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

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

STHDR - 275 Transaction Header

STHDR

ST

275 Transaction Header

02

STHDR_ST02_TCN

String

Transaction Set Control Number

03

STHDR_ST03_VERS_REL_IND_ID

String

Version, Release, or Industry Identifier

STHDR

BGN

Beginning Segment

01

STHDR_BGN01_TS_PURP_CD

String

Transaction Set Purpose Code

02

STHDR_BGN02_TS_REF_NR

String

Transaction Set Reference Number

03

STHDR_BGN03_TS_CRTN_D8

Date (YYYYMMDD)

Transaction Set Creation Date

L1000A - Payer Name

L1000A

NM1

Payer Name

03

L1000A_NM103_NONPSN_ENTY

String

Non-Person Entity

09

L1000A_NM109_PAYR_ID

String

Payor Identification

09

L1000A_NM109_HCFA_PLAN_ID

String

Centers for Medicare and Medicaid Services PlanID

L1000A

PER

Payer Contact Information

02

L1000A_PER02_PYR_CON_NM

String

Payer Contact Name

04

L1000A_PER04_EDI_ACS_NR

String

Electronic Data Interchange Access Number

04

L1000A_PER04_EMAIL

String

Electronic Mail

04

L1000A_PER04_FAX

String

Facsimile

04

L1000A_PER04_PHN_NR

String

Telephone

06

L1000A_PER06_EDI_ACS_NR

String

Electronic Data Interchange Access Number

06

L1000A_PER06_EMAIL

String

Electronic Mail

06

L1000A_PER06_PHN_EXT

String

Telephone Extension

06

L1000A_PER06_FAX

String

Facsimile

06

L1000A_PER06_PHN_NR

String

Telephone

08

L1000A_PER08_EDI_ACS_NR

String

Electronic Data Interchange Access Number

08

L1000A_PER08_EMAIL

String

Electronic Mail

08

L1000A_PER08_PHN_EXT

String

Telephone Extension

08

L1000A_PER08_FAX

String

Facsimile

08

L1000A_PER08_PHN_NR

String

Telephone

L1000B - Submitter Information

L1000B

NM1

Submitter Information

03

L1000B_NM103_PERSN

String

Person

03

L1000B_NM103_NONPSN_ENTY

String

Non-Person Entity

04

L1000B_NM104_SBM_FNM

String

Submitter First Name

05

L1000B_NM105_SBM_MNM

String

Submitter Middle Name or Initial

09

L1000B_NM109_ETN_NR

String

Electronic Transmitter Identification Number (ETIN)

L1000C - Provider Name Information

L1000C

NM1

Provider Name Information

03

L1000C_NM103_PERSN

String

Person

03

L1000C_NM103_NONPSN_ENTY

String

Non-Person Entity

04

L1000C_NM104_PVR_FNM

String

Provider First Name

05

L1000C_NM105_PVR_MNM

String

Provider Middle Name

07

L1000C_NM107_PVR_SFX

String

Provider Name Suffix

09

L1000C_NM109_NPI

String

Centers for Medicare and Medicaid Services National Provider Identifier

L1000C

PRV

Provider Taxonomy Information

03

L1000C_PRV03_PVD_TAXNMY_CD

String

Health Care Provider Taxonomy Code

L1000C

REF

Provider Secondary Identification

02

L1000C_REF_STAT_LIC_NR

String

State License Number

02

L1000C_REF_UPIN

String

Provider UPIN Number

02

L1000C_REF_PVR_COMM_NR

String

Provider Commercial Number

02

L1000C_REF_LOC_NR

String

Location Number

L1100C - Provider Identification

L1100C

NX1

Provider Identification

01

L1100C_NX101_ENTY_ID_CD

String

Entity Identifier Code

L1100C

N3

Provider Address

01

L1100C_N301_PVR_ADDR

String

Provider Address Line

02

L1100C_N302_PVR_ADDR

String

Provider Address Line

L1100C

N4

Provider City, State, ZIP Code

01

L1100C_N401_PVR_CITY

String

Provider City Name

02

L1100C_N402_STAT_CD

String

Provider State or Province Code

03

L1100C_N403_ZIP_CD

String

Postal Code

04

L1100C_N404_CNTRY_CD

String

Country Code

07

L1100C_N407_CNTRY_SUBDV_CD

String

Country Subdivision Code

L1000D - Patient Name

L1000D

NM1

Patient Name

03

L1000D_NM103_PERSN

String

Person

04

L1000D_NM104_PT_FNM

String

Patient First Name

05

L1000D_NM105_PT_MNM

String

Patient Middle Name or Initial

07

L1000D_NM107_PT_SFX

String

Patient Name Suffix

09

L1000D_NM109_UNQ_HLTH_ID

String

Standard Unique Health Identifier for each Individual in the United States

09

L1000D_NM109_MEM_ID_NR

String

Member Identification Number

L1000D

REF

Patient Control Number

02

L1000D_REF_PATNT_ACCT_NR

String

Patient Account Number

L1000D

REF

Institutional Type Of Bill

02

L1000D_REF_BILL_TYP

String

Billing Type

L1000D

REF

Medical Record Identification Number

02

L1000D_REF_MED_REC_ID

String

Medical Record Identification Number

L1000D

REF

Claim Identification Number for Clearinghouses and Other Transmission Intermediaries

02

L1000D_REF_CLM_NR

String

Claim Number

L1000D

DTP

Claim Service Date

03

L1000D_DTP_SVC_D8

Date (YYYYMMDD)

Service

03

L1000D_DTP_SVC_RD8_1

Start Date (YYYYMMDD)

Service

03

L1000D_DTP_SVC_RD8_2

End Date (YYYYMMDD)

Service

L2000A - Assigned Number

L2000A

LX

Assigned Number

01

L2000A_LX01_ASSGD_NR

Integer

Assigned Number

L2000A

TRN

Payer Claim Control Number/Provider Attachment Control Number

01

L2000A_TRN01_TRAC_TYP_CD

String

Trace Type Code

02

L2000A_TRN02_PYR_CTL_NR

String

Payer Claim Control Number or Provider Attachment Control Number

L2000A

STC

Status Information

01

01

L2000A_STC0101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

01

02

L2000A_STC0102_ADDL_NFO_CD

String

Additional Information Request Code

01

04

L2000A_STC0104_CD_LST_QL

String

Code List Qualifier Code

10

01

L2000A_STC1001_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

10

02

L2000A_STC1002_ADDL_NFO_MOD

String

Additional Information Request Modifier

10

04

L2000A_STC1004_CD_LST_QL

String

Code List Qualifier Code

11

01

L2000A_STC1101_HTCRCLM_CAT_CD

String

Health Care Claim Status Category Code

11

02

L2000A_STC1102_ADDL_NFO_MOD

String

Additional Information Request Modifier

11

04

L2000A_STC1104_CD_LST_QL

String

Code List Qualifier Code

L2000A

REF

Service Line Item Identification

02

L2000A_REF_PRV_CTL_NR

String

Provider Control Number

02

L2000A_REF_LIN_ITM

String

Line Item Control Number

L2000A

REF

Procedure or Revenue Code

02

L2000A_REF_CPT_TRM_CD

String

Current Procedural Terminology Code

02

L2000A_REF_ORIG_REF_NR

String

Original Reference Number

02

L2000A_REF_DRUG_FML_NR

String

Drug Formulary Number

02

L2000A_REF_PROD_TYP

String

Product Type

02

L2000A_REF_RAT_CD_NR

String

Rate code number

02

L2000A_REF_VENDR_PROD_NR

String

Vendor Product Number

02

L2000A_REF_REV_SRC

String

Revenue Source

02

L2000A_REF_MUTLY_DEF

String

Mutually Defined

04

02

L2000A_REF0402_REV_CD

String

Revenue Source

L2000A

REF

Procedure Code Modifier

02

L2000A_REF_SVC_CHG_NR

String

Service Change Number

04

02

L2000A_REF0402_PROC_CD_MOD

String

Object Code

04

04

L2000A_REF0404_PROC_CD_MOD

String

System Number

04

06

L2000A_REF0406_PROC_CD_MOD

String

Special Payment Reference Number

L2100A - Service Line Date of Service

L2100A

DTP

Service Line Date of Service

03

L2100A_DTP_SVC_D8

Date (YYYYMMDD)

Service

03

L2100A_DTP_SVC_RD8_1

Start Date (YYYYMMDD)

Service

03

L2100A_DTP_SVC_RD8_2

End Date (YYYYMMDD)

Service

L2100B - Additional Information Submission Date

L2100B

DTP

Additional Information Submission Date

03

L2100B_DTP_SUBMTL_D8

Date (YYYYMMDD)

Submittal

L2100B

CAT

Category of Patient Information Service

02

L2100B_CAT02_ADDL_NFO_FMT

String

Attachment Information Format Code

03

L2100B_CAT03_VERS_ID_CD

String

Version Identification Code

L2110B - Electronic Format Identification

L2110B

EFI

Electronic Format Identification

01

L2110B_EFI01_SEC_LVL_CD

String

Security Level Code

L2110B

BIN

Binary Data Segment

01

L2110B_BIN01_BIN_LEN

Integer

Binary Data Length Number

02

L2110B_BIN02_MIME_TYP

String

MIME Type

02

L2110B_BIN02_MIME_DISP

String

MIME Disposition

02

L2110B_BIN02_ATTCHMNT

Binary

Binary Attachment

STHDR

SE

275 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