[LOOPS]
ISA
GS
ST
1000A
1000B
2000A
2000B
SE
GE
IEA

#--- start of loop details ---#

[ISA]
segment=ISA:::ISA:R:1

[GS]
segment=GS:::GS:R:1

#LOOP ID - HEADER
[ST]
segment=ST:::820 Header:R:1
segment=BPR:::Financial Information:R:1
segment=TRN:::Reassociation Key:R:1
segment=CUR:::Non-US Dollars Currency:S:1
segment=REF:::Premium Receivers Identification Key:S:>1
segment=DTM:::Process Date:S:1
segment=DTM:::Delivery Date:S:1
segment=DTM:::Coverage Period:S:1

#LOOP ID - 1000A PREMIUM RECEIVER’S NAME 1
[1000A]
segment=N1:1:PE:Premium Receiver’s Name:R:1
segment=N2:::Premium Receiver Additional Name:S:1
segment=N3:::Premium Receiver’s Address:S:1
segment=N4:::Premium Receiver’s City, State, Zip:S:1

#LOOP ID - 1000B PREMIUM PAYER’S NAME 1
[1000B]
segment=N1:1:PR:Premium Payer’s Name:R:1
segment=N2:::Premium Payer Additional Name:S:1
segment=N3:::Premium Payer’s Address:S:1
segment=N4:::Premium Payer’s City, State, Zip:S:1
segment=PER:::Premium Payer’s Administrative Contact:S:>1

#LOOP ID - 2000A ORGANIZATION SUMMARY REMITTANCE 1
[2000A]
segment=ENT:::Organization Summary Remittance:S:1
loop=2300A

#LOOP ID - 2300A ORGANIZATION SUMMARY REMITTANCE DETAIL >1
[2300A]
segment=RMR:::Organization Summary Remittance Detail:R:1
loop=2310A
loop=2320A

#LOOP ID - 2310A SUMMARY LINE ITEM 1
[2310A]
segment=IT1:::Summary Line Item:S:1
loop=2315A

#LOOP ID - 2315A MEMBER COUNT >1
[2315A]
segment=SLN:::Member Count:S:1

#LOOP ID - 2320A ORGANIZATION SUMMARY REMITTANCE LEVEL ADJUSTMENT >1
[2320A]
segment=ADX:::Organization Summary Remittance Level Adjustment:S:1

#LOOP ID - 2000B INDIVIDUAL REMITTANCE >1
[2000B]
segment=ENT:::Individual Remittance:S:1
loop=2100B
loop=2300B

#LOOP ID - 2100B INDIVIDUAL NAME >1
[2100B]
segment=NM1:1:EY:Individual Name:S:1

#LOOP ID - 2300B INDIVIDUAL PREMIUM REMITTANCE DETAIL >1
[2300B]
segment=RMR:::Individual Premium Remittance Detail:S:1
segment=DTM:::Individual Coverage Period:S:1
loop=2320B

#LOOP ID - 2320B INDIVIDUAL PREMIUM ADJUSTMENT >1
[2320B]
segment=ADX:::Individual Premium Adjustment:S:1

#LOOP ID - TRAILER
[SE]
segment=SE:::820 Trailer:R:1

[GE]
segment=GE:::GE:R:1

[IEA]
segment=IEA:::IEA:R:1