 PWK Claim Supplemental Information S 10 175 AMT Patient Amount Paid S 1 175 AMT Credit/Debit Card - Maximum Amount S 1 180 REF Predetermination Identification S 5 180 REF Service Authorization Exception Code S 1 180 REF Original Reference Number (ICN/DCN) S 1 180 REF Prior Authorization or Referral Number S 2 180 REF Claim Identification Number for Clearinghouses and Other Transmission Intermediaries S 1 190 NTE Claim Note S 20 250 2310A - Referring Provider Name 250 NM1 Referring Provider Name R 1 255 PRV Referring Provider Specialty Information S 1 271 REF Referring Provider Secondary Identification S 5 250 2310B - Rendering Provider Name 250 NM1 Rendering Provider Name R 1 255 PRV Rendering Provider Specialty Information S 1 271 REF Rendering Provider Secondary Identification S 5 250 2310C - Service Facility Location 250 NM1 Service Facility Location R 1 271 REF Service Facility Location Secondary Identification S 5 250 2310D - Assistant Surgeon Name 250 NM1 Assistant Surgeon Name R 1 255 PRV Assistant Surgeon Specialty Information S 1 271 REF Assistant Surgeon Secondary Identification S 1 290 2320 - Other Subscriber Information 290 SBR Other Subscriber Information R 1 295 CAS Claim Adjustment S 5 300 AMT Coordination of Benefits (COB) Payer Paid Amount S 1 300 AMT Coordination of Benefits (COB) Approved Amount S 1 300 AMT Coordination of Benefits (COB) Allowed Amount S 1 300 AMT Coordination of Benefits (COB) Patient Responsibility Amount S 1 300 AMT Coordination of Benefits (COB) Covered Amount S 1 300 AMT Coordination of Benefits (COB) Discount Amount S 1 300 AMT Coordination of Benefits (COB) Patient Paid Amount S 1 305 DMG Other Insured Demographic Information S 1 310 OI Other Insurance Coverage Information R 1 325 2330A - Other Subscriber Name 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 325 NM1 Other Payer Name R 1 345 PER Other Payer Contact Information S 2 350 DTP Claim Paid Date S 1 355 REF Other Payer Secondary Identifier S 3 355 REF Other Payer Prior Authorization or Referral Number S 2 355 REF Other Payer Claim Adjustment Indicator S 1 325 2330C - Other Payer Patient Information 325 NM1 Other Payer Patient Information R 1 355 REF Other Payer Patient Identification S 3 325 2330D - Other Payer Referring Provider 325 NM1 Other Payer Referring Provider R 1 355 REF Other Payer Referring Provider Identification S 3 325 2330E - Other Payer Rendering Provider 325 NM1 Other Payer Rendering Provider R 1 355 REF Other Payer Rendering Provider Identification S 3 365 2400 - Line Counter 365 LX Line Counter R 1 380 SV3 Dental Service R 1 382 TOO Tooth Information S 32 455 DTP Date - Service S 1 455 DTP Date - Prior Placement S 1 455 DTP Date - Appliance Placement S 1 455 DTP Date - Replacement S 1 460 QTY Anesthesia Quantity S 5 470 REF Service Predetermination Identification S 1 470 REF Prior Authorization or Referral Number S 2 470 REF Line Item Control Number S 1 475 AMT Approved Amount S 1 475 AMT Sales Tax Amount S 1 485 NTE Line Note S 10 500 2420A - Rendering Provider Name 500 NM1 Rendering Provider Name R 1 505 PRV Rendering Provider Specialty Information S 1 525 REF Rendering Provider Secondary Identification S 5 500 2420B - Other Payer Prior Authorization or Referral Number 500 NM1 Other Payer Prior Authorization or Referral Number R 1 525 REF Other Payer Prior Authorization or Referral Number S 2 500 2420C - Assistant Surgeon Name 500 NM1 Assistant Surgeon Name S 1 505 PRV Assistant Surgeon Specialty Information S 1 525 REF Assistant Surgeon Secondary Identification S 1 540 2430 - Line Adjudication Information 540 SVD Line Adjudication Information R 1 545 CAS Service Adjustment S 99 550 DTP Line Adjudication Date R 1 140 2000C - Patient Hierarchical Level 001 HL Patient Hierarchical Level R 1 007 PAT Patient Information R 1 015 2010CA - Patient Name 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 S 5 035 REF Property and Casualty Claim Number S 1 130 2300 - Claim Information 130 CLM Claim Information R 1 135 DTP Date - Admission S 1 135 DTP Date - Discharge S 1 135 DTP Date - Referral S 1 135 DTP Date - Accident S 1 135 DTP Date - Appliance Placement S 5 135 DTP Date - Service S 1 145 DN1 Orthodontic Total Months of Treatment S 1 150 DN2 Tooth Status S 35 155 PWK Claim Supplemental Information S 10 175 AMT Patient Amount Paid S 1 175 AMT Credit/Debit Card - Maximum Amount S 1 180 REF Predetermination Identification S 5 180 REF Service Authorization Exception Code S 1 180 REF Original Reference Number (ICN/DCN) S 1 180 REF Prior Authorization or Referral Number S 2 180 REF Claim Identification Number for Clearinghouses and Other Transmission Intermediaries S 1 190 NTE Claim Note S 20 250 2310A - Referring Provider Name 250 NM1 Referring Provider Name R 1 255 PRV Referring Provider Specialty Information S 1 271 REF Referring Provider Secondary Identification S 5 250 2310B - Rendering Provider Name 250 NM1 Rendering Provider Name R 1 255 PRV Rendering Provider Specialty Information S 1 271 REF Rendering Provider Secondary Identification S 5 250 2310C - Service Facility Location 250 NM1 Service Facility Location R 1 271 REF Service Facility Location Secondary Identification S 5 250 2310D - Assistant Surgeon Name 250 NM1 Assistant Surgeon Name R 1 255 PRV Assistant Surgeon Specialty Information S 1 271 REF Assistant Surgeon Secondary Identification S 1 290 2320 - Other Subscriber Information 290 SBR Other Subscriber Information R 1 295 CAS Claim Adjustment S 5 300 AMT Coordination of Benefits (COB) Payer Paid Amount S 1 300 AMT Coordination of Benefits (COB) Approved Amount S 1 300 AMT Coordination of Benefits (COB) Allowed Amount S 1 300 AMT Coordination of Benefits (COB) Patient Responsibility Amount S 1 300 AMT Coordination of Benefits (COB) Covered Amount S 1 300 AMT Coordination of Benefits (COB) Discount Amount S 1 300 AMT Coordination of Benefits (COB) Patient Paid Amount S 1 305 DMG Other Insured Demographic Information S 1 310 OI Other Insurance Coverage Information R 1 325 2330A - Other Subscriber Name 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 325 NM1 Other Payer Name R 1 345 PER Other Payer Contact Information S 2 350 DTP Claim Paid Date S 1 355 REF Other Payer Secondary Identifier S 3 355 REF Other Payer Prior Authorization or Referral Number S 2 355 REF Other Payer Claim Adjustment Indicator S 1 325 2330C - Other Payer Patient Information 325 NM1 Other Payer Patient Information R 1 355 REF Other Payer Patient Identification S 3 325 2330D - Other Payer Referring Provider 325 NM1 Other Payer Referring Provider R 1 355 REF Other Payer Referring Provider Identification S 3 325 2330E - Other Payer Rendering Provider 325 NM1 Other Payer Rendering Provider R 1 355 REF Other Payer Rendering Provider Identification S 3 365 2400 - Line Counter 365 LX Line Counter R 1 380 SV3 Dental Service R 1 382 TOO Tooth Information S 32 455 DTP Date - Service S 1 455 DTP Date - Prior Placement S 1 455 DTP Date - Appliance Placement S 1 455 DTP Date - Replacement S 1 460 QTY Anesthesia Quantity S 5 470 REF Service Predetermination Identification S 1 470 REF Prior Authorization or Referral Number S 2 470 REF Line Item Control Number S 1 475 AMT Approved Amount S 1 475 AMT Sales Tax Amount S 1 485 NTE Line Note S 10 500 2420A - Rendering Provider Name 500 NM1 Rendering Provider Name R 1 505 PRV Rendering Provider Specialty Information S 1 525 REF Rendering Provider Secondary Identification S 5 500 2420B - Other Payer Prior Authorization or Referral Number 500 NM1 Other Payer Prior Authorization or Referral Number R 1 525 REF Other Payer Prior Authorization or Referral Number S 2 500 2420C - Assistant Surgeon Name 500 NM1 Assistant Surgeon Name S 1 505 PRV Assistant Surgeon Specialty Information S 1 525 REF Assistant Surgeon Secondary Identification S 1 540 2430 - Line Adjudication Information 540 SVD Line Adjudication Information R 1 545 CAS Service Adjustment S 99 550 DTP Line Adjudication Date R 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	1
030	IEA	Interchange Control Trailer	R	1