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_IMP_CONV_REF_ID

String

Implementation Convention Reference 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

04

STHDR_BGN04_TS_CRTN_TM

Time (HHMM)

Transaction Set Creation Time

04

STHDR_BGN04_TS_CRTN_TM8

Time (HHMMSSCC)

Transaction Set Creation Time

L1000A - Information Source Name

L1000A

NM1

Information Source Name

01

L1000A_NM101_ENTY_ID_CD

String

Entity Identifier Code

03

L1000A_NM103_PERSN

String

Person

03

L1000A_NM103_NONPSN_ENTY

String

Non-Person Entity

04

L1000A_NM104_NFO_SRC_FNM

String

Information Source First Name

05

L1000A_NM105_NFO_SRC_MNM

String

Information Source Middle Name

07

L1000A_NM107_NFO_SRC_SFX

String

Information Source Name Suffix

09

L1000A_NM109_EIN

String

Employer's Identification Number

09

L1000A_NM109_SSN

String

Social Security Number

09

L1000A_NM109_ETN_NR

String

Electronic Transmitter Identification Number (ETIN)

09

L1000A_NM109_PAYR_ID

String

Payor Identification

09

L1000A_NM109_HCFA_PLAN_ID

String

Centers for Medicare and Medicaid Services PlanID

09

L1000A_NM109_NPI

String

Centers for Medicare and Medicaid Services National Provider Identifier

L1000A

PER

Information Source Contact Information

02

L1000A_PER02_NFOSRC_CN_NM

String

Information Source Contact Name

04

L1000A_PER04_EMAIL

String

Electronic Mail

04

L1000A_PER04_FAX

String

Facsimile

04

L1000A_PER04_PHN_NR

String

Telephone

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_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

L1000A

REF

Provider Secondary Information

02

L1000A_REF_STAT_LIC_NR

String

State License Number

02

L1000A_REF_BLCS_PVR_NR

String

Blue Cross Provider Number

02

L1000A_REF_BLSH_PROV_NR

String

Blue Shield Provider Number

02

L1000A_REF_MDCR_PVR_NR

String

Medicare Provider Number

02

L1000A_REF_MDCD_PVR_NR

String

Medicaid Provider Number

02

L1000A_REF_DENT_LIC_NR

String

Dentist License Number

02

L1000A_REF_UPIN

String

Provider UPIN Number

02

L1000A_REF_CHAMPUS_ID

String

CHAMPUS Identification Number

02

L1000A_REF_FAC_ID

String

Facility ID Number

02

L1000A_REF_PPO_NR

String

Preferred Provider Organization Number

02

L1000A_REF_HMO_CD_NR

String

Health Maintenance Organization Code Number

02

L1000A_REF_EIN

String

Employer's Identification Number

02

L1000A_REF_CLINC_NR

String

Clinic Number

02

L1000A_REF_PVR_COMM_NR

String

Provider Commercial Number

02

L1000A_REF_PVR_SIT_NR

String

Provider Site Number

02

L1000A_REF_LOC_NR

String

Location Number

02

L1000A_REF_SSN

String

Social Security Number

02

L1000A_REF_TAX_ID

String

Federal Taxpayer's Identification Number

02

L1000A_REF_USIN

String

Unique Supplier Identification Number (USIN)

02

L1000A_REF_SIA_PRV_NR

String

State Industrial Accident Provider Number

L1000B - Information Receiver Name

L1000B

NM1

Information Receiver Name

01

L1000B_NM101_ENTY_ID_CD

String

Entity Identifier Code

03

L1000B_NM103_PERSN

String

Person

03

L1000B_NM103_NONPSN_ENTY

String

Non-Person Entity

04

L1000B_NM104_NFO_REC_FNM

String

Information Receiver First Name

05

L1000B_NM105_NFO_REC_MNM

String

Information Receiver Middle Name

07

L1000B_NM107_NFO_RCV_SFX

String

Information Receiver Name Suffix

09

L1000B_NM109_EIN

String

Employer's Identification Number

09

L1000B_NM109_SSN

String

Social Security Number

09

L1000B_NM109_ETN_NR

String

Electronic Transmitter Identification Number (ETIN)

09

L1000B_NM109_PAYR_ID

String

Payor Identification

09

L1000B_NM109_HCFA_PLAN_ID

String

Centers for Medicare and Medicaid Services PlanID

09

L1000B_NM109_NPI

String

Centers for Medicare and Medicaid Services National Provider Identifier

L1000B

PER

Information Receiver Contact Information

02

L1000B_PER02_NFO_RC_CN_NM

String

Information Receiver Contact Name

L1000B

REF

Provider Secondary Information

02

L1000B_REF_STAT_LIC_NR

String

State License Number

02

L1000B_REF_BLCS_PVR_NR

String

Blue Cross Provider Number

02

L1000B_REF_BLSH_PROV_NR

String

Blue Shield Provider Number

02

L1000B_REF_MDCR_PVR_NR

String

Medicare Provider Number

02

L1000B_REF_MDCD_PVR_NR

String

Medicaid Provider Number

02

L1000B_REF_DENT_LIC_NR

String

Dentist License Number

02

L1000B_REF_UPIN

String

Provider UPIN Number

02

L1000B_REF_CHAMPUS_ID

String

CHAMPUS Identification Number

02

L1000B_REF_FAC_ID

String

Facility ID Number

02

L1000B_REF_PPO_NR

String

Preferred Provider Organization Number

02

L1000B_REF_HMO_CD_NR

String

Health Maintenance Organization Code Number

02

L1000B_REF_EIN

String

Employer's Identification Number

02

L1000B_REF_CLINC_NR

String

Clinic Number

02

L1000B_REF_PVR_COMM_NR

String

Provider Commercial Number

02

L1000B_REF_PVR_SIT_NR

String

Provider Site Number

02

L1000B_REF_LOC_NR

String

Location Number

02

L1000B_REF_SSN

String

Social Security Number

02

L1000B_REF_TAX_ID

String

Federal Taxpayer's Identification Number

02

L1000B_REF_USIN

String

Unique Supplier Identification Number (USIN)

02

L1000B_REF_SIA_PRV_NR

String

State Industrial Accident Provider Number

L1000C - Patient Name

L1000C

NM1

Patient Name

01

L1000C_NM101_ENTY_ID_CD

String

Entity Identifier Code

03

L1000C_NM103_PERSN

String

Person

04

L1000C_NM104_PT_FNM

String

Patient First Name

05

L1000C_NM105_PT_MNM

String

Patient Middle Name or Initial

07

L1000C_NM107_PT_SFX

String

Patient Name Suffix

09

L1000C_NM109_UNQ_HLTH_ID

String

Standard Unique Health Identifier for each Individual in the United States

09

L1000C_NM109_MEM_ID

String

Member Identification Number

L1000C

REF

Patient Account Number

02

L1000C_REF_PATNT_ACCT_NR

String

Patient Account Number

L1000C

REF

Patient Event Tracking Number

02

L1000C_REF_TRCK_NR

String

Tracking Number

L2000A - Assigned Number

L2000A

LX

Assigned Number

01

L2000A_LX01_ASSGD_NR

Integer

Assigned Number

L2000A

TRN

Attachment Control Number

01

L2000A_TRN01_TRAC_TYP_CD

String

Trace Type Code

02

L2000A_TRN02_ATTACH_CTL_NR

String

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_CD

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

Diagnosis Code

02

L2000A_REF_ICD9CM

String

ICD-9-CM (International Classification of Diseases)

02

L2000A_REF_SIC_CD

String

Standard Industry Classification (SIC) Code

L2000A

REF

Service Trace Number

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_NATL_VERS_CD

String

Version Code - National

02

L2000A_REF_DRUG_FML_NR

String

Drug Formulary Number

02

L2000A_REF_ICD9CM

String

ICD-9-CM (International Classification of Diseases)

02

L2000A_REF_REV_SRC

String

Revenue Source

02

L2000A_REF_MUTLY_DEF

String

Mutually Defined

L2100A - Date Additional Information Was Submitted

L2100A

DTP

Date Additional Information Was Submitted

03

L2100A_DTP_SUBMTL_D8

Date (YYYYMMDD)

Submittal

L2100A

CAT

Category of Additional Information

02

L2100A_CAT02_ADDL_NFO_FMT

String

Attachment Information Format Code

L2110A - Electronic Format Identification

L2110A

EFI

Electronic Format Identification

01

L2110A_EFI01_SEC_LVL_CD

String

Security Level Code

L2110A

BIN

Binary Data Segment

01

L2110A_BIN01_BIN_LEN

Integer

Binary Data Length Number

02

L2110A_BIN02_MIME_TYP

String

MIME Type

02

L2110A_BIN02_MIME_DISP

String

MIME Disposition

02

L2110A_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