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

Functional 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

07

GSHDR_GS07_RESP_AGNCY_CD

String

Responsible Agency Code

STHDR - TRANSACTION SET HEADER

STHDR

ST

Transaction Set Header

02

STHDR_ST02_TCN

String

Transaction Set Control Number

03

STHDR_ST03_IMP_GUID_VERS_NM

String

Implementation Guide Version Name

STHDR

BPR

Financial Information

02

STHDR_BPR02_TOT_PMT_AMT

Number

Total Payment Amount

04

STHDR_BPR04_PMT_METHD_CD

String

Payment Method Code

05

STHDR_BPR05_PMT_FMT_CD

String

Payment Format Code

10

STHDR_BPR10_ORG_CO_ID

String

Originating Company Identifier

11

STHDR_BPR11_ORG_CO_SUPP_CD

String

Originating Company Supplemental Code

13

STHDR_BPR13_ABA_RT_NR

String

ABA Transit Routing Number Including Check Digits (9 digits)

13

STHDR_BPR13_SWIFT_ID

String

Swift Identification (8 or 11 characters)

13

STHDR_BPR13_CAN_BNK_NR

String

Canadian Bank Branch and Institution Number

15

STHDR_BPR15_DEMND_DEPST

String

Demand Deposit

15

STHDR_BPR15_SAVNGS

String

Savings

16

STHDR_BPR16_CHK_EFT_EFDT_D8

Date (YYYYMMDD)

Check Issue or EFT Effective Date

STHDR

TRN

Reassociation Trace Number

02

STHDR_TRN02_CHK_EFT_TRC_NR

String

Check or EFT Trace Number

STHDR

REF

Exchange Assigned Qualified Health Plan Identifier

02

STHDR_REF_MSTR_PLCY_NR

String

Master Policy Number

STHDR

REF

Issuer Assigned Qualified Health Plan Identifier

02

STHDR_REF_LOB

String

Line of Business

STHDR

REF

Exchange Assigned Employer Group Identifier

02

STHDR_REF_PLAN_NR

String

Plan Number

STHDR

REF

Issuer Assigned Employer Group Identifier

02

STHDR_REF_GRP_POLCY_NR

String

Group or Policy Number

L1000A - PAYEE NAME

L1000A

N1

Payee Name

02

L1000A_N102_PAYEE_ORG_NM

String

Payee Organization Name

04

L1000A_N104_TAX_ID

String

Federal Taxpayers Identification Number

L1000A

REF

Unique Health Plan Identifier

02

L1000A_REF_MDCR_MDCD_PLANID

String

Centers for Medicare and Medicaid Services Plan ID

L1000B - PAYERS NAME

L1000B

N1

Payers Name

02

L1000B_N102_PYR_NM

String

Payer Name

04

L1000B_N104_ORIG_COMP_NR

String

Originating Company Number

L1000B

PER

Payers Administrative Contact Information

Iterated: [01-99]

02

L1000B_nnPER02_PREM_PYR_CON_NM

String

Premium Payer Contact Name

04

L1000B_nnPER04_EMAIL

String

Electronic Mail

04

L1000B_nnPER04_FAX

String

Facsimile

04

L1000B_nnPER04_PHN_NR

String

Telephone

06

L1000B_nnPER06_EMAIL

String

Electronic Mail

06

L1000B_nnPER06_PHN_EXT

String

Telephone Extension

06

L1000B_nnPER06_FAX

String

Facsimile

06

L1000B_nnPER06_PHN_NR

String

Telephone

08

L1000B_nnPER08_EMAIL

String

Electronic Mail

08

L1000B_nnPER08_PHN_EXT

String

Telephone Extension

08

L1000B_nnPER08_FAX

String

Facsimile

08

L1000B_nnPER08_PHN_NR

String

Telephone

L2000 - REMITTANCE INFORMATION

L2000

ENT

Remittance Information

01

L2000_ENT01_ASSGD_NR

Integer

Assigned Number

L2100 - INDIVIDUAL NAME

L2100

NM1

Individual Name

03

L2100_NM103_IND_LNM

String

Indvidual Last Name

04

L2100_NM104_IND_FNM

String

Individual First Name

05

L2100_NM105_IND_MNM

String

Individual Middle Name

06

L2100_NM106_IND_PFX

String

Individual Name Prefix

07

L2100_NM107_IND_SFX

String

Individual Name Suffix

09

L2100_NM109_INSRD_SUB

String

Insured or Subscriber

L2100

REF

Exchange Assigned Qualified Health Plan Identifier

02

L2100_REF_MSTR_PLCY_NR

String

Master Policy Number

L2100

REF

Issuer Assigned Qualified Health Plan Identifier

02

L2100_REF_LOB

String

Line of Business

L2100

REF

Exchange Assigned Employer Group Identifier

02

L2100_REF_PLAN_NR

String

Plan Number

L2100

REF

Issuer Assigned Employer Group Identifier

02

L2100_REF_GRP_POLCY_NR

String

Group or Policy Number

L2100

REF

Exchange Assigned Policy Identifier

Segment Suffix: B

02

L2100_REFB_POLCY_NR

String

Policy Number

L2100

REF

Issuer Assigned Policy Identifier

02

L2100_REF_HLTH_INS_PLCY

String

Health Insurance Policy Number

L2100

REF

Exchange Assigned APTC Contributor/Tax Payer Identifier

02

L2100_REF_PIN

String

Personal Identification Number (PIN)

L2100

REF

Issuer Assigned APTC Contributor/Tax Payer Identifier

02

L2100_REF_CLNT_NR

String

Client Number

L2100

REF

Exchange Assigned Dependent Identifier

02

L2100_REF_XREF_NR

String

Exchange Assigned Dependent Identifier

L2100

REF

Issuer Assigned Dependent Identifier

02

L2100_REF_MEM_ID

String

Member Identification Number

L2100

REF

Issuer Assigend Subscriber Identifier

02

L2100_REF_SUB_NR

String

Subscriber Number

L2300 - REMITTANCE DETAIL

L2300

RMR

Remittance Detail

02

L2300_RMR02_XCHG_PMT_TYP

String

Exchange Payment Type

04

L2300_RMR04_PMT_AMT

Number

Payment Amount

L2300

REF

Exchange Report Document Control Number

Iterated: [01-99]

02

L2300_nnREF_ATCHD_TO

String

Attached To

03

L2300_nnREF03_DESCR

String

L2300

DTM

Individual Coverage Period

02

L2300_DTM02_D8

Date (YYYYMMDD)

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