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 EDI 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 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 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 Hierarchical Level 001 HL Subscriber Hierarchical Level R 1 005 SBR Subscriber Information R 1 007 PAT Patient Information S 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 - Destination Payer 015 NM1 Destination Payer Name R 1 025 N3 Destination Payer Address S 1 030 N4 Destination Payer City/State/ZIP Code S 1 035 REF Destination Payer Secondary Identification S 3 015 2010BC - Responsible Party Name 015 NM1 Responsible Party Name R 1 025 N3 Responsible Party Address R 1 030 N4 Responsible Party City/State/ZIP Code R 1 015 2010BD - Credit/Debit Card Holder Name 015 NM1 Credit/Debit Card Holder Name R 1 035 REF Credit/Debit Card Information S 2 130 2300 - Claim Information 130 CLM Claim Information R 1 135 DTP Date - Initial Treatment S 1 135 DTP Date - Date Last Seen S 1 135 DTP Date - Onset of Current Illness/Symptom S 1 135 DTP Date - Acute Manifestation S 5 135 DTP Date - Similar Illness/Symptom Onset S 10 135 DTP Date - Accident S 10 135 DTP Date - Last Menstrual Period S 1 135 DTP Date - Last X-Ray S 1 135 DTP Date - Hearing and Vision Prescription Date S 1 135 DTP Date - Disability Begin S 5 135 DTP Date - Disability End S 5 135 DTP Date - Last Worked S 1 135 DTP Date - Authorized Return to Work S 1 135 DTP Date - Admission S 1 135 DTP Date - Discharge S 1 135 DTP Date - Assumed and Relinquished Care Dates S 2 155 PWK Claim Supplemental Information S 10 160 CN1 Contract Information S 1 175 AMT Credit/Debit Card Maximum Amount S 1 175 AMT Patient Amount Paid S 1 175 AMT Total Purchased Service Amount S 1 180 REF Service Authorization Exception Code S 1 180 REF Mandatory Medicare (Section 4081) Crossover Indicator S 1 180 REF Mammography Certification Number S 1 180 REF Prior Authorization or Referral Number S 2 180 REF Original Reference Number (ICN/DCN) S 1 180 REF Clinical Laboratory Improvement Amendment (CLIA) Number S 3 180 REF Repriced Claim Number S 1 180 REF Adjusted Repriced Claim Number S 1 180 REF Investigational Device Exemption Number S 1 180 REF Claim Identification Number for Clearing Houses and Other Transmission Intermediaries S 1 180 REF Ambulatory Patient Group (APG) S 4 180 REF Medical Record Number S 1 180 REF Demonstration Project Identifier S 1 185 K3 File Information S 10 190 NTE Claim Note S 1 195 CR1 Ambulance Transport Information S 1 200 CR2 Spinal Manipulation Service Information S 1 220 CRC Ambulance Certification S 3 220 CRC Patient Condition Information: Vision S 3 220 CRC Homebound Indicator S 1 220 CRC EPSDT Referral S 1 231 HI Health Care Diagnosis Code S 1 241 HCP Claim Pricing/Repricing Information S 1 242 2305 - Home Health Care Plan Information 242 CR7 Home Health Care Plan Information R 1 243 HSD Health Care Services Delivery S 3 250 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 - Purchased Service Provider Name 250 NM1 Purchased Service Provider Name R 1 271 REF Purchased Service Provider Secondary Identification S 5 250 2310D - Service Facility Location 250 NM1 Service Facility Location R 1 265 N3 Service Facility Location Address R 1 270 N4 Service Facility Location City/State/ZIP R 1 271 REF Service Facility Location Secondary Identification S 5 250 2310E - Supervising Provider Name 250 NM1 Supervising Provider Name R 1 271 REF Supervising Provider Secondary Identification S 5 290 2320 - Other Subscriber Information 290 SBR Other Subscriber Information R 1 295 CAS Claim Level Adjustments 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) Per Day Limit Amount S 1 300 AMT Coordination of Benefits (COB) Patient Paid Amount S 1 300 AMT Coordination of Benefits (COB) Tax Amount S 1 300 AMT Coordination of Benefits (COB) Total Claim Before Taxes Amount S 1 305 DMG Subscriber Demographic Information S 1 310 OI Other Insurance Coverage Information R 1 320 MOA Medicare Outpatient Adjudication Information S 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 2 345 DTP Claim Adjudication Date S 1 355 REF Other Payer Secondary Identifier S 2 355 REF Other Payer Prior Authorization or Referral Number S 2 355 REF Other Payer Claim Adjustment Indicator S 2 325 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 R 3 325 2330E - Other Payer Rendering Provider 325 NM1 Other Payer Rendering Provider R 1 355 REF Other Payer Rendering Provider Secondary Identification R 3 325 2330F - Other Payer Purchased Service Provider 325 NM1 Other Payer Purchased Service Provider R 1 355 REF Other Payer Purchased Service Provider Identification R 3 325 2330G - Other Payer Service Facility Location 325 NM1 Other Payer Service Facility Location R 1 355 REF Other Payer Service Facility Location Identification R 3 325 2330H - Other Payer Supervising Provider 325 NM1 Other Payer Supervising Provider R 1 355 REF Other Payer Supervising Provider Identification R 3 365 2400 - Service Line 365 LX Service Line R 1 370 SV1 Professional Service R 1 400 SV5 Durable Medical Equipment Service S 1 420 PWK DMERC CMN Indicator S 1 425 CR1 Ambulance Transport Information S 1 430 CR2 Spinal Manipulation Service Information S 5 435 CR3 Durable Medical Equipment Certification S 1 445 CR5 Home Oxygen Therapy Information S 1 450 CRC Ambulance Certification S 3 450 CRC Hospice Employee Indicator S 1 450 CRC DMERC Condition Indicator S 2 455 DTP Date - Service Date R 1 455 DTP Date - Certification Revision Date S 1 455 DTP Date - Begin Therapy Date S 1 455 DTP Date - Last Certification Date S 1 455 DTP Date - Date Last Seen S 1 455 DTP Date - Test S 2 455 DTP Date - Oxygen Saturation/Arterial Blood Gas Test S 3 455 DTP Date - Shipped S 1 455 DTP Date - Onset of Current Symptom/Illness S 1 455 DTP Date - Last X-ray S 1 455 DTP Date - Acute Manifestation S 1 455 DTP Date - Initial Treatment S 1 455 DTP Date - Similar Illness/Symptom Onset S 1 462 MEA Test Result S 20 465 CN1 Contract Information S 1 470 REF Repriced Line Item Reference Number S 1 470 REF Adjusted Repriced Line Item Reference Number S 1 470 REF Prior Authorization or Referral Number S 2 470 REF Line Item Control Number S 1 470 REF Mammography Certification Number S 1 470 REF Clinical Laboratory Improvement Amendment (CLIA) Identification S 1 470 REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification S 1 470 REF Immunization Batch Number S 1 470 REF Ambulatory Patient Group (APG) S 4 470 REF Oxygen Flow Rate S 1 470 REF Universal Product Number (UPN) S 1 475 AMT Sales Tax Amount S 1 475 AMT Approved Amount S 1 475 AMT Postage Claimed Amount S 1 480 K3 File Information S 10 485 NTE Line Note S 1 488 PS1 Purchased Service Information S 1 491 HSD Health Care Services Delivery S 1 492 HCP Line Pricing/Repricing Information S 1 494 2410 - Drug Identification 494 LIN Drug Identification R 1 495 CTP Drug Pricing S 1 496 REF Prescription Number S 1 500 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 - Purchased Service Provider Name 500 NM1 Purchased Service Provider Name R 1 525 REF Purchased Service Provider Secondary Identification S 5 500 2420C - Service Facility Location 500 NM1 Service Facility Location R 1 514 N3 Service Facility Location Address R 1 520 N4 Service Facility Location City/State/ZIP R 1 525 REF Service Facility Location Secondary Identification S 5 500 2420D - Supervising Provider Name 500 NM1 Supervising Provider Name R 1 525 REF Supervising Provider Secondary Identification S 5 500 2420E - Ordering Provider Name 500 NM1 Ordering Provider Name R 1 514 N3 Ordering Provider Address S 1 520 N4 Ordering Provider City/State/ZIP Code S 1 525 REF Ordering Provider Secondary Identification S 5 530 PER Ordering Provider Contact Information S 1 500 2420F - Referring Provider Name 500 NM1 Referring Provider Name R 1 505 PRV Referring Provider Specialty Information S 1 525 REF Referring Provider Secondary Identification S 5 500 2420G - 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 R 2 540 2430 - Line Adjudication Information 540 SVD Line Adjudication Information R 1 545 CAS Line Adjustment S 99 550 DTP Line Adjudication Date R 1 551 2440 - Form Identification Code 551 LQ Form Identification Code R 1 552 FRM Supporting Documentation R 99 140 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 - Initial Treatment S 1 135 DTP Date - Date Last Seen S 1 135 DTP Date - Onset of Current Illness/Symptom S 1 135 DTP Date - Acute Manifestation S 5 135 DTP Date - Similar Illness/Symptom Onset S 10 135 DTP Date - Accident S 10 135 DTP Date - Last Menstrual Period S 1 135 DTP Date - Last X-Ray S 1 135 DTP Date - Hearing and Vision Prescription Date S 1 135 DTP Date - Disability Begin S 5 135 DTP Date - Disability End S 5 135 DTP Date - Last Worked S 1 135 DTP Date - Authorized Return to Work S 1 135 DTP Date - Admission S 1 135 DTP Date - Discharge S 1 135 DTP Date - Assumed and Relinquished Care Dates S 2 155 PWK Claim Supplemental Information S 10 160 CN1 Contract Information S 1 175 AMT Credit/Debit Card Maximum Amount S 1 175 AMT Patient Amount Paid S 1 175 AMT Total Purchased Service Amount S 1 180 REF Service Authorization Exception Code S 1 180 REF Mandatory Medicare (Section 4081) Crossover Indicator S 1 180 REF Mammography Certification Number S 1 180 REF Prior Authorization or Referral Number S 2 180 REF Original Reference Number (ICN/DCN) S 1 180 REF Clinical Laboratory Improvement Amendment (CLIA) Number S 3 180 REF Repriced Claim Number S 1 180 REF Adjusted Repriced Claim Number S 1 180 REF Investigational Device Exemption Number S 1 180 REF Claim Identification Number for Clearing Houses and Other Transmission Intermediaries S 1 180 REF Ambulatory Patient Group (APG) S 4 180 REF Medical Record Number S 1 180 REF Demonstration Project Identifier S 1 185 K3 File Information S 10 190 NTE Claim Note S 1 195 CR1 Ambulance Transport Information S 1 200 CR2 Spinal Manipulation Service Information S 1 220 CRC Ambulance Certification S 3 220 CRC Patient Condition Information: Vision S 3 220 CRC Homebound Indicator S 1 220 CRC EPSDT Referral S 1 231 HI Health Care Diagnosis Code S 1 241 HCP Claim Pricing/Repricing Information S 1 242 2305 - Home Health Care Plan Information 242 CR7 Home Health Care Plan Information R 1 243 HSD Health Care Services Delivery S 3 250 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 - Purchased Service Provider Name 250 NM1 Purchased Service Provider Name R 1 271 REF Purchased Service Provider Secondary Identification S 5 250 2310D - Service Facility Location 250 NM1 Service Facility Location R 1 265 N3 Service Facility Location Address R 1 270 N4 Service Facility Location City/State/ZIP R 1 271 REF Service Facility Location Secondary Identification S 5 250 2310E - Supervising Provider Name 250 NM1 Supervising Provider Name R 1 271 REF Supervising Provider Secondary Identification S 5 290 2320 - Other Subscriber Information 290 SBR Other Subscriber Information R 1 295 CAS Claim Level Adjustments 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) Per Day Limit Amount S 1 300 AMT Coordination of Benefits (COB) Patient Paid Amount S 1 300 AMT Coordination of Benefits (COB) Tax Amount S 1 300 AMT Coordination of Benefits (COB) Total Claim Before Taxes Amount S 1 305 DMG Subscriber Demographic Information S 1 310 OI Other Insurance Coverage Information R 1 320 MOA Medicare Outpatient Adjudication Information S 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 2 345 DTP Claim Adjudication Date S 1 355 REF Other Payer Secondary Identifier S 2 355 REF Other Payer Prior Authorization or Referral Number S 2 355 REF Other Payer Claim Adjustment Indicator S 2 325 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 R 3 325 2330E - Other Payer Rendering Provider 325 NM1 Other Payer Rendering Provider R 1 355 REF Other Payer Rendering Provider Secondary Identification R 3 325 2330F - Other Payer Purchased Service Provider 325 NM1 Other Payer Purchased Service Provider R 1 355 REF Other Payer Purchased Service Provider Identification R 3 325 2330G - Other Payer Service Facility Location 325 NM1 Other Payer Service Facility Location R 1 355 REF Other Payer Service Facility Location Identification R 3 325 2330H - Other Payer Supervising Provider 325 NM1 Other Payer Supervising Provider R 1 355 REF Other Payer Supervising Provider Identification R 3 365 2400 - Service Line 365 LX Service Line R 1 370 SV1 Professional Service R 1 400 SV5 Durable Medical Equipment Service S 1 420 PWK DMERC CMN Indicator S 1 425 CR1 Ambulance Transport Information S 1 430 CR2 Spinal Manipulation Service Information S 5 435 CR3 Durable Medical Equipment Certification S 1 445 CR5 Home Oxygen Therapy Information S 1 450 CRC Ambulance Certification S 3 450 CRC Hospice Employee Indicator S 1 450 CRC DMERC Condition Indicator S 2 455 DTP Date - Service Date R 1 455 DTP Date - Certification Revision Date S 1 455 DTP Date - Begin Therapy Date S 1 455 DTP Date - Last Certification Date S 1 455 DTP Date - Date Last Seen S 1 455 DTP Date - Test S 2 455 DTP Date - Oxygen Saturation/Arterial Blood Gas Test S 3 455 DTP Date - Shipped S 1 455 DTP Date - Onset of Current Symptom/Illness S 1 455 DTP Date - Last X-ray S 1 455 DTP Date - Acute Manifestation S 1 455 DTP Date - Initial Treatment S 1 455 DTP Date - Similar Illness/Symptom Onset S 1 462 MEA Test Result S 20 465 CN1 Contract Information S 1 470 REF Repriced Line Item Reference Number S 1 470 REF Adjusted Repriced Line Item Reference Number S 1 470 REF Prior Authorization or Referral Number S 2 470 REF Line Item Control Number S 1 470 REF Mammography Certification Number S 1 470 REF Clinical Laboratory Improvement Amendment (CLIA) Identification S 1 470 REF Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Identification S 1 470 REF Immunization Batch Number S 1 470 REF Ambulatory Patient Group (APG) S 4 470 REF Oxygen Flow Rate S 1 470 REF Universal Product Number (UPN) S 1 475 AMT Sales Tax Amount S 1 475 AMT Approved Amount S 1 475 AMT Postage Claimed Amount S 1 480 K3 File Information S 10 485 NTE Line Note S 1 488 PS1 Purchased Service Information S 1 491 HSD Health Care Services Delivery S 1 492 HCP Line Pricing/Repricing Information S 1 494 2410 - Drug Identification 494 LIN Drug Identification R 1 495 CTP Drug Pricing S 1 496 REF Prescription Number S 1 500 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 - Purchased Service Provider Name 500 NM1 Purchased Service Provider Name R 1 525 REF Purchased Service Provider Secondary Identification S 5 500 2420C - Service Facility Location 500 NM1 Service Facility Location R 1 514 N3 Service Facility Location Address R 1 520 N4 Service Facility Location City/State/ZIP R 1 525 REF Service Facility Location Secondary Identification S 5 500 2420D - Supervising Provider Name 500 NM1 Supervising Provider Name R 1 525 REF Supervising Provider Secondary Identification S 5 500 2420E - Ordering Provider Name 500 NM1 Ordering Provider Name R 1 514 N3 Ordering Provider Address S 1 520 N4 Ordering Provider City/State/ZIP Code S 1 525 REF Ordering Provider Secondary Identification S 5 530 PER Ordering Provider Contact Information S 1 500 2420F - Referring Provider Name 500 NM1 Referring Provider Name R 1 505 PRV Referring Provider Specialty Information S 1 525 REF Referring Provider Secondary Identification S 5 500 2420G - 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 R 2 540 2430 - Line Adjudication Information 540 SVD Line Adjudication Information R 1 545 CAS Line Adjustment S 99 550 DTP Line Adjudication Date R 1 551 2440 - Form Identification Code 551 LQ Form Identification Code R 1 552 FRM Supporting Documentation R 99 030 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