Chiapas EDI 2012 Mapping Guide

5010_837D 5010 Health Care Claim: Dental - Code:V0

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	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	SE	Transaction Set Trailer
STHDR	SE01	Transaction Segment Count	STHDR_S06_SE01_SEG_CT
STHDR	SE02	Transaction Set Control Number	STHDR_S06_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 or Initial	L1000A_S01_NM105_MNAME_INTL
L1000A	NM109	Electronic Transmitter Identification Number (ETIN)	L1000A_S01_NM109_SUBMTR_ID_OVL_ETN_NR
L1000A	PER	Submitter EDI Contact Information
L1000A	PER01	Contact Function Code	L1000A_S02_PER01_FUNCTN_CD
L1000A	PER02	Submitter Contact Name	L1000A_S02_PER02_CONTCT_NM
L1000A	PER04	Electronic Mail	L1000A_S02_PER04_COMM_NR_OVL_EMAIL
L1000A	PER04	Facsimile	L1000A_S02_PER04_COMM_NR_OVL_FACSML
L1000A	PER04	Telephone	L1000A_S02_PER04_COMM_NR_OVL_TELPHN
L1000A	PER06	Electronic Mail	L1000A_S02_PER06_COMM_NR_OVL_EMAIL
L1000A	PER06	Telephone Extension	L1000A_S02_PER06_COMM_NR_OVL_PHN_EXTNS
L1000A	PER06	Facsimile	L1000A_S02_PER06_COMM_NR_OVL_FACSML
L1000A	PER06	Telephone	L1000A_S02_PER06_COMM_NR_OVL_TELPHN
L1000A	PER08	Electronic Mail	L1000A_S02_PER08_COMM_NR_OVL_EMAIL
L1000A	PER08	Telephone Extension	L1000A_S02_PER08_COMM_NR_OVL_PHN_EXTNS
L1000A	PER08	Facsimile	L1000A_S02_PER08_COMM_NR_OVL_FACSML
L1000A	PER08	Telephone	L1000A_S02_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

2000A - BILLING PROVIDER HIERARCHICAL LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000A	HL	Billing 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 Provider Specialty Information
L2000A	PRV01	Provider Code	L2000A_S02_PRV01_PROV_CD
L2000A	PRV03	Health Care Provider Taxonomy Code	L2000A_S02_PRV03_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
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 or Initial	L2010AA_S01_NM105_BILNG_PROV_MNAME_INTL
L2010AA	NM107	Billing Provider Name Suffix	L2010AA_S01_NM107_BILNG_PROV_NM_SUFX
L2010AA	NM109	Centers for Medicare and Medicaid Services	L2010AA_S01_NM109_PROV_ID_OVL_CENTRS_MEDCR_MEDCD_SVCS
L2010AA	N3	Billing Provider Address
L2010AA	N301	Billing Provider Address Line	L2010AA_S02_N301_BILNG_PROV_ADRS_LIN
L2010AA	N302	Billing Provider Address Line	L2010AA_S02_N302_BILNG_PROV_ADRS_LIN
L2010AA	N4	Billing Provider City, State, ZIP Code
L2010AA	N401	Billing Provider City Name	L2010AA_S03_N401_BILNG_PROV_CITY_NM
L2010AA	N402	Billing Provider State or Province Code	L2010AA_S03_N402_STAT_PROVNC_CD
L2010AA	N403	Billing Provider Postal Zone or ZIP Code	L2010AA_S03_N403_POSTL_ZON_ZIP_CD
L2010AA	N404	Country Code	L2010AA_S03_N404_CNTRY_CD
L2010AA	N407	Country Subdivision Code	L2010AA_S03_N407_COUNTRY_SUBDVSN_CD
L2010AA	REF	Billing Provider Tax Identification
L2010AA	REF02	Employer’s Identification Number	L2010AA_S04_REF02_ID_NR_OVL_EMPLYR_ID_NR
L2010AA	REF02	Social Security Number	L2010AA_S04_REF02_ID_NR_OVL_SSN
L2010AA	REF	Billing Provider UPIN/License Information
L2010AA	REF02	State License Number	L2010AA_S05_REF02_LICNS_R_UPN_NFO_OVL_STAT_LICNS_NR
L2010AA	REF02	Provider UPIN Number	L2010AA_S05_REF02_LICNS_R_UPN_NFO_OVL_PROV_UPN_NR
L2010AA	PER	Billing Provider Contact Information
L2010AA	PER01	Contact Function Code	L2010AA_S06_PER01_FUNCTN_CD
L2010AA	PER02	Billing Provider Contact Name	L2010AA_S06_PER02_BILNG_PROV_CONTCT_NM
L2010AA	PER04	Electronic Mail	L2010AA_S06_PER04_COMM_NR_OVL_EMAIL
L2010AA	PER04	Facsimile	L2010AA_S06_PER04_COMM_NR_OVL_FACSML
L2010AA	PER04	Telephone	L2010AA_S06_PER04_COMM_NR_OVL_TELPHN
L2010AA	PER06	Electronic Mail	L2010AA_S06_PER06_COMM_NR_OVL_EMAIL
L2010AA	PER06	Telephone Extension	L2010AA_S06_PER06_COMM_NR_OVL_PHN_EXTNS
L2010AA	PER06	Facsimile	L2010AA_S06_PER06_COMM_NR_OVL_FACSML
L2010AA	PER06	Telephone	L2010AA_S06_PER06_COMM_NR_OVL_TELPHN
L2010AA	PER08	Electronic Mail	L2010AA_S06_PER08_COMM_NR_OVL_EMAIL
L2010AA	PER08	Telephone Extension	L2010AA_S06_PER08_COMM_NR_OVL_PHN_EXTNS
L2010AA	PER08	Facsimile	L2010AA_S06_PER08_COMM_NR_OVL_FACSML
L2010AA	PER08	Telephone	L2010AA_S06_PER08_COMM_NR_OVL_TELPHN

2010AB - PAY-TO ADDRESS NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010AB	NM1	Pay-to Address Name
L2010AB	NM102	Entity Type Qualifier	L2010AB_S01_NM102_ENTY_TYPE_QUAL
L2010AB	N3	Pay-to Address - ADDRESS
L2010AB	N301	Pay-To Address Line	L2010AB_S02_N301_ADRS_LIN
L2010AB	N302	Pay-To Address Line	L2010AB_S02_N302_ADRS_LIN
L2010AB	N4	Pay-To Address City, State, ZIP Code
L2010AB	N401	Pay-to Address City Name	L2010AB_S03_N401_PAYT_ADRS_CITY_NM
L2010AB	N402	Pay-To Address State or Province Code	L2010AB_S03_N402_STAT_PROVNC_CD
L2010AB	N403	Pay-to Address Postal Zone or ZIP Code	L2010AB_S03_N403_POSTL_ZON_ZIP_CD
L2010AB	N404	Country Code	L2010AB_S03_N404_CNTRY_CD
L2010AB	N407	Country Subdivision Code	L2010AB_S03_N407_COUNTRY_SUBDVSN_CD

2010AC - PAY-TO PLAN NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2010AC	NM1	Pay-To Plan Name
L2010AC	NM103	Non-Person Entity	L2010AC_S01_NM103_PAYT_PLAN_ORGL_NM_OVL_NONPRSN_ENTY
L2010AC	NM109	Payor Identification	L2010AC_S01_NM109_PAYT_PLAN_PRIMRY_ID_OVL_PAYR_ID
L2010AC	NM109	Centers for Medicare and Medicaid Services PlanID	L2010AC_S01_NM109_PAYT_PLAN_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_PLAND
L2010AC	N3	Pay-to Plan Address
L2010AC	N301	Pay-To Plan Address Line	L2010AC_S02_N301_PAYT_PLAN_ADRS_LIN
L2010AC	N302	Pay-To Plan Address Line	L2010AC_S02_N302_PAYT_PLAN_ADRS_LIN
L2010AC	N4	Pay-To Plan City, State, ZIP Code
L2010AC	N401	Pay-To Plan City Name	L2010AC_S03_N401_PAYT_PLAN_CITY_NM
L2010AC	N402	Pay-To Plan State or Province Code	L2010AC_S03_N402_STAT_PROVNC_CD
L2010AC	N403	Pay-To Plan Postal Zone or ZIP Code	L2010AC_S03_N403_POSTL_ZON_ZIP_CD
L2010AC	N404	Country Code	L2010AC_S03_N404_CNTRY_CD
L2010AC	N407	Country Subdivision Code	L2010AC_S03_N407_COUNTRY_SUBDVSN_CD
L2010AC	REF	Pay-to Plan Secondary Identification
L2010AC	REF02	Payer Identification Number	L2010AC_S04_REF02_PAYT_PLAN_2ND_ID_OVL_PAYR_ID_NR
L2010AC	REF02	Claim Office Number	L2010AC_S04_REF02_PAYT_PLAN_2ND_ID_OVL_CLM_OFC_NR
L2010AC	REF02	National Association of Insurance Commissioners (NAIC) Code	L2010AC_S04_REF02_PAYT_PLAN_2ND_ID_OVL_NAIC_CD
L2010AC	REF	Pay-To Plan Tax Identification Number
L2010AC	REF02	Employer’s Identification Number	L2010AC_S05_REF02_NR_OVL_EMPLYR_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	Subscriber Group or Policy Number	L2000B_S02_SBR03_SUB_GRP_POLCY_NR
L2000B	SBR04	Subscriber Group Name	L2000B_S02_SBR04_GRP_NM
L2000B	SBR05	Insurance Type Code	L2000B_S02_SBR05_INS_TYPE_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 or Initial	L2010BA_S01_NM105_MNAME_INTL
L2010BA	NM107	Subscriber Name Suffix	L2010BA_S01_NM107_NM_SUFX
L2010BA	NM109	Standard Unique Health Identifier for each Individual in the United States	L2010BA_S01_NM109_PRIMRY_ID_OVL_STANDRD_UNQ_HEALTH_ID
L2010BA	NM109	Member Identification Number	L2010BA_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR
L2010BA	N3	Subscriber Address
L2010BA	N301	Subscriber Address Line	L2010BA_S02_N301_ADRS_LIN
L2010BA	N302	Subscriber Address Line	L2010BA_S02_N302_ADRS_LIN
L2010BA	N4	Subscriber City, State, ZIP Code
L2010BA	N401	Subscriber City Name	L2010BA_S03_N401_CITY_NM
L2010BA	N402	Subscriber State Code	L2010BA_S03_N402_STAT_CD
L2010BA	N403	Subscriber Postal Zone or ZIP Code	L2010BA_S03_N403_SUB_POSTL_ZON_ZIP_CD
L2010BA	N404	Country Code	L2010BA_S03_N404_CNTRY_CD
L2010BA	N407	Country Subdivision Code	L2010BA_S03_N407_COUNTRY_SUBDVSN_CD
L2010BA	DMG	Subscriber Demographic Information
L2010BA	DMG02	Date Expressed in Format CCYYMMDD	L2010BA_S04_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD
L2010BA	DMG03	Subscriber Gender Code	L2010BA_S04_DMG03_GENDR_CD
L2010BA	REF	Subscriber Secondary Identification
L2010BA	REF02	Social Security Number	L2010BA_S05_REF02_SUPP_ID_OVL_SSN
L2010BA	REF	Property and Casualty Claim Number
L2010BA	REF02	Agency Claim Number	L2010BA_S06_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	Centers for Medicare and Medicaid Services PlanID	L2010BB_S01_NM109_PAYR_ID_OVL_MDCR_MDCD_SVCS_PLAND
L2010BB	N3	Payer Address
L2010BB	N301	Payer Address Line	L2010BB_S02_N301_ADRS_LIN
L2010BB	N302	Payer Address Line	L2010BB_S02_N302_ADRS_LIN
L2010BB	N4	Payer City, State, ZIP Code
L2010BB	N401	Payer City Name	L2010BB_S03_N401_CITY_NM
L2010BB	N402	Payer State Code	L2010BB_S03_N402_STAT_CD
L2010BB	N403	Payer Postal Zone or ZIP Code	L2010BB_S03_N403_PAYR_POSTL_ZON_ZIP_CD
L2010BB	N404	Country Code	L2010BB_S03_N404_CNTRY_CD
L2010BB	N407	Country Subdivision Code	L2010BB_S03_N407_COUNTRY_SUBDVSN_CD
L2010BB	REF	Payer Secondary Identification
L2010BB	REF02	Payer Identification Number	L2010BB_S04_REF02_2ND_ID_OVL_PAYR_ID_NR
L2010BB	REF02	Employer’s Identification Number	L2010BB_S04_REF02_2ND_ID_OVL_EMPLYR_ID_NR
L2010BB	REF02	Claim Office Number	L2010BB_S04_REF02_2ND_ID_OVL_CLM_OFC_NR
L2010BB	REF02	National Association of Insurance Commissioners (NAIC) Code	L2010BB_S04_REF02_2ND_ID_OVL_NAIC_CD
L2010BB	REF	Billing Provider Secondary Identification
L2010BB	REF02	Provider Commercial Number	L2010BB_S05_REF02_BILNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2010BB	REF02	Location Number	L2010BB_S05_REF02_BILNG_PROV_2ND_ID_OVL_LOC_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

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 or Initial	L2010CA_S01_NM105_MNAME_INTL
L2010CA	NM107	Patient Name Suffix	L2010CA_S01_NM107_NM_SUFX
L2010CA	N3	Patient Address
L2010CA	N301	Patient Address Line	L2010CA_S02_N301_ADRS_LIN
L2010CA	N302	Patient Address Line	L2010CA_S02_N302_ADRS_LIN
L2010CA	N4	Patient City, State, ZIP Code
L2010CA	N401	Patient City Name	L2010CA_S03_N401_CITY_NM
L2010CA	N402	Patient State Code	L2010CA_S03_N402_STAT_CD
L2010CA	N403	Patient Postal Zone or ZIP Code	L2010CA_S03_N403_PATNT_POSTL_ZON_ZIP_CD
L2010CA	N404	Country Code	L2010CA_S03_N404_CNTRY_CD
L2010CA	N407	Country Subdivision Code	L2010CA_S03_N407_COUNTRY_SUBDVSN_CD
L2010CA	DMG	Patient Demographic Information
L2010CA	DMG02	Date Expressed in Format CCYYMMDD	L2010CA_S04_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD
L2010CA	DMG03	Patient Gender Code	L2010CA_S04_DMG03_GENDR_CD
L2010CA	REF	Property and Casualty Claim Number
L2010CA	REF02	Agency Claim Number	L2010CA_S05_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 Control Number	L2300_S01_CLM01_PATNT_CONTRL_NR
L2300	CLM02	Total Claim Charge Amount	L2300_S01_CLM02_TOTL_CLM_CHG_AMT
L2300	CLM05-01	Place of Service Code	L2300_S01_CLM05_01_PLAC_SVC_CD
L2300	CLM05-03	Place of Service Codes for Professional or Dental	L2300_S01_CLM05_03_CLM_FREQNCY_CD_OVL_PLAC_SVC_CODS_PROF_DENTL
L2300	CLM06	Provider or Supplier Signature Indicator	L2300_S01_CLM06_PROV_SUPLR_SIGNTR_IND
L2300	CLM07	Assignment or Plan Participation Code	L2300_S01_CLM07_ASGNMNT_PLAN_PARTCPTN_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	CLM11-04	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	Predetermination of Benefits Code	L2300_S01_CLM19_PREDTRMNTN_BENFTS_CD
L2300	CLM20	Delay Reason Code	L2300_S01_CLM20_DELY_RSN_CD
L2300	DTP	Date - Accident
L2300	DTP03	Accident (D8)	L2300_S02_DTP03_ACDNT_DT_OVL_ACDNT_D8
L2300	DTP	Date - Appliance Placement
L2300	DTP03	Appliance Placement (D8)	L2300_S03_DTP03_ORTHDNTC_BANDNG_DT_OVL_APLNC_PLACMNT_D8
L2300	DTP	Date - Service Date
L2300	DTP03	Service (D8)	L2300_S04_DTP03_SVC_DT_OVL_SVC_D8
L2300	DTP03	Service (RD8)	L2300_S04_DTP03_SVC_DT_OVL_SVC_RD8
L2300	DTP	Date - Repricer Received Date
L2300	DTP03	Received (D8)	L2300_S05_DTP03_RECVD_DT_OVL_RECVD_D8
L2300	DN1	Orthodontic Total Months of Treatment
L2300	DN101	Orthodontic Treatment Months Count	L2300_S06_DN101_ORTHO_TRTMNT_MONTHS_CT
L2300	DN102	Orthodontic Treatment Months Remaining Count	L2300_S06_DN102_ORTHO_TRTMNT_MONTHS_REMNG_CT
L2300	DN104	Orthodontic Treatment Indicator	L2300_S06_DN104_TREATMNT_IND
L2300	DN2	Tooth Status
L2300	DN201	Tooth Number	L2300_S07_DN201_TOTH_NR
L2300	DN202	Tooth Status Code	L2300_S07_DN202_STATS_CD
L2300	PWK	Claim Supplemental Information
L2300	PWK01	Attachment Report Type Code	L2300_S08_PWK01_ATCHMNT_REPRT_TYPE_CD
L2300	PWK02	Attachment Transmission Code	L2300_S08_PWK02_ATCHMNT_TRANSMSN_CD
L2300	PWK06	Attachment Control Number	L2300_S08_PWK06_ATCHMNT_CONTRL_NR_OVL_ATCHMNT_CONTRL_NR
L2300	CN1	Contract Information
L2300	CN101	Contract Type Code	L2300_S09_CN101_TYPE_CD
L2300	CN102	Contract Amount	L2300_S09_CN102_CONTRCT_AMT
L2300	CN103	Contract Percentage	L2300_S09_CN103_CONTRCT_PERCNTG
L2300	CN104	Contract Code	L2300_S09_CN104_CONTRCT_CD
L2300	CN105	Terms Discount Percentage	L2300_S09_CN105_TERMS_DISCNT_PERCNTG
L2300	CN106	Contract Version Identifier	L2300_S09_CN106_VERSN_ID
L2300	AMT	Patient Amount Paid
L2300	AMT01	Amount Qualifier Code	L2300_S10_AMT01_QUAL_CD
L2300	AMT02	Patient Amount Paid	L2300_S10_AMT02_AMT_PD
L2300	REF	Predetermination Identification
L2300	REF02	Predetermination of Benefits Identification Number	L2300_S11_REF02_BENFTS_ID_OVL_PREDTRMNTN_BENFTS_ID_NR
L2300	REF	Service Authorization Exception Code
L2300	REF02	Special Payment Reference Number	L2300_S12_REF02_SVC_AUTH_EXCPTN_CD_OVL_SPECL_PMT_REF_NR
L2300	REF	Payer Claim Control Number
L2300	REF02	Original Reference Number	L2300_S13_REF02_PAYR_CLM_CONTRL_NR_OVL_ORGNL_REF_NR
L2300	REF	Referral Number
L2300	REF02	Referral Number	L2300_S14_REF02_REFL_NR_OVL_REFL_NR
L2300	REF	Prior Authorization
L2300	REF02	Prior Authorization Number	L2300_S15_REF02_AUTH_NR_OVL_PRI_AUTH_NR
L2300	REF	Repriced Claim Number
L2300	REF02	Repriced Claim Reference Number	L2300_S16_REF02_REPRCD_CLM_REF_NR_OVL_REPRCD_CLM_REF_NR
L2300	REF	Adjusted Repriced Claim Number
L2300	REF02	Adjusted Repriced Claim Reference Number	L2300_S17_REF02_REF_NR_OVL_ADJSTD_REPRCD_CLM_REF_NR
L2300	REF	Claim Identifier For Transmission Intermediaries
L2300	REF02	Claim Number	L2300_S18_REF02_VAL_AD_NETWRK_TRAC_NR_OVL_CLM_NR
L2300	K3	File Information
L2300	K301	Fixed Format Information	L2300_S19_K301_FIXD_FORMT_NFO
L2300	NTE	Claim Note
L2300	NTE02	Additional Information	L2300_S20_NTE02_NOT_TEXT_OVL_ADDL_NFO
L2300	HI	Health Care Diagnosis Code
L2300	HI01-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis	L2300_S21_HI01_02_PRINCPL_DIAG_CD_OVL_ICD10CM_PRINCPL_DIAG
L2300	HI01-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis	L2300_S21_HI01_02_PRINCPL_DIAG_CD_OVL_ICD9CM_PRINCPL_DIAG
L2300	HI01-02	Systemized Nomenclature of Dentistry (SNODENT)	L2300_S21_HI01_02_PRINCPL_DIAG_CD_OVL_SNODNT
L2300	HI02-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2300_S21_HI02_02_DIAG_CD_OVL_ICD10CM_DIAG
L2300	HI02-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2300_S21_HI02_02_DIAG_CD_OVL_ICD9CM_DIAG
L2300	HI02-02	Systemized Nomenclature of Dentistry (SNODENT)	L2300_S21_HI02_02_DIAG_CD_OVL_SNODNT
L2300	HI03-01	Code List Qualifier Code	L2300_S21_HI03_01_CD_LIST_QUAL_CD
L2300	HI03-02	Diagnosis Code	L2300_S21_HI03_02_DIAG_CD
L2300	HI04-01	Code List Qualifier Code	L2300_S21_HI04_01_CD_LIST_QUAL_CD
L2300	HI04-02	Diagnosis Code	L2300_S21_HI04_02_DIAG_CD
L2300	HCP	Claim Pricing/Repricing Information
L2300	HCP01	Pricing Methodology	L2300_S22_HCP01_PRICNG_METHDLGY
L2300	HCP02	Repriced Allowed Amount	L2300_S22_HCP02_REPRCD_ALWD_AMT
L2300	HCP03	Repriced Saving Amount	L2300_S22_HCP03_REPRCD_SAVNG_AMT
L2300	HCP04	Repricing Organization Identifier	L2300_S22_HCP04_REPRCNG_ORG_ID
L2300	HCP05	Repricing Per Diem or Flat Rate Amount	L2300_S22_HCP05_REPRCNG_DIEM_FLAT_RT_AMT
L2300	HCP06	Repriced Approved Ambulatory Patient Group	L2300_S22_HCP06_REPRCD_APRVD_AMBLTRY_PATNT_GROUP
L2300	HCP13	Reject Reason Code	L2300_S22_HCP13_REJCT_RSN_CD
L2300	HCP14	Policy Compliance Code	L2300_S22_HCP14_POLCY_COMPLNC_CD
L2300	HCP15	Exception Code	L2300_S22_HCP15_EXCPTN_CD

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	NM104	Referring Provider First Name	L2310A_XX_S01_NM104_PROV_FNAME
L2310A	NM105	Referring Provider Middle Name or Initial	L2310A_XX_S01_NM105_REFNG_PROV_MNAME_INTL
L2310A	NM107	Referring Provider Name Suffix	L2310A_XX_S01_NM107_REFNG_PROV_NM_SUFX
L2310A	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310A_XX_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310A	PRV	Referring Provider Specialty Information
L2310A	PRV01	Provider Code	L2310A_XX_S02_PRV01_PROV_CD
L2310A	PRV03	Health Care Provider Taxonomy Code	L2310A_XX_S02_PRV03_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
L2310A	REF	Referring Provider Secondary Identification
L2310A	REF02	State License Number	L2310A_XX_S03_REF02_REFNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2310A	REF02	Provider UPIN Number	L2310A_XX_S03_REF02_REFNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2310A	REF02	Provider Commercial Number	L2310A_XX_S03_REF02_REFNG_PROV_2ND_ID_OVL_PROV_COMRCL_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 or Initial	L2310B_S01_NM105_RENDRNG_PROV_MNAME_INTL
L2310B	NM107	Rendering Provider Name Suffix	L2310B_S01_NM107_RENDRNG_PROV_NM_SUFX
L2310B	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310B_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310B	PRV	Rendering Provider Specialty Information
L2310B	PRV01	Provider Code	L2310B_S02_PRV01_PROV_CD
L2310B	PRV03	Health Care Provider Taxonomy Code	L2310B_S02_PRV03_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
L2310B	REF	Rendering Provider Secondary Identification
L2310B	REF02	State License Number	L2310B_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2310B	REF02	Provider UPIN Number	L2310B_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2310B	REF02	Provider Commercial Number	L2310B_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2310B	REF02	Location Number	L2310B_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_LOC_NR

2310C - SERVICE FACILITY LOCATION NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310C	NM1	Service Facility Location Name
L2310C	NM103	Non-Person Entity	L2310C_S01_NM103_LAB_FACLTY_NM_OVL_NONPRSN_ENTY
L2310C	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310C_S01_NM109_LAB_FACLTY_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310C	N3	Service Facility Location Address
L2310C	N301	Laboratory or Facility Address Line	L2310C_S02_N301_LAB_FACLTY_ADRS_LIN
L2310C	N302	Laboratory or Facility Address Line	L2310C_S02_N302_LAB_FACLTY_ADRS_LIN
L2310C	N4	Service Facility Location City, State, ZIP Code
L2310C	N401	Laboratory or Facility City Name	L2310C_S03_N401_LAB_FACLTY_CITY_NM
L2310C	N402	Laboratory or Facility State or Province Code	L2310C_S03_N402_LAB_FACLTY_STAT_PROVNC_CD
L2310C	N403	Laboratory or Facility Postal Zone or ZIP Code	L2310C_S03_N403_LAB_FACLTY_POSTL_ZON_ZIP_CD
L2310C	N404	Country Code	L2310C_S03_N404_CNTRY_CD
L2310C	N407	Country Subdivision Code	L2310C_S03_N407_COUNTRY_SUBDVSN_CD
L2310C	REF	Service Facility Location Secondary Identification
L2310C	REF02	State License Number	L2310C_S04_REF02_LAB_FACLTY_2ND_ID_OVL_STAT_LICNS_NR
L2310C	REF02	Provider Commercial Number	L2310C_S04_REF02_LAB_FACLTY_2ND_ID_OVL_PROV_COMRCL_NR
L2310C	REF02	Location Number	L2310C_S04_REF02_LAB_FACLTY_2ND_ID_OVL_LOC_NR

2310D - ASSISTANT SURGEON NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310D	NM1	Assistant Surgeon Name
L2310D	NM103	Person	L2310D_S01_NM103_SURGN_LNAME_OVL_PERSN
L2310D	NM104	Assistant Surgeon First Name	L2310D_S01_NM104_SURGN_FNAME
L2310D	NM105	Assistant Surgeon Middle Name or Initial	L2310D_S01_NM105_ASTNT_SURGN_MNAME_INTL
L2310D	NM107	Assistant Surgeon Name Suffix	L2310D_S01_NM107_ASTNT_SURGN_NM_SUFX
L2310D	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310D_S01_NM109_ASTNT_SURGN_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310D	PRV	Assistant Surgeon Specialty Information
L2310D	PRV01	Provider Code	L2310D_S02_PRV01_PROV_CD
L2310D	PRV03	Health Care Provider Taxonomy Code	L2310D_S02_PRV03_PROV_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
L2310D	REF	Assistant Surgeon Secondary Identification
L2310D	REF02	State License Number	L2310D_S03_REF02_ASTNT_SURGN_2ND_ID_OVL_STAT_LICNS_NR
L2310D	REF02	Provider UPIN Number	L2310D_S03_REF02_ASTNT_SURGN_2ND_ID_OVL_PROV_UPN_NR
L2310D	REF02	Provider Commercial Number	L2310D_S03_REF02_ASTNT_SURGN_2ND_ID_OVL_PROV_COMRCL_NR
L2310D	REF02	Location Number	L2310D_S03_REF02_ASTNT_SURGN_2ND_ID_OVL_LOC_NR

2310E - SUPERVISING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2310E	NM1	Supervising Provider Name
L2310E	NM103	Person	L2310E_S01_NM103_PROV_LNAME_OVL_PERSN
L2310E	NM104	Supervising Provider First Name	L2310E_S01_NM104_PROV_FNAME
L2310E	NM105	Supervising Provider Middle Name or Initial	L2310E_S01_NM105_SUPER_PROV_MNAME_INTL
L2310E	NM107	Supervising Provider Name Suffix	L2310E_S01_NM107_SUPER_PROV_NM_SUFX
L2310E	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2310E_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2310E	REF	Supervising Provider Secondary Identification
L2310E	REF02	State License Number	L2310E_S02_REF02_SUPER_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2310E	REF02	Provider UPIN Number	L2310E_S02_REF02_SUPER_PROV_2ND_ID_OVL_PROV_UPN_NR
L2310E	REF02	Provider Commercial Number	L2310E_S02_REF02_SUPER_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2310E	REF02	Location Number	L2310E_S02_REF02_SUPER_PROV_2ND_ID_OVL_LOC_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	Other Insured Group Name	L2320_S01_SBR04_OTHR_INSRD_GRP_NM
L2320	SBR05	Insurance Type Code	L2320_S01_SBR05_INS_TYPE_CD
L2320	SBR09	Claim Filing Indicator Code	L2320_S01_SBR09_CLM_FILNG_IND_CD
L2320	CAS	Claim Level Adjustments
L2320	CAS01	Claim Adjustment Group Code	L2320_S02_CAS01_CLM_ADJ_GRP_CD
L2320	CAS02	Adjustment Reason Code	L2320_S02_CAS02_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_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_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_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_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_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	Remaining Patient Liability
L2320	AMT01	Amount Qualifier Code	L2320_S04_AMT01_AMT_QUAL_CD
L2320	AMT02	Remaining Patient Liability	L2320_S04_AMT02_PATNT_LIABLTY
L2320	AMT	Coordination of Benefits (COB) Total Non-Covered Amount
L2320	AMT02	Noncovered Charges - Actual	L2320_S05_AMT02_CHG_AMT_OVL_NONCVRD_CHGS_ACTL
L2320	OI	Other Insurance Coverage Information
L2320	OI03	Benefits Assignment Certification Indicator	L2320_S06_OI03_BENFTS_ASGNMNT_CERT_IND
L2320	OI06	Release of Information Code	L2320_S06_OI06_RELS_NFO_CD
L2320	MOA	Outpatient Adjudication Information
L2320	MOA01	Reimbursement Rate	L2320_S07_MOA01_REIMBRSMNT_RAT
L2320	MOA02	HCPCS Payable Amount	L2320_S07_MOA02_HCPCS_PAYBL_AMT
L2320	MOA03	Claim Payment Remark Code	L2320_S07_MOA03_CLM_PMT_REMRK_CD
L2320	MOA04	Claim Payment Remark Code	L2320_S07_MOA04_CLM_PMT_REMRK_CD
L2320	MOA05	Claim Payment Remark Code	L2320_S07_MOA05_CLM_PMT_REMRK_CD
L2320	MOA06	Claim Payment Remark Code	L2320_S07_MOA06_CLM_PMT_REMRK_CD
L2320	MOA07	Claim Payment Remark Code	L2320_S07_MOA07_CLM_PMT_REMRK_CD
L2320	MOA09	Non-Payable Professional Component Billed	L2320_S07_MOA09_NONPYBL_PROF_COMPNT_BILD

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	Standard Unique Health Identifier for each Individual in the United States	L2330A_S01_NM109_INSRD_ID_OVL_STANDRD_UNQ_HEALTH_ID
L2330A	NM109	Member Identification Number	L2330A_S01_NM109_INSRD_ID_OVL_MEM_ID_NR
L2330A	N3	Other Subscriber Address
L2330A	N301	Other Insured Address Line	L2330A_S02_N301_OTHR_INSRD_ADRS_LIN
L2330A	N302	Other Insured Address Line	L2330A_S02_N302_OTHR_INSRD_ADRS_LIN
L2330A	N4	Other Subscriber City, State, ZIP Code
L2330A	N401	Other Insured City Name	L2330A_S03_N401_OTHR_INSRD_CITY_NM
L2330A	N402	Other Insured State Code	L2330A_S03_N402_OTHR_INSRD_STAT_CD
L2330A	N403	Other Insured Postal Zone or ZIP Code	L2330A_S03_N403_OTHR_INSRD_POSTL_ZON_ZIP_CD
L2330A	N404	Country Code	L2330A_S03_N404_CNTRY_CD
L2330A	N407	Country Subdivision Code	L2330A_S03_N407_COUNTRY_SUBDVSN_CD
L2330A	REF	Other Subscriber Secondary Identification
L2330A	REF02	Social Security Number	L2330A_S04_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	Centers for Medicare and Medicaid Services PlanID	L2330B_S01_NM109_OTHR_PAYR_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_PLAND
L2330B	N3	Other Payer Address
L2330B	N301	Other Payer Address Line	L2330B_S02_N301_OTHR_PAYR_ADRS_LIN
L2330B	N302	Other Payer Address Line	L2330B_S02_N302_OTHR_PAYR_ADRS_LIN
L2330B	N4	Other Payer City, State, ZIP Code
L2330B	N401	Other Payer City Name	L2330B_S03_N401_OTHR_PAYR_CITY_NM
L2330B	N402	Other Payer State Code	L2330B_S03_N402_OTHR_PAYR_STAT_CD
L2330B	N403	Other Payer Postal Zone or ZIP Code	L2330B_S03_N403_POSTL_ZON_ZIP_CD
L2330B	N404	Country Code	L2330B_S03_N404_CNTRY_CD
L2330B	N407	Country Subdivision Code	L2330B_S03_N407_COUNTRY_SUBDVSN_CD
L2330B	DTP	Claim Check or Remittance Date
L2330B	DTP03	Date Claim Paid (D8)	L2330B_S04_DTP03_ADJDCTN_PMT_DT_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	Employer’s Identification Number	L2330B_S05_REF02_OTHR_PAYR_2ND_ID_OVL_EMPLYR_ID_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	REF	Other Payer Prior Authorization Number
L2330B	REF02	Prior Authorization Number	L2330B_S06_REF02_AUTH_NR_OVL_PRI_AUTH_NR
L2330B	REF	Other Payer Referral Number
L2330B	REF02	Referral Number	L2330B_S07_REF02_OTHR_PAYR_REFL_NR_OVL_REFL_NR
L2330B	REF	Other Payer Claim Adjustment Indicator
L2330B	REF02	Signal Code	L2330B_S08_REF02_IND_OVL_SIGNL_CD
L2330B	REF	Other Payer Predetermination Identification
L2330B	REF02	Predetermination of Benefits Identification Number	L2330B_S09_REF02_OTHR_PAYR_PREDTRMNTN_BENFTS_OVL_PREDTRMNTN_BENFTS_ID_NR
L2330B	REF	Other Payer Claim Control Number
L2330B	REF02	Original Reference Number	L2330B_S10_REF02_NR_OVL_ORGNL_REF_NR

2330C - OTHER PAYER REFERRING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330C	NM1	Other Payer Referring Provider
L2330C	NM102	Entity Type Qualifier	L2330C_S01_NM102_ENTY_TYPE_QUAL
L2330C	REF	Other Payer Referring Provider Secondary Identification
L2330C	REF02	State License Number	L2330C_S02_REF02_2ND_OVL_STAT_LICNS_NR
L2330C	REF02	Provider UPIN Number	L2330C_S02_REF02_2ND_OVL_PROV_UPN_NR
L2330C	REF02	Provider Commercial Number	L2330C_S02_REF02_2ND_OVL_PROV_COMRCL_NR

2330C2 - OTHER PAYER REFERRING PROVIDER I02

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330C2	NM1	Other Payer Referring Provider
L2330C2	NM102	Entity Type Qualifier	L2330C2_S01_NM102_ENTY_TYPE_QUAL
L2330C2	REF	Other Payer Referring Provider Secondary Identification
L2330C2	REF02	State License Number	L2330C2_S02_REF02_2ND_OVL_STAT_LICNS_NR
L2330C2	REF02	Provider UPIN Number	L2330C2_S02_REF02_2ND_OVL_PROV_UPN_NR
L2330C2	REF02	Provider Commercial Number	L2330C2_S02_REF02_2ND_OVL_PROV_COMRCL_NR

2330D - OTHER PAYER RENDERING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330D	NM1	Other Payer Rendering Provider
L2330D	NM102	Entity Type Qualifier	L2330D_S01_NM102_ENTY_TYPE_QUAL
L2330D	REF	Other Payer Rendering Provider Secondary Identification
L2330D	REF02	State License Number	L2330D_S02_REF02_2ND_OVL_STAT_LICNS_NR
L2330D	REF02	Provider UPIN Number	L2330D_S02_REF02_2ND_OVL_PROV_UPN_NR
L2330D	REF02	Provider Commercial Number	L2330D_S02_REF02_2ND_OVL_PROV_COMRCL_NR
L2330D	REF02	Location Number	L2330D_S02_REF02_2ND_OVL_LOC_NR

2330E - OTHER PAYER SUPERVISING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330E	NM1	Other Payer Supervising Provider
L2330E	NM102	Entity Type Qualifier	L2330E_S01_NM102_ENTY_TYPE_QUAL
L2330E	REF	Other Payer Supervising Provider Secondary Identification
L2330E	REF02	State License Number	L2330E_S02_REF02_2ND_OVL_STAT_LICNS_NR
L2330E	REF02	Provider UPIN Number	L2330E_S02_REF02_2ND_OVL_PROV_UPN_NR
L2330E	REF02	Provider Commercial Number	L2330E_S02_REF02_2ND_OVL_PROV_COMRCL_NR
L2330E	REF02	Location Number	L2330E_S02_REF02_2ND_OVL_LOC_NR

2330F - OTHER PAYER BILLING PROVIDER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330F	NM1	Other Payer Billing Provider
L2330F	NM102	Entity Type Qualifier	L2330F_S01_NM102_ENTY_TYPE_QUAL
L2330F	REF	Other Payer Billing Provider Secondary Identification
L2330F	REF02	Provider Commercial Number	L2330F_S02_REF02_2ND_ID_OVL_PROV_COMRCL_NR
L2330F	REF02	Location Number	L2330F_S02_REF02_2ND_ID_OVL_LOC_NR

2330G - OTHER PAYER SERVICE FACILITY LOCATION

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330G	NM1	Other Payer Service Facility Location
L2330G	NM102	Entity Type Qualifier	L2330G_S01_NM102_ENTY_TYPE_QUAL
L2330G	REF	Other Payer Service Facility Location Secondary Identification
L2330G	REF02	State License Number	L2330G_S02_REF02_LOC_ID_OVL_STAT_LICNS_NR
L2330G	REF02	Provider Commercial Number	L2330G_S02_REF02_LOC_ID_OVL_PROV_COMRCL_NR
L2330G	REF02	Location Number	L2330G_S02_REF02_LOC_ID_OVL_LOC_NR

2330H - OTHER PAYER ASSISTANT SURGEON

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2330H	NM1	Other Payer Assistant Surgeon
L2330H	NM102	Entity Type Qualifier	L2330H_S01_NM102_ENTY_TYPE_QUAL
L2330H	REF	Other Payer Assistant Surgeon Secondary Identifier
L2330H	REF02	State License Number	L2330H_S02_REF02_2ND_OVL_STAT_LICNS_NR
L2330H	REF02	Provider UPIN Number	L2330H_S02_REF02_2ND_OVL_PROV_UPN_NR
L2330H	REF02	Provider Commercial Number	L2330H_S02_REF02_2ND_OVL_PROV_COMRCL_NR
L2330H	REF02	Location Number	L2330H_S02_REF02_2ND_OVL_LOC_NR

2400 - SERVICE LINE NUMBER

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2400	LX	Service Line Number
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	SV301-07	Procedure Code Description	L2400_S02_SV301_07_PROC_CD_DESCRPTN
L2400	SV302	Line Item Charge Amount	L2400_S02_SV302_LIN_ITM_CHG_AMT
L2400	SV303	Place of Service Code	L2400_S02_SV303_PLAC_SVC_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	SV311-01	Diagnosis Code Pointer	L2400_S02_SV311_01_DIAG_CD_POINTR
L2400	SV311-02	Diagnosis Code Pointer	L2400_S02_SV311_02_DIAG_CD_POINTR
L2400	SV311-03	Diagnosis Code Pointer	L2400_S02_SV311_03_DIAG_CD_POINTR
L2400	SV311-04	Diagnosis Code Pointer	L2400_S02_SV311_04_DIAG_CD_POINTR
L2400	TOO	Tooth Information
L2400	TOO02	Universal National Tooth Designation System	L2400_S03_TOO02_TOTH_CD_OVL_UNVRSL_NATNL_TOTH_DESGNTN_SYS
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 Date
L2400	DTP03	Service (D8)	L2400_S04_DTP03_SVC_DT_OVL_SVC_D8
L2400	DTP	Date - Prior Placement
L2400	DTP03	Estimated (D8)	L2400_S05_DTP03_PLACMNT_DT_OVL_EST_D8
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	DTP	Date - Treatment Start
L2400	DTP03	Start (D8)	L2400_S08_DTP03_START_DT_OVL_START_D8
L2400	DTP	Date - Treatment Completion
L2400	DTP03	Completion (D8)	L2400_S09_DTP03_COMPLTN_DT_OVL_COMPLTN_D8
L2400	CN1	Contract Information
L2400	CN101	Contract Type Code	L2400_S10_CN101_TYPE_CD
L2400	CN102	Contract Amount	L2400_S10_CN102_CONTRCT_AMT
L2400	CN103	Contract Percentage	L2400_S10_CN103_CONTRCT_PERCNTG
L2400	CN104	Contract Code	L2400_S10_CN104_CONTRCT_CD
L2400	CN105	Terms Discount Percentage	L2400_S10_CN105_TERMS_DISCNT_PERCNTG
L2400	CN106	Contract Version Identifier	L2400_S10_CN106_VERSN_ID
L2400	REF	Service Predetermination Identification
L2400	REF02	Predetermination of Benefits Identification Number	L2400_S11_REF02_BENFTS_ID_OVL_PREDTRMNTN_BENFTS_ID_NR
L2400	REF04-02	Payer Identification Number	L2400_S11_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR
L2400	REF	Prior Authorization
L2400	REF02	Prior Authorization Number	L2400_S12_REF02_PRI_AUTH_REFL_NR_OVL_PRI_AUTH_NR
L2400	REF04-02	Payer Identification Number	L2400_S12_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR
L2400	REF	Line Item Control Number
L2400	REF02	Provider Control Number	L2400_S13_REF02_LIN_ITM_CONTRL_NR_OVL_PROV_CONTRL_NR
L2400	REF	Repriced Claim Number
L2400	REF02	Repriced Claim Reference Number	L2400_S14_REF02_REPRCD_CLM_REF_NR_OVL_REPRCD_CLM_REF_NR
L2400	REF	Adjusted Repriced Claim Number
L2400	REF02	Adjusted Repriced Claim Reference Number	L2400_S15_REF02_REF_NR_OVL_ADJSTD_REPRCD_CLM_REF_NR
L2400	REF	Referral Number
L2400	REF02	Referral Number	L2400_S16_REF02_REFL_NR_OVL_REFL_NR
L2400	REF04-02	Payer Identification Number	L2400_S16_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR
L2400	AMT	Sales Tax Amount
L2400	AMT02	Tax	L2400_S17_AMT02_TAX_AMT_OVL_TAX
L2400	K3	File Information
L2400	K301	Fixed Format Information	L2400_S18_K301_FIXD_FORMT_NFO
L2400	HCP	Line Pricing/Repricing Information
L2400	HCP01	Pricing Methodology	L2400_S19_HCP01_PRICNG_METHDLGY
L2400	HCP02	Repriced Allowed Amount	L2400_S19_HCP02_REPRCD_ALWD_AMT
L2400	HCP03	Repriced Saving Amount	L2400_S19_HCP03_REPRCD_SAVNG_AMT
L2400	HCP04	Repricing Organization Identifier	L2400_S19_HCP04_REPRCNG_ORG_ID
L2400	HCP05	Repricing Per Diem or Flat Rate Amount	L2400_S19_HCP05_REPRCNG_DIEM_FLAT_RT_AMT
L2400	HCP10	American Dental Association Codes	L2400_S19_HCP10_REPRCD_APRVD_HCPCS_CD_OVL_AMRCN_DENTL_ASCTN_CD
L2400	HCP12	Unit	L2400_S19_HCP12_REPRCD_APRVD_SVC_UNT_CT_OVL_UNT
L2400	HCP13	Reject Reason Code	L2400_S19_HCP13_REJCT_RSN_CD
L2400	HCP14	Policy Compliance Code	L2400_S19_HCP14_POLCY_COMPLNC_CD
L2400	HCP15	Exception Code	L2400_S19_HCP15_EXCPTN_CD

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 or Initial	L2420A_S01_NM105_RENDRNG_PROV_MNAME_INTL
L2420A	NM107	Rendering Provider Name Suffix	L2420A_S01_NM107_RENDRNG_PROV_NM_SUFX
L2420A	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420A_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420A	PRV	Rendering Provider Specialty Information
L2420A	PRV01	Provider Code	L2420A_S02_PRV01_PROV_CD
L2420A	PRV03	Health Care Provider Taxonomy Code	L2420A_S02_PRV03_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
L2420A	REF	Rendering Provider Secondary Identification
L2420A	REF02	State License Number	L2420A_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2420A	REF02	Provider UPIN Number	L2420A_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_UPN_NR
L2420A	REF02	Provider Commercial Number	L2420A_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2420A	REF02	Location Number	L2420A_S03_REF02_RENDRNG_PROV_2ND_ID_OVL_LOC_NR
L2420A	REF04-02	Payer Identification Number	L2420A_S03_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR

2420B - ASSISTANT SURGEON NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420B	NM1	Assistant Surgeon Name
L2420B	NM103	Person	L2420B_S01_NM103_LAST_ORG_NM_OVL_PERSN
L2420B	NM104	Assistant Surgeon First Name	L2420B_S01_NM104_SURGN_FNAME
L2420B	NM105	Assistant Surgeon Middle Name or Initial	L2420B_S01_NM105_ASTNT_SURGN_MNAME_INTL
L2420B	NM107	Assistant Surgeon Name Suffix	L2420B_S01_NM107_ASTNT_SURGN_NM_SUFX
L2420B	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420B_S01_NM109_ASTNT_SURGN_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420B	PRV	Assistant Surgeon Specialty Information
L2420B	PRV01	Provider Code	L2420B_S02_PRV01_PROV_CD
L2420B	PRV03	Health Care Provider Taxonomy Code	L2420B_S02_PRV03_PROV_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_CD
L2420B	REF	Assistant Surgeon Secondary Identification
L2420B	REF02	State License Number	L2420B_S03_REF02_ASTNT_SURGN_2ND_ID_OVL_STAT_LICNS_NR
L2420B	REF02	Provider UPIN Number	L2420B_S03_REF02_ASTNT_SURGN_2ND_ID_OVL_PROV_UPN_NR
L2420B	REF02	Provider Commercial Number	L2420B_S03_REF02_ASTNT_SURGN_2ND_ID_OVL_PROV_COMRCL_NR
L2420B	REF02	Location Number	L2420B_S03_REF02_ASTNT_SURGN_2ND_ID_OVL_LOC_NR
L2420B	REF04-02	Payer Identification Number	L2420B_S03_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR

2420C - SUPERVISING PROVIDER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420C	NM1	Supervising Provider Name
L2420C	NM103	Person	L2420C_S01_NM103_PROV_LNAME_OVL_PERSN
L2420C	NM104	Supervising Provider First Name	L2420C_S01_NM104_PROV_FNAME
L2420C	NM105	Supervising Provider Middle Name or Initial	L2420C_S01_NM105_SUPER_PROV_MNAME_INTL
L2420C	NM107	Supervising Provider Name Suffix	L2420C_S01_NM107_SUPER_PROV_NM_SUFX
L2420C	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420C_S01_NM109_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420C	REF	Supervising Provider Secondary Identification
L2420C	REF02	State License Number	L2420C_S02_REF02_SUPER_PROV_2ND_ID_OVL_STAT_LICNS_NR
L2420C	REF02	Provider UPIN Number	L2420C_S02_REF02_SUPER_PROV_2ND_ID_OVL_PROV_UPN_NR
L2420C	REF02	Provider Commercial Number	L2420C_S02_REF02_SUPER_PROV_2ND_ID_OVL_PROV_COMRCL_NR
L2420C	REF02	Location Number	L2420C_S02_REF02_SUPER_PROV_2ND_ID_OVL_LOC_NR
L2420C	REF04-02	Payer Identification Number	L2420C_S02_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_NR

2420D - SERVICE FACILITY LOCATION NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2420D	NM1	Service Facility Location Name
L2420D	NM103	Non-Person Entity	L2420D_S01_NM103_LAB_FACLTY_NM_OVL_NONPRSN_ENTY
L2420D	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2420D_S01_NM109_LAB_FACLTY_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2420D	N3	Service Facility Location Address
L2420D	N301	Laboratory or Facility Address Line	L2420D_S02_N301_LAB_FACLTY_ADRS_LIN
L2420D	N302	Laboratory or Facility Address Line	L2420D_S02_N302_LAB_FACLTY_ADRS_LIN
L2420D	N4	Service Facility Location City, State, ZIP Code
L2420D	N401	Laboratory or Facility City Name	L2420D_S03_N401_LAB_FACLTY_CITY_NM
L2420D	N402	Laboratory or Facility State or Province Code	L2420D_S03_N402_LAB_FACLTY_STAT_PROVNC_CD
L2420D	N403	Laboratory or Facility Postal Zone or ZIP Code	L2420D_S03_N403_LAB_FACLTY_POSTL_ZON_ZIP_CD
L2420D	N404	Country Code	L2420D_S03_N404_CNTRY_CD
L2420D	N407	Country Subdivision Code	L2420D_S03_N407_COUNTRY_SUBDVSN_CD
L2420D	REF	Service Facility Location Secondary Identification
L2420D	REF02	Provider UPIN Number	L2420D_S04_REF02_SVC_FACLTY_LOC_2ND_ID_OVL_PROV_UPN_NR
L2420D	REF02	Provider Commercial Number	L2420D_S04_REF02_SVC_FACLTY_LOC_2ND_ID_OVL_PROV_COMRCL_NR
L2420D	REF02	Location Number	L2420D_S04_REF02_SVC_FACLTY_LOC_2ND_ID_OVL_LOC_NR
L2420D	REF04-02	Payer Identification Number	L2420D_S04_REF04_02_OTHR_PAYR_PRIMRY_ID_OVL_PAYR_ID_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	Jurisdiction Specific Procedure and Supply Codes	L2430_S01_SVD03_02_PROC_CD_OVL_JURSDCTN_SPECFC_PROC_SUPLY_CD
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	Line 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 Check or Remittance Date
L2430	DTP03	Date Claim Paid (D8)	L2430_S03_DTP03_ADJDCTN_PMT_DT_OVL_DAT_CLM_PAID_D8
L2430	AMT	Remaining Patient Liability
L2430	AMT01	Amount Qualifier Code	L2430_S04_AMT01_AMT_QUAL_CD
L2430	AMT02	Remaining Patient Liability	L2430_S04_AMT02_PATNT_LIABLTY