(C) Copyright 2012 Chiapas EDI Technologies, Inc.
5010_276 5010 Health Care Claim Status Request - Code:O0
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 | ST03 | Version, Release, or Industry Identifier | STHDR_S01_ST03_VERS_RELS_INDSTRY_ID |
| 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 | Reference Identification | STHDR_S02_BHT03_REF_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 | SE | Transaction Set Trailer | |
| STHDR | SE01 | Transaction Segment Count | STHDR_S04_SE01_SEG_CT |
| STHDR | SE02 | Transaction Set Control Number | STHDR_S04_SE02_TCN |
2000A - INFORMATION SOURCE LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000A | HL | Information Source Level | |
| L2000A | HL01 | Hierarchical ID Number | L2000A_S01_HL01_HIERCHCL_ID_NR |
| L2000A | HL04 | Hierarchical Child Code | L2000A_S01_HL04_HIERCHCL_CHILD_CD |
2100A - PAYER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100A | NM1 | Payer Name | |
| L2100A | NM103 | Non-Person Entity | L2100A_S01_NM103_PAYR_NM_OVL_NONPRSN_ENTY |
| L2100A | NM109 | Payor Identification | L2100A_S01_NM109_PAYR_ID_OVL_PAYR_ID |
| L2100A | NM109 | Centers for Medicare and Medicaid Services PlanID | L2100A_S01_NM109_PAYR_ID_OVL_MDCR_MDCD_SVCS_PLAND |
2000B - INFORMATION RECEIVER LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000B | HL | Information Receiver 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 |
2100B - INFORMATION RECEIVER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100B | NM1 | Information Receiver Name | |
| L2100B | NM102 | Entity Type Qualifier | L2100B_S01_NM102_ENTY_TYPE_QUAL |
| L2100B | NM103 | Information Receiver Last or Organization Name | L2100B_S01_NM103_NFO_RECVR_LAST_ORG_NM |
| L2100B | NM104 | Information Receiver First Name | L2100B_S01_NM104_NFO_RECVR_FNAME |
| L2100B | NM105 | Information Receiver Middle Name | L2100B_S01_NM105_NFO_RECVR_MNAME |
| L2100B | NM109 | Electronic Transmitter Identification Number (ETIN) | L2100B_S01_NM109_NFO_RECVR_ID_NR_OVL_ETN_NR |
2000C - SERVICE PROVIDER LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000C | HL | Service Provider 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 |
2100C - PROVIDER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100C | NM1 | Provider Name | |
| L2100C | NM102 | Entity Type Qualifier | L2100C_S01_NM102_ENTY_TYPE_QUAL |
| L2100C | NM103 | Provider Last or Organization Name | L2100C_S01_NM103_PROV_LAST_ORG_NM |
| L2100C | NM104 | Provider First Name | L2100C_S01_NM104_PROV_FNAME |
| L2100C | NM105 | Provider Middle Name | L2100C_S01_NM105_PROV_MNAME |
| L2100C | NM107 | Provider Name Suffix | L2100C_S01_NM107_NM_SUFX |
| L2100C | NM109 | Federal Taxpayer’s Identification Number | L2100C_S01_NM109_PROV_ID_OVL_FED_TAX_ID_NR |
| L2100C | NM109 | Service Provider Number | L2100C_S01_NM109_PROV_ID_OVL_SVC_PROV_NR |
| L2100C | NM109 | Centers for Medicare and Medicaid Services National Provider Identifier | L2100C_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID |
2000D - SUBSCRIBER LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000D | HL | Subscriber Level | |
| L2000D | HL01 | Hierarchical ID Number | L2000D_S01_HL01_HIERCHCL_ID_NR |
| L2000D | HL02 | Hierarchical Parent ID Number | L2000D_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000D | HL04 | Hierarchical Child Code | L2000D_S01_HL04_HIERCHCL_CHILD_CD |
| L2000D | DMG | Subscriber Demographic Information | |
| L2000D | DMG02 | Date Expressed in Format CCYYMMDD | L2000D_S02_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2000D | DMG03 | Subscriber Gender Code | L2000D_S02_DMG03_GENDR_CD |
2100D - SUBSCRIBER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100D | NM1 | Subscriber Name | |
| L2100D | NM103 | Person | L2100D_S01_NM103_SUB_LNAME_OVL_PERSN |
| L2100D | NM103 | Non-Person Entity | L2100D_S01_NM103_SUB_LNAME_OVL_NONPRSN_ENTY |
| L2100D | NM104 | Subscriber First Name | L2100D_S01_NM104_SUB_FNAME |
| L2100D | NM105 | Subscriber Middle Name or Initial | L2100D_S01_NM105_MNAME_INTL |
| L2100D | NM107 | Subscriber Name Suffix | L2100D_S01_NM107_NM_SUFX |
| L2100D | NM109 | Employer’s Identification Number | L2100D_S01_NM109_SUB_ID_OVL_EMPLYR_ID_NR |
| L2100D | NM109 | Standard Unique Health Identifier for each Individual in the United States | L2100D_S01_NM109_SUB_ID_OVL_STANDRD_UNQ_HEALTH_ID |
| L2100D | NM109 | Member Identification Number | L2100D_S01_NM109_SUB_ID_OVL_MEM_ID_NR |
2200D - CLAIM STATUS TRACKING NUMBER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200D | TRN | Claim Status Tracking Number | |
| L2200D | TRN01 | Trace Type Code | L2200D_S01_TRN01_TYPE_CD |
| L2200D | TRN02 | Current Transaction Trace Number | L2200D_S01_TRN02_CURNT_TRANSCTN_TRAC_NR |
| L2200D | REF | Payer Claim Control Number | |
| L2200D | REF02 | Payor’s Claim Number | L2200D_S02_REF02_PAYR_CLM_CONTRL_NR_OVL_PAYR_CLM_NR |
| L2200D | REF | Institutional Bill Type Identification | |
| L2200D | REF02 | Billing Type | L2200D_S03_REF02_TYPE_ID_OVL_BILNG_TYPE |
| L2200D | REF | Application or Location System Identifier | |
| L2200D | REF02 | Location Number | L2200D_S04_REF02_APLCTN_LOC_SYS_ID_OVL_LOC_NR |
| L2200D | REF | Group Number | |
| L2200D | REF02 | Group Number | L2200D_S05_REF02_GRP_NR_OVL_GRP_NR |
| L2200D | REF | Patient Control Number | |
| L2200D | REF02 | Patient Account Number | L2200D_S06_REF02_CONTRL_NR_OVL_PATNT_ACNT_NR |
| L2200D | REF | Pharmacy Prescription Number | |
| L2200D | REF02 | Pharmacy Prescription Number | L2200D_S07_REF02_RX_NR_OVL_PHARMCY_RX_NR |
| L2200D | REF | Claim Identification Number For Clearinghouses and Other Transmission Intermediaries | |
| L2200D | REF02 | Claim Number | L2200D_S08_REF02_TRAC_NR_OVL_CLM_NR |
| L2200D | AMT | Claim Submitted Charges | |
| L2200D | AMT02 | Total Submitted Charges | L2200D_S09_AMT02_TOTL_CLM_CHG_AMT_OVL_TOTL_SUBMTD_CHGS |
| L2200D | DTP | Claim Service Date | |
| L2200D | DTP03 | Service (D8) | L2200D_S10_DTP03_SVC_PERD_OVL_SVC_D8 |
| L2200D | DTP03 | Service (RD8) | L2200D_S10_DTP03_SVC_PERD_OVL_SVC_RD8 |
2210D - SERVICE LINE INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2210D | SVC | Service Line Information | |
| L2210D | SVC01-02 | American Dental Association Codes | L2210D_S01_SVC01_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD |
| L2210D | SVC01-02 | Jurisdiction Specific Procedure and Supply Codes | L2210D_S01_SVC01_02_PROC_CD_OVL_JURSDCTN_SPECFC_PROC_SUPLY_CD |
| L2210D | SVC01-02 | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | L2210D_S01_SVC01_02_PROC_CD_OVL_HCPCS_CD |
| L2210D | SVC01-02 | Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code | L2210D_S01_SVC01_02_PROC_CD_OVL_HIPPS_SNIF_RAT |
| L2210D | SVC01-02 | Home Infusion EDI Coalition (HIEC) Product/Service | L2210D_S01_SVC01_02_PROC_CD_OVL_HIEC_PRODCT_SRVC |
| L2210D | SVC01-02 | National Drug Code in 5-4-2 Format | L2210D_S01_SVC01_02_PROC_CD_OVL_NDC_542_FORMT |
| L2210D | SVC01-02 | National Uniform Billing Committee (NUBC) UB92 | L2210D_S01_SVC01_02_PROC_CD_OVL_NUBC_UB92 |
| L2210D | SVC01-02 | Advanced Billing Concepts (ABC) Codes | L2210D_S01_SVC01_02_PROC_CD_OVL_ABC_CD |
| L2210D | SVC01-03 | Procedure Modifier | L2210D_S01_SVC01_03_PROC_MODFR |
| L2210D | SVC01-04 | Procedure Modifier | L2210D_S01_SVC01_04_PROC_MODFR |
| L2210D | SVC01-05 | Procedure Modifier | L2210D_S01_SVC01_05_PROC_MODFR |
| L2210D | SVC01-06 | Procedure Modifier | L2210D_S01_SVC01_06_PROC_MODFR |
| L2210D | SVC02 | Line Item Charge Amount | L2210D_S01_SVC02_LIN_ITM_CHG_AMT |
| L2210D | SVC04 | Revenue Code | L2210D_S01_SVC04_REVN_CD |
| L2210D | SVC07 | Units of Service Count | L2210D_S01_SVC07_UNTS_SVC_CT |
| L2210D | REF | Service Line Item Identification | |
| L2210D | REF02 | Line Item Control Number | L2210D_S02_REF02_LIN_ITM_CONTRL_NR_OVL_LIN_ITM_CONTRL_NR |
| L2210D | DTP | Service Line Date | |
| L2210D | DTP03 | Service (D8) | L2210D_S03_DTP03_SVC_LIN_DT_OVL_SVC_D8 |
| L2210D | DTP03 | Service (RD8) | L2210D_S03_DTP03_SVC_LIN_DT_OVL_SVC_RD8 |
2000E - DEPENDENT LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000E | HL | Dependent Level | |
| L2000E | HL01 | Hierarchical ID Number | L2000E_S01_HL01_HIERCHCL_ID_NR |
| L2000E | HL02 | Hierarchical Parent ID Number | L2000E_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000E | DMG | Dependent Demographic Information | |
| L2000E | DMG02 | Date Expressed in Format CCYYMMDD | L2000E_S02_DMG02_PATNT_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2000E | DMG03 | Patient Gender Code | L2000E_S02_DMG03_PATNT_GENDR_CD |
2100E - DEPENDENT NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100E | NM1 | Dependent Name | |
| L2100E | NM103 | Person | L2100E_S01_NM103_PATNT_LNAME_OVL_PERSN |
| L2100E | NM104 | Patient First Name | L2100E_S01_NM104_PATNT_FNAME |
| L2100E | NM105 | Patient Middle Name or Initial | L2100E_S01_NM105_PATNT_MNAME_INTL |
| L2100E | NM107 | Patient Name Suffix | L2100E_S01_NM107_PATNT_NM_SUFX |
2200E - CLAIM STATUS TRACKING NUMBER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200E | TRN | Claim Status Tracking Number | |
| L2200E | TRN01 | Trace Type Code | L2200E_S01_TRN01_TYPE_CD |
| L2200E | TRN02 | Current Transaction Trace Number | L2200E_S01_TRN02_CURNT_TRANSCTN_TRAC_NR |
| L2200E | REF | Payer Claim Control Number | |
| L2200E | REF02 | Payor’s Claim Number | L2200E_S02_REF02_PAYR_CLM_CONTRL_NR_OVL_PAYR_CLM_NR |
| L2200E | REF | Institutional Bill Type Identification | |
| L2200E | REF02 | Billing Type | L2200E_S03_REF02_TYPE_ID_OVL_BILNG_TYPE |
| L2200E | REF | Application or Location System Identifier | |
| L2200E | REF02 | Location Number | L2200E_S04_REF02_APLCTN_LOC_SYS_ID_OVL_LOC_NR |
| L2200E | REF | Group Number | |
| L2200E | REF02 | Group Number | L2200E_S05_REF02_GRP_NR_OVL_GRP_NR |
| L2200E | REF | Patient Control Number | |
| L2200E | REF02 | Patient Account Number | L2200E_S06_REF02_CONTRL_NR_OVL_PATNT_ACNT_NR |
| L2200E | REF | Pharmacy Prescription Number | |
| L2200E | REF02 | Pharmacy Prescription Number | L2200E_S07_REF02_RX_NR_OVL_PHARMCY_RX_NR |
| L2200E | REF | Claim Identification Number For Clearinghouses and Other Transmission Intermediaries | |
| L2200E | REF02 | Claim Number | L2200E_S08_REF02_TRAC_NR_OVL_CLM_NR |
| L2200E | AMT | Claim Submitted Charges | |
| L2200E | AMT02 | Total Submitted Charges | L2200E_S09_AMT02_TOTL_CLM_CHG_AMT_OVL_TOTL_SUBMTD_CHGS |
| L2200E | DTP | Claim Service Date | |
| L2200E | DTP03 | Service (D8) | L2200E_S10_DTP03_SVC_PERD_OVL_SVC_D8 |
| L2200E | DTP03 | Service (RD8) | L2200E_S10_DTP03_SVC_PERD_OVL_SVC_RD8 |
2210E - SERVICE LINE INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2210E | SVC | Service Line Information | |
| L2210E | SVC01-02 | American Dental Association Codes | L2210E_S01_SVC01_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD |
| L2210E | SVC01-02 | Jurisdiction Specific Procedure and Supply Codes | L2210E_S01_SVC01_02_PROC_CD_OVL_JURSDCTN_SPECFC_PROC_SUPLY_CD |
| L2210E | SVC01-02 | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | L2210E_S01_SVC01_02_PROC_CD_OVL_HCPCS_CD |
| L2210E | SVC01-02 | Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code | L2210E_S01_SVC01_02_PROC_CD_OVL_HIPPS_SNIF_RAT |
| L2210E | SVC01-02 | Home Infusion EDI Coalition (HIEC) Product/Service | L2210E_S01_SVC01_02_PROC_CD_OVL_HIEC_PRODCT_SRVC |
| L2210E | SVC01-02 | National Drug Code in 5-4-2 Format | L2210E_S01_SVC01_02_PROC_CD_OVL_NDC_542_FORMT |
| L2210E | SVC01-02 | National Uniform Billing Committee (NUBC) UB92 | L2210E_S01_SVC01_02_PROC_CD_OVL_NUBC_UB92 |
| L2210E | SVC01-02 | Advanced Billing Concepts (ABC) Codes | L2210E_S01_SVC01_02_PROC_CD_OVL_ABC_CD |
| L2210E | SVC01-03 | Procedure Modifier | L2210E_S01_SVC01_03_PROC_MODFR |
| L2210E | SVC01-04 | Procedure Modifier | L2210E_S01_SVC01_04_PROC_MODFR |
| L2210E | SVC01-05 | Procedure Modifier | L2210E_S01_SVC01_05_PROC_MODFR |
| L2210E | SVC01-06 | Procedure Modifier | L2210E_S01_SVC01_06_PROC_MODFR |
| L2210E | SVC02 | Line Item Charge Amount | L2210E_S01_SVC02_LIN_ITM_CHG_AMT |
| L2210E | SVC04 | Revenue Code | L2210E_S01_SVC04_REVN_CD |
| L2210E | SVC07 | Units of Service Count | L2210E_S01_SVC07_UNTS_SVC_CT |
| L2210E | REF | Service Line Item Identification | |
| L2210E | REF02 | Line Item Control Number | L2210E_S02_REF02_LIN_ITM_CONTRL_NR_OVL_LIN_ITM_CONTRL_NR |
| L2210E | DTP | Service Line Date | |
| L2210E | DTP03 | Service (D8) | L2210E_S03_DTP03_SVC_LIN_DT_OVL_SVC_D8 |
| L2210E | DTP03 | Service (RD8) | L2210E_S03_DTP03_SVC_LIN_DT_OVL_SVC_RD8 |