[LOOPS]
ISA
GS
ST
1000A
1000B
1000C
2000
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:::Transaction Set Header:R:1
segment=BGN:::Beginning Segment:R:1
segment=REF:::Transaction Set Policy Number:S:1
segment=DTP:::File Effective Date:S:>1

#LOOP ID - 1000A SPONSOR NAME 1
[1000A]
segment=N1:1:P5:Sponsor Name:R:1

#LOOP ID - 1000B PAYER 1
[1000B]
segment=N1:1:1N:Payer:R:1

#LOOP ID - 1000C TPA/BROKER NAME 2
[1000C]
segment=N1:1:TV:TPA/Broker Name:S:1
loop=1100C

#LOOP ID - 1100C TPA/BROKER ACCOUNT INFORMATION 1
[1100C]
segment=ACT:::TPA/Broker Account Information:S:1

#LOOP ID - 2000 MEMBER LEVEL DETAIL >1
[2000]
segment=INS:::Member Level Detail:R:1
segment=REF:::Subscriber Number:R:1
segment=REF:::Member Policy Number:S:1
segment=REF:::Member Identification Number:S:5
segment=REF:::Prior Coverage Months:S:1
segment=DTP:::Member Level Dates:S:20
loop=2100A
loop=2100B
loop=2100C
loop=2100D
loop=2100E
loop=2100F
loop=2100G
loop=2200
loop=2300

#LOOP ID - 2100A MEMBER NAME 1
[2100A]
segment=NM1:1:IL:Member Name:R:1
segment=PER:::Member Communications Numbers:S:1
segment=N3:::Member Residence Street Address:S:1
segment=N4:::Member Residence City, State, ZIP Code:S:1
segment=DMG:::Member Demographics:S:1
segment=ICM:::Member Income:S:1
segment=AMT:::Member Policy Amounts:S:4
segment=HLH:::Member Health Information:S:1
segment=LUI:::Member Language:S:5

#LOOP ID - 2100B INCORRECT MEMBER NAME 1
[2100B]
segment=NM1:1:70:Incorrect Member Name:S:1
segment=DMG:::Incorrect Member Demographics:S:1

#LOOP ID - 2100C MEMBER MAILING ADDRESS 1
[2100C]
segment=NM1:1:31:Member Mailing Address:S:1
segment=N3:::Member Mail Street Address:S:1
segment=N4:::Member Mail City, State, Zip:S:1

#LOOP ID - 2100D MEMBER EMPLOYER 3
[2100D]
segment=NM1:1:ES:Member Employer:S:1
segment=PER:::Member Employer Communications Numbers:S:1
segment=N3:::Member Employer Street Address:S:1
segment=N4:::Member Employer City, State, Zip:S:1

#LOOP ID - 2100E MEMBER SCHOOL 3
[2100E]
segment=NM1:1:M8:Member School:S:1
segment=PER:::Member School Commmunications Numbers:S:1
segment=N3:::Member School Street Address:S:1
segment=N4:::Member School City, State, Zip:S:1

#LOOP ID - 2100F CUSTODIAL PARENT 1
[2100F]
segment=NM1:1:S3:Custodial Parent:S:1
segment=PER:::Custodial Parent Communications Numbers:S:1
segment=N3:::Custodial Parent Street Address:S:1
segment=N4:::Custodial Parent City, State, Zip:S:1

#LOOP ID - 2100G RESPONSIBLE PERSON 1
[2100G]
segment=NM1:1:QD:Responsible Person:S:1
segment=PER:::Responsible Person Communications Numbers:S:1
segment=N3:::Responsible Person Street Address:S:1
segment=N4:::Responsible Person City, State, Zip:S:1

#LOOP ID - 2200 DISABILITY INFORMATION 1
[2200]
segment=DSB:::Disability Information:S:1
segment=DTP:::Disability Eligibility Dates:S:2

#LOOP ID - 2300 HEALTH COVERAGE 99
[2300]
segment=HD:::Health Coverage:S:1
segment=DTP:::Health Coverage Dates:R:4
segment=AMT:::Health Coverage Policy:S:4
segment=REF:::Health Coverage Policy Number:S:2
segment=IDC:::Identification Card:S:10
loop=2310
loop=2320

#LOOP ID - 2310 PROVIDER INFORMATION 30
[2310]
segment=LX:::Provider Information:S:1
segment=NM1:::Provider Name:R:1
segment=N4:::Provider City, State, ZIP Code:S:1
segment=PER:::Provider Communications Numbers:S:2
segment=PLA:::PCP Change Reason:S:1

#LOOP ID - 2320 COORDINATION OF BENEFITS 5
[2320]
segment=COB:::Coordination of Benefits:S:1
segment=REF:::Additional Coordination of Benefits Identifiers:S:5
segment=N1:::Other Insurance Company Name:S:1
segment=DTP:::Coordination of Benefits Eligibility Dates:S:2

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

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

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