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

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

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

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

[ST]
segment=ST:1:835:Transaction Set Header:R:1
segment=BPR:::Financial Information:R:1
segment=TRN:::Reassociation Trace Number:R:1
segment=CUR:::Foreign Currency Information:S:1
segment=REF:1:EV:Receiver Identification:S:1
segment=REF:1:F2:Version Identification:S:1
segment=DTM:1:405:Production Date:S:1

[1000A]
segment=N1:1:PR:Payer Identification:R:1
segment=N3:::Payer Address:R:1
segment=N4:::Payer City, State, ZIP Code:R:1
segment=REF:1:2U,EO,HI,NF:Additional Payer Identification:S:4
segment=PER:1:CX:Payer Contact Information:S:1

[1000B]
segment=N1:1:PE:Payee Identification:R:1
segment=N3:::Payee Address:S:1
segment=N4:::Payee City, State, ZIP Code:S:1
segment=REF:::Payee Additional Identification:S:>1

[2000]
segment=LX:::Header Number:S:1
segment=TS3:::Provider Summary Information:S:1
segment=TS2:::Provider Supplemental Summary Information:S:1
loop=2100

[2100]
segment=CLP:::Claim Payment Information:R:1
segment=CAS:1:PR:Claim Adjustment:S:99
segment=NM1:1:QC:Patient Name:R:1
segment=NM1:1:IL:Insured Name:S:1
segment=NM1:1:74:Corrected Patient/Insured Name:S:1
segment=NM1:1:82:Service Provider Name:S:1
segment=NM1:1:TT:Crossover Carrier Name:S:1
segment=NM1:1:PR:Corrected Priority Payer Name:S:2
segment=MIA:::Inpatient Adjudication Information:S:1
segment=MOA:::Outpatient Adjudication Information:S:1
segment=REF:::Other Claim Related Identification:S:5
segment=REF:::Rendering Provider Identification:S:10
segment=DTM:::Claim Date:S:4
segment=PER:::Claim Contact Information:S:3
segment=AMT:::Claim Supplemental Information:S:14
segment=QTY:::Claim Supplemental Information Quantity:S:15
loop=2110

[2110]
segment=SVC:::Service Payment Information:S:1
segment=DTM:::Service Date:S:3
segment=CAS:::Service Adjustment:S:99
segment=REF:::Service Identification:S:7
segment=REF:::Rendering Provider Information:S:10
segment=AMT:::Service Supplemental Amount:S:12
segment=QTY:::Service Supplemental Quantity:S:6
segment=LQ:::Health Care Remark Codes:S:99
segment=PLB:::Provider Adjustment:S:>1

[SE]
segment=SE:::Transaction Set Trailer:R:1

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

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