(C) Copyright 2012 Chiapas EDI Technologies, Inc.
5010_820X 5010 820X Health Insurance Exchange Related Payments - Code:S5
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 | Implementation Guide Version Name | STHDR_S01_ST03_IMPLMNTN_GUID_VERSN_NM |
| STHDR | BPR | Financial Information | |
| STHDR | BPR01 | Transaction Handling Code | STHDR_S02_BPR01_TRANSCTN_HANDLNG_CD |
| STHDR | BPR02 | Total Payment Amount | STHDR_S02_BPR02_TOTL_PMT_AMT |
| 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 | BPR11 | Originating Company Supplemental Code | STHDR_S02_BPR11_ORGNTNG_CO_SUPP_CD |
| STHDR | BPR13 | ABA Transit Routing Number Including Check Digits (9 digits) | STHDR_S02_BPR13_DFI_ID_NR_OVL_ABA_RTNG_NR |
| STHDR | BPR13 | Swift Identification (8 or 11 characters) | STHDR_S02_BPR13_DFI_ID_NR_OVL_SWIFT_ID |
| STHDR | BPR13 | Canadian Bank Branch and Institution Number | STHDR_S02_BPR13_DFI_ID_NR_OVL_CANDN_BANK_NR |
| 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 | REF | Exchange Assigned Qualified Health Plan Identifier | |
| STHDR | REF02 | Master Policy Number | STHDR_S04_REF02_EXCHG_HLTH_PLAN_ID_OVL_MASTR_POLCY_NR |
| STHDR | REF | Issuer Assigned Qualified Health Plan Identifier | |
| STHDR | REF02 | Line of Business | STHDR_S05_REF02_EXCHG_HLTH_PLAN_ID_OVL_LIN_OF_BUSNS |
| STHDR | REF | Exchange Assigned Employer Group Identifier | |
| STHDR | REF02 | Plan Number | STHDR_S06_REF02_EXCHG_ASSGN_EMP_GRP_ID_OVL_PLAN_NR |
| STHDR | REF | Issuer Assigned Employer Group Identifier | |
| STHDR | REF02 | Group or Policy Number | STHDR_S07_REF02_ISSR_ASSGN_EMP_GRP_ID_OVL_GRP_POLCY_NR |
| STHDR | SE | Transaction Set Trailer | |
| STHDR | SE01 | Transaction Segment Count | STHDR_S11_SE01_SEG_CT |
| STHDR | SE02 | Transaction Set Control Number | STHDR_S11_SE02_TCN |
1000A - Payee Name
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L1000A | N1 | Payee Name | |
| L1000A | N102 | Payee Organization Name | L1000A_S01_N102_PAYEE_ORG_NM |
| L1000A | N104 | Federal Taxpayers Identification Number | L1000A_S01_N104_PAYEE_TAX_ID_NR_OVL_FED_TAX_ID_NR |
| L1000A | REF | Unique Health Plan Identifier | |
| L1000A | REF02 | Centers for Medicare and Medicaid Services Plan ID | L1000A_S02_REF02_UNQ_HLTH_PLAN_ID_OVL_MDCR_MDCD_PLAN_ID |
1000B - Payers Name
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L1000B | N1 | Payers Name | |
| L1000B | N102 | Payer Name | L1000B_S01_N102_PAYER_NM |
| L1000B | N104 | Originating Company Number | L1000B_S01_N104_PAYER_ID_OVL_ORGN_CO_NR |
| L1000B | PER | Payers Administrative Contact Information | |
| L1000B | PER01 | Contact Function Code | L1000B_S02_PER01_FUNCTN_CD |
| L1000B | PER02 | Premium Payer Contact Name | L1000B_S02_PER02_PREM_PYR_CONTCT_NM |
| L1000B | PER04 | Electronic Mail | L1000B_S02_PER04_COMNCTN_NR_OVL_EMAIL |
| L1000B | PER04 | Facsimile | L1000B_S02_PER04_COMNCTN_NR_OVL_FACSML |
| L1000B | PER04 | Telephone | L1000B_S02_PER04_COMNCTN_NR_OVL_TELPHN |
| L1000B | PER06 | Electronic Mail | L1000B_S02_PER06_NFO_RECVR_COMNCTN_NR_OVL_EMAIL |
| L1000B | PER06 | Telephone Extension | L1000B_S02_PER06_NFO_RECVR_COMNCTN_NR_OVL_PHN_EXTNS |
| L1000B | PER06 | Facsimile | L1000B_S02_PER06_NFO_RECVR_COMNCTN_NR_OVL_FACSML |
| L1000B | PER06 | Telephone | L1000B_S02_PER06_NFO_RECVR_COMNCTN_NR_OVL_TELPHN |
| L1000B | PER08 | Electronic Mail | L1000B_S02_PER08_NFO_RECVR_COMNCTN_NR_OVL_EMAIL |
| L1000B | PER08 | Telephone Extension | L1000B_S02_PER08_NFO_RECVR_COMNCTN_NR_OVL_PHN_EXTNS |
| L1000B | PER08 | Facsimile | L1000B_S02_PER08_NFO_RECVR_COMNCTN_NR_OVL_FACSML |
| L1000B | PER08 | Telephone | L1000B_S02_PER08_NFO_RECVR_COMNCTN_NR_OVL_TELPHN |
2000 - Remittance Information
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000 | ENT | Remittance Information | |
| L2000 | ENT01 | Assigned Number | L2000_S01_ENT01_ASGND_NR |
2100 - Individual Name
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100 | NM1 | Individual Name | |
| L2100 | NM102 | Entity Type Qualifier | L2100_S01_NM102_ENTY_TYPE_QUAL |
| L2100 | NM103 | Indvidual Last Name | L2100_S01_NM103_INDVDL_LAST_NM |
| L2100 | NM104 | Individual First Name | L2100_S01_NM104_INDVDL_FRST_NM |
| L2100 | NM105 | Individual Middle Name | L2100_S01_NM105_INDVDL_MDDL_NM |
| L2100 | NM106 | Individual Name Prefix | L2100_S01_NM106_INDVDL_NM_PREFX |
| L2100 | NM107 | Individual Name Suffix | L2100_S01_NM107_NFO_SOURC_NM_SUFX |
| L2100 | NM109 | Insured or Subscriber | L2100_S01_NM109_EXCHNG_ASSGND_SUB_ID_OVL_INSRD_SUBSCRBR |
| L2100 | REF | Exchange Assigned Qualified Health Plan Identifier | |
| L2100 | REF02 | Master Policy Number | L2100_S02_REF02_EXCHG_ASSGND_QUAL_HLTH_PLAN_ID_OVL_MASTR_POLCY_NR |
| L2100 | REF | Issuer Assigned Qualified Health Plan Identifier | |
| L2100 | REF02 | Line of Business | L2100_S03_REF02_ISSR_ASSGND_QUAL_HLTH_PLAN_ID_OVL_LOB |
| L2100 | REF | Exchange Assigned Employer Group Identifier | |
| L2100 | REF02 | Plan Number | L2100_S04_REF02_EXCHG_ASSGND_EMP_GRP_ID_OVL_PLAN_NR |
| L2100 | REF | Issuer Assigned Employer Group Identifier | |
| L2100 | REF02 | Group or Policy Number | L2100_S05_REF02_ISSR_ASSGND_EMP_GRP_ID_OVL_GRP_POLCY_NR |
| L2100 | REF | Exchange Assigned Policy Identifier | |
| L2100 | REF02 | Policy Number | L2100_S06_REF02_EXCHG_ASSGND_POLCY_ID_OVL_POLCY_NR |
| L2100 | REF | Issuer Assigned Policy Identifier | |
| L2100 | REF02 | Health Insurance Policy Number | L2100_S07_REF02_ISSR_ASSGND_POLCY_ID_OVL_HLTG_INSR_POLCY_NR |
| L2100 | REF | Exchange Assigned APTC Contributor/Tax Payer Identifier | |
| L2100 | REF02 | Personal Identification Number (PIN) | L2100_S08_REF02_APTC_TAX_PAYR_ID_OVL_PIN |
| L2100 | REF | Issuer Assigned APTC Contributor/Tax Payer Identifier | |
| L2100 | REF02 | Client Number | L2100_S09_REF02_ISSR_ASSGND_APTC_TAX_PAYR_ID_OVL_CLNT_NR |
| L2100 | REF | Exchange Assigned Dependent Identifier | |
| L2100 | REF02 | Centers for Medicare and Medicaid Services Plan ID | L2100_S10_REF02_UNQ_HLTH_PLAN_ID_OVL_MDCR_MDCD_PLAN_ID |
| L2100 | REF | Issuer Assigned Dependent Identifier | |
| L2100 | REF02 | Member Identification Number | L2100_S11_REF02_ISSR_ASSGND_DEP_ID_OVL_MEM_ID_NR |
| L2100 | REF | Issuer Assigend Subscriber Identifier | |
| L2100 | REF02 | Subscriber Number | L2100_S12_REF02_ISSR_ASSGND_SUB_ID_OVL_SUB_NR |
2300 - Remittance Detail
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2300 | RMR | Remittance Detail | |
| L2300 | RMR01 | Reference Identification Qualifier | L2300_S01_RMR01_REF_ID_QUAL |
| L2300 | RMR02 | Exchange Payment Type | L2300_S01_RMR02_EXCHG_PMT_TYP |
| L2300 | RMR04 | Payment Amount | L2300_S01_RMR04_PMT_AMT |
| L2300 | REF | Exchange Report Document Control Number | |
| L2300 | REF02 | Attached To | L2300_S02_REF02_EXCHG_RPT_TYP_OVL_ATTCHD_TO |
| L2300 | DTM | Individual Coverage Period | |
| L2300 | DTM05 | Date Time Period Format Qualifier | L2300_S03_DTM05_DT_TM_PERD_FORMT_QUAL |
| L2300 | DTM06 | Coverage Period | L2300_S03_DTM06_COVG_PERD |