Chiapas EDI 2012 Mapping Guide

4010_837D 4010 Health Care Claim: Dental - Code:J0

ISA - GROUP HEADERS

Loop	Segment	Segment Name	Chiapas Gate Mapping
OEISA	ISA	Interchange Control Header
OEISA	ISA02	No Authorization Information Present	OEISA_S01_ISA02_AUTH_NFO_OVL_NO_AUTH_NFO
OEISA	ISA02	Additional Data Identification	OEISA_S01_ISA02_AUTH_NFO_OVL_ADDL_ID
OEISA	ISA04	No Security Information Present	OEISA_S01_ISA04_SEC_NFO_OVL_NO_SEC_NFO
OEISA	ISA04	Password	OEISA_S01_ISA04_SEC_NFO_OVL_PASSWD
OEISA	ISA06	Dun and Brandstreet	OEISA_S01_ISA06_SENDR_ID_OVL_DUNS_ID
OEISA	ISA06	Duns Plus Suffix	OEISA_S01_ISA06_SENDR_ID_OVL_DUNS_SUFFX_ID
OEISA	ISA06	Health Industry Number	OEISA_S01_ISA06_SENDR_ID_OVL_HIN_ID
OEISA	ISA06	Carrier Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_CARR_ID
OEISA	ISA06	Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_FIIN_ID
OEISA	ISA06	Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_MEDCR_ID
OEISA	ISA06	US Federal Tax Identification Number	OEISA_S01_ISA06_SENDR_ID_OVL_TAX_ID
OEISA	ISA06	National Association of Insurance Commissioners Company Code	OEISA_S01_ISA06_SENDR_ID_OVL_NAIC_ID
OEISA	ISA06	Mutually Defined	OEISA_S01_ISA06_SENDR_ID_OVL_MUTLY_DEFND_ID
OEISA	ISA08	Dun and Brandstreet	OEISA_S01_ISA08_RECVR_ID_OVL_DUNS_ID
OEISA	ISA08	Duns Plus Suffix	OEISA_S01_ISA08_RECVR_ID_OVL_DUNS_SUFFX_ID
OEISA	ISA08	Health Industry Number	OEISA_S01_ISA08_RECVR_ID_OVL_HIN_ID
OEISA	ISA08	Carrier Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_CARR_ID
OEISA	ISA08	Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_FIIN_ID
OEISA	ISA08	Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration	OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_MEDCR_ID
OEISA	ISA08	US Federal Tax Identification Number	OEISA_S01_ISA08_RECVR_ID_OVL_TAX_ID
OEISA	ISA08	National Association of Insurance Commissioners Company Code	OEISA_S01_ISA08_RECVR_ID_OVL_NAIC_ID
OEISA	ISA08	Mutually Defined	OEISA_S01_ISA08_RECVR_ID_OVL_MUTLY_DEFND_ID
OEISA	ISA09	Interchange Date	OEISA_S01_ISA09_DT
OEISA	ISA10	Interchange Time	OEISA_S01_ISA10_TM
OEISA	ISA11	Repetition Separator	OEISA_S01_ISA11_REPTN_SEPRTR
OEISA	ISA12	Interchang Control Version Number	OEISA_S01_ISA12_VERSN_NR
OEISA	ISA13	Interchange Control Number	OEISA_S01_ISA13_ICN
OEISA	ISA14	Acknowledgment Requested	OEISA_S01_ISA14_ACK_REQ
OEISA	ISA15	Interchange Usage Indicator	OEISA_S01_ISA15_USG_IND
OEISA	ISA16	Component Element Separator	OEISA_S01_ISA16_SUBELE_SEP
OEISA	IEA	Interchange Control Trailer
OEISA	IEA01	Number of Included Functional Groups	OEISA_S03_IEA01_GS_CT
OEISA	IEA02	Interchange Control Number	OEISA_S03_IEA02_ICN

GSHDR - GROUP HEADER

Loop	Segment	Segment Name	Chiapas Gate Mapping
GSHDR	GS	Functional Group Header
GSHDR	GS01	Functional Identifier Code	GSHDR_S01_GS01_FUNCTL_ID_CD
GSHDR	GS02	Application Senders Code	GSHDR_S01_GS02_APP_SENDR_CD
GSHDR	GS03	Application Receivers Code	GSHDR_S01_GS03_APP_RECVR_CD
GSHDR	GS04	Date	GSHDR_S01_GS04_DT
GSHDR	GS05	Time	GSHDR_S01_GS05_TM
GSHDR	GS06	Group Control Number	GSHDR_S01_GS06_GCN
GSHDR	GS07	Responsible Agency Code	GSHDR_S01_GS07_RESP_AGNCY_CD
GSHDR	GE	Functional Group Trailer
GSHDR	GE01	Number of Transaction Sets Included	GSHDR_S03_GE01_TS_CT
GSHDR	GE02	Group Control Number	GSHDR_S03_GE02_GCN

STHDR - TRANSACTION SET HEADER

Loop	Segment	Segment Name	Chiapas Gate Mapping
STHDR	ST	Transaction Set Header
STHDR	ST01	Transaction Set Identifier Code	STHDR_S01_ST01_ID_CD
STHDR	ST02	Transaction Set Control Number	STHDR_S01_ST02_CONTRL_NR
STHDR	BHT	Beginning of Hierarchical Transaction
STHDR	BHT01	Hierarchical Structure Code	STHDR_S02_BHT01_STRUCTR_CD
STHDR	BHT02	Transaction Set Purpose Code	STHDR_S02_BHT02_TS_PURPS_CD
STHDR	BHT03	Originator Application Transaction Identifier	STHDR_S02_BHT03_ORGNTR_APLCTN_TRANSCTN_ID
STHDR	BHT04	Transaction Set Creation Date	STHDR_S02_BHT04_TS_CREATN_DT
STHDR	BHT05	Transaction Set Creation Time	STHDR_S02_BHT05_TS_CREATN_TIM
STHDR	BHT06	Claim or Encounter Identifier	STHDR_S02_BHT06_CLM_ENCNTR_ID
STHDR	REF	Transmission Type Identification
STHDR	REF02	Functional Category	STHDR_S03_REF02_TYPE_CD_OVL_FUNCTNL_CATGRY
STHDR	SE	Transaction Set Trailer
STHDR	SE01	Transaction Segment Count	STHDR_S07_SE01_SEG_CT
STHDR	SE02	Transaction Set Control Number	STHDR_S07_SE02_TCN

1000A - SUBMITTER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L1000A	NM1	Submitter Name
L1000A	NM103	Person	L1000A_S01_NM103_SUBMTR_LAST_ORG_NM_OVL_PERSN
L1000A	NM103	Non-Person Entity	L1000A_S01_NM103_SUBMTR_LAST_ORG_NM_OVL_NONPRSN_ENTY
L1000A	NM104	Submitter First Name	L1000A_S01_NM104_SUBMTR_FNAME
L1000A	NM105	Submitter Middle Name	L1000A_S01_NM105_SUBMTR_MNAME
L1000A	NM109	Electronic Transmitter Identification Number (ETIN)	L1000A_S01_NM109_SUBMTR_ID_OVL_ETN_NR
L1000A	N2	Additional Submitter Name Information
L1000A	N201	Additional Submitter Name	L1000A_S02_N201_SUBMTR_NM
L1000A	PER	Submitter Contact Information
L1000A	PER01	Contact Function Code	L1000A_S03_PER01_FUNCTN_CD
L1000A	PER02	Submitter Contact Name	L1000A_S03_PER02_CONTCT_NM
L1000A	PER04	Electronic Data Interchange Access Number	L1000A_S03_PER04_COMM_NR_OVL_EDI_ACS_NR
L1000A	PER04	Electronic Mail	L1000A_S03_PER04_COMM_NR_OVL_EMAIL
L1000A	PER04	Facsimile	L1000A_S03_PER04_COMM_NR_OVL_FACSML
L1000A	PER04	Telephone	L1000A_S03_PER04_COMM_NR_OVL_TELPHN
L1000A	PER06	Electronic Data Interchange Access Number	L1000A_S03_PER06_COMM_NR_OVL_EDI_ACS_NR
L1000A	PER06	Electronic Mail	L1000A_S03_PER06_COMM_NR_OVL_EMAIL
L1000A	PER06	Telephone Extension	L1000A_S03_PER06_COMM_NR_OVL_PHN_EXTNS
L1000A	PER06	Facsimile	L1000A_S03_PER06_COMM_NR_OVL_FACSML
L1000A	PER06	Telephone	L1000A_S03_PER06_COMM_NR_OVL_TELPHN
L1000A	PER08	Electronic Data Interchange Access Number	L1000A_S03_PER08_COMM_NR_OVL_EDI_ACS_NR
L1000A	PER08	Electronic Mail	L1000A_S03_PER08_COMM_NR_OVL_EMAIL
L1000A	PER08	Telephone Extension	L1000A_S03_PER08_COMM_NR_OVL_PHN_EXTNS
L1000A	PER08	Facsimile	L1000A_S03_PER08_COMM_NR_OVL_FACSML
L1000A	PER08	Telephone	L1000A_S03_PER08_COMM_NR_OVL_TELPHN

1000B - RECEIVER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L1000B	NM1	Receiver Name
L1000B	NM103	Non-Person Entity	L1000B_S01_NM103_RECVR_NM_OVL_NONPRSN_ENTY
L1000B	NM109	Electronic Transmitter Identification Number (ETIN)	L1000B_S01_NM109_PRIMRY_ID_OVL_ETN_NR
L1000B	N2	Receiver Additional Name Information
L1000B	N201	Receiver Additional Name	L1000B_S02_N201_ADDL_NM

2000A - BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000A	HL	Billing/Pay-to Provider Hierarchical Level
L2000A	HL01	Hierarchical ID Number	L2000A_S01_HL01_HIERCHCL_ID_NR
L2000A	HL04	Hierarchical Child Code	L2000A_S01_HL04_HIERCHCL_CHILD_CD
L2000A	PRV	Billing/Pay-to Provider Specialty Information
L2000A	PRV01	Provider Code	L2000A_S02_PRV01_PROV_CD
L2000A	PRV03	Mutually Defined	L2000A_S02_PRV03_TAXNMY_CD_OVL_MUTLY_DEFND
L2000A	CUR	Foreign Currency Information
L2000A	CUR01	Entity Identifier Code	L2000A_S03_CUR01_ENTY_ID_CD
L2000A	CUR02	Currency Code	L2000A_S03_CUR02_CURNCY_CD

2010AA - BILLING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010AA	NM1	Billing Provider Name
L2010AA	NM103	Person	L2010AA_S01_NM103_LAST_ORGL_NM_OVL_PERSN
L2010AA	NM103	Non-Person Entity	L2010AA_S01_NM103_LAST_ORGL_NM_OVL_NONPRSN_ENTY
L2010AA	NM104	Billing Provider First Name	L2010AA_S01_NM104_PROV_FNAME
L2010AA	NM105	Billing Provider Middle Name	L2010AA_S01_NM105_PROV_MNAME
L2010AA	NM107	Billing Provider Name Suffix	L2010AA_S01_NM107_BILNG_PROV_NM_SUFX
L2010AA	NM109	Employer’s Identification Number	L2010AA_S01_NM109_PROV_ID_OVL_EMPLYR_ID_NR
L2010AA	NM109	Social Security Number	L2010AA_S01_NM109_PROV_ID_OVL_SSN
L2010AA	NM109	Health Care Financing Administration National	L2010AA_S01_NM109_PROV_ID_OVL_HCFA_NATNL
L2010AA	N2	Additional Billing Provider Name Information
L2010AA	N201	Billing Provider Additional Name	L2010AA_S02_N201_BILNG_PROV_ADDL_NM
L2010AA	N3	Billing Provider Address
L2010AA	N301	Billing Provider Address Line	L2010AA_S03_N301_BILNG_PROV_ADRS_LIN
L2010AA	N302	Billing Provider Address Line	L2010AA_S03_N302_BILNG_PROV_ADRS_LIN
L2010AA	N4	Billing Provider City/State/ZIP Code
L2010AA	N401	Billing Provider City Name	L2010AA_S04_N401_BILNG_PROV_CITY_NM
L2010AA	N402	Billing Provider State or Province Code	L2010AA_S04_N402_STAT_PROVNC_CD
L2010AA	N403	Billing Provider Postal Zone or ZIP Code	L2010AA_S04_N403_POSTL_ZON_ZIP_CD
L2010AA	N404	Country Code	L2010AA_S04_N404_CNTRY_CD
L2010AA	REF	Billing Provider Secondary Identification Number
L2010AA	REF02	State License Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_STAT_LICNS_NR
L2010AA	REF02	Blue Cross Provider Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_BLUE_CROS_PROV_NR
L2010AA	REF02	Blue Shield Provider Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_BLUE_SHIELD_PROV_NR
L2010AA	REF02	Medicare Provider Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_MEDCR_PROV_NR
L2010AA	REF02	Medicaid Provider Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_MEDCD_PROV_NR
L2010AA	REF02	Dentist License Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_DENTST_LICNS_NR
L2010AA	REF02	CHAMPUS Identification Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_CHAMPS_ID_NR
L2010AA	REF02	Employer’s Identification Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_EMPLYR_ID_NR
L2010AA	REF02	Provider Commercial Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_PROV_COMRCL_NR
L2010AA	REF02	Provider Site Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_PROV_SIT_NR
L2010AA	REF02	Location Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_LOC_NR
L2010AA	REF02	Social Security Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_SSN
L2010AA	REF02	Federal Taxpayer’s Identification Number	L2010AA_S05_REF02_BILNG_PROV_ADDL_ID_OVL_FED_TAX_ID_NR
L2010AA	REF	Claim Submitter Credit/Debit Card Information
L2010AA	REF02	System Number	L2010AA_S06_REF02_BILNG_PROV_CC_ID_OVL_SYS_NR
L2010AA	REF02	Bank Assigned Security Identifier	L2010AA_S06_REF02_BILNG_PROV_CC_ID_OVL_BANK_ASGND_SECRTY_ID
L2010AA	REF02	Electronic Payment Reference Number	L2010AA_S06_REF02_BILNG_PROV_CC_ID_OVL_ELCTRNC_PMT_REF_NR
L2010AA	REF02	Standard Industry Classification (SIC) Code	L2010AA_S06_REF02_BILNG_PROV_CC_ID_OVL_SIC_CD
L2010AA	REF02	Location Number	L2010AA_S06_REF02_BILNG_PROV_CC_ID_OVL_LOC_NR
L2010AA	REF02	Rate code number	L2010AA_S06_REF02_BILNG_PROV_CC_ID_OVL_RAT_COD_NR
L2010AA	REF02	Store Number	L2010AA_S06_REF02_BILNG_PROV_CC_ID_OVL_ST_NR
L2010AA	REF02	Terminal Code	L2010AA_S06_REF02_BILNG_PROV_CC_ID_OVL_TERMNL_CD

2010AB - PAY-TO PROVIDERS NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010AB	NM1	Pay-to Provider’s Name
L2010AB	NM103	Person	L2010AB_S01_NM103_LAST_ORGL_NM_OVL_PERSN
L2010AB	NM103	Non-Person Entity	L2010AB_S01_NM103_LAST_ORGL_NM_OVL_NONPRSN_ENTY
L2010AB	NM104	Pay-to Provider First Name	L2010AB_S01_NM104_PROV_FNAME
L2010AB	NM105	Pay-to Provider Middle Name	L2010AB_S01_NM105_PROV_MNAME
L2010AB	NM107	Pay-to Provider Name Suffix	L2010AB_S01_NM107_PAYT_PROV_NM_SUFX
L2010AB	NM109	Employer’s Identification Number	L2010AB_S01_NM109_PROV_ID_OVL_EMPLYR_ID_NR
L2010AB	NM109	Social Security Number	L2010AB_S01_NM109_PROV_ID_OVL_SSN
L2010AB	NM109	Health Care Financing Administration National Provider Identifier	L2010AB_S01_NM109_PROV_ID_OVL_HCFA_NATNL_PROV_ID
L2010AB	N2	Additional Pay-to Provider Name Information
L2010AB	N201	Pay-to Provider Additional Name	L2010AB_S02_N201_PAYT_PROV_ADDL_NM
L2010AB	N3	Pay-to Provider’s Address
L2010AB	N301	Pay-to Provider Address Line	L2010AB_S03_N301_PAYT_PROV_ADRS_LIN
L2010AB	N302	Pay-to Provider Address Line	L2010AB_S03_N302_PAYT_PROV_ADRS_LIN
L2010AB	N4	Pay-to Provider City/State/Zip
L2010AB	N401	Pay-to Provider City Name	L2010AB_S04_N401_PAYT_PROV_CITY_NM
L2010AB	N402	Pay-to Provider State Code	L2010AB_S04_N402_PAYT_PROV_STAT_CD
L2010AB	N403	Pay-to Provider Postal Zone or ZIP Code	L2010AB_S04_N403_POSTL_ZON_ZIP_CD
L2010AB	N404	Country Code	L2010AB_S04_N404_CNTRY_CD
L2010AB	REF	Pay-to Provider Secondary Identification Number
L2010AB	REF02	State License Number	L2010AB_S05_REF02_PROV_ID_OVL_STAT_LICNS_NR
L2010AB	REF02	Blue Cross Provider Number	L2010AB_S05_REF02_PROV_ID_OVL_BLUE_CROS_PROV_NR
L2010AB	REF02	Blue Shield Provider Number	L2010AB_S05_REF02_PROV_ID_OVL_BLUE_SHIELD_PROV_NR
L2010AB	REF02	Medicare Provider Number	L2010AB_S05_REF02_PROV_ID_OVL_MEDCR_PROV_NR
L2010AB	REF02	Medicaid Provider Number	L2010AB_S05_REF02_PROV_ID_OVL_MEDCD_PROV_NR
L2010AB	REF02	Dentist License Number	L2010AB_S05_REF02_PROV_ID_OVL_DENTST_LICNS_NR
L2010AB	REF02	CHAMPUS Identification Number	L2010AB_S05_REF02_PROV_ID_OVL_CHAMPS_ID_NR
L2010AB	REF02	Employer’s Identification Number	L2010AB_S05_REF02_PROV_ID_OVL_EMPLYR_ID_NR
L2010AB	REF02	Provider Commercial Number	L2010AB_S05_REF02_PROV_ID_OVL_PROV_COMRCL_NR
L2010AB	REF02	Provider Site Number	L2010AB_S05_REF02_PROV_ID_OVL_PROV_SIT_NR
L2010AB	REF02	Location Number	L2010AB_S05_REF02_PROV_ID_OVL_LOC_NR
L2010AB	REF02	Social Security Number	L2010AB_S05_REF02_PROV_ID_OVL_SSN
L2010AB	REF02	Federal Taxpayer’s Identification Number	L2010AB_S05_REF02_PROV_ID_OVL_FED_TAX_ID_NR

2000B - SUBSCRIBER HIERARCHICAL LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000B	HL	Subscriber Hierarchical Level
L2000B	HL01	Hierarchical ID Number	L2000B_S01_HL01_HIERCHCL_ID_NR
L2000B	HL02	Hierarchical Parent ID Number	L2000B_S01_HL02_HIERCHCL_PARNT_ID_NR
L2000B	HL04	Hierarchical Child Code	L2000B_S01_HL04_HIERCHCL_CHILD_CD
L2000B	SBR	Subscriber Information
L2000B	SBR01	Payer Responsibility Sequence Number Code	L2000B_S02_SBR01_PAYR_RESP_SEQNC_NR_CD
L2000B	SBR02	Individual Relationship Code	L2000B_S02_SBR02_INDVDL_REL_CD
L2000B	SBR03	Insured Group or Policy Number	L2000B_S02_SBR03_INSRD_GRP_POLCY_NR
L2000B	SBR04	Insured Group Name	L2000B_S02_SBR04_INSRD_GRP_NM
L2000B	SBR06	Coordination of Benefits Code	L2000B_S02_SBR06_COB_CD
L2000B	SBR09	Claim Filing Indicator Code	L2000B_S02_SBR09_CLM_FILNG_IND_CD

2010BA - SUBSCRIBER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010BA	NM1	Subscriber Name
L2010BA	NM103	Person	L2010BA_S01_NM103_SUB_LNAME_OVL_PERSN
L2010BA	NM103	Non-Person Entity	L2010BA_S01_NM103_SUB_LNAME_OVL_NONPRSN_ENTY
L2010BA	NM104	Subscriber First Name	L2010BA_S01_NM104_SUB_FNAME
L2010BA	NM105	Subscriber Middle Name	L2010BA_S01_NM105_SUB_MNAME
L2010BA	NM107	Subscriber Name Suffix	L2010BA_S01_NM107_NM_SUFX
L2010BA	NM109	Member Identification Number	L2010BA_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR
L2010BA	NM109	Mutually Defined	L2010BA_S01_NM109_PRIMRY_ID_OVL_MUTLY_DEFND
L2010BA	N2	Additional Subscriber Name Information
L2010BA	N201	Subscriber Supplemental Description	L2010BA_S02_N201_SUPP_DESCRPTN
L2010BA	N3	Subscriber Address
L2010BA	N301	Subscriber Address Line	L2010BA_S03_N301_ADRS_LIN
L2010BA	N302	Subscriber Address Line	L2010BA_S03_N302_ADRS_LIN
L2010BA	N4	Subscriber City/State/ZIP Code
L2010BA	N401	Subscriber City Name	L2010BA_S04_N401_CITY_NM
L2010BA	N402	Subscriber State Code	L2010BA_S04_N402_STAT_CD
L2010BA	N403	Subscriber Postal Zone or ZIP Code	L2010BA_S04_N403_SUB_POSTL_ZON_ZIP_CD
L2010BA	N404	Country Code	L2010BA_S04_N404_CNTRY_CD
L2010BA	DMG	Subscriber Demographic Information
L2010BA	DMG02	Date Expressed in Format CCYYMMDD	L2010BA_S05_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD
L2010BA	DMG03	Subscriber Gender Code	L2010BA_S05_DMG03_GENDR_CD
L2010BA	REF	Subscriber Secondary Identification
L2010BA	REF02	Member Identification Number	L2010BA_S06_REF02_SUPP_ID_OVL_MEM_ID_NR
L2010BA	REF02	Client Number	L2010BA_S06_REF02_SUPP_ID_OVL_CLIENT_NR
L2010BA	REF02	Insurance Policy Number	L2010BA_S06_REF02_SUPP_ID_OVL_INS_POLCY_NR
L2010BA	REF02	Social Security Number	L2010BA_S06_REF02_SUPP_ID_OVL_SSN
L2010BA	REF	Property and Casualty Claim Number
L2010BA	REF02	Agency Claim Number	L2010BA_S07_REF02_PROPRTY_CASLTY_CLM_NR_OVL_AGNCY_CLM_NR

2010BB - PAYER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010BB	NM1	Payer Name
L2010BB	NM103	Non-Person Entity	L2010BB_S01_NM103_PAYR_NM_OVL_NONPRSN_ENTY
L2010BB	NM109	Payor Identification	L2010BB_S01_NM109_PAYR_ID_OVL_PAYR_ID
L2010BB	NM109	Health Care Financing Administration National PlanID	L2010BB_S01_NM109_PAYR_ID_OVL_HCFA_NATNL_PLAND
L2010BB	N2	Additional Payer Name Information
L2010BB	N201	Payer Additional Name	L2010BB_S02_N201_ADDL_NM
L2010BB	N3	Payer Address
L2010BB	N301	Payer Address Line	L2010BB_S03_N301_ADRS_LIN
L2010BB	N302	Payer Address Line	L2010BB_S03_N302_ADRS_LIN
L2010BB	N4	Payer City/State/ZIP Code
L2010BB	N401	Payer City Name	L2010BB_S04_N401_CITY_NM
L2010BB	N402	Payer State Code	L2010BB_S04_N402_STAT_CD
L2010BB	N403	Payer Postal Zone or ZIP Code	L2010BB_S04_N403_PAYR_POSTL_ZON_ZIP_CD
L2010BB	N404	Payer Postal Zone or ZIP Code	L2010BB_S04_N404_PAYR_POSTL_ZON_ZIP_CD
L2010BB	REF	Payer Secondary Identification Number
L2010BB	REF02	Payer Identification Number	L2010BB_S05_REF02_ADDL_ID_OVL_PAYR_ID_NR
L2010BB	REF02	Claim Office Number	L2010BB_S05_REF02_ADDL_ID_OVL_CLM_OFC_NR
L2010BB	REF02	National Association of Insurance Commissioners (NAIC) Code	L2010BB_S05_REF02_ADDL_ID_OVL_NAIC_CD
L2010BB	REF02	Federal Taxpayer’s Identification Number	L2010BB_S05_REF02_ADDL_ID_OVL_FED_TAX_ID_NR

2010BC - CREDIT/DEBIT CARD HOLDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010BC	NM1	Credit/Debit Card Holder Name
L2010BC	NM103	Person	L2010BC_S01_NM103_LAST_ORGL_NM_OVL_PERSN
L2010BC	NM103	Non-Person Entity	L2010BC_S01_NM103_LAST_ORGL_NM_OVL_NONPRSN_ENTY
L2010BC	NM104	Entity Type Qualifier	L2010BC_S01_NM104_ENTY_TYPE_QUAL
L2010BC	NM105	Credit or Debit Card Holder Middle Name	L2010BC_S01_NM105_HOLDR_MNAME
L2010BC	NM107	Credit or Debit Card Holder Name Suffix	L2010BC_S01_NM107_CC_HOLDR_NM_SUFX
L2010BC	NM109	Member Identification Number	L2010BC_S01_NM109_CC_NR_OVL_MEM_ID_NR
L2010BC	N2	Additional Credit/Debit Card Holder Name Information
L2010BC	N201	Credit or Debit Card Holder Additional Name	L2010BC_S02_N201_CC_HOLDR_ADDL_NM
L2010BC	N202	Credit or Debit Card Holder Additional Name	L2010BC_S02_N202_CC_HOLDR_ADDL_NM
L2010BC	REF	Credit/Debit Card Information
L2010BC	REF02	Authorization Number	L2010BC_S03_REF02_AUTH_NR_OVL_AUTH_NR

2000C - PATIENT HIERARCHICAL LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000C	HL	Patient Hierarchical Level
L2000C	HL01	Hierarchical ID Number	L2000C_S01_HL01_HIERCHCL_ID_NR
L2000C	HL02	Hierarchical Parent ID Number	L2000C_S01_HL02_HIERCHCL_PARNT_ID_NR
L2000C	HL04	Hierarchical Child Code	L2000C_S01_HL04_HIERCHCL_CHILD_CD
L2000C	PAT	Patient Information
L2000C	PAT01	Individual Relationship Code	L2000C_S02_PAT01_INDVDL_REL_CD
L2000C	PAT04	Student Status Code	L2000C_S02_PAT04_STUDNT_STATS_CD

2010CA - PATIENT NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010CA	NM1	Patient Name
L2010CA	NM103	Person	L2010CA_S01_NM103_PATNT_LNAME_OVL_PERSN
L2010CA	NM104	Patient First Name	L2010CA_S01_NM104_PATNT_FNAME
L2010CA	NM105	Patient Middle Name	L2010CA_S01_NM105_PATNT_MNAME
L2010CA	NM107	Patient Name Suffix	L2010CA_S01_NM107_NM_SUFX
L2010CA	NM109	Member Identification Number	L2010CA_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR
L2010CA	NM109	Mutually Defined	L2010CA_S01_NM109_PRIMRY_ID_OVL_MUTLY_DEFND
L2010CA	N2	Additional Name Information
L2010CA	N201	Patient Additional Name	L2010CA_S02_N201_PATNT_ADDL_NM
L2010CA	N3	Patient Address
L2010CA	N301	Patient Address Line	L2010CA_S03_N301_ADRS_LIN
L2010CA	N302	Patient Address Line	L2010CA_S03_N302_ADRS_LIN
L2010CA	N4	Patient City/State/ZIP Code
L2010CA	N401	Patient City Name	L2010CA_S04_N401_CITY_NM
L2010CA	N402	Patient State Code	L2010CA_S04_N402_STAT_CD
L2010CA	N403	Patient Postal Zone or ZIP Code	L2010CA_S04_N403_PATNT_POSTL_ZON_ZIP_CD
L2010CA	N404	Country Code	L2010CA_S04_N404_CNTRY_CD
L2010CA	DMG	Patient Demographic Information
L2010CA	DMG02	Date Expressed in Format CCYYMMDD	L2010CA_S05_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD
L2010CA	DMG03	Patient Gender Code	L2010CA_S05_DMG03_GENDR_CD
L2010CA	REF	Patient Secondary Identification
L2010CA	REF02	Member Identification Number	L2010CA_S06_REF02_2ND_ID_OVL_MEM_ID_NR
L2010CA	REF02	Client Number	L2010CA_S06_REF02_2ND_ID_OVL_CLIENT_NR
L2010CA	REF02	Insurance Policy Number	L2010CA_S06_REF02_2ND_ID_OVL_INS_POLCY_NR
L2010CA	REF02	Social Security Number	L2010CA_S06_REF02_2ND_ID_OVL_SSN
L2010CA	REF	Property and Casualty Claim Number
L2010CA	REF02	Agency Claim Number	L2010CA_S07_REF02_PROPRTY_CASLTY_CLM_NR_OVL_AGNCY_CLM_NR

2300 - CLAIM INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2300	CLM	Claim Information
L2300	CLM01	Patient Account Number	L2300_S01_CLM01_PATNT_ACNT_NR
L2300	CLM02	Total Claim Charge Amount	L2300_S01_CLM02_TOTL_CLM_CHG_AMT
L2300	CLM05-01	Facility Type Code	L2300_S01_CLM05_01_FACLTY_TYPE_CD
L2300	CLM05-03	Claim Submission Reason Code	L2300_S01_CLM05_03_CLM_SUBMSN_RSN_CD
L2300	CLM06	Provider or Supplier Signature Indicator	L2300_S01_CLM06_PROV_SUPLR_SIGNTR_IND
L2300	CLM07	Medicare Assignment Code	L2300_S01_CLM07_MEDCR_ASGNMNT_CD
L2300	CLM08	Benefits Assignment Certification Indicator	L2300_S01_CLM08_BENFTS_ASGNMNT_CERT_IND
L2300	CLM09	Release of Information Code	L2300_S01_CLM09_RELS_NFO_CD
L2300	CLM11-01	Related Causes Code	L2300_S01_CLM11_01_RELTD_CAUS_CD
L2300	CLM11-02	Related Causes Code	L2300_S01_CLM11_02_RELTD_CAUS_CD
L2300	CLM11-03	Related Causes Code	L2300_S01_CLM11_03_RELTD_CAUS_CD
L2300	CLM11-04	Auto Accident State or Province Code	L2300_S01_CLM11_04_AUT_ACDNT_STAT_PROVNC_CD
L2300	CLM11-05	Country Code	L2300_S01_CLM11_05_CNTRY_CD
L2300	CLM12	Special Program Indicator	L2300_S01_CLM12_SPECL_PROGRM_IND
L2300	CLM19	Claim Submission Reason Code	L2300_S01_CLM19_CLM_SUBMSN_RSN_CD
L2300	CLM20	Delay Reason Code	L2300_S01_CLM20_DELY_RSN_CD
L2300	DTP	Date - Admission
L2300	DTP03	Admission (D8)	L2300_S02_DTP03_RELTD_HOSPTLZTN_ADMSN_DT_OVL_ADMSN_D8
L2300	DTP	Date - Discharge
L2300	DTP03	Discharge (D8)	L2300_S03_DTP03_DISCHRG_END_CAR_DT_OVL_DISCHRG_D8
L2300	DTP	Date - Referral
L2300	DTP03	Referral Date (D8)	L2300_S04_DTP03_REFL_DT_OVL_REFL_DT_D8
L2300	DTP	Date - Accident
L2300	DTP03	Accident (D8)	L2300_S05_DTP03_ACDNT_DT_OVL_ACDNT_D8
L2300	DTP	Date - Appliance Placement
L2300	DTP03	Appliance Placement (D8)	L2300_S06_DTP03_ORTHDNTC_BANDNG_DT_OVL_APLNC_PLACMNT_D8
L2300	DTP	Date - Service
L2300	DTP03	Service (D8)	L2300_S07_DTP03_SVC_DT_OVL_SVC_D8
L2300	DTP03	Service (RD8)	L2300_S07_DTP03_SVC_DT_OVL_SVC_RD8
L2300	DN1	Orthodontic Total Months of Treatment
L2300	DN101	Orthodontic Treatment Months Count	L2300_S08_DN101_ORTHO_TRTMNT_MONTHS_CT
L2300	DN102	Orthodontic Treatment Months Remaining Count	L2300_S08_DN102_ORTHO_TRTMNT_MONTHS_REMNG_CT
L2300	DN103	Question Response	L2300_S08_DN103_QUESTN_RESPNS
L2300	DN2	Tooth Status
L2300	DN201	Tooth Number	L2300_S09_DN201_TOTH_NR
L2300	DN202	Tooth Status Code	L2300_S09_DN202_STATS_CD
L2300	PWK	Claim Supplemental Information
L2300	PWK01	Attachment Report Type Code	L2300_S10_PWK01_ATCHMNT_REPRT_TYPE_CD
L2300	PWK02	Attachment Transmission Code	L2300_S10_PWK02_ATCHMNT_TRANSMSN_CD
L2300	PWK06	Attachment Control Number	L2300_S10_PWK06_ATCHMNT_CONTRL_NR_OVL_ATCHMNT_CONTRL_NR
L2300	AMT	Patient Amount Paid
L2300	AMT01	Amount Qualifier Code	L2300_S11_AMT01_QUAL_CD
L2300	AMT02	Patient Amount Paid	L2300_S11_AMT02_AMT_PD
L2300	AMT	Credit/Debit Card - Maximum Amount
L2300	AMT02	Maximum Amount	L2300_S12_AMT02_MAX_AMT_OVL_MAX_AMT
L2300	REF	Predetermination Identification
L2300	REF02	Predetermination of Benefits Identification Number	L2300_S13_REF02_BENFTS_ID_OVL_PREDTRMNTN_BENFTS_ID_NR
L2300	REF	Service Authorization Exception Code
L2300	REF02	Special Payment Reference Number	L2300_S14_REF02_SVC_AUTH_EXCPTN_CD_OVL_SPECL_PMT_REF_NR
L2300	REF	Original Reference Number (ICN/DCN)
L2300	REF02	Original Reference Number	L2300_S15_REF02_CLM_ORGNL_REF_NR_OVL_ORGNL_REF_NR
L2300	REF	Referral Identification
L2300	REF02	Referral Number	L2300_S16_REF02_REFL_NR_OVL_REFL_NR
L2300	REF	Claim Identification Number for Clearinghouses and Other Transmission Intermediaries
L2300	REF02	Claim Number	L2300_S17_REF02_VAL_AD_NETWRK_TRAC_NR_OVL_CLM_NR
L2300	NTE	Claim Note
L2300	NTE02	Additional Information	L2300_S18_NTE02_NOT_TEXT_OVL_ADDL_NFO

2310A - REFERRING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
2310A		Qualified Loop
L2310A		Referring Provider	L2310A_DN
L2310A		Primary Care Provider	L2310A_P3
L2310A	NM1	Referring Provider Name
L2310A	NM103	Person	L2310A_XX_S01_NM103_PROV_LNAME_OVL_PERSN
L2310A	NM103	Non-Person Entity	L2310A_XX_S01_NM103_PROV_LNAME_OVL_NONPRSN_ENTY
L2310A	NM104	Referring Provider First Name	L2310A_XX_S01_NM104_PROV_FNAME
L2310A	NM105	Referring Provider Middle Name	L2310A_XX_S01_NM105_PROV_MNAME
L2310A	NM107	Referring Provider Name Suffix	L2310A_XX_S01_NM107_REFNG_PROV_NM_SUFX
L2310A	NM109	Employer’s Identification Number	L2310A_XX_S01_NM109_PROV_ID_OVL_EMPLYR_ID_NR
L2310A	NM109	Social Security Number	L2310A_XX_S01_NM109_PROV_ID_OVL_SSN
L2310A	NM109	Health Care Financing Administration National	L2310A_XX_S01_NM109_PROV_ID_OVL_HCFA_NATNL
L2310A	PRV	Referring Provider Specialty Information
L2310A	PRV01	Provider Code	L2310A_XX_S02_PRV01_PROV_CD
L2310A	PRV03	Mutually Defined	L2310A_XX_S02_PRV03_TAXNMY_CD_OVL_MUTLY_DEFND
L2310A	N2	Additional Referring Provider Name Information
L2310A	N201	Referring Provider Name Additional Text	L2310A_XX_S03_N201_ADDL_TEXT
L2310A	REF	Referring Provider Secondary Identification
L2310A	REF02	State License Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2310A	REF02	Blue Cross Provider Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_BLUE_CROS_PROV_NR
L2310A	REF02	Blue Shield Provider Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_BLUE_SHIELD_PROV_NR
L2310A	REF02	Medicare Provider Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_MEDCR_PROV_NR
L2310A	REF02	Medicaid Provider Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_MEDCD_PROV_NR
L2310A	REF02	Dentist License Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_DENTST_LICNS_NR
L2310A	REF02	CHAMPUS Identification Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_CHAMPS_ID_NR
L2310A	REF02	Employer’s Identification Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_EMPLYR_ID_NR
L2310A	REF02	Provider Commercial Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2310A	REF02	Provider Site Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_PROV_SIT_NR
L2310A	REF02	Location Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_LOC_NR
L2310A	REF02	Social Security Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_SSN
L2310A	REF02	Federal Taxpayer’s Identification Number	L2310A_XX_S04_REF02_REFNG_PROV_2ND_ID_OVL_FED_TAX_ID_NR

2310B - RENDERING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310B	NM1	Rendering Provider Name
L2310B	NM103	Person	L2310B_S01_NM103_LAST_ORG_NM_OVL_PERSN
L2310B	NM103	Non-Person Entity	L2310B_S01_NM103_LAST_ORG_NM_OVL_NONPRSN_ENTY
L2310B	NM104	Rendering Provider First Name	L2310B_S01_NM104_PROV_FNAME
L2310B	NM105	Rendering Provider Middle Name	L2310B_S01_NM105_PROV_MNAME
L2310B	NM107	Rendering Provider Name Suffix	L2310B_S01_NM107_RENDRNG_PROV_NM_SUFX
L2310B	NM109	Employer’s Identification Number	L2310B_S01_NM109_PROV_ID_OVL_EMPLYR_ID_NR
L2310B	NM109	Social Security Number	L2310B_S01_NM109_PROV_ID_OVL_SSN
L2310B	NM109	Health Care Financing Administration National	L2310B_S01_NM109_PROV_ID_OVL_HCFA_NATNL
L2310B	PRV	Rendering Provider Specialty Information
L2310B	PRV01	Provider Code	L2310B_S02_PRV01_PROV_CD
L2310B	PRV03	Mutually Defined	L2310B_S02_PRV03_TAXNMY_CD_OVL_MUTLY_DEFND
L2310B	N2	Additional Rendering Provider Name Information
L2310B	N201	Rendering Provider Name Additional Text	L2310B_S03_N201_ADDL_TEXT
L2310B	REF	Rendering Provider Secondary Identification
L2310B	REF02	State License Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2310B	REF02	Blue Cross Provider Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_BLUE_CROS_PROV_NR
L2310B	REF02	Blue Shield Provider Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_BLUE_SHIELD_PROV_NR
L2310B	REF02	Medicare Provider Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_MEDCR_PROV_NR
L2310B	REF02	Medicaid Provider Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_MEDCD_PROV_NR
L2310B	REF02	Dentist License Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_DENTST_LICNS_NR
L2310B	REF02	CHAMPUS Identification Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_CHAMPS_ID_NR
L2310B	REF02	Employer’s Identification Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_EMPLYR_ID_NR
L2310B	REF02	Provider Commercial Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2310B	REF02	Provider Site Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_SIT_NR
L2310B	REF02	Location Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_LOC_NR
L2310B	REF02	Social Security Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_SSN
L2310B	REF02	Federal Taxpayer’s Identification Number	L2310B_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_FED_TAX_ID_NR

2310C - SERVICE FACILITY LOCATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310C	NM1	Service Facility Location
L2310C	NM103	Non-Person Entity	L2310C_S01_NM103_LAB_FACLTY_NM_OVL_NONPRSN_ENTY
L2310C	NM109	Employer’s Identification Number	L2310C_S01_NM109_LAB_FACLTY_PRIMRY_ID_OVL_EMPLYR_ID_NR
L2310C	NM109	Social Security Number	L2310C_S01_NM109_LAB_FACLTY_PRIMRY_ID_OVL_SSN
L2310C	NM109	Health Care Financing Administration National	L2310C_S01_NM109_LAB_FACLTY_PRIMRY_ID_OVL_HCFA_NATNL
L2310C	N2	Additional Service Facility Location Name Information
L2310C	N201	Laboratory or Facility Name Additional Text	L2310C_S02_N201_LAB_FACLTY_NM_ADDL_TEXT
L2310C	REF	Service Facility Location Secondary Identification
L2310C	REF02	State License Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_STAT_LICNS_NR
L2310C	REF02	Blue Cross Provider Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_BLUE_CROS_PROV_NR
L2310C	REF02	Blue Shield Provider Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_BLUE_SHIELD_PROV_NR
L2310C	REF02	Medicare Provider Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_MEDCR_PROV_NR
L2310C	REF02	Medicaid Provider Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_MEDCD_PROV_NR
L2310C	REF02	Provider UPIN Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_PROV_UPN_NR
L2310C	REF02	CHAMPUS Identification Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_CHAMPS_ID_NR
L2310C	REF02	Provider Commercial Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_PROV_COMRCL_NR
L2310C	REF02	Location Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_LOC_NR
L2310C	REF02	Federal Taxpayer’s Identification Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_FED_TAX_ID_NR
L2310C	REF02	Clinical Laboratory Improvement Amendment Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_CLINCL_LAB_NR
L2310C	REF02	State Industrial Accident Provider Number	L2310C_S03_REF02_LAB_FACLTY_2ND_ID_OVL_STAT_INDSTRL_ACDNT_PROV_NR

2320 - OTHER SUBSCRIBER INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2320	SBR	Other Subscriber Information
L2320	SBR01	Payer Responsibility Sequence Number Code	L2320_S01_SBR01_PAYR_RESP_SEQNC_NR_CD
L2320	SBR02	Individual Relationship Code	L2320_S01_SBR02_INDVDL_REL_CD
L2320	SBR03	Insured Group or Policy Number	L2320_S01_SBR03_INSRD_GRP_POLCY_NR
L2320	SBR04	Policy Name	L2320_S01_SBR04_POLCY_NM
L2320	SBR09	Claim Filing Indicator Code	L2320_S01_SBR09_CLM_FILNG_IND_CD
L2320	CAS	Claim Adjustment
L2320	CAS01	Claim Adjustment Group Code	L2320_S02_CAS01_CLM_ADJ_GRP_CD
L2320	CAS02	Adjustment Reason Code	L2320_S02_CAS02_ADJ_RSN_CD
L2320	CAS03	Adjustment Amount	L2320_S02_CAS03_ADJ_AMT
L2320	CAS04	Adjustment Quantity	L2320_S02_CAS04_ADJ_QTY
L2320	CAS05	Adjustment Reason Code	L2320_S02_CAS05_ADJ_RSN_CD
L2320	CAS06	Adjustment Amount	L2320_S02_CAS06_ADJ_AMT
L2320	CAS07	Adjustment Quantity	L2320_S02_CAS07_ADJ_QTY
L2320	CAS08	Adjustment Reason Code	L2320_S02_CAS08_ADJ_RSN_CD
L2320	CAS09	Adjustment Amount	L2320_S02_CAS09_ADJ_AMT
L2320	CAS10	Adjustment Quantity	L2320_S02_CAS10_ADJ_QTY
L2320	CAS11	Adjustment Reason Code	L2320_S02_CAS11_ADJ_RSN_CD
L2320	CAS12	Adjustment Amount	L2320_S02_CAS12_ADJ_AMT
L2320	CAS13	Adjustment Quantity	L2320_S02_CAS13_ADJ_QTY
L2320	CAS14	Adjustment Reason Code	L2320_S02_CAS14_ADJ_RSN_CD
L2320	CAS15	Adjustment Amount	L2320_S02_CAS15_ADJ_AMT
L2320	CAS16	Adjustment Quantity	L2320_S02_CAS16_ADJ_QTY
L2320	CAS17	Adjustment Reason Code	L2320_S02_CAS17_ADJ_RSN_CD
L2320	CAS18	Adjustment Amount	L2320_S02_CAS18_ADJ_AMT
L2320	CAS19	Adjustment Quantity	L2320_S02_CAS19_ADJ_QTY
L2320	AMT	Coordination of Benefits (COB) Payer Paid Amount
L2320	AMT02	Payor Amount Paid	L2320_S03_AMT02_PD_AMT_OVL_PAYR_AMT_PAID
L2320	AMT	Coordination of Benefits (COB) Approved Amount
L2320	AMT02	Approved Amount	L2320_S04_AMT02_APRVD_AMT_OVL_APRVD_AMT
L2320	AMT	Coordination of Benefits (COB) Allowed Amount
L2320	AMT02	Allowed - Actual	L2320_S05_AMT02_ALWD_AMT_OVL_ALWD_ACTL
L2320	AMT	Coordination of Benefits (COB) Patient Responsibility Amount
L2320	AMT02	Patient Responsibility - Actual	L2320_S06_AMT02_RESP_AMT_OVL_PATNT_RESP_ACTL
L2320	AMT	Coordination of Benefits (COB) Covered Amount
L2320	AMT02	Coverage Amount	L2320_S07_AMT02_COVRD_AMT_OVL_COVG_AMT
L2320	AMT	Coordination of Benefits (COB) Discount Amount
L2320	AMT02	Discount Amount	L2320_S08_AMT02_OTHR_PAYR_DISCNT_AMT_OVL_DISCNT_AMT
L2320	AMT	Coordination of Benefits (COB) Patient Paid Amount
L2320	AMT02	Patient Amount Paid	L2320_S09_AMT02_OTHR_PAYR_PATNT_PD_AMT_OVL_PATNT_AMT_PAID
L2320	DMG	Other Insured Demographic Information
L2320	DMG02	Date Expressed in Format CCYYMMDD	L2320_S10_DMG02_OTHR_INSRD_BIRTH_DT_OVL_DT_CCYYMMDD
L2320	DMG03	Other Insured Gender Code	L2320_S10_DMG03_OTHR_INSRD_GENDR_CD
L2320	OI	Other Insurance Coverage Information
L2320	OI03	Benefits Assignment Certification Indicator	L2320_S11_OI03_BENFTS_ASGNMNT_CERT_IND
L2320	OI06	Release of Information Code	L2320_S11_OI06_RELS_NFO_CD

2330A - OTHER SUBSCRIBER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330A	NM1	Other Subscriber Name
L2330A	NM103	Person	L2330A_S01_NM103_INSRD_LNAME_OVL_PERSN
L2330A	NM103	Non-Person Entity	L2330A_S01_NM103_INSRD_LNAME_OVL_NONPRSN_ENTY
L2330A	NM104	Other Insured First Name	L2330A_S01_NM104_INSRD_FNAME
L2330A	NM105	Other Insured Middle Name	L2330A_S01_NM105_INSRD_MNAME
L2330A	NM107	Other Insured Name Suffix	L2330A_S01_NM107_OTHR_INSRD_NM_SUFX
L2330A	NM109	Employer’s Identification Number	L2330A_S01_NM109_INSRD_ID_OVL_EMPLYR_ID_NR
L2330A	NM109	Member Identification Number	L2330A_S01_NM109_INSRD_ID_OVL_MEM_ID_NR
L2330A	NM109	Mutually Defined	L2330A_S01_NM109_INSRD_ID_OVL_MUTLY_DEFND
L2330A	N2	Additional Other Subscriber Name Information
L2330A	N201	Other Insured Additional Name	L2330A_S02_N201_OTHR_INSRD_ADDL_NM
L2330A	N3	Other Subscriber Address
L2330A	N301	Other Insured Address Line	L2330A_S03_N301_OTHR_INSRD_ADRS_LIN
L2330A	N302	Other Insured Address Line	L2330A_S03_N302_OTHR_INSRD_ADRS_LIN
L2330A	N4	Other Subscriber City/State/Zip Code
L2330A	N401	Other Insured City Name	L2330A_S04_N401_OTHR_INSRD_CITY_NM
L2330A	N402	Other Insured State Code	L2330A_S04_N402_OTHR_INSRD_STAT_CD
L2330A	N403	Other Insured Postal Zone or ZIP Code	L2330A_S04_N403_OTHR_INSRD_POSTL_ZON_ZIP_CD
L2330A	N404	Country Code	L2330A_S04_N404_CNTRY_CD
L2330A	REF	Other Subscriber Secondary Identification
L2330A	REF02	Member Identification Number	L2330A_S05_REF02_OTHR_INSRD_ADDL_ID_OVL_MEM_ID_NR
L2330A	REF02	Client Number	L2330A_S05_REF02_OTHR_INSRD_ADDL_ID_OVL_CLIENT_NR
L2330A	REF02	Insurance Policy Number	L2330A_S05_REF02_OTHR_INSRD_ADDL_ID_OVL_INS_POLCY_NR
L2330A	REF02	Social Security Number	L2330A_S05_REF02_OTHR_INSRD_ADDL_ID_OVL_SSN

2330B - OTHER PAYER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330B	NM1	Other Payer Name
L2330B	NM103	Non-Person Entity	L2330B_S01_NM103_LAST_ORG_NM_OVL_NONPRSN_ENTY
L2330B	NM109	Payor Identification	L2330B_S01_NM109_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID
L2330B	NM109	Health Care Financing Administration National PlanID	L2330B_S01_NM109_OTHR_PAYR_PRIMRY_ID_OVL_HCFA_NATNL_PLAND
L2330B	N2	Additional Other Payer Name Information
L2330B	N201	Other Payer Additional Name Text	L2330B_S02_N201_ADDL_NM_TEXT
L2330B	PER	Other Payer Contact Information
L2330B	PER01	Contact Function Code	L2330B_S03_PER01_FUNCTN_CD
L2330B	PER02	Other Payer Contact Name	L2330B_S03_PER02_OTHR_PAYR_CONTCT_NM
L2330B	PER04	Electronic Data Interchange Access Number	L2330B_S03_PER04_COMM_NR_OVL_EDI_ACS_NR
L2330B	PER04	Electronic Mail	L2330B_S03_PER04_COMM_NR_OVL_EMAIL
L2330B	PER04	Facsimile	L2330B_S03_PER04_COMM_NR_OVL_FACSML
L2330B	PER04	Telephone	L2330B_S03_PER04_COMM_NR_OVL_TELPHN
L2330B	PER06	Telephone	L2330B_S03_PER06_COMM_NR_OVL_TELPHN
L2330B	PER08	Electronic Data Interchange Access Number	L2330B_S03_PER08_COMM_NR_OVL_EDI_ACS_NR
L2330B	PER08	Electronic Mail	L2330B_S03_PER08_COMM_NR_OVL_EMAIL
L2330B	PER08	Telephone Extension	L2330B_S03_PER08_COMM_NR_OVL_PHN_EXTNS
L2330B	PER08	Facsimile	L2330B_S03_PER08_COMM_NR_OVL_FACSML
L2330B	PER08	Telephone	L2330B_S03_PER08_COMM_NR_OVL_TELPHN
L2330B	DTP	Claim Paid Date
L2330B	DTP03	Date Claim Paid (D8)	L2330B_S04_DTP03_DAT_CLM_PD_OVL_DAT_CLM_PAID_D8
L2330B	REF	Other Payer Secondary Identifier
L2330B	REF02	Payer Identification Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_PAYR_ID_NR
L2330B	REF02	Loss Report Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_LOS_REPRT_NR
L2330B	REF02	Original Reference Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_ORGNL_REF_NR
L2330B	REF02	Claim Office Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_CLM_OFC_NR
L2330B	REF02	National Association of Insurance Commissioners (NAIC) Code	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_NAIC_CD
L2330B	REF02	Federal Taxpayer’s Identification Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_FED_TAX_ID_NR
L2330B	REF	Other Payer Referral Number
L2330B	REF02	Referral Number	L2330B_S06_REF02_PRI_AUTH_REFL_NR_OVL_REFL_NR
L2330B	REF	Other Payer Claim Adjustment Indicator
L2330B	REF02	Signal Code	L2330B_S07_REF02_IND_OVL_SIGNL_CD

2330C - OTHER PAYER PATIENT INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330C	NM1	Other Payer Patient Information
L2330C	NM103	Person	L2330C_S01_NM103_OTHR_PAYR_PATNT_LNAME_OVL_PERSN
L2330C	NM109	Member Identification Number	L2330C_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR
L2330C	REF	Other Payer Patient Identification
L2330C	REF02	Member Identification Number	L2330C_S02_REF02_PRIMRY_ID_OVL_MEM_ID_NR
L2330C	REF02	Client Number	L2330C_S02_REF02_PRIMRY_ID_OVL_CLIENT_NR
L2330C	REF02	Insurance Policy Number	L2330C_S02_REF02_PRIMRY_ID_OVL_INS_POLCY_NR
L2330C	REF02	Social Security Number	L2330C_S02_REF02_PRIMRY_ID_OVL_SSN

2330D - OTHER PAYER REFERRING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
2330D		Qualified Loop
L2330D		Referring Provider	L2330D_DN
L2330D		Primary Care Provider	L2330D_P3
L2330D	NM1	Other Payer Referring Provider
L2330D	NM102	Entity Type Qualifier	L2330D_XX_S01_NM102_ENTY_TYPE_QUAL
L2330D	REF	Other Payer Referring Provider Identification
L2330D	REF02	State License Number	L2330D_XX_S02_REF02_ID_OVL_STAT_LICNS_NR
L2330D	REF02	Blue Cross Provider Number	L2330D_XX_S02_REF02_ID_OVL_BLUE_CROS_PROV_NR
L2330D	REF02	Blue Shield Provider Number	L2330D_XX_S02_REF02_ID_OVL_BLUE_SHIELD_PROV_NR
L2330D	REF02	Medicare Provider Number	L2330D_XX_S02_REF02_ID_OVL_MEDCR_PROV_NR
L2330D	REF02	Medicaid Provider Number	L2330D_XX_S02_REF02_ID_OVL_MEDCD_PROV_NR
L2330D	REF02	Dentist License Number	L2330D_XX_S02_REF02_ID_OVL_DENTST_LICNS_NR
L2330D	REF02	CHAMPUS Identification Number	L2330D_XX_S02_REF02_ID_OVL_CHAMPS_ID_NR
L2330D	REF02	Employer’s Identification Number	L2330D_XX_S02_REF02_ID_OVL_EMPLYR_ID_NR
L2330D	REF02	Provider Commercial Number	L2330D_XX_S02_REF02_ID_OVL_PROV_COMRCL_NR
L2330D	REF02	Provider Site Number	L2330D_XX_S02_REF02_ID_OVL_PROV_SIT_NR
L2330D	REF02	Location Number	L2330D_XX_S02_REF02_ID_OVL_LOC_NR
L2330D	REF02	Social Security Number	L2330D_XX_S02_REF02_ID_OVL_SSN
L2330D	REF02	Federal Taxpayer’s Identification Number	L2330D_XX_S02_REF02_ID_OVL_FED_TAX_ID_NR

2330E - OTHER PAYER RENDERING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330E	NM1	Other Payer Rendering Provider
L2330E	NM102	Entity Type Qualifier	L2330E_S01_NM102_ENTY_TYPE_QUAL
L2330E	REF	Other Payer Rendering Provider Identification
L2330E	REF02	State License Number	L2330E_S02_REF02_ID_OVL_STAT_LICNS_NR
L2330E	REF02	Blue Cross Provider Number	L2330E_S02_REF02_ID_OVL_BLUE_CROS_PROV_NR
L2330E	REF02	Blue Shield Provider Number	L2330E_S02_REF02_ID_OVL_BLUE_SHIELD_PROV_NR
L2330E	REF02	Medicare Provider Number	L2330E_S02_REF02_ID_OVL_MEDCR_PROV_NR
L2330E	REF02	Medicaid Provider Number	L2330E_S02_REF02_ID_OVL_MEDCD_PROV_NR
L2330E	REF02	Dentist License Number	L2330E_S02_REF02_ID_OVL_DENTST_LICNS_NR
L2330E	REF02	CHAMPUS Identification Number	L2330E_S02_REF02_ID_OVL_CHAMPS_ID_NR
L2330E	REF02	Employer’s Identification Number	L2330E_S02_REF02_ID_OVL_EMPLYR_ID_NR
L2330E	REF02	Provider Commercial Number	L2330E_S02_REF02_ID_OVL_PROV_COMRCL_NR
L2330E	REF02	Provider Site Number	L2330E_S02_REF02_ID_OVL_PROV_SIT_NR
L2330E	REF02	Location Number	L2330E_S02_REF02_ID_OVL_LOC_NR
L2330E	REF02	Social Security Number	L2330E_S02_REF02_ID_OVL_SSN
L2330E	REF02	Federal Taxpayer’s Identification Number	L2330E_S02_REF02_ID_OVL_FED_TAX_ID_NR

2400 - LINE COUNTER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2400	LX	Line Counter
L2400	LX01	Assigned Number	L2400_S01_LX01_ASGND_NR
L2400	SV3	Dental Service
L2400	SV301-02	American Dental Association Codes	L2400_S02_SV301_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD
L2400	SV301-03	Procedure Modifier	L2400_S02_SV301_03_PROC_MODFR
L2400	SV301-04	Procedure Modifier	L2400_S02_SV301_04_PROC_MODFR
L2400	SV301-05	Procedure Modifier	L2400_S02_SV301_05_PROC_MODFR
L2400	SV301-06	Procedure Modifier	L2400_S02_SV301_06_PROC_MODFR
L2400	SV302	Line Item Charge Amount	L2400_S02_SV302_LIN_ITM_CHG_AMT
L2400	SV303	Facility Type Code	L2400_S02_SV303_FACLTY_TYPE_CD
L2400	SV304-01	Oral Cavity Designation Code	L2400_S02_SV304_01_ORL_CAVTY_DESGNTN_CD
L2400	SV304-02	Oral Cavity Designation Code	L2400_S02_SV304_02_ORL_CAVTY_DESGNTN_CD
L2400	SV304-03	Oral Cavity Designation Code	L2400_S02_SV304_03_ORL_CAVTY_DESGNTN_CD
L2400	SV304-04	Oral Cavity Designation Code	L2400_S02_SV304_04_ORL_CAVTY_DESGNTN_CD
L2400	SV304-05	Oral Cavity Designation Code	L2400_S02_SV304_05_ORL_CAVTY_DESGNTN_CD
L2400	SV305	Prosthesis, Crown, or Inlay Code	L2400_S02_SV305_PROSTHS_CROWN_INLY_CD
L2400	SV306	Procedure Count	L2400_S02_SV306_PROC_CT
L2400	TOO	Tooth Information
L2400	TOO01	Code List Qualifier Code	L2400_S03_TOO01_CD_LIST_QUAL_CD
L2400	TOO02	Tooth Code	L2400_S03_TOO02_TOTH_CD
L2400	TOO03-01	Tooth Surface Code	L2400_S03_TOO03_01_TOTH_SURFC_CD
L2400	TOO03-02	Tooth Surface Code	L2400_S03_TOO03_02_TOTH_SURFC_CD
L2400	TOO03-03	Tooth Surface Code	L2400_S03_TOO03_03_TOTH_SURFC_CD
L2400	TOO03-04	Tooth Surface Code	L2400_S03_TOO03_04_TOTH_SURFC_CD
L2400	TOO03-05	Tooth Surface Code	L2400_S03_TOO03_05_TOTH_SURFC_CD
L2400	DTP	Date - Service
L2400	DTP03	Service (D8)	L2400_S04_DTP03_SVC_DT_OVL_SVC_D8
L2400	DTP	Date - Prior Placement
L2400	DTP03	Prior Placement (D8)	L2400_S05_DTP03_PLACMNT_DT_OVL_PRI_PLACMNT_D8
L2400	DTP	Date - Appliance Placement
L2400	DTP03	Appliance Placement (D8)	L2400_S06_DTP03_ORTHDNTC_BANDNG_DT_OVL_APLNC_PLACMNT_D8
L2400	DTP	Date - Replacement
L2400	DTP03	Replacement (D8)	L2400_S07_DTP03_REPLCMNT_DT_OVL_REPLCMNT_D8
L2400	QTY	Anesthesia Quantity
L2400	QTY02	Age Modifying Units	L2400_S08_QTY02_UNT_CT_OVL_AG_MODFYNG_UNTS
L2400	QTY02	Emergency Modifying Units	L2400_S08_QTY02_UNT_CT_OVL_EMRGNCY_MODFYNG_UNTS
L2400	QTY02	Use of Hypothermia	L2400_S08_QTY02_UNT_CT_OVL_US_HYPOTHRM
L2400	QTY02	Use of Hypotension	L2400_S08_QTY02_UNT_CT_OVL_US_HYPOTNSN
L2400	QTY02	Use of Hyperbaric Pressurization	L2400_S08_QTY02_UNT_CT_OVL_US_HYPERBRC_PRESRZTN
L2400	QTY02	Physical Status III	L2400_S08_QTY02_UNT_CT_OVL_PHYSICL_STATS_I
L2400	QTY02	Physical Status IV	L2400_S08_QTY02_UNT_CT_OVL_PHYSICL_STATS_IV
L2400	QTY02	Physical Status V	L2400_S08_QTY02_UNT_CT_OVL_PHYSICL_STATS_V
L2400	QTY02	Swan-Ganz	L2400_S08_QTY02_UNT_CT_OVL_SWANGNZ
L2400	REF	Service Predetermination Identification
L2400	REF02	Predetermination of Benefits Identification Number	L2400_S09_REF02_BENFTS_ID_OVL_PREDTRMNTN_BENFTS_ID_NR
L2400	REF	Referral Number
L2400	REF02	Referral Number	L2400_S10_REF02_REFL_NR_OVL_REFL_NR
L2400	REF	Line Item Control Number
L2400	REF02	Provider Control Number	L2400_S11_REF02_LIN_ITM_CONTRL_NR_OVL_PROV_CONTRL_NR
L2400	AMT	Approved Amount
L2400	AMT02	Approved Amount	L2400_S12_AMT02_APRVD_AMT_OVL_APRVD_AMT
L2400	NTE	Line Note
L2400	NTE02	Additional Information	L2400_S13_NTE02_CLM_NOT_TEXT_OVL_ADDL_NFO

2420A - RENDERING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420A	NM1	Rendering Provider Name
L2420A	NM103	Person	L2420A_S01_NM103_LAST_ORG_NM_OVL_PERSN
L2420A	NM103	Non-Person Entity	L2420A_S01_NM103_LAST_ORG_NM_OVL_NONPRSN_ENTY
L2420A	NM104	Rendering Provider First Name	L2420A_S01_NM104_PROV_FNAME
L2420A	NM105	Rendering Provider Middle Name	L2420A_S01_NM105_PROV_MNAME
L2420A	NM107	Rendering Provider Name Suffix	L2420A_S01_NM107_RENDRNG_PROV_NM_SUFX
L2420A	NM109	Employer’s Identification Number	L2420A_S01_NM109_PROV_ID_OVL_EMPLYR_ID_NR
L2420A	NM109	Social Security Number	L2420A_S01_NM109_PROV_ID_OVL_SSN
L2420A	NM109	Health Care Financing Administration National Provider Identifier	L2420A_S01_NM109_PROV_ID_OVL_HCFA_NATNL_PROV_ID
L2420A	PRV	Rendering Provider Specialty Information
L2420A	PRV01	Provider Code	L2420A_S02_PRV01_PROV_CD
L2420A	PRV03	Mutually Defined	L2420A_S02_PRV03_TAXNMY_CD_OVL_MUTLY_DEFND
L2420A	N2	Additional Rendering Provider Name Information
L2420A	N201	Rendering Provider Name Additional Text	L2420A_S03_N201_ADDL_TEXT
L2420A	REF	Rendering Provider Secondary Identification
L2420A	REF02	State License Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2420A	REF02	Blue Cross Provider Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_BLUE_CROS_PROV_NR
L2420A	REF02	Blue Shield Provider Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_BLUE_SHIELD_PROV_NR
L2420A	REF02	Medicare Provider Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_MEDCR_PROV_NR
L2420A	REF02	Medicaid Provider Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_MEDCD_PROV_NR
L2420A	REF02	Dentist License Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_DENTST_LICNS_NR
L2420A	REF02	CHAMPUS Identification Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_CHAMPS_ID_NR
L2420A	REF02	Employer’s Identification Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_EMPLYR_ID_NR
L2420A	REF02	Provider Commercial Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2420A	REF02	Provider Site Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_SIT_NR
L2420A	REF02	Location Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_LOC_NR
L2420A	REF02	Social Security Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_SSN
L2420A	REF02	Federal Taxpayer’s Identification Number	L2420A_S04_REF02_RENDRNG_PROV_2ND_ID_OVL_FED_TAX_ID_NR

2420B - OTHER PAYER REFERRAL NUMBER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420B	NM1	Other Payer Referral Number
L2420B	NM103	Non-Person Entity	L2420B_S01_NM103_LAST_ORG_NM_OVL_NONPRSN_ENTY
L2420B	NM108	Identification Code Qualifier	L2420B_S01_NM108_ID_CD_QUAL
L2420B	NM109	Other Payer Referral Number	L2420B_S01_NM109_OTHR_PAYR_REFL_NR
L2420B	REF	Other Payer Referral Number
L2420B	REF02	Referral Number	L2420B_S02_REF02_PRI_AUTH_REFL_NR_OVL_REFL_NR

2430 - LINE ADJUDICATION INFORMATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2430	SVD	Line Adjudication Information
L2430	SVD01	Other Payer Primary Identifier	L2430_S01_SVD01_OTHR_PAYR_PRIMRY_ID
L2430	SVD02	Service Line Paid Amount	L2430_S01_SVD02_SVC_LIN_PD_AMT
L2430	SVD03-02	American Dental Association Codes	L2430_S01_SVD03_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD
L2430	SVD03-02	Mutually Defined	L2430_S01_SVD03_02_PROC_CD_OVL_MUTLY_DEFND
L2430	SVD03-03	Procedure Modifier	L2430_S01_SVD03_03_PROC_MODFR
L2430	SVD03-04	Procedure Modifier	L2430_S01_SVD03_04_PROC_MODFR
L2430	SVD03-05	Procedure Modifier	L2430_S01_SVD03_05_PROC_MODFR
L2430	SVD03-06	Procedure Modifier	L2430_S01_SVD03_06_PROC_MODFR
L2430	SVD03-07	Procedure Code Description	L2430_S01_SVD03_07_PROC_CD_DESCRPTN
L2430	SVD05	Paid Service Unit Count	L2430_S01_SVD05_PD_SVC_UNT_CT
L2430	SVD06	Bundled or Unbundled Line Number	L2430_S01_SVD06_BUNDLD_UNBNDLD_LIN_NR
L2430	CAS	Service Adjustment
L2430	CAS01	Claim Adjustment Group Code	L2430_S02_CAS01_CLM_ADJ_GRP_CD
L2430	CAS02	Adjustment Reason Code	L2430_S02_CAS02_ADJ_RSN_CD
L2430	CAS03	Adjustment Amount	L2430_S02_CAS03_ADJ_AMT
L2430	CAS04	Adjustment Quantity	L2430_S02_CAS04_ADJ_QTY
L2430	CAS05	Adjustment Reason Code	L2430_S02_CAS05_ADJ_RSN_CD
L2430	CAS06	Adjustment Amount	L2430_S02_CAS06_ADJ_AMT
L2430	CAS07	Adjustment Quantity	L2430_S02_CAS07_ADJ_QTY
L2430	CAS08	Adjustment Reason Code	L2430_S02_CAS08_ADJ_RSN_CD
L2430	CAS09	Adjustment Amount	L2430_S02_CAS09_ADJ_AMT
L2430	CAS10	Adjustment Quantity	L2430_S02_CAS10_ADJ_QTY
L2430	CAS11	Adjustment Reason Code	L2430_S02_CAS11_ADJ_RSN_CD
L2430	CAS12	Adjustment Amount	L2430_S02_CAS12_ADJ_AMT
L2430	CAS13	Adjustment Quantity	L2430_S02_CAS13_ADJ_QTY
L2430	CAS14	Adjustment Reason Code	L2430_S02_CAS14_ADJ_RSN_CD
L2430	CAS15	Adjustment Amount	L2430_S02_CAS15_ADJ_AMT
L2430	CAS16	Adjustment Quantity	L2430_S02_CAS16_ADJ_QTY
L2430	CAS17	Adjustment Reason Code	L2430_S02_CAS17_ADJ_RSN_CD
L2430	CAS18	Adjustment Amount	L2430_S02_CAS18_ADJ_AMT
L2430	CAS19	Adjustment Quantity	L2430_S02_CAS19_ADJ_QTY
L2430	DTP	Line Adjudication Date
L2430	DTP03	Date Claim Paid (D8)	L2430_S03_DTP03_PMT_DT_OVL_DAT_CLM_PAID_D8