[LOOPS]
ISA
GS
ST
1000A
1000B
2000A
2000B
2000C
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=BHT:::Beginning of Hierarchical Transaction:R:1
segment=REF:::Transmission Type Identification:R:1

#LOOP ID - 1000A SUBMITTER NAME 1
[1000A]
segment=NM1:1:41:Submitter Name:R:1
segment=PER:::Submitter EDI Contact Information:R:2

#LOOP ID - 1000B RECEIVER NAME 1
[1000B]
segment=NM1:1:40:Receiver Name:R:1

#LOOP ID - 2000A BILLING/PAY-TO PROVIDER HIERARCHICAL LEVEL >1
[2000A]
segment=HL:3:20:Billing/Pay-To Provider Hierarchical Level:R:1
segment=PRV:::Billing/Pay-To Provider Specialty Information:S:1
segment=CUR:::Foreign Currency Information:S:1
loop=2010AA
loop=2010AB

#LOOP ID - 2010AA BILLING PROVIDER NAME 1
[2010AA]
segment=NM1:1:85:Billing Provider Name:R:1
segment=N3:::Billing Provider Address:R:1
segment=N4:::Billing Provider City/State/ZIP Code:R:1
segment=REF:::Billing Provider Secondary Identification:S:8
segment=REF:::Credit/Debit Card Billing Information:S:8
segment=PER:::Billing Provider Contact Information:S:2

#LOOP ID - 2010AB PAY-TO PROVIDER NAME 1
[2010AB]
segment=NM1:1:87:Pay-To Provider Name:S:1
segment=N3:::Pay-To Provider Address:R:1
segment=N4:::Pay-To Provider City/State/ZIP Code:R:1
segment=REF:::Pay-To Provider Secondary Identification:S:5

#LOOP ID - 2000B SUBSCRIBER HIERARCHICAL LEVEL >1
[2000B]
segment=HL:3:22:Subscriber Hierarchical Level:R:1
segment=SBR:::Subscriber Information:R:1
segment=PAT:::Patient Information:S:1
loop=2010BA
loop=2010BB
loop=2010BC
loop=2010BD
loop=2300

#LOOP ID - 2010BA SUBSCRIBER NAME 1
[2010BA]
segment=NM1:1:IL:Subscriber Name:R:1
segment=N3:::Subscriber Address:S:1
segment=N4:::Subscriber City/State/ZIP Code:S:1
segment=DMG:::Subscriber Demographic Information:S:1
segment=REF:::Subscriber Secondary Identification:S:4
segment=REF:::Property and Casualty Claim Number:S:1

#LOOP ID - 2010BB CREDIT/DEBIT CARD ACCOUNT HOLDER NAME 1
[2010BB]
segment=NM1:1:AO:Credit/Debit Card Account Holder Name:S:1
segment=REF:::Credit/Debit Card Information:S:2

#LOOP ID - 2010BC PAYER NAME 1
[2010BC]
segment=NM1:1:PR:Payer Name:R:1
segment=N3:::Payer Address:S:1
segment=N4:::Payer City/State/ZIP Code:S:1
segment=REF:::Payer Secondary Identification:S:3

#LOOP ID - 2010BD RESPONSIBLE PARTY NAME 1
[2010BD]
segment=NM1:1:QD:Responsible Party Name:S:1
segment=N3:::Responsible Party Address:R:1
segment=N4:::Responsible Party City/State/ZIP Code:R:1

#LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL >1
[2000C]
segment=HL:3:23:Patient Hierarchical Level:S:1
segment=PAT:::Patient Information:R:1
loop=2010CA
loop=2300

#LOOP ID - 2010CA PATIENT NAME 1
[2010CA]
segment=NM1:1:QC:Patient Name:R:1
segment=N3:::Patient Address:R:1
segment=N4:::Patient City/State/ZIP Code:R:1
segment=DMG:::Patient Demographic Information:R:1
segment=REF:::Patient Secondary Identification Number:S:5
segment=REF:::Property and Casualty Claim Number:S:1

#LOOP ID - 2300 CLAIM INFORMATION 100
[2300]
segment=CLM:::Claim information:R:1
segment=DTP:::Discharge Hour:S:1
segment=DTP:::Statement Dates:R:1
segment=DTP:::Admission Date/Hour:S:1
segment=CL1:::Institutional Claim Code:S:1
segment=PWK:::Claim Supplemental Information:S:10
segment=CN1:::Contract Information:S:1
segment=AMT:::Payer Estimated Amount Due:S:1
segment=AMT:::Patient Estimated Amount Due:S:1
segment=AMT:::Patient Paid Amount:S:1
segment=AMT:::Credit/Debit Card Maximum Amount:S:1
segment=REF:::Adjusted Repriced Claim Number:S:1
segment=REF:::Repriced Claim Number:S:1
segment=REF:::Claim Identification Number For Clearinghouses and Other Transmission Intermediaries:S:1
segment=REF:::Document Identification Code:S:1
segment=REF:::Original Reference Number (ICN/DCN):S:1
segment=REF:::Investigational Device Exemption Number:S:1
segment=REF:::Service Authorization Exception Code:S:1
segment=REF:::Peer Review Organization (PRO) Approval Number:S:1
segment=REF:::Prior Authorization or Referral Number:S:2
segment=REF:::Medical Record Number:S:1
segment=REF:::Demonstration Project Identifier:S:1
segment=K3:::File Information:S:10
segment=NTE:::Claim Note:S:10
segment=NTE:::Billing Note:S:1
segment=CR6:::Home Health Care Information:S:1
segment=CRC:::Home Health Functional Limitations:S:3
segment=CRC:::Home Health Activities Permitted:S:3
segment=CRC:::Home Health Mental Status:S:2
segment=HI:::Principal, Admitting, E-Code and Patient Reason For Visit Diagnosis Information:R:1
segment=HI:::Diagnosis Related Group (DRG) Information:S:1
segment=HI:::Other Diagnosis Information:S:2
segment=HI:::Principal Procedure Information:S:1
segment=HI:::Other Procedure Information:S:2
segment=HI:::Occurrence Span Information:S:2
segment=HI:::Occurrence Information:S:2
segment=HI:::Value Information:S:2
segment=HI:::Condition Information:S:2
segment=HI:::Treatment Code Information:S:2
segment=QTY:::Claim Quantity:S:4
segment=HCP:::Claim Pricing/Repricing Information:S:1
loop=2305
loop=2310A
loop=2310B
loop=2310C
loop=2310D
loop=2310E
loop=2320
loop=2400

#LOOP ID - 2305 HOME HEALTH CARE PLAN INFORMATION 6
[2305]
segment=CR7:::Home Health Care Plan Information:S:1
segment=HSD:::Health Care Services Delivery:S:12

#LOOP ID - 2310A ATTENDING PHYSICIAN NAME 1
[2310A]
segment=NM1:1:71:Attending Physician Name:S:1
segment=PRV:::Attending Physician Specialty Information:R:1
segment=REF:::Attending Physician Secondary Identification:S:5

#LOOP ID - 2310B OPERATING PHYSICIAN NAME 1
[2310B]
segment=NM1:1:72:Operating Physician Name:S:1
segment=PRV:::Operating Physician Specialty Information:S:1
segment=REF:::Operating Physician Secondary Identification:S:5

#LOOP ID - 2310C OTHER PROVIDER NAME 1
[2310C]
segment=NM1:1:73:Other Provider Name:S:1
segment=PRV:::Other Provider Specialty Information:R:1
segment=REF:::Other Provider Secondary Identification:S:5

#LOOP ID - 2310D REFERRING PROVIDER NAME 2
[2310D]
segment=NM1:1:DN,P3:Referring Provider Name:S:1
segment=PRV:::Referring Provider Specialty Information:S:1
segment=REF:::Referring Provider Secondary Identification:S:5

#LOOP ID - 2310E SERVICE FACILITY NAME 1
[2310E]
segment=NM1:1:FA:Service Facility Name:S:1
segment=PRV:::Service Facility Specialty Information:S:1
segment=N3:::Service Facility Address:R:1
segment=N4:::Service Facility City/State/Zip Code:R:1
segment=REF:::Service Facility Secondary Identification:S:5

#LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION 10
[2320]
segment=SBR:::Other Subscriber Information:S:1
segment=CAS:::Claim Level Adjustment:S:5
segment=AMT:::Payer Prior Payment:S:1
segment=AMT:::Coordination of Benefits (COB) Total Allowed Amount:S:1
segment=AMT:::Coordination of Benefits (COB) Total Submitted Charges:S:1
segment=AMT:::Diagnostic Related Group (DRG) Outlier Amount:S:1
segment=AMT:::Coordination of Benefits (COB) Total Medicare Paid Amount:S:1
segment=AMT:::Medicare Paid Amount - 100%:S:1
segment=AMT:::Medicare Paid Amount - 80%:S:1
segment=AMT:::Coordination of Benefits (COB) Medicare A Trust Fund Paid Amount:S:1
segment=AMT:::Coordination of Benefits (COB) Medicare B Trust Fund Paid Amount:S:1
segment=AMT:::Coordination of Benefits (COB) Total Non-covered Amount:S:1
segment=AMT:::Coordination of Benefits (COB) Total Denied Amount:S:1
segment=DMG:::Other Subscriber Demographic Information:S:1
segment=OI:::Other Insurance Coverage Information:R:1
segment=MIA:::Medicare Inpatient Adjudication Information:S:1
segment=MOA:::Medicare Outpatient Adjudication Information:S:1
loop=2330A
loop=2330B
loop=2330C
loop=2330D
loop=2330E
loop=2330F
loop=2330G
loop=2330H

#LOOP ID - 2330A OTHER SUBSCRIBER NAME 1
[2330A]
segment=NM1:1:IL:Other Subscriber Name:R:1
segment=N3:::Other Subscriber Address:S:1
segment=N4:::Other Subscriber City/State/ZIP Code:S:1
segment=REF:::Other Subscriber Secondary Information:S:3

#LOOP ID - 2330B OTHER PAYER NAME 1
[2330B]
segment=NM1:1:PR:Other Payer Name:R:1
segment=N3:::Other Payer Address:S:1
segment=N4:::Other Payer City/State/ZIP Code:S:1
segment=DTP:::Claim Adjudication Date:S:1
segment=REF:::Other Payer Secondary Identification and Reference Number:S:2
segment=REF:::Other Payer Prior Authorization or Referral Number:S:1

#LOOP ID - 2330C OTHER PAYER PATIENT INFORMATION 1
[2330C]
segment=NM1:1:QC:Other Payer Patient Information:S:1
segment=REF:::Other Payer Patient Identification Number:S:3

#LOOP ID - 2330D OTHER PAYER ATTENDING PROVIDER 1
[2330D]
segment=NM1:1:71:Other Payer Attending Provider:S:1
segment=REF:::Other Payer Attending Provider Identification:R:3

#LOOP ID - 2330E OTHER PAYER OPERATING PROVIDER 1
[2330E]
segment=NM1:1:72:Other Payer Operating Provider:S:1
segment=REF:::Other Payer Operating Provider Identification:R:3

#LOOP ID - 2330F OTHER PAYER OTHER PROVIDER 1
[2330F]
segment=NM1:1:73:Other Payer Other Provider:S:1
segment=REF:::Other Payer Other Provider Identification:R:3

#LOOP ID - 2330G OTHER PAYER REFERRING PROVIDER 2
[2330G]
segment=NM1:1:DN,P3:Other Payer Referring Provider:S:1
segment=REF:::Other Payer Referring Provider Identification:R:3

#LOOP ID - 2330H OTHER PAYER SERVICE FACILITY PROVIDER 1
[2330H]
segment=NM1:1:FA:Other Payer Service Facility Provider:S:1
segment=REF:::Other Payer Service Facility Provider Identification:R:3

#LOOP ID - 2400 SERVICE LINE NUMBER 999
[2400]
segment=LX:::Service Line Number:R:1
segment=SV2:::Institutional Service Line:R:1
segment=SV4:::Prescription Number:S:1
segment=PWK:::Line Supplemental Information:S:5
segment=DTP:::Service Line Date:S:1
segment=DTP:::Assessment Date:S:1
segment=AMT:::Service Tax Amount:S:1
segment=AMT:::Facility Tax Amount:S:1
loop=2420A
loop=2420B
loop=2420C
loop=2420D
loop=2430

#LOOP ID - 2420A ATTENDING PHYSICIAN NAME 1
[2420A]
segment=NM1:1:71:Attending Physician Name:S:1
segment=PRV:::Attending Physician Specialty Information:R:1
segment=REF:::Attending Physician Secondary Identification:S:1

#LOOP ID - 2420B OPERATING PHYSICIAN NAME 1
[2420B]
segment=NM1:1:72:Operating Physician Name:S:1
segment=PRV:::Operating Physician Specialty Information:S:1
segment=REF:::Operating Physician Secondary Identification:S:1

#LOOP ID - 2420C OTHER PROVIDER NAME 1
[2420C]
segment=NM1:1:73:Other Provider Name:S:1
segment=PRV:::Other Provider Specialty Information:S:1
segment=REF:::Other Provider Secondary Identification:S:1

#LOOP ID - 2420D REFERRING PROVIDER NAME 1
[2420D]
segment=NM1:1:DN:Referring Provider Name:S:1
segment=PRV:::Referring Provider Specialty Information:S:1
segment=REF:::Referring Provider Secondary Identification:S:1

#LOOP ID - 2430 SERVICE LINE ADJUDICATION INFORMATION 25
[2430]
segment=SVD:::Service Line Adjudication Information:S:1
segment=CAS:::Service Line Adjustment:S:99
segment=DTP:::Service Adjudication Date:S:1

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

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

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