Segment Modifiers:
X - Distinguishing Identifier Suffix
nn - Segment Iteration (only after first iterartion)
nn - Element Repeat Iteration (only after first iterartion)

ISA - GROUP HEADERS

ISA

ISA

Interchange Control Header

02

ISA_ISA02_NO_AUTH_NFO

String

No Authorization Information Present

02

ISA_ISA02_ADDL_DATA_ID

String

Additional Data Identification

04

ISA_ISA04_NO_SEC_NFO

String

No Security Information Present

04

ISA_ISA04_PSSWD

String

Password

06

ISA_ISA06_DUN_BRDST

String

Dun and Brandstreet

06

ISA_ISA06_DUN_BRDST_SFX

String

Duns Plus Suffix

06

ISA_ISA06_HIN

String

Health Industry Number

06

ISA_ISA06_CARR_ID

String

Carrier Identification Number as assigned by Health Care Financing Administration

06

ISA_ISA06_HCFA_FIIN

String

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration

06

ISA_ISA06_HCFA_ID

String

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration

06

ISA_ISA06_TAX_ID

String

US Federal Tax Identification Number

06

ISA_ISA06_NAIC_CD

String

National Association of Insurance Commissioners Company Code

06

ISA_ISA06_MUTLY_DEF

String

Mutually Defined

08

ISA_ISA08_DUN_BRDST

String

Dun and Brandstreet

08

ISA_ISA08_DUN_BRDST_SFX

String

Duns Plus Suffix

08

ISA_ISA08_HIN

String

Health Industry Number

08

ISA_ISA08_CARR_ID

String

Carrier Identification Number as assigned by Health Care Financing Administration

08

ISA_ISA08_HCFA_FIIN

String

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration

08

ISA_ISA08_HCFA_ID

String

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration

08

ISA_ISA08_TAX_ID

String

US Federal Tax Identification Number

08

ISA_ISA08_NAIC_CD

String

National Association of Insurance Commissioners Company Code

08

ISA_ISA08_MUTLY_DEF

String

Mutually Defined

09

ISA_ISA09_INTCHG_DT

Date (YYMMDD)

Interchange Date

10

ISA_ISA10_INTCHG_TM

Time (HHMM)

Interchange Time

11

ISA_ISA11_REPTN_SEP

String

Repetition Separator

12

ISA_ISA12_ICN_VERS_NR

String

Interchang Control Version Number

13

ISA_ISA13_ICN

Integer

Interchange Control Number

14

ISA_ISA14_ACK_REQ

String

Acknowledgment Requested

15

ISA_ISA15_ICN_USG_IND

String

Interchange Usage Indicator

16

ISA_ISA16_COMP_ELE_SEP

String

Component Element Separator

GSHDR - GROUP HEADER

GSHDR

GS

Function Group Header

02

GSHDR_GS02_APP_SNDR_CD

String

Application Senders Code

03

GSHDR_GS03_APP_RCV_CD

String

Application Receivers Code

04

GSHDR_GS04_D8

Date (YYYYMMDD)

Date

05

GSHDR_GS05_TM

Time (HHMM)

Time

05

GSHDR_GS05_TM8

Time (HHMMSSCC)

Time

06

GSHDR_GS06_GCN

Integer

Group Control Number

STHDR - TRANSACTION SET HEADER

STHDR

ST

Transaction Set Header

02

STHDR_ST02_TCN

String

Transaction Set Control Number

STHDR

BHT

Beginning of Hierarchical Transaction

03

STHDR_BHT03_REF_ID

String

Reference Identification

04

STHDR_BHT04_TS_CRTN_D8

Date (YYYYMMDD)

Transaction Set Creation Date

05

STHDR_BHT05_TS_CRTN_TM

Time (HHMM)

Transaction Set Creation Time

05

STHDR_BHT05_TS_CRTN_TM8

Time (HHMMSSCC)

Transaction Set Creation Time

L2000A - INFORMATION SOURCE LEVEL

L2000A

HL

Information Source Level

01

L2000A_HL01_HIER_ID_NR

String

Hierarchical ID Number

L2100A - INFORMATION SOURCE NAME (Value Qualified)

Mapping Prefix: L2100A_AY - Clearinghouse

Mapping Prefix: L2100A_PR - Payer

L2100A

NM1

Information Source Name

03

L2100A_yy_NM103_NONPSNENT_NM

String

Non-Person Entity Name

09

L2100A_yy_NM109_ETN_NR

String

Electronic Transmitter Identification Number

09

L2100A_yy_NM109_TAX_ID

String

Federal Taxpayer's Identification Number

09

L2100A_yy_NM109_PAYR_ID

String

Payor Identification

09

L2100A_yy_NM109_HCFA_PLAN_ID

String

Centers for Medicare abd Medicaid Services PlanID

L2200A - TRANSMISSION RECEIPT CONTROL IDENTIFIER (Inherited Value Qualifier)

Mapping Prefix: L2200A_AY - Clearinghouse

Mapping Prefix: L2200A_PR - Payer

L2200A

TRN

Transmission Receipt Control Identifier

02

L2200A_yy_TRN02_NFO_SRC_AP_TRC

String

Information Source Application Trace Identifier

L2200A

DTP

Information Source Receipt Date

03

L2200A_yy_DTP_RCVD_D8

Date (YYYYMMDD)

Received Date

L2200A

DTP

Information Source Process Date

03

L2200A_yy_DTP_PRCS_D8

Date (YYYYMMDD)

Process Date

L2000B - INFORMATION RECEIVER LEVEL

L2000B

HL

Information Receiver Level

01

L2000B_HL01_HIER_ID_NR

String

Hierarchical ID Number

02

L2000B_HL02_HIER_PARNT_ID_NR

String

Hierarchical Parent ID Number

04

L2000B_HL04_HL_CHLD_CD

String

Hierarchical Child Code

L2100B - INFORMATION RECEIVER NAME

L2100B

NM1

Information Receiver Name

03

L2100B_NM103_PERSN_LNM

String

Person Last Name

03

L2100B_NM103_NONPSNENT_NM

String

Non-Person Entity Name

04

L2100B_NM104_NFO_REC_FNM

String

Information Receiver First Name

05

L2100B_NM105_NFO_REC_MNM

String

Information Receiver Middle Name

09

L2100B_NM109_ETN_NR

String

Electronic Transmitter Identification Number (ETIN)

L2200B - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

L2200B

TRN

Information Receiver Application Trace Identifier

02

L2200B_TRN02_CLM_TRNS_BAT_NR

String

Claim Transaction Batch Number

04

L2200B_TRN04_REF_ID

String

Reference Identification

L2200BX - INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER - STC CUTOUT

L2200BX

STC

Information Receiver Status Information

01

01

L2200BX_STC0101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

01

02

L2200BX_STC0102_HTCRCLM_STATCD

String

Health Care Claim Status Code

01

03

L2200BX_STC0103_ENTY_ID_CD

String

Entity Identifier Code

02

L2200BX_STC02_STMT_NFO_EFF_D8

Date (YYYYMMDD)

Status Information Effective Date

03

L2200BX_STC03_ACTN_CD

String

Action Code

04

L2200BX_STC04_TOT_SBR_CHG_WK

Number

Total Submitted Charges for Work

10

01

L2200BX_STC1001_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

10

02

L2200BX_STC1002_HTCRCLM_STATCD

String

Health Care Claim Status Code

10

03

L2200BX_STC1003_ENTY_ID_CD

String

Entity Identifier Code

11

01

L2200BX_STC1101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

11

02

L2200BX_STC1102_HTCRCLM_STATCD

String

Health Care Claim Status Code

11

03

L2200BX_STC1103_ENTY_ID_CD

String

Entity Identifier Code

L2200B

QTY

Total Accepted Quantity

02

L2200B_QTY02_ACK_QTY

Number

Acknowledged Quantity

L2200B

QTY

Total Rejected Quantity

02

L2200B_QTY02_UNACK_QTY

Number

Unacknowledged Quantity

L2200B

AMT

Total Accepted Amount

02

L2200B_AMT02_IN_PROCS

Number

In Process

L2200B

AMT

Total Rejected Amount

02

L2200B_AMT02_RETRND

Number

Returned

L2000C - BILLING PROVIDER OF SERVICE LEVEL

L2000C

HL

Billing Provider of Service Level

01

L2000C_HL01_HIER_ID_NR

String

Hierarchical ID Number

02

L2000C_HL02_HIER_PARNT_ID_NR

String

Hierarchical Parent ID Number

04

L2000C_HL04_HL_CHLD_CD

String

Hierarchical Child Code

L2100C - BILLING PROVIDER NAME

L2100C

NM1

Billing Provider Name

03

L2100C_NM103_PERSN_LNM

String

Person Last Name

03

L2100C_NM103_NONPSNENT_NM

String

Non-Person Entity Name

04

L2100C_NM104_PVR_FNM

String

Provider First Name

05

L2100C_NM105_PVR_MNM

String

Provider Middle Name

07

L2100C_NM107_PVR_SFX

String

Provider Name Suffix

09

L2100C_NM109_TAX_ID

String

Federal Taxpayer's Identification Number

09

L2100C_NM109_NPI

String

Centers for Medicare and Medicaid Services National Provider Identifier

L2200C - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

L2200C

TRN

Provider of Service Information Trace Identifier

02

L2200C_TRN02_PVR_SVCNFO_TRC_ID

String

Provider of Service Information Trace Identifier

L2200CX - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER - STC CUTOUT

L2200CX

STC

Billing Provider Status Information

01

01

L2200CX_STC0101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

01

02

L2200CX_STC0102_HTCRCLM_STATCD

String

Health Care Claim Status Code

01

03

L2200CX_STC0103_ENTY_ID_CD

String

Entity Identifier Code

03

L2200CX_STC03_ACTN_CD

String

Action Code

04

L2200CX_STC04_TOT_SBR_CHG_WRK

Number

Total Submitted Charges for Unit Work

10

01

L2200CX_STC1001_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

10

02

L2200CX_STC1002_HTCRCLM_STATCD

String

Health Care Claim Status Code

10

03

L2200CX_STC1003_ENTY_ID_CD

String

Entity Identifier Code

11

01

L2200CX_STC1101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

11

02

L2200CX_STC1102_HTCRCLM_STATCD

String

Health Care Claim Status Code

11

03

L2200CX_STC1103_ENTY_ID_CD

String

Entity Identifier Code

L2200C

REF

Provider Secondary Identifier

02

L2200C_nnREF_STAT_LIC_NR

String

State License Number

02

L2200C_nnREF_UPIN

String

Provider UPIN Number

02

L2200C_nnREF_PVR_COMM_NR

String

Provider Commercial Number

02

L2200C_nnREF_LOC_NR

String

Location Number

02

L2200C_nnREF_SSN

String

Social Security Number

02

L2200C_nnREF_TAX_ID

String

Federal Taxpayer's Identification Number

L2200C

QTY

Total Accepted Quantity

02

L2200C_QTY02_QTY_APPR

Number

Quantity Approved

L2200C

QTY

Total Rejected Quantity

02

L2200C_QTY02_QTY_DSPRVD

Number

Quantity Disapproved

L2200C

AMT

Total Accepted Amount

02

L2200C_AMT02_IN_PROCS

Number

In Process

L2200C

AMT

Total Rejected Amount

02

L2200C_AMT02_RETRND

Number

Returned

L2000D - PATIENT LEVEL

L2000D

HL

Patient Level

01

L2000D_HL01_HIER_ID_NR

String

Hierarchical ID Number

02

L2000D_HL02_HIER_PARNT_ID_NR

String

Hierarchical Parent ID Number

L2100D - PATIENT NAME

L2100D

NM1

Patient Name

03

L2100D_NM103_PERSN_LNM

String

Person Last Name

04

L2100D_NM104_PT_FNM

String

Patient First Name

05

L2100D_NM105_PT_MNM

String

Patient Middle Name or Initial

07

L2100D_NM107_PT_SFX

String

Patient Name Suffix

09

L2100D_NM109_UNQ_HLTH_ID

String

Standard Unique Health Identifier for each Individual in the United States

09

L2100D_NM109_MEM_ID_NR

String

Member Identification Number

L2200D - CLAIM STATUS TRACKING NUMBER

L2200D

TRN

Claim Status Tracking Number

02

L2200D_TRN02_PT_CTL_NR

String

Patient Control Number

04

L2200D_TRN04_TRC_ASS_ADDL_ID

String

Trace Assigning Entity Additional Identifier

L2200DX - CLAIM STATUS TRACKING NUMBER - STC CUTOUT

L2200DX

STC

Claim Level Status Information

01

01

L2200DX_STC0101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

01

02

L2200DX_STC0102_HTCRCLM_STATCD

String

Health Care Claim Status Code

01

03

L2200DX_STC0103_ENTY_ID_CD

String

Entity Identifier Code

02

L2200DX_STC02_STMT_NFO_EFF_D8

Date (YYYYMMDD)

Status Information Effective Date

03

L2200DX_STC03_ACTN_CD

String

Action Code

04

L2200DX_STC04_TOT_CLM_CHG_AMT

Number

Total Claim Charge Amount

10

01

L2200DX_STC1001_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

10

02

L2200DX_STC1002_HTCRCLM_STATCD

String

Health Care Claim Status Code

10

03

L2200DX_STC1003_ENTY_ID_CD

String

Entity Identifier Code

11

01

L2200DX_STC1101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

11

02

L2200DX_STC1102_HTCRCLM_STATCD

String

Health Care Claim Status Code

11

03

L2200DX_STC1103_ENTY_ID_CD

String

Entity Identifier Code

12

L2200DX_STC12_FRFM_MSG_TXT

String

Free-form Message Text

L2200D

REF

Payer Claim Control Number

02

L2200D_REF_PYR_CLM_NR

String

Payor's Claim Number

L2200D

REF

Claim Identifier Number For Clearinghouse and Other Transmission Intermediaries

02

L2200D_REF_CLM_NR

String

Claim Number

L2200D

REF

Institutional Bill Type Identification

02

L2200D_REF_BILL_TYP

String

Billing Type

L2200D

DTP

Claim Level Service Date

03

L2200D_DTP_SVC_D8

Date (YYYYMMDD)

Service Date

03

L2200D_DTP_SVC_RD8_1

Start Date (YYYYMMDD)

Service Date

03

L2200D_DTP_SVC_RD8_2

End Date (YYYYMMDD)

Service Date

L2220D - SERVICE LINE INFORMATION

L2220D

SVC

Service Line Information

01

02

L2220D_SVC0102_ADA_CD

String

American Dental Association Codes

01

02

L2220D_SVC0102_JS_PRC_SPY_CD

String

Jurisdiction Specific Procedure and Supply Codes

01

02

L2220D_SVC0102_HCPCS_CD

String

Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

01

02

L2220D_SVC0102_HIPPS_SNF_RT_CD

String

Health Insurance Prospective Payment System (HIPPS) Skill Nursing Facility Rate Code

01

02

L2220D_SVC0102_NUBC_UB92_CD

String

National Uniform Billing Committe (NUBC) UB92 Codes

01

02

L2220D_SVC0102_ABC_CD

String

Advanced Billing Concepts (ABC) Codes

01

03

L2220D_SVC0103_PROC_MOD

String

Procedure Modifier

01

04

L2220D_SVC0104_PROC_MOD

String

Procedure Modifier

01

05

L2220D_SVC0105_PROC_MOD

String

Procedure Modifier

01

06

L2220D_SVC0106_PROC_MOD

String

Procedure Modifier

02

L2220D_SVC02_LIN_ITM_CHG_AMT

Number

Line Item Charge Amount

04

L2220D_SVC04_REV_CD

String

Revenue Code

07

L2220D_SVC07_ORG_UN_SVC_CT

String

Original Units of Service Count

L2220DX - SERVICE LINE INFORMATION - STC CUTOUT

L2220DX

STC

Service Line Level Status Information

01

01

L2220DX_STC0101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

01

02

L2220DX_STC0102_HTCRCLM_STATCD

String

Health Care Claim Status Code

01

03

L2220DX_STC0103_ENTY_ID_CD

String

Entity Identifier Code

10

01

L2220DX_STC1001_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

10

02

L2220DX_STC1002_HTCRCLM_STATCD

String

Health Care Claim Status Code

10

03

L2220DX_STC1003_ENTY_ID_CD

String

Entity Identifier Code

11

01

L2220DX_STC1101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

11

02

L2220DX_STC1102_HTCRCLM_STATCD

String

Health Care Claim Status Code

11

03

L2220DX_STC1103_ENTY_ID_CD

String

Entity Identifier Code

12

L2220DX_STC12_FRFM_MSG_TXT

String

Free-form Message Text

L2220D

REF

Service Line Item Identification

02

L2220D_REF_LIN_ITM

String

Line Item Control Number

L2220D

REF

Pharmacy Prescription Number

02

L2220D_REF_PHRM_RX_NR

String

Pharmacy Prescription Number

03

L2220D_REF03_NFORCV_AD_ID

String

L2220D

DTP

Service Line Date

03

L2220D_DTP_SVC_D8

Date (YYYYMMDD)

Service Date

03

L2220D_DTP_SVC_RD8_1

Start Date (YYYYMMDD)

Service Date

03

L2220D_DTP_SVC_RD8_2

End Date (YYYYMMDD)

Service Date

STHDR

SE

Transaction Set Trailer

01

STHDR_SE01_TS_SEG_CT

Integer

Transaction Segment Count

02

STHDR_SE02_TCN

String

Transaction Set Control Number

GSHDR

GE

Functional Group Trailer

01

GSHDR_GE01_NR_TS_INCLUDED

Integer

Number of Transaction Sets Included

02

GSHDR_GE02_GCN

Integer

Group Control Number

ISA

IEA

Interchange Control Trailer

01

ISA_IEA01_NR_INC_FUNC_GRP

Integer

Number of Included Functional Groups

02

ISA_IEA02_ICN

Integer

Interchange Control Number