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 Hierarchical Level
015 2010BA - Subscriber Name
015 2010BB - Destination Payer
015 2010BC - Responsible Party Name
015 2010BD - Credit/Debit Card Holder Name
130 2300 - Claim Information
242 2305 - Home Health Care Plan Information
250 2310A - Referring Provider Name
250 2310B - Rendering Provider Name
250 2310C - Purchased Service Provider Name
250 2310D - Service Facility Location
250 2310E - Supervising Provider 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
325 2330F - Other Payer Purchased Service Provider
325 2330G - Other Payer Service Facility Location
325 2330H - Other Payer Supervising Provider
365 2400 - Service Line
494 2410 - Drug Identification
500 2420A - Rendering Provider Name
500 2420B - Purchased Service Provider Name
500 2420C - Service Facility Location
500 2420D - Supervising Provider Name
500 2420E - Ordering Provider Name
500 2420F - Referring Provider Name
500 2420G - Other Payer Prior Authorization or Referral Number
540 2430 - Line Adjudication Information
551 2440 - Form Identification Code
140 2000C - Patient Hierarchical Level
015 2010CA - Patient Name
130 2300 - Claim Information
242 2305 - Home Health Care Plan Information
250 2310A - Referring Provider Name
250 2310B - Rendering Provider Name
250 2310C - Purchased Service Provider Name
250 2310D - Service Facility Location
250 2310E - Supervising Provider 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
325 2330F - Other Payer Purchased Service Provider
325 2330G - Other Payer Service Facility Location
325 2330H - Other Payer Supervising Provider
365 2400 - Service Line
494 2410 - Drug Identification
500 2420A - Rendering Provider Name
500 2420B - Purchased Service Provider Name
500 2420C - Service Facility Location
500 2420D - Supervising Provider Name
500 2420E - Ordering Provider Name
500 2420F - Referring Provider Name
500 2420G - Other Payer Prior Authorization or Referral Number
540 2430 - Line Adjudication Information
551 2440 - Form Identification Code
030 FOOTER - Table 3 - Footer