(C) Copyright 2012 Chiapas EDI Technologies, Inc.
5010_820 5010 Payroll Deducted and Other Group Premium Payment for Insurance Products - Code:S0
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 | 820 Header | |
| STHDR | ST01 | Transaction Set Identifier Code | STHDR_S01_ST01_TS_ID_CD |
| STHDR | ST02 | Transaction Set Control Number | STHDR_S01_ST02_TS_CONTRL_NR |
| STHDR | ST03 | Implementation Convention Reference | STHDR_S01_ST03_IMPLMNTN_CONVNTN_REFNC |
| STHDR | BPR | Financial Information | |
| STHDR | BPR02 | Payment Accompanies Remittance Advice | STHDR_S02_BPR02_TOTL_PREM_PMT_AMT_OVL_PMT_ACMPNS_REMTNC_ADVC |
| STHDR | BPR02 | Make Payment Only | STHDR_S02_BPR02_TOTL_PREM_PMT_AMT_OVL_MAK_PMT_ONLY |
| STHDR | BPR02 | Remittance Information Only | STHDR_S02_BPR02_TOTL_PREM_PMT_AMT_OVL_REMTNC_NFO_ONLY |
| STHDR | BPR02 | Prenotification of Future Transfers | STHDR_S02_BPR02_TOTL_PREM_PMT_AMT_OVL_PRENTFCTN_FUTR_XFERS |
| STHDR | BPR02 | Split Payment and Remittance | STHDR_S02_BPR02_TOTL_PREM_PMT_AMT_OVL_SPLIT_PMT_REMTNC |
| STHDR | BPR02 | Handling Party’s Option to Split Payment and Remittance | STHDR_S02_BPR02_TOTL_PREM_PMT_AMT_OVL_OPTN_TO_SPLIT_PMT_REMTNC |
| STHDR | BPR03 | Credit or Debit Flag Code | STHDR_S02_BPR03_CREDT_DEBT_FLAG_CD |
| STHDR | BPR04 | Payment Method Code | STHDR_S02_BPR04_PMT_METHD_CD |
| STHDR | BPR05 | Payment Format Code | STHDR_S02_BPR05_PMT_FORMT_CD |
| STHDR | BPR06 | Depository Financial Institution (DFI) network. If not required by this implementation guide do not | STHDR_S02_BPR06_DFI_NETWRK |
| STHDR | BPR07 | Originating Depository Financial Institution (DFI) | STHDR_S02_BPR07_ORGNTNG_DFI |
| STHDR | BPR09 | Agency Location Code (ALC) | STHDR_S02_BPR09_SENDR_BANK_ACNT_NR_OVL_ALC |
| STHDR | BPR09 | Demand Deposit | STHDR_S02_BPR09_SENDR_BANK_ACNT_NR_OVL_DEMND_DEPST |
| STHDR | BPR10 | Payer Identifier | STHDR_S02_BPR10_PAYR_ID |
| STHDR | BPR11 | Originating Company Supplemental Code | STHDR_S02_BPR11_ORGNTNG_CO_SUPP_CD |
| STHDR | BPR12 | Depository Financial Institution (DFI) not required by this implementation guide, do not send. | STHDR_S02_BPR12_DFI |
| STHDR | BPR13 | Receiving Depository Financial Institution (DFI) | STHDR_S02_BPR13_RECVNG_DFI |
| STHDR | BPR15 | Demand Deposit | STHDR_S02_BPR15_RECVR_BANK_ACNT_NR_OVL_DEMND_DEPST |
| STHDR | BPR15 | Savings | STHDR_S02_BPR15_RECVR_BANK_ACNT_NR_OVL_SAVNGS |
| STHDR | BPR16 | Check Issue or EFT Effective Date | STHDR_S02_BPR16_CHK_IS_EFT_EFF_DT |
| STHDR | TRN | Reassociation Trace Number | |
| STHDR | TRN01 | Trace Type Code | STHDR_S03_TRN01_TYPE_CD |
| STHDR | TRN02 | Check or EFT Trace Number | STHDR_S03_TRN02_CHK_EFT_TRAC_NR |
| STHDR | TRN03 | Originating Company Identifier | STHDR_S03_TRN03_ORGNTNG_CO_ID |
| STHDR | TRN04 | Originating Company Supplemental Code | STHDR_S03_TRN04_ORGNTNG_CO_SUPP_CD |
| STHDR | CUR | Foreign Currency Information | |
| STHDR | CUR01 | Entity Identifier Code | STHDR_S04_CUR01_ENTY_ID_CD |
| STHDR | CUR02 | Currency Code | STHDR_S04_CUR02_CURNCY_CD |
| STHDR | REF | Premium Receivers Identification Key | |
| STHDR | REF02 | Master Account Number | STHDR_S05_REF02_PREM_RECVR_REF_ID_OVL_MASTR_ACNT_NR |
| STHDR | REF02 | Client Reporting Category | STHDR_S05_REF02_PREM_RECVR_REF_ID_OVL_CLIENT_REPRTNG_CATGRY |
| STHDR | REF02 | Plan Number | STHDR_S05_REF02_PREM_RECVR_REF_ID_OVL_PLAN_NR |
| STHDR | REF02 | Consolidated Invoice Number | STHDR_S05_REF02_PREM_RECVR_REF_ID_OVL_CONSLDTD_INVC_NR |
| STHDR | REF02 | Master Policy Number | STHDR_S05_REF02_PREM_RECVR_REF_ID_OVL_MASTR_POLCY_NR |
| STHDR | REF02 | Schedule Reference Number | STHDR_S05_REF02_PREM_RECVR_REF_ID_OVL_SCHEDL_REF_NR |
| STHDR | REF02 | Lockbox | STHDR_S05_REF02_PREM_RECVR_REF_ID_OVL_LOCKBX |
| STHDR | DTM | Process Date | |
| STHDR | DTM02 | Process | STHDR_S06_DTM02_PAYR_PROCS_DT_OVL_PROCS |
| STHDR | DTM | Delivery Date | |
| STHDR | DTM02 | Delivered | STHDR_S07_DTM02_PREM_DELVRY_DT_OVL_DELVRD |
| STHDR | DTM | Coverage Period | |
| STHDR | DTM01 | Date Time Qualifier | STHDR_S08_DTM01_DT_TM_QUAL |
| STHDR | DTM06 | Range of Dates Expressed in Format CCYYMMDD- CCYYMMDD | STHDR_S08_DTM06_COVG_PERD_OVL_RANG_DT_CCYYMMDD |
| STHDR | DTM | Creation Date | |
| STHDR | DTM02 | Transaction Creation | STHDR_S09_DTM02_DT_OVL_TRANSCTN_CREATN |
| STHDR | SE | Transaction Set Trailer | |
| STHDR | SE01 | Transaction Segment Count | STHDR_S15_SE01_SEG_CT |
| STHDR | SE02 | Transaction Set Control Number | STHDR_S15_SE02_TCN |
1000A - PREMIUM RECEIVERS NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L1000A | N1 | Premium Receiver’s Name | |
| L1000A | N102 | Premium Receiver’s Last or Organization Name | L1000A_S01_N102_LAST_ORG_NM |
| L1000A | N104 | D-U-N-S Number, Dun and Bradstreet | L1000A_S01_N104_PREM_RECVR_ID_CD_OVL_DUNS_NR_DUN_BRADSTRT |
| L1000A | N104 | D-U-N-S+4, D-U-N-S Number with Four Character Suffix | L1000A_S01_N104_PREM_RECVR_ID_CD_OVL_DUNS4_DUNS_NR_WITH_4CHAR_SUFX |
| L1000A | N104 | Insurance Company Assigned Identification Number | L1000A_S01_N104_PREM_RECVR_ID_CD_OVL_INS_CO_ASGND_ID_NR |
| L1000A | N104 | Federal Taxpayer’s Identification Number | L1000A_S01_N104_PREM_RECVR_ID_CD_OVL_FED_TAX_ID_NR |
| L1000A | N104 | Centers for Medicare and Medicaid Services PlanID | L1000A_S01_N104_PREM_RECVR_ID_CD_OVL_MDCR_MDCD_SVCS_PLAND |
| L1000A | N2 | Premium Receiver Additional Name | |
| L1000A | N201 | Premium Receiver’s Additional Name | L1000A_S02_N201_PREM_RECVR_ADDL_NM |
| L1000A | N3 | Premium Receiver’s Address | |
| L1000A | N301 | Premium Receiver’s Address Line | L1000A_S03_N301_PREM_RECVR_ADRS_LIN |
| L1000A | N302 | Premium Receiver’s Address Line | L1000A_S03_N302_PREM_RECVR_ADRS_LIN |
| L1000A | N4 | Premium Receiver’s City, State, and ZIP Code | |
| L1000A | N401 | Premium Receiver’s City Name | L1000A_S04_N401_PREM_RECVR_CITY_NM |
| L1000A | N402 | Premium Receiver’s State Code | L1000A_S04_N402_PREM_RECVR_STAT_CD |
| L1000A | N403 | Premium Receiver’s Postal Zone or Zip Code | L1000A_S04_N403_POSTL_ZON_ZIP_CD |
| L1000A | N404 | Country Code | L1000A_S04_N404_CNTRY_CD |
| L1000A | N407 | Country Subdivision Code | L1000A_S04_N407_COUNTRY_SUBDVSN_CD |
| L1000A | RDM | Premium Receiver’s Remittance Delivery Method | |
| L1000A | RDM01 | Remittance Delivery Method Code | L1000A_S05_RDM01_REMTNC_DELVRY_METHD_CD |
| L1000A | RDM02 | Premium Receiver’s Last or Organization Name | L1000A_S05_RDM02_LAST_ORG_NM |
| L1000A | RDM03 | Premium Receiver’s Communication Number | L1000A_S05_RDM03_PREM_RECVR_COMNCTN_NR |
1000B - PREMIUM PAYERS NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L1000B | N1 | Premium Payer’s Name | |
| L1000B | N102 | Premium Payer Name | L1000B_S01_N102_PAYR_NM |
| L1000B | N104 | D-U-N-S Number, Dun and Bradstreet | L1000B_S01_N104_PAYR_ID_OVL_DUNS_NR_DUN_BRADSTRT |
| L1000B | N104 | D-U-N-S+4, D-U-N-S Number with Four Character Suffix | L1000B_S01_N104_PAYR_ID_OVL_DUNS4_DUNS_NR_WITH_4CHAR_SUFX |
| L1000B | N104 | Employer’s Identification Number | L1000B_S01_N104_PAYR_ID_OVL_EMPLYR_ID_NR |
| L1000B | N104 | State or Province Assigned Number | L1000B_S01_N104_PAYR_ID_OVL_STAT_PROVNC_ASGND_NR |
| L1000B | N104 | Insurance Company Assigned Identification Number | L1000B_S01_N104_PAYR_ID_OVL_INS_CO_ASGND_ID_NR |
| L1000B | N104 | Federal Taxpayer’s Identification Number | L1000B_S01_N104_PAYR_ID_OVL_FED_TAX_ID_NR |
| L1000B | N104 | Payor Identification | L1000B_S01_N104_PAYR_ID_OVL_PAYR_ID |
| L1000B | N2 | Premium Payer Additional Name | |
| L1000B | N201 | Premium Payer Additional Name | L1000B_S02_N201_PREM_PAYR_ADDL_NM |
| L1000B | N3 | Premium Payer’s Address | |
| L1000B | N301 | Premium Payer Address Line | L1000B_S03_N301_PREM_PAYR_ADRS_LIN |
| L1000B | N302 | Premium Payer Address Line | L1000B_S03_N302_PREM_PAYR_ADRS_LIN |
| L1000B | N4 | Premium Payer’s City, State, ZIP Code | |
| L1000B | N401 | Premium Payer City Name | L1000B_S04_N401_PREM_PAYR_CITY_NM |
| L1000B | N402 | Premium Payer State Code | L1000B_S04_N402_PREM_PAYR_STAT_CD |
| L1000B | N403 | Premium Payer Postal Zone or ZIP Code | L1000B_S04_N403_POSTL_ZON_ZIP_CD |
| L1000B | N404 | Country Code | L1000B_S04_N404_CNTRY_CD |
| L1000B | N407 | Country Subdivision Code | L1000B_S04_N407_COUNTRY_SUBDVSN_CD |
| L1000B | PER | Premium Payer’s Administrative Contact | |
| L1000B | PER01 | Contact Function Code | L1000B_S05_PER01_CONTCT_FUNCTN_CD |
| L1000B | PER02 | Premium Payer Contact Name | L1000B_S05_PER02_PREM_PAYR_CONTCT_NM |
| L1000B | PER04 | Electronic Mail | L1000B_S05_PER04_COMM_NR_OVL_EMAIL |
| L1000B | PER04 | Facsimile | L1000B_S05_PER04_COMM_NR_OVL_FACSML |
| L1000B | PER04 | Telephone | L1000B_S05_PER04_COMM_NR_OVL_TELPHN |
| L1000B | PER06 | Electronic Mail | L1000B_S05_PER06_COMM_NR_OVL_EMAIL |
| L1000B | PER06 | Telephone Extension | L1000B_S05_PER06_COMM_NR_OVL_PHN_EXTNS |
| L1000B | PER06 | Facsimile | L1000B_S05_PER06_COMM_NR_OVL_FACSML |
| L1000B | PER06 | Telephone | L1000B_S05_PER06_COMM_NR_OVL_TELPHN |
| L1000B | PER08 | Electronic Mail | L1000B_S05_PER08_COMM_NR_OVL_EMAIL |
| L1000B | PER08 | Telephone Extension | L1000B_S05_PER08_COMM_NR_OVL_PHN_EXTNS |
| L1000B | PER08 | Facsimile | L1000B_S05_PER08_COMM_NR_OVL_FACSML |
| L1000B | PER08 | Telephone | L1000B_S05_PER08_COMM_NR_OVL_TELPHN |
1000C - INTERMEDIARY BANK INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 1000C | Qualified Loop | ||
| L1000C | Asset Account Holder | L1000C_04 | |
| L1000C | Interim Funding Organization | L1000C_0B | |
| L1000C | Payment Address | L1000C_8W | |
| L1000C | Party to Whom Acknowledgment Should Be Sent | L1000C_AK | |
| L1000C | Beneficiary | L1000C_BE | |
| L1000C | Bank | L1000C_BK | |
| L1000C | In Care Of Party no. 1 | L1000C_C1 | |
| L1000C | In Care Of Party no. 2 | L1000C_C2 | |
| L1000C | Party Executing and Verifying | L1000C_IAT | |
| L1000C | Financial Institution | L1000C_MJ | |
| L1000C | Receiving Bank | L1000C_RB | |
| L1000C | Transferring Party | L1000C_Z6 | |
| L1000C | Party to Receive Credit | L1000C_ZB | |
| L1000C | Federal Medicare or Medicaid Payment Mandate - Category 2 | L1000C_ZL | |
| L1000C | N1 | Intermediary Bank Information | |
| L1000C | N102 | Intermediary Bank Name | L1000C_XX_S01_N102_BANK_NM |
| L1000C | N104 | Bank Identification Code | L1000C_XX_S01_N104_BANK_ID_OVL_BANK_ID_CD |
| L1000C | N104 | Department | L1000C_XX_S01_N104_BANK_ID_OVL_DEPRTMNT |
| L1000C | N104 | Code assigned by the organization that is the ultimate destination of the transaction set | L1000C_XX_S01_N104_BANK_ID_OVL_CD_ASGND_DESTNTN_ORG |
| L1000C | N104 | Assigned by Third Party | L1000C_XX_S01_N104_BANK_ID_OVL_ASGND_by_3RD_PARTY |
| L1000C | N104 | Assigned by Clearinghouse | L1000C_XX_S01_N104_BANK_ID_OVL_ASGND_BY_CLEARNGHS |
| L1000C | N104 | Financial Identification Numbering System (FINS) | L1000C_XX_S01_N104_BANK_ID_OVL_FINS |
| L1000C | N104 | Canadian Financial Institution Routing Number | L1000C_XX_S01_N104_BANK_ID_OVL_CANDN_FINCL_INSTN_ROUTNG_NR |
| L1000C | N104 | Payee Identification Number | L1000C_XX_S01_N104_BANK_ID_OVL_PAY_ID_NR |
| L1000C | N104 | Secondary Agent Identification | L1000C_XX_S01_N104_BANK_ID_OVL_2ND_AGNT_ID |
| L1000C | N2 | Intermediary Bank Additional Name | |
| L1000C | N201 | Intermediary Bank Additional Name | L1000C_XX_S02_N201_INTRMDRY_BANK_ADDL_NM |
| L1000C | N3 | Intermediary Bank’s Address | |
| L1000C | N301 | Intermediary Bank Address Line | L1000C_XX_S03_N301_INTRMDRY_BANK_ADRS_LIN |
| L1000C | N302 | Intermediary Bank Address Line | L1000C_XX_S03_N302_INTRMDRY_BANK_ADRS_LIN |
| L1000C | N4 | Intermediary Bank’s City, State, ZIP Code | |
| L1000C | N401 | Intermediary Bank City Name | L1000C_XX_S04_N401_INTRMDRY_BANK_CITY_NM |
| L1000C | N402 | Intermediary Bank State Code | L1000C_XX_S04_N402_INTRMDRY_BANK_STAT_CD |
| L1000C | N403 | Intermediary Bank Postal Zone or ZIP Code | L1000C_XX_S04_N403_POSTL_ZON_ZIP_CD |
| L1000C | N404 | Country Code | L1000C_XX_S04_N404_CNTRY_CD |
| L1000C | N407 | Country Subdivision Code | L1000C_XX_S04_N407_COUNTRY_SUBDVSN_CD |
| L1000C | PER | Intermediary Bank’s Administrative Contact | |
| L1000C | PER01 | Contact Function Code | L1000C_XX_S05_PER01_CONTCT_FUNCTN_CD |
| L1000C | PER02 | Intermediary Bank Contact Name | L1000C_XX_S05_PER02_INTRMDRY_BANK_CONTCT_NM |
| L1000C | PER04 | Electronic Mail | L1000C_XX_S05_PER04_COMM_NR_OVL_EMAIL |
| L1000C | PER04 | Facsimile | L1000C_XX_S05_PER04_COMM_NR_OVL_FACSML |
| L1000C | PER04 | Telephone | L1000C_XX_S05_PER04_COMM_NR_OVL_TELPHN |
| L1000C | PER06 | Electronic Mail | L1000C_XX_S05_PER06_COMM_NR_OVL_EMAIL |
| L1000C | PER06 | Telephone Extension | L1000C_XX_S05_PER06_COMM_NR_OVL_PHN_EXTNS |
| L1000C | PER06 | Facsimile | L1000C_XX_S05_PER06_COMM_NR_OVL_FACSML |
| L1000C | PER06 | Telephone | L1000C_XX_S05_PER06_COMM_NR_OVL_TELPHN |
| L1000C | PER08 | Electronic Mail | L1000C_XX_S05_PER08_COMM_NR_OVL_EMAIL |
| L1000C | PER08 | Telephone Extension | L1000C_XX_S05_PER08_COMM_NR_OVL_PHN_EXTNS |
| L1000C | PER08 | Facsimile | L1000C_XX_S05_PER08_COMM_NR_OVL_FACSML |
| L1000C | PER08 | Telephone | L1000C_XX_S05_PER08_COMM_NR_OVL_TELPHN |
2000A - ORGANIZATION SUMMARY REMITTANCE
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2000A | Qualified Loop | ||
| L2000A | Corporation | L2000A_2L | |
| L2000A | Agent/Agency | L2000A_AG | |
| L2000A | Association | L2000A_NH | |
| L2000A | Responsible Government Agency | L2000A_RGA | |
| L2000A | Union | L2000A_UN | |
| L2000A | ENT | Organization Summary Remittance | |
| L2000A | ENT01 | Assigned Number | L2000A_XX_S01_ENT01_ASGND_NR |
| L2000A | ENT04 | D-U-N-S Number, Dun and Bradstreet | L2000A_XX_S01_ENT04_ID_CD_OVL_DUNS_NR_DUN_BRADSTRT |
| L2000A | ENT04 | D-U-N-S+4, D-U-N-S Number with Four Character | L2000A_XX_S01_ENT04_ID_CD_OVL_DUNS4_DUNS_NR_WITH_4CHAR_SUFX |
| L2000A | ENT04 | Employer’s Identification Number | L2000A_XX_S01_ENT04_ID_CD_OVL_EMPLYR_ID_NR |
| L2000A | ENT04 | Federal Taxpayer’s Identification Number | L2000A_XX_S01_ENT04_ID_CD_OVL_FED_TAX_ID_NR |
2200A - ORGANIZATION SUMMARY REMITTANCE LEVEL ADJUSTMENT FOR PREVIOUS PAYMENT
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200A | ADX | Organization Summary Remittance Level Adjustment for Previous Payment | |
| L2200A | ADX01 | Premium Payment Adjustment Amount | L2200A_S01_ADX01_PREM_PMT_ADJ_AMT |
| L2200A | ADX02 | Premium Payment Adjustment Reason | L2200A_S01_ADX02_PREM_PMT_ADJ_RSN |
2300A - ORGANIZATION SUMMARY REMITTANCE DETAIL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2300A | RMR | Organization Summary Remittance Detail | |
| L2300A | RMR02 | Account Number | L2300A_S01_RMR02_CONTRCT_INVC_ACNT_GROUP_POLCY_OVL_ACNT_NR |
| L2300A | RMR02 | Group or Policy Number | L2300A_S01_RMR02_CONTRCT_INVC_ACNT_GROUP_POLCY_OVL_GRP_POLCY_NR |
| L2300A | RMR02 | Contract Number | L2300A_S01_RMR02_CONTRCT_INVC_ACNT_GROUP_POLCY_OVL_CONTRCT_NR |
| L2300A | RMR02 | Invoice Number | L2300A_S01_RMR02_CONTRCT_INVC_ACNT_GROUP_POLCY_OVL_INVC_NR |
| L2300A | RMR04 | Payment in Advance | L2300A_S01_RMR04_DETL_PREM_PMT_AMT_OVL_PMT_IN_ADVNC |
| L2300A | RMR04 | Pay Item | L2300A_S01_RMR04_DETL_PREM_PMT_AMT_OVL_PAY_ITM |
| L2300A | RMR04 | Payment on Account | L2300A_S01_RMR04_DETL_PREM_PMT_AMT_OVL_PMT_ON_ACNT |
| L2300A | RMR04 | Partial Payment | L2300A_S01_RMR04_DETL_PREM_PMT_AMT_OVL_PARTL_PMT |
| L2300A | RMR05 | Billed Premium Amount | L2300A_S01_RMR05_BILD_PREM_AMT |
| L2300A | REF | Reference Information | |
| L2300A | REF02 | Master Account Number | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_MASTR_ACNT_NR |
| L2300A | REF02 | Client Reporting Category | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_CLIENT_REPRTNG_CATGRY |
| L2300A | REF02 | Plan Number | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_PLAN_NR |
| L2300A | REF02 | Consolidated Invoice Number | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_CONSLDTD_INVC_NR |
| L2300A | REF02 | Master Policy Number | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_MASTR_POLCY_NR |
| L2300A | REF02 | Attachment Code | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_ATCHMNT_CD |
| L2300A | REF02 | Lockbox | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_LOCKBX |
| L2300A | REF02 | Location Number | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_LOC_NR |
| L2300A | REF02 | Mutually Defined | L2300A_S02_REF02_ORGNZTNL_REF_ID_OVL_MUTLY_DEFND |
| L2300A | DTM | Organizational Coverage Period | |
| L2300A | DTM01 | Date Time Qualifier | L2300A_S03_DTM01_DT_TM_QUAL |
| L2300A | DTM02 | Date | L2300A_S03_DTM02_DT |
| L2300A | DTM06 | Range of Dates Expressed in Format CCYYMMDD- CCYYMMDD | L2300A_S03_DTM06_COVG_PERD_OVL_RANG_DT_CCYYMMDD |
2310A - SUMMARY LINE ITEM
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2310A | IT1 | Summary Line Item | |
| L2310A | IT101 | Line Item Control Number | L2310A_S01_IT101_LIN_ITM_CONTRL_NR |
2312A - SERVICE, PROMOTION, ALLOWANCE, OR CHARGE INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2312A | SAC | Service, Promotion, Allowance, or Charge Information | |
| L2312A | SAC01 | Allowance or Charge Indicator | L2312A_S01_SAC01_CHG_IND |
| L2312A | SAC02 | Service, Promotion, Allowance, or Charge Code | L2312A_S01_SAC02_CD |
| L2312A | SAC05 | Amount | L2312A_S01_SAC05_AMT |
2315A - MEMBER COUNT
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2315A | SLN | Member Count | |
| L2315A | SLN01 | Line Item Control Number | L2315A_S01_SLN01_LIN_ITM_CONTRL_NR |
| L2315A | SLN03 | Information Only Indicator | L2315A_S01_SLN03_NFO_ONLY_IND |
| L2315A | SLN04 | Head Count | L2315A_S01_SLN04_HEAD_CT |
| L2315A | SLN05-01 | Unit or Basis for Measurement Code | L2315A_S01_SLN05_01_UN_BAS_MEASRMNT_CD |
2320A - ORGANIZATION SUMMARY REMITTANCE LEVEL ADJUSTMENT FOR CURRENT PAYMENT
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2320A | ADX | Organization Summary Remittance Level Adjustment for Current Payment | |
| L2320A | ADX01 | Adjustment Amount | L2320A_S01_ADX01_ADJ_AMT |
| L2320A | ADX02 | Adjustment Reason Code | L2320A_S01_ADX02_RSN_CD |
2000B - INDIVIDUAL REMITTANCE
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000B | ENT | Individual Remittance | |
| L2000B | ENT01 | Assigned Number | L2000B_S01_ENT01_ASGND_NR |
| L2000B | ENT04 | Social Security Number | L2000B_S01_ENT04_RECVR_INDVDL_ID_OVL_SSN |
| L2000B | ENT04 | Employee Identification Number | L2000B_S01_ENT04_RECVR_INDVDL_ID_OVL_EMPLY_ID_NR |
| L2000B | ENT04 | Standard Unique Health Identifier for each Individual in the United States | L2000B_S01_ENT04_RECVR_INDVDL_ID_OVL_STANDRD_UNQ_HEALTH_ID |
2100B - INDIVIDUAL NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2100B | Qualified Loop | ||
| L2100B | Dependent Name | L2100B_DO | |
| L2100B | Employee Name | L2100B_EY | |
| L2100B | Insured or Subscriber | L2100B_IL | |
| L2100B | Policyholder | L2100B_QE | |
| L2100B | NM1 | Individual Name | |
| L2100B | NM102 | Entity Type Qualifier | L2100B_XX_S01_NM102_ENTY_TYPE_QUAL |
| L2100B | NM103 | Individual Last Name | L2100B_XX_S01_NM103_INDVDL_LNAME |
| L2100B | NM104 | Individual First Name | L2100B_XX_S01_NM104_INDVDL_FNAME |
| L2100B | NM105 | Individual Middle Name | L2100B_XX_S01_NM105_INDVDL_MNAME |
| L2100B | NM106 | Individual Name Prefix | L2100B_XX_S01_NM106_NM_PREFX |
| L2100B | NM107 | Individual Name Suffix | L2100B_XX_S01_NM107_NM_SUFX |
| L2100B | NM109 | Social Security Number | L2100B_XX_S01_NM109_INDVDL_ID_OVL_SSN |
| L2100B | NM109 | Employee Identification Number | L2100B_XX_S01_NM109_INDVDL_ID_OVL_EMPLY_ID_NR |
| L2100B | NM109 | Insured’s Unique Identification Number | L2100B_XX_S01_NM109_INDVDL_ID_OVL_INSRD_UNQ_ID_NR |
2200B - INDIVIDUAL PREMIUM ADJUSTMENT FOR PREVIOUS PAYMENT
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200B | ADX | Individual Premium Adjustment for Previous Payment | |
| L2200B | ADX01 | Premium Payment Adjustment Amount | L2200B_S01_ADX01_PREM_PMT_ADJ_AMT |
| L2200B | ADX02 | Premium Payment Adjustment Reason | L2200B_S01_ADX02_PREM_PMT_ADJ_RSN |
2300B - INDIVIDUAL PREMIUM REMITTANCE DETAIL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2300B | RMR | Individual Premium Remittance Detail | |
| L2300B | RMR02 | Account Number | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_ACNT_NR |
| L2300B | RMR02 | Pension Contract | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_PENSN_CONTRCT |
| L2300B | RMR02 | Health Insurance Policy Number | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_HEALTH_INS_POLCY_NR |
| L2300B | RMR02 | Life Insurance Policy Number | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_LIF_INS_POLCY_NR |
| L2300B | RMR02 | Contract Number | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_CONTRCT_NR |
| L2300B | RMR02 | Insurance Certificate Number | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_INS_CERT_NR |
| L2300B | RMR02 | Insurance Policy Number | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_INS_POLCY_NR |
| L2300B | RMR02 | Invoice Number | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_INVC_NR |
| L2300B | RMR02 | Certification | L2300B_S01_RMR02_INS_REMTNC_REF_NR_OVL_CERT |
| L2300B | RMR04 | Detail Premium Payment Amount | L2300B_S01_RMR04_DETL_PREM_PMT_AMT |
| L2300B | RMR05 | Billed Premium Amount | L2300B_S01_RMR05_BILD_PREM_AMT |
| L2300B | REF | Reference Information | |
| L2300B | REF02 | Master Account Number | L2300B_S02_REF02_ORGNZTNL_REF_ID_OVL_MASTR_ACNT_NR |
| L2300B | REF02 | Plan Number | L2300B_S02_REF02_ORGNZTNL_REF_ID_OVL_PLAN_NR |
| L2300B | REF02 | Consolidated Invoice Number | L2300B_S02_REF02_ORGNZTNL_REF_ID_OVL_CONSLDTD_INVC_NR |
| L2300B | REF02 | Master Policy Number | L2300B_S02_REF02_ORGNZTNL_REF_ID_OVL_MASTR_POLCY_NR |
| L2300B | REF02 | Attachment Code | L2300B_S02_REF02_ORGNZTNL_REF_ID_OVL_ATCHMNT_CD |
| L2300B | REF02 | Location Number | L2300B_S02_REF02_ORGNZTNL_REF_ID_OVL_LOC_NR |
| L2300B | REF02 | Mutually Defined | L2300B_S02_REF02_ORGNZTNL_REF_ID_OVL_MUTLY_DEFND |
| L2300B | DTM | Individual Coverage Period | |
| L2300B | DTM01 | Date Time Qualifier | L2300B_S03_DTM01_DT_TM_QUAL |
| L2300B | DTM02 | Date | L2300B_S03_DTM02_DT |
| L2300B | DTM06 | Range of Dates Expressed in Format CCYYMMDD- CCYYMMDD | L2300B_S03_DTM06_COVG_PERD_OVL_RANG_DT_CCYYMMDD |
2320B - INDIVIDUAL PREMIUM ADJUSTMENT FOR CURRENT PAYMENT
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2320B | ADX | Individual Premium Adjustment for Current Payment | |
| L2320B | ADX01 | Adjustment Amount | L2320B_S01_ADX01_ADJ_AMT |
| L2320B | ADX02 | Adjustment Reason Code | L2320B_S01_ADX02_RSN_CD |