Altova User Support Forum

Rank: Member

Joined: 2/21/2017
Posts: 14

Hello Everyone,

We are using Altova to map the 837 Professional EDI file. The entity we get the files from is adding a loop that is NOT in the implementation guide. Therefore, I created a copy of the 837P.config file called 837P_Modified.config and made necessary changes to the XML. However, below is what we are getting.

Any ideas why the Loop 2300 is repeated? The underlined Loop2010BC is what is added by the entity.

James

Rank: Member

Joined: 2/21/2017
Posts: 14

Here is the config file below. It's pretty much the same as what comes with Altova just includes one loop and a few fields marked as used that were before marked as unused. Nothing really special.

Code:

<?xml version="1.0" encoding="utf-8"?>
<Config xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:noNamespaceSchemaLocation="../EDIConfig4.xsd" Version="4">
<Meta>
<Release>5010</Release>
<Agency>X12</Agency>
</Meta>
<Format standard="X12" />
<Include href="X12.Segment" />
<Include href="X12.Codelist" />
<Message>
<MessageType>837-Q3</MessageType>
<Completion singleConditions="1" singleValues="1" HL="1" />
<Description>Health Care Claim: Institutional</Description>
<Group name="Message_837-Q3" info="Health Care Claim: Institutional" maxOccurs="unbounded">
<Segment name="ST" info="Transaction Set Header">
<Condition path="F1705" value="005010X223A2" />
<Data ref="F143" info="Transaction Set Identifier Code">
<Values>
<Value Code="837" />
</Values>
</Data>
<Data ref="F329" info="Transaction Set Control Number" />
<Data ref="F1705" info="Version, Release, or Industry Identifier" />
</Segment>
<Segment name="BHT" info="Beginning of Hierarchical Transaction">
<Data ref="F1005" info="Hierarchical Structure Code">
<Values>
<Value Code="0019" />
</Values>
</Data>
<Data ref="F353" info="Transaction Set Purpose Code">
<Values>
<Value Code="00" />
<Value Code="18" />
</Values>
</Data>
<Data ref="F127" info="Originator Application Transaction Identifier" />
<Data ref="F373" info="Transaction Set Creation Date" />
<Data ref="F337" info="Transaction Set Creation Time" />
<Data ref="F640" info="Claim Identifier">
<Values>
<Value Code="31" />
<Value Code="CH" />
<Value Code="RP" />
</Values>
</Data>
</Segment>
<Group name="Loop1000A" info="Submitter Name">
<Segment name="NM1" info="Submitter Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="41" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Submitter Last or Organization Name" />
<Data ref="F1036" minOccurs="0" info="Submitter First Name" />
<Data ref="F1037" minOccurs="0" info="Submitter Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" info="Identification Code Qualifier">
<Values>
<Value Code="46" />
</Values>
</Data>
<Data ref="F67" info="Submitter Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="PER" maxOccurs="2" info="Submitter EDI Contact Information">
<Data ref="F366" info="Contact Function Code">
<Values>
<Value Code="IC" />
</Values>
</Data>
<Data ref="F93" minOccurs="0" info="Submitter Contact Name" />
<Data ref="F365" info="Communication Number Qualifier" nodeName="F365_1">
<Values>
<Value Code="EM" />
<Value Code="FX" />
<Value Code="TE" />
            <Value Code="ED" />
</Values>
</Data>
<Data ref="F364" info="Communication Number" nodeName="F364_1" />
<Data ref="F365" minOccurs="0" info="Communication Number Qualifier" nodeName="F365_2">
<Values>
<Value Code="EM" />
<Value Code="EX" />
<Value Code="FX" />
<Value Code="TE" />
            <Value Code="ED" />
</Values>
</Data>
<Data ref="F364" minOccurs="0" info="Communication Number" nodeName="F364_2" />
<Data ref="F365" minOccurs="0" info="Communication Number Qualifier" nodeName="F365_3">
<Values>
<Value Code="EM" />
<Value Code="EX" />
<Value Code="FX" />
<Value Code="TE" />
            <Value Code="ED" />
</Values>
</Data>
<Data ref="F364" minOccurs="0" info="Communication Number" nodeName="F364_3" />
<Data ref="F443" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop1000B" info="Receiver Name">
<Segment name="NM1" info="Receiver Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="40" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Receiver Name" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" info="Identification Code Qualifier">
<Values>
<Value Code="46" />
</Values>
</Data>
<Data ref="F67" info="Receiver Primary Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
</Group>
<Group name="Loop2000A" maxOccurs="unbounded" info="Billing Provider Hierarchical Level">
<Segment name="HL" info="Billing Provider Hierarchical Level">
<Condition path="F735" />
<Data ref="F628" info="Hierarchical ID Number" />
<Data ref="F734" minOccurs="0" maxOccurs="0" />
<Data ref="F735" info="Hierarchical Level Code">
<Values>
<Value Code="20" />
</Values>
</Data>
<Data ref="F736" info="Hierarchical Child Code">
<Values>
<Value Code="1" />
</Values>
</Data>
</Segment>
<Segment name="PRV" minOccurs="0" info="Billing Provider Specialty Information">
<Data ref="F1221" info="Provider Code">
<Values>
<Value Code="BI" />
</Values>
</Data>
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="PXC" />
</Values>
</Data>
<Data ref="F127" info="Provider Taxonomy Code" />
<Data ref="F156" minOccurs="0" maxOccurs="0" />
<Composite name="C035" minOccurs="0" maxOccurs="0" />
<Data ref="F1223" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="CUR" minOccurs="0" info="Foreign Currency Information">
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="85" />
</Values>
</Data>
<Data ref="F100" info="Currency Code" />
<Data ref="F280" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F100" minOccurs="0" maxOccurs="0" nodeName="F100_unused_2" />
<Data ref="F669" minOccurs="0" maxOccurs="0" />
<Data ref="F374" minOccurs="0" maxOccurs="0" nodeName="F374_unused_1" />
<Data ref="F373" minOccurs="0" maxOccurs="0" nodeName="F373_unused_1" />
<Data ref="F337" minOccurs="0" maxOccurs="0" nodeName="F337_unused_1" />
<Data ref="F374" minOccurs="0" maxOccurs="0" nodeName="F374_unused_2" />
<Data ref="F373" minOccurs="0" maxOccurs="0" nodeName="F373_unused_2" />
<Data ref="F337" minOccurs="0" maxOccurs="0" nodeName="F337_unused_2" />
<Data ref="F374" minOccurs="0" maxOccurs="0" nodeName="F374_unused_3" />
<Data ref="F373" minOccurs="0" maxOccurs="0" nodeName="F373_unused_3" />
<Data ref="F337" minOccurs="0" maxOccurs="0" nodeName="F337_unused_3" />
<Data ref="F374" minOccurs="0" maxOccurs="0" nodeName="F374_unused_4" />
<Data ref="F373" minOccurs="0" maxOccurs="0" nodeName="F373_unused_4" />
<Data ref="F337" minOccurs="0" maxOccurs="0" nodeName="F337_unused_4" />
<Data ref="F374" minOccurs="0" maxOccurs="0" nodeName="F374_unused_5" />
<Data ref="F373" minOccurs="0" maxOccurs="0" nodeName="F373_unused_5" />
<Data ref="F337" minOccurs="0" maxOccurs="0" nodeName="F337_unused_5" />
</Segment>
<Group name="Loop2010AA" info="Billing Provider Name">
<Segment name="NM1" info="Billing Provider Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="85" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Billing Provider Organizational Name" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Billing Provider Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" info="Billing Provider Address">
<Data ref="F166" info="Billing Provider Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" info="Billing Provider City, State, ZIP Code">
<Data ref="F19" info="Billing Provider City Name" />
<Data ref="F156" minOccurs="0" info="Billing Provider State or Province Code" />
<Data ref="F116" minOccurs="0" info="Billing Provider Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
<Segment name="REF" info="Billing Provider Tax Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="EI" />
</Values>
</Data>
<Data ref="F127" info="Billing Provider Tax Identification Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="PER" minOccurs="0" maxOccurs="2" info="Billing Provider Contact Information">
<Data ref="F366" info="Contact Function Code">
<Values>
<Value Code="IC" />
</Values>
</Data>
<Data ref="F93" minOccurs="0" info="Billing Provider Contact Name" />
<Data ref="F365" info="Communication Number Qualifier" nodeName="F365_1">
<Values>
<Value Code="EM" />
<Value Code="FX" />
<Value Code="TE" />
</Values>
</Data>
<Data ref="F364" info="Communication Number" nodeName="F364_1" />
<Data ref="F365" minOccurs="0" info="Communication Number Qualifier" nodeName="F365_2">
<Values>
<Value Code="EM" />
<Value Code="EX" />
<Value Code="FX" />
<Value Code="TE" />
</Values>
</Data>
<Data ref="F364" minOccurs="0" info="Communication Number" nodeName="F364_2" />
<Data ref="F365" minOccurs="0" info="Communication Number Qualifier" nodeName="F365_3">
<Values>
<Value Code="EM" />
<Value Code="EX" />
<Value Code="FX" />
<Value Code="TE" />
</Values>
</Data>
<Data ref="F364" minOccurs="0" info="Communication Number" nodeName="F364_3" />
<Data ref="F443" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2010AB" minOccurs="0" info="Pay-to Address Name">
<Segment name="NM1" info="Pay-to Address Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="87" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_1" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" maxOccurs="0" />
<Data ref="F67" minOccurs="0" maxOccurs="0" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" info="Pay-to Address - ADDRESS">
<Data ref="F166" info="Pay-To Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" info="Pay-To Address City, State, ZIP Code">
<Data ref="F19" info="Pay-to Address City Name" />
<Data ref="F156" minOccurs="0" info="Pay-to Address State Code" />
<Data ref="F116" minOccurs="0" info="Pay-to Address Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
</Group>
<Group name="Loop2010AC" minOccurs="0" info="Pay-To Plan Name">
<Segment name="NM1" info="Pay-To Plan Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="PE" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Pay-To Plan Organizational Name" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" info="Identification Code Qualifier">
<Values>
<Value Code="PI" />
<Value Code="XV" />
</Values>
</Data>
<Data ref="F67" info="Pay-To Plan Primary Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" info="Pay-to Plan Address">
<Data ref="F166" info="Pay-To Plan Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" info="Pay-To Plan City, State, ZIP Code">
<Data ref="F19" info="Pay-To Plan City Name" />
<Data ref="F156" minOccurs="0" info="Pay-To Plan State or Province Code" />
<Data ref="F116" minOccurs="0" info="Pay-To Plan Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
<Segment name="REF" minOccurs="0" info="Pay-to Plan Secondary Identification" nodeName="REF_1">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="2U" />
<Value Code="FY" />
<Value Code="NF" />
</Values>
</Data>
<Data ref="F127" info="Pay-to Plan Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" info="Pay-To Plan Tax Identification Number" nodeName="REF_2">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="EI" />
</Values>
</Data>
<Data ref="F127" info="Pay-To Plan Tax Identification Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2000B" maxOccurs="unbounded" info="Subscriber Hierarchical Level">
<Segment name="HL" info="Subscriber Hierarchical Level">
<Condition path="F735" />
<Data ref="F628" info="Hierarchical ID Number" />
<Data ref="F734" info="Hierarchical Parent ID Number" />
<Data ref="F735" info="Hierarchical Level Code">
<Values>
<Value Code="22" />
</Values>
</Data>
<Data ref="F736" info="Hierarchical Child Code">
<Values>
<Value Code="0" />
<Value Code="1" />
</Values>
</Data>
</Segment>
<Segment name="SBR" info="Subscriber Information">
<Data ref="F1138" info="Payer Responsibility Sequence Number Code">
<Values>
<Value Code="A" />
<Value Code="B" />
<Value Code="C" />
<Value Code="D" />
<Value Code="E" />
<Value Code="F" />
<Value Code="G" />
<Value Code="H" />
<Value Code="P" />
<Value Code="S" />
<Value Code="T" />
<Value Code="U" />
</Values>
</Data>
<Data ref="F1069" minOccurs="0" info="Individual Relationship Code">
<Values>
<Value Code="18" />
</Values>
</Data>
<Data ref="F127" minOccurs="0" info="Subscriber Group or Policy Number" />
<Data ref="F93" minOccurs="0" info="Subscriber Group Name" />
<Data ref="F1336" minOccurs="0" maxOccurs="0" />
<Data ref="F1143" minOccurs="0" maxOccurs="0" />
<Data ref="F1073" minOccurs="0" maxOccurs="0" />
<Data ref="F584" minOccurs="0" maxOccurs="0" />
<Data ref="F1032" minOccurs="0" info="Claim Filing Indicator Code">
<Values>
<Value Code="11" />
<Value Code="12" />
<Value Code="13" />
<Value Code="14" />
<Value Code="15" />
<Value Code="16" />
<Value Code="17" />
<Value Code="AM" />
<Value Code="BL" />
<Value Code="CH" />
<Value Code="CI" />
<Value Code="DS" />
<Value Code="FI" />
<Value Code="HM" />
<Value Code="LM" />
<Value Code="MA" />
<Value Code="MB" />
<Value Code="MC" />
<Value Code="OF" />
<Value Code="TV" />
<Value Code="VA" />
<Value Code="WC" />
<Value Code="ZZ" />
</Values>
</Data>
</Segment>
<Group name="Loop2010BA" info="Subscriber Name">
<Segment name="NM1" info="Subscriber Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="IL" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Subscriber Last Name" />
<Data ref="F1036" minOccurs="0" info="Subscriber First Name" />
<Data ref="F1037" minOccurs="0" info="Subscriber Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Subscriber Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="II" />
<Value Code="MI" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Subscriber Primary Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" minOccurs="0" info="Subscriber Address">
<Data ref="F166" info="Subscriber Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" minOccurs="0" info="Subscriber City, State, ZIP Code">
<Data ref="F19" info="Subscriber City Name" />
<Data ref="F156" minOccurs="0" info="Subscriber State Code" />
<Data ref="F116" minOccurs="0" info="Subscriber Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
<Segment name="DMG" minOccurs="0" info="Subscriber Demographic Information">
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
</Values>
</Data>
<Data ref="F1251" info="Subscriber Birth Date" />
<Data ref="F1068" info="Subscriber Gender Code">
<Values>
<Value Code="F" />
<Value Code="M" />
<Value Code="U" />
</Values>
</Data>
<Data ref="F1067" minOccurs="0" maxOccurs="0" />
<Composite name="C056" minOccurs="0" maxOccurs="0" />
<Data ref="F1066" minOccurs="0" maxOccurs="0" />
<Data ref="F26" minOccurs="0" maxOccurs="0" />
<Data ref="F659" minOccurs="0" maxOccurs="0" />
<Data ref="F380" minOccurs="0" maxOccurs="0" />
<Data ref="F1270" minOccurs="0" maxOccurs="0" />
<Data ref="F1271" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Subscriber Secondary Identification" nodeName="REF_1">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="SY" />
</Values>
</Data>
<Data ref="F127" info="Subscriber Supplemental Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Property and Casualty Claim Number" nodeName="REF_2">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="Y4" />
</Values>
</Data>
<Data ref="F127" info="Property Casualty Claim Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2010BB" info="Payer Name">
<Segment name="NM1" info="Payer Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="PR" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Payer Name" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" info="Identification Code Qualifier">
<Values>
<Value Code="PI" />
<Value Code="XV" />
</Values>
</Data>
<Data ref="F67" info="Payer Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" minOccurs="0" info="Payer Address">
<Data ref="F166" info="Payer Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" minOccurs="0" info="Payer City, State, ZIP Code">
<Data ref="F19" info="Payer City Name" />
<Data ref="F156" minOccurs="0" info="Payer State Code" />
<Data ref="F116" minOccurs="0" info="Payer Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="3" info="Payer Secondary Identification" nodeName="REF_1">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="2U" />
<Value Code="EI" />
<Value Code="FY" />
<Value Code="NF" />
</Values>
</Data>
<Data ref="F127" info="Payer Additional Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Billing Provider Secondary Identification" nodeName="REF_2">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Billing Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
        <Group name="Loop2010BC" info="Adjuster Name">
<Segment name="NM1" info="Adjuster Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="A1" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Adjuster Name" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" info="Identification Code Qualifier">
<Values>
<Value Code="MI" />
</Values>
</Data>
<Data ref="F67" info="Payer Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" minOccurs="0" info="Adjuster Address">
<Data ref="F166" info="Adjuster Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" minOccurs="0" info="Adjuster City, State, ZIP Code">
<Data ref="F19" info="Adjuster City Name" />
<Data ref="F156" minOccurs="0" info="Adjuster State Code" />
<Data ref="F116" minOccurs="0" info="Adjuster Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
          <Segment name="PER" minOccurs="0" maxOccurs="2" info="Adjuster Contact Information">
<Data ref="F366" info="Contact Function Code">
<Values>
<Value Code="IC" />
</Values>
</Data>
<Data ref="F93" minOccurs="0" info="Adjuster Contact Name" />
<Data ref="F365" info="Communication Number Qualifier" nodeName="F365_1">
<Values>
<Value Code="EM" />
<Value Code="FX" />
<Value Code="TE" />
              <Value Code="ED" />
</Values>
</Data>
<Data ref="F364" info="Communication Number" nodeName="F364_1" />
<Data ref="F365" minOccurs="0" info="Communication Number Qualifier" nodeName="F365_2">
<Values>
<Value Code="EM" />
<Value Code="EX" />
<Value Code="FX" />
<Value Code="TE" />
              <Value Code="ED" />
</Values>
</Data>
<Data ref="F364" minOccurs="0" info="Communication Number" nodeName="F364_2" />
<Data ref="F365" minOccurs="0" info="Communication Number Qualifier" nodeName="F365_3">
<Values>
<Value Code="EM" />
<Value Code="EX" />
<Value Code="FX" />
<Value Code="TE" />
              <Value Code="ED" />
</Values>
</Data>
<Data ref="F364" minOccurs="0" info="Communication Number" nodeName="F364_3" />
<Data ref="F443" minOccurs="0" maxOccurs="0" />
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        </Group>
<Group ref="2300-837-Q3" maxOccurs="100" minOccurs="0" info="Claim Information (floating)" />
<Group name="Loop2000C" maxOccurs="unbounded" minOccurs="0" info="Patient Hierarchical Level">
<Segment name="HL" info="Patient Hierarchical Level">
<Condition path="F735" />
<Data ref="F628" info="Hierarchical ID Number" />
<Data ref="F734" info="Hierarchical Parent ID Number" />
<Data ref="F735" info="Hierarchical Level Code">
<Values>
<Value Code="23" />
</Values>
</Data>
<Data ref="F736" info="Hierarchical Child Code">
<Values>
<Value Code="0" />
</Values>
</Data>
</Segment>
<Segment name="PAT" info="Patient Information">
<Data ref="F1069" info="Individual Relationship Code">
<Values>
<Value Code="01" />
<Value Code="19" />
<Value Code="20" />
<Value Code="21" />
<Value Code="39" />
<Value Code="40" />
<Value Code="53" />
<Value Code="G8" />
</Values>
</Data>
<Data ref="F1384" minOccurs="0" maxOccurs="0" />
<Data ref="F584" minOccurs="0" maxOccurs="0" />
<Data ref="F1220" minOccurs="0" maxOccurs="0" />
<Data ref="F1250" minOccurs="0" maxOccurs="0" />
<Data ref="F1251" minOccurs="0" maxOccurs="0" />
<Data ref="F355" minOccurs="0" maxOccurs="0" />
<Data ref="F81" minOccurs="0" maxOccurs="0" />
<Data ref="F1073" minOccurs="0" maxOccurs="0" />
</Segment>
<Group name="Loop2010CA" info="Patient Name">
<Segment name="NM1" info="Patient Name">
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="QC" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Patient Last Name" />
<Data ref="F1036" minOccurs="0" info="Patient First Name" />
<Data ref="F1037" minOccurs="0" info="Patient Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Patient Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
                  <Values>
                      <Value Code="MI" />
                  </Values>
              </Data>
<Data ref="F67" minOccurs="0" info="Patients Social Security Number" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" info="Patient Address">
<Data ref="F166" info="Patient Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" info="Patient City, State, ZIP Code">
<Data ref="F19" info="Patient City Name" />
<Data ref="F156" minOccurs="0" info="Patient State Code" />
<Data ref="F116" minOccurs="0" info="Patient Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
<Segment name="DMG" info="Patient Demographic Information">
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
</Values>
</Data>
<Data ref="F1251" info="Patient Birth Date" />
<Data ref="F1068" info="Patient Gender Code">
<Values>
<Value Code="F" />
<Value Code="M" />
<Value Code="U" />
</Values>
</Data>
<Data ref="F1067" minOccurs="0" maxOccurs="0" />
<Composite name="C056" minOccurs="0" maxOccurs="0" />
<Data ref="F1066" minOccurs="0" maxOccurs="0" />
<Data ref="F26" minOccurs="0" maxOccurs="0" />
<Data ref="F659" minOccurs="0" maxOccurs="0" />
<Data ref="F380" minOccurs="0" maxOccurs="0" />
<Data ref="F1270" minOccurs="0" maxOccurs="0" />
<Data ref="F1271" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Property and Casualty Claim Number" nodeName="REF_1">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="Y4" />
</Values>
</Data>
<Data ref="F127" info="Property Casualty Claim Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Property and Casualty Patient Identifier" nodeName="REF_2">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="1W" />
<Value Code="SY" />
</Values>
</Data>
<Data ref="F127" info="Property and Casualty Patient Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
            <Segment name="REF" minOccurs="0" info="Branch Office ID" nodeName="REF_3">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="3L" />
</Values>
</Data>
<Data ref="F127" minOccurs="0" info="Branch ID" />
<Data ref="F352" minOccurs="0" info="Branch Office Name" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
            <Segment name="REF" minOccurs="0" info="OBN ID" nodeName="REF_4">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="D7" />
</Values>
</Data>
<Data ref="F127" minOccurs="0" info="OBN Eligibility" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2300" maxOccurs="100" info="Claim Information" id="2300-837-Q3">
<Segment name="CLM" info="Claim Information">
<Data ref="F1028" info="Patient Control Number" />
<Data ref="F782" info="Total Claim Charge Amount" />
<Data ref="F1032" minOccurs="0" maxOccurs="0" />
<Data ref="F1343" minOccurs="0" maxOccurs="0" />
<Composite name="C023" info="Health Care Service Location Information">
<Data ref="F1331" info="Facility Type Code" />
<Data ref="F1332" info="Facility Code Qualifier">
<Values>
<Value Code="A" />
</Values>
</Data>
<Data ref="F1325" info="Claim Frequency Code" />
</Composite>
<Data ref="F1073" minOccurs="0" maxOccurs="0" nodeName="F1073_unused_1" />
<Data ref="F1359" info="Assignment or Plan Participation Code">
<Values>
<Value Code="A" />
<Value Code="B" />
<Value Code="C" />
</Values>
</Data>
<Data ref="F1073" info="Benefits Assignment Certification Indicator">
<Values>
<Value Code="N" />
<Value Code="W" />
<Value Code="Y" />
</Values>
</Data>
<Data ref="F1363" info="Release of Information Code">
<Values>
<Value Code="I" />
<Value Code="Y" />
</Values>
</Data>
<Data ref="F1351" minOccurs="0" maxOccurs="0" />
<Composite name="C024" minOccurs="0" info="Related Causes Information">
<Data ref="F1362" info="Related Causes Code" nodeName="F1362_1">
<Values>
<Value Code="AA" />
<Value Code="EM" />
<Value Code="OA" />
</Values>
</Data>
<Data ref="F1362" minOccurs="0" info="Related Causes Code" nodeName="F1362_2" />
<Data ref="F1362" minOccurs="0" maxOccurs="0" />
<Data ref="F156" minOccurs="0" info="Auto Accident State or Province Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
</Composite>
<Data ref="F1366" minOccurs="0" maxOccurs="0" />
<Data ref="F1073" minOccurs="0" maxOccurs="0" nodeName="F1073_unused_2" />
<Data ref="F1338" minOccurs="0" maxOccurs="0" />
<Data ref="F1073" minOccurs="0" maxOccurs="0" nodeName="F1073_unused_3" />
<Data ref="F1360" minOccurs="0" info="Provider Agreement Code" />
<Data ref="F1029" minOccurs="0" maxOccurs="0" />
<Data ref="F1073" minOccurs="0" maxOccurs="0" nodeName="F1073_unused_4" />
<Data ref="F1383" minOccurs="0" maxOccurs="0" />
<Data ref="F1514" minOccurs="0" info="Delay Reason Code">
<Values>
<Value Code="1" />
<Value Code="2" />
<Value Code="3" />
<Value Code="4" />
<Value Code="5" />
<Value Code="6" />
<Value Code="7" />
<Value Code="8" />
<Value Code="9" />
<Value Code="10" />
<Value Code="11" />
<Value Code="15" />
</Values>
</Data>
</Segment>
<Segment name="DTP" minOccurs="0" info="Discharge Hour" nodeName="DTP_1">
<Condition path="F374" />
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="096" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="TM" />
</Values>
</Data>
<Data ref="F1251" info="Discharge Time" />
</Segment>
<Segment name="DTP" info="Statement Dates" nodeName="DTP_2">
<Condition path="F374" />
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="434" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="RD8" />
</Values>
</Data>
<Data ref="F1251" info="Statement From and To Date" />
</Segment>
<Segment name="DTP" minOccurs="0" info="Admission Date/Hour" nodeName="DTP_3">
<Condition path="F374" />
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="435" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
<Value Code="DT" />
</Values>
</Data>
<Data ref="F1251" info="Admission Date and Hour" />
</Segment>
<Segment name="DTP" minOccurs="0" info="Date - Repricer Received Date" nodeName="DTP_4">
<Condition path="F374" />
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="050" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
</Values>
</Data>
<Data ref="F1251" info="Repricer Received Date" />
</Segment>
            <Segment name="DTP" minOccurs="0" info="Claim Date" nodeName="DTP_5">
<Condition path="F374" />
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="523" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
</Values>
</Data>
<Data ref="F1251" info="Claim Date" />
</Segment>
            <Segment name="DTP" minOccurs="0" info="Date Injured" nodeName="DTP_6">
<Condition path="F374" />
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="439" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
</Values>
</Data>
<Data ref="F1251" info="Date Injured" />
</Segment>
            <Segment name="DTP" minOccurs="0" info="Date Initial Treatment" nodeName="DTP_7">
<Condition path="F374" />
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="454" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
</Values>
</Data>
<Data ref="F1251" info="Date Initial Treatment" />
</Segment>
<Segment name="CL1" info="Institutional Claim Code">
<Data ref="F1315" info="Admission Type Code" />
<Data ref="F1314" minOccurs="0" info="Admission Source Code" />
<Data ref="F1352" info="Patient Status Code" />
<Data ref="F1345" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="PWK" minOccurs="0" maxOccurs="10" info="Claim Supplemental Information">
<Data ref="F755" info="Attachment Report Type Code">
<Values>
<Value Code="03" />
<Value Code="04" />
<Value Code="05" />
<Value Code="06" />
<Value Code="07" />
<Value Code="08" />
<Value Code="09" />
<Value Code="10" />
<Value Code="11" />
<Value Code="13" />
<Value Code="15" />
<Value Code="21" />
<Value Code="A3" />
<Value Code="A4" />
<Value Code="AM" />
<Value Code="AS" />
<Value Code="B2" />
<Value Code="B3" />
<Value Code="B4" />
<Value Code="BR" />
<Value Code="BS" />
<Value Code="BT" />
<Value Code="CB" />
<Value Code="CK" />
<Value Code="CT" />
<Value Code="D2" />
<Value Code="DA" />
<Value Code="DB" />
<Value Code="DG" />
<Value Code="DJ" />
<Value Code="DS" />
<Value Code="EB" />
<Value Code="HC" />
<Value Code="HR" />
<Value Code="I5" />
<Value Code="IR" />
<Value Code="LA" />
<Value Code="M1" />
<Value Code="MT" />
<Value Code="NN" />
<Value Code="OB" />
<Value Code="OC" />
<Value Code="OD" />
<Value Code="OE" />
<Value Code="OX" />
<Value Code="OZ" />
<Value Code="P4" />
<Value Code="P5" />
<Value Code="PE" />
<Value Code="PN" />
<Value Code="PO" />
<Value Code="PQ" />
<Value Code="PY" />
<Value Code="PZ" />
<Value Code="RB" />
<Value Code="RR" />
<Value Code="RT" />
<Value Code="RX" />
<Value Code="SG" />
<Value Code="V5" />
<Value Code="XP" />
</Values>
</Data>
<Data ref="F756" info="Attachment Transmission Code">
<Values>
<Value Code="AA" />
<Value Code="BM" />
<Value Code="EL" />
<Value Code="EM" />
<Value Code="FT" />
<Value Code="FX" />
</Values>
</Data>
<Data ref="F757" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="AC" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Attachment Control Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C002" minOccurs="0" maxOccurs="0" />
<Data ref="F1525" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="CN1" minOccurs="0" info="Contract Information">
<Data ref="F1166" info="Contract Type Code">
<Values>
<Value Code="01" />
<Value Code="02" />
<Value Code="03" />
<Value Code="04" />
<Value Code="05" />
<Value Code="06" />
<Value Code="09" />
</Values>
</Data>
<Data ref="F782" minOccurs="0" info="Contract Amount" />
<Data ref="F332" minOccurs="0" info="Contract Percentage" />
<Data ref="F127" minOccurs="0" info="Contract Code" />
<Data ref="F338" minOccurs="0" info="Terms Discount Percentage" />
<Data ref="F799" minOccurs="0" info="Contract Version Identifier" />
</Segment>
<Segment name="AMT" minOccurs="0" info="Patient Estimated Amount Due">
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="F3" />
                  <Value Code="F5" />
</Values>
</Data>
<Data ref="F782" info="Patient Responsibility Amount" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Service Authorization Exception Code" nodeName="REF_1">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="4N" />
</Values>
</Data>
<Data ref="F127" info="Service Authorization Exception Code" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Referral Number" nodeName="REF_2">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="9F" />
</Values>
</Data>
<Data ref="F127" info="Referral Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Prior Authorization" nodeName="REF_3">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="G1" />
</Values>
</Data>
<Data ref="F127" info="Prior Authorization Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Payer Claim Control Number" nodeName="REF_4">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="F8" />
</Values>
</Data>
<Data ref="F127" info="Payer Claim Control Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Repriced Claim Number" nodeName="REF_5">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="9A" />
</Values>
</Data>
<Data ref="F127" info="Repriced Claim Reference Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Adjusted Repriced Claim Number" nodeName="REF_6">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="9C" />
</Values>
</Data>
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<Data ref="F1251" minOccurs="0" maxOccurs="0" />
<Data ref="F782" minOccurs="0" maxOccurs="0" />
<Data ref="F380" minOccurs="0" maxOccurs="0" />
<Data ref="F799" minOccurs="0" maxOccurs="0" />
<Data ref="F1271" minOccurs="0" maxOccurs="0" nodeName="F1271_unused_2" />
<Data ref="F1073" minOccurs="0" maxOccurs="0" />
</Composite>
</Segment>
<Segment name="HCP" minOccurs="0" info="Claim Pricing/Repricing Information">
<Data ref="F1473" info="Pricing Methodology">
<Values>
<Value Code="00" />
<Value Code="01" />
<Value Code="02" />
<Value Code="03" />
<Value Code="04" />
<Value Code="05" />
<Value Code="06" />
<Value Code="07" />
<Value Code="08" />
<Value Code="09" />
<Value Code="10" />
<Value Code="11" />
<Value Code="12" />
<Value Code="13" />
<Value Code="14" />
</Values>
</Data>
<Data ref="F782" info="Repriced Allowed Amount" nodeName="F782_1" />
<Data ref="F782" minOccurs="0" info="Repriced Saving Amount" nodeName="F782_2" />
<Data ref="F127" minOccurs="0" info="Repricing Organization Identifier" nodeName="F127_1" />
<Data ref="F118" minOccurs="0" info="Repricing Per Diem or Flat Rate Amount" />
<Data ref="F127" minOccurs="0" info="Repriced Approved DRG Code" nodeName="F127_2" />
<Data ref="F782" minOccurs="0" info="Repriced Approved Amount" nodeName="F782_3" />
<Data ref="F234" minOccurs="0" info="Repriced Approved Revenue Code" />
<Data ref="F235" minOccurs="0" maxOccurs="0" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_2" />
<Data ref="F355" minOccurs="0" info="Unit or Basis for Measurement Code">
<Values>
<Value Code="DA" />
<Value Code="UN" />
</Values>
</Data>
<Data ref="F380" minOccurs="0" info="Repriced Approved Service Unit Count" />
<Data ref="F901" minOccurs="0" info="Reject Reason Code">
<Values>
<Value Code="T1" />
<Value Code="T2" />
<Value Code="T3" />
<Value Code="T4" />
<Value Code="T5" />
<Value Code="T6" />
</Values>
</Data>
<Data ref="F1526" minOccurs="0" info="Policy Compliance Code">
<Values>
<Value Code="1" />
<Value Code="2" />
<Value Code="3" />
<Value Code="4" />
<Value Code="5" />
</Values>
</Data>
<Data ref="F1527" minOccurs="0" info="Exception Code">
<Values>
<Value Code="1" />
<Value Code="2" />
<Value Code="3" />
<Value Code="4" />
<Value Code="5" />
<Value Code="6" />
</Values>
</Data>
</Segment>
<Group name="Loop2310A" minOccurs="0" info="Attending Provider Name">
<Segment name="NM1" info="Attending Provider Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="71" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Attending Provider Last Name" />
<Data ref="F1036" minOccurs="0" info="Attending Provider First Name" />
<Data ref="F1037" minOccurs="0" info="Attending Provider Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Attending Provider Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Attending Provider Primary Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="PRV" minOccurs="0" info="Attending Provider Specialty Information">
<Data ref="F1221" info="Provider Code">
<Values>
<Value Code="AT" />
</Values>
</Data>
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="PXC" />
</Values>
</Data>
<Data ref="F127" info="Provider Taxonomy Code" />
<Data ref="F156" minOccurs="0" maxOccurs="0" />
<Composite name="C035" minOccurs="0" maxOccurs="0" />
<Data ref="F1223" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="4" info="Attending Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Attending Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2310B" minOccurs="0" info="Operating Physician Name">
<Segment name="NM1" info="Operating Physician Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="72" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Operating Physician Last Name" />
<Data ref="F1036" minOccurs="0" info="Operating Physician First Name" />
<Data ref="F1037" minOccurs="0" info="Operating Physician Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Operating Physician Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Operating Physician Primary Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="4" info="Operating Physician Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Operating Physician Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2310C" minOccurs="0" info="Other Operating Physician Name">
<Segment name="NM1" info="Other Operating Physician Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="ZZ" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Other Operating Physician Last Name" />
<Data ref="F1036" minOccurs="0" info="Other Operating Physician First Name" />
<Data ref="F1037" minOccurs="0" info="Other Operating Physician Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Other Operating Physician Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Other Operating Physician Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="4" info="Other Operating Physician Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Other Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2310D" minOccurs="0" info="Rendering Provider Name">
<Segment name="NM1" info="Rendering Provider Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="82" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Rendering Provider Last Name" />
<Data ref="F1036" minOccurs="0" info="Rendering Provider First Name" />
<Data ref="F1037" minOccurs="0" info="Rendering Provider Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Rendering Provider Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Rendering Provider Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="4" info="Rendering Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Rendering Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2310E" minOccurs="0" info="Service Facility Location Name">
<Segment name="NM1" info="Service Facility Location Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="77" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Laboratory or Facility Name" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Laboratory or Facility Primary Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" info="Service Facility Location Address">
<Data ref="F166" info="Laboratory or Facility Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" info="Service Facility Location City, State, ZIP Code">
<Data ref="F19" info="Laboratory or Facility City Name" />
<Data ref="F156" minOccurs="0" info="Laboratory or Facility State or Province Code" />
<Data ref="F116" minOccurs="0" info="Laboratory or Facility Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="3" info="Service Facility Location Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Laboratory or Facility Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2310F" minOccurs="0" info="Referring Provider Name">
<Segment name="NM1" info="Referring Provider Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="DN" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Referring Provider Last Name" />
<Data ref="F1036" minOccurs="0" info="Referring Provider First Name" />
<Data ref="F1037" minOccurs="0" info="Referring Provider Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Referring Provider Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Referring Provider Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="3" info="Referring Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
</Values>
</Data>
<Data ref="F127" info="Referring Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2320" maxOccurs="10" minOccurs="0" info="Other Subscriber Information">
<Segment name="SBR" info="Other Subscriber Information">
<Data ref="F1138" info="Payer Responsibility Sequence Number Code">
<Values>
<Value Code="A" />
<Value Code="B" />
<Value Code="C" />
<Value Code="D" />
<Value Code="E" />
<Value Code="F" />
<Value Code="G" />
<Value Code="H" />
<Value Code="P" />
<Value Code="S" />
<Value Code="T" />
<Value Code="U" />
</Values>
</Data>
<Data ref="F1069" info="Individual Relationship Code">
<Values>
<Value Code="01" />
<Value Code="18" />
<Value Code="19" />
<Value Code="20" />
<Value Code="21" />
<Value Code="39" />
<Value Code="40" />
<Value Code="53" />
<Value Code="G8" />
</Values>
</Data>
<Data ref="F127" minOccurs="0" info="Insured Group or Policy Number" />
<Data ref="F93" minOccurs="0" info="Other Insured Group Name" />
<Data ref="F1336" minOccurs="0" maxOccurs="0" />
<Data ref="F1143" minOccurs="0" maxOccurs="0" />
<Data ref="F1073" minOccurs="0" maxOccurs="0" />
<Data ref="F584" minOccurs="0" maxOccurs="0" />
<Data ref="F1032" minOccurs="0" info="Claim Filing Indicator Code">
<Values>
<Value Code="11" />
<Value Code="12" />
<Value Code="13" />
<Value Code="14" />
<Value Code="15" />
<Value Code="16" />
<Value Code="17" />
<Value Code="AM" />
<Value Code="BL" />
<Value Code="CH" />
<Value Code="CI" />
<Value Code="DS" />
<Value Code="FI" />
<Value Code="HM" />
<Value Code="LM" />
<Value Code="MA" />
<Value Code="MB" />
<Value Code="MC" />
<Value Code="OF" />
<Value Code="TV" />
<Value Code="VA" />
<Value Code="WC" />
<Value Code="ZZ" />
</Values>
</Data>
</Segment>
<Segment name="CAS" minOccurs="0" maxOccurs="5" info="Claim Level Adjustments">
<Data ref="F1033" info="Claim Adjustment Group Code">
<Values>
<Value Code="CO" />
<Value Code="CR" />
<Value Code="OA" />
<Value Code="PI" />
<Value Code="PR" />
</Values>
</Data>
<Data ref="F1034" info="Adjustment Reason Code" nodeName="F1034_1" />
<Data ref="F782" info="Adjustment Amount" nodeName="F782_1" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_1" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_2" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_2" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_2" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_3" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_3" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_3" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_4" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_4" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_4" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_5" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_5" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_5" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_6" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_6" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_6" />
</Segment>
<Segment name="AMT" minOccurs="0" info="Coordination of Benefits (COB) Payer Paid Amount" nodeName="AMT_1">
<Condition path="F522" />
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="D" />
</Values>
</Data>
<Data ref="F782" info="Payer Paid Amount" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="AMT" minOccurs="0" info="Remaining Patient Liability" nodeName="AMT_2">
<Condition path="F522" />
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="EAF" />
</Values>
</Data>
<Data ref="F782" info="Remaining Patient Liability" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="AMT" minOccurs="0" info="Coordination of Benefits (COB) Total Non-Covered Amount" nodeName="AMT_3">
<Condition path="F522" />
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="A8" />
</Values>
</Data>
<Data ref="F782" info="Non-Covered Charge Amount" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="OI" info="Other Insurance Coverage Information">
<Data ref="F1032" minOccurs="0" maxOccurs="0" />
<Data ref="F1383" minOccurs="0" maxOccurs="0" />
<Data ref="F1073" info="Benefits Assignment Certification Indicator">
<Values>
<Value Code="N" />
<Value Code="W" />
<Value Code="Y" />
</Values>
</Data>
<Data ref="F1351" minOccurs="0" maxOccurs="0" />
<Data ref="F1360" minOccurs="0" maxOccurs="0" />
<Data ref="F1363" info="Release of Information Code">
<Values>
<Value Code="I" />
<Value Code="Y" />
</Values>
</Data>
</Segment>
<Segment name="MIA" minOccurs="0" info="Inpatient Adjudication Information">
<Data ref="F380" info="Covered Days or Visits Count" nodeName="F380_1" />
<Data ref="F782" minOccurs="0" maxOccurs="0" />
<Data ref="F380" minOccurs="0" info="Lifetime Psychiatric Days Count" nodeName="F380_2" />
<Data ref="F782" minOccurs="0" info="Claim DRG Amount" nodeName="F782_1" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_1" />
<Data ref="F782" minOccurs="0" info="Claim Disproportionate Share Amount" nodeName="F782_2" />
<Data ref="F782" minOccurs="0" info="Claim MSP Pass-through Amount" nodeName="F782_3" />
<Data ref="F782" minOccurs="0" info="Claim PPS Capital Amount" nodeName="F782_4" />
<Data ref="F782" minOccurs="0" info="PPS-Capital FSP DRG Amount" nodeName="F782_5" />
<Data ref="F782" minOccurs="0" info="PPS-Capital HSP DRG Amount" nodeName="F782_6" />
<Data ref="F782" minOccurs="0" info="PPS-Capital DSH DRG Amount" nodeName="F782_7" />
<Data ref="F782" minOccurs="0" info="Old Capital Amount" nodeName="F782_8" />
<Data ref="F782" minOccurs="0" info="PPS-Capital IME amount" nodeName="F782_9" />
<Data ref="F782" minOccurs="0" info="PPS-Operating Hospital Specific DRG Amount" nodeName="F782_10" />
<Data ref="F380" minOccurs="0" info="Cost Report Day Count" nodeName="F380_3" />
<Data ref="F782" minOccurs="0" info="PPS-Operating Federal Specific DRG Amount" nodeName="F782_11" />
<Data ref="F782" minOccurs="0" info="Claim PPS Capital Outlier Amount" nodeName="F782_12" />
<Data ref="F782" minOccurs="0" info="Claim Indirect Teaching Amount" nodeName="F782_13" />
<Data ref="F782" minOccurs="0" info="Non-Payable Professional Component Billed Amount" nodeName="F782_14" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_2" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_3" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_4" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_5" />
<Data ref="F782" minOccurs="0" info="PPS-Capital Exception Amount" nodeName="F782_15" />
</Segment>
<Segment name="MOA" minOccurs="0" info="Outpatient Adjudication Information">
<Data ref="F954" minOccurs="0" info="Reimbursement Rate" />
<Data ref="F782" minOccurs="0" info="HCPCS Payable Amount" nodeName="F782_1" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_1" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_2" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_3" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_4" />
<Data ref="F127" minOccurs="0" info="Claim Payment Remark Code" nodeName="F127_5" />
<Data ref="F782" minOccurs="0" info="End Stage Renal Disease Payment Amount" nodeName="F782_2" />
<Data ref="F782" minOccurs="0" info="Non-Payable Professional Component Billed Amount" nodeName="F782_3" />
</Segment>
<Group name="Loop2330A" info="Other Subscriber Name">
<Segment name="NM1" info="Other Subscriber Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="IL" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Other Insured Last Name" />
<Data ref="F1036" minOccurs="0" info="Other Insured First Name" />
<Data ref="F1037" minOccurs="0" info="Other Insured Middle Name" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Other Insured Name Suffix" />
<Data ref="F66" info="Identification Code Qualifier">
<Values>
<Value Code="II" />
<Value Code="MI" />
</Values>
</Data>
<Data ref="F67" info="Other Insured Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" minOccurs="0" info="Other Subscriber Address">
<Data ref="F166" info="Other Insured Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" minOccurs="0" info="Other Subscriber City, State, ZIP Code">
<Data ref="F19" info="Other Insured City Name" />
<Data ref="F156" minOccurs="0" info="Other Insured State Code" />
<Data ref="F116" minOccurs="0" info="Other Insured Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="2" info="Other Subscriber Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="SY" />
</Values>
</Data>
<Data ref="F127" info="Other Insured Additional Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2330B" info="Other Payer Name">
<Segment name="NM1" info="Other Payer Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="PR" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" info="Other Payer Last or Organization Name" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" info="Identification Code Qualifier">
<Values>
<Value Code="PI" />
<Value Code="XV" />
</Values>
</Data>
<Data ref="F67" info="Other Payer Primary Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="N3" minOccurs="0" info="Other Payer Address">
<Data ref="F166" info="Other Payer Address Line" mergedEntries="2" />
</Segment>
<Segment name="N4" minOccurs="0" info="Other Payer City, State, ZIP Code">
<Data ref="F19" info="Other Payer City Name" />
<Data ref="F156" minOccurs="0" info="Other Payer State Code" />
<Data ref="F116" minOccurs="0" info="Other Payer Postal Zone or ZIP Code" />
<Data ref="F26" minOccurs="0" info="Country Code" />
<Data ref="F309" minOccurs="0" maxOccurs="0" />
<Data ref="F310" minOccurs="0" maxOccurs="0" />
<Data ref="F1715" minOccurs="0" info="Country Subdivision Code" />
</Segment>
<Segment name="DTP" minOccurs="0" info="Claim Check or Remittance Date">
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="573" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
</Values>
</Data>
<Data ref="F1251" info="Adjudication or Payment Date" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="2" info="Other Payer Secondary Identifier" nodeName="REF_1">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="2U" />
<Value Code="EI" />
<Value Code="FY" />
<Value Code="NF" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Other Payer Prior Authorization Number" nodeName="REF_2">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="G1" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Prior Authorization Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Other Payer Referral Number" nodeName="REF_3">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="9F" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Prior Authorization or Referral Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Other Payer Claim Adjustment Indicator" nodeName="REF_4">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="T4" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Claim Adjustment Indicator" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Other Payer Claim Control Number" nodeName="REF_5">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="F8" />
</Values>
</Data>
<Data ref="F127" info="Other Payer's Claim Control Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2330C" minOccurs="0" info="Other Payer Attending Provider">
<Segment name="NM1" info="Other Payer Attending Provider">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="71" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_1" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" maxOccurs="0" />
<Data ref="F67" minOccurs="0" maxOccurs="0" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" maxOccurs="4" info="Other Payer Attending Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Attending Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2330D" minOccurs="0" info="Other Payer Operating Physician">
<Segment name="NM1" info="Other Payer Operating Physician">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="72" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_1" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" maxOccurs="0" />
<Data ref="F67" minOccurs="0" maxOccurs="0" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" maxOccurs="4" info="Other Payer Operating Physician Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Operating Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2330E" minOccurs="0" info="Other Payer Other Operating Physician">
<Segment name="NM1" info="Other Payer Other Operating Physician">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="ZZ" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_1" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" maxOccurs="0" />
<Data ref="F67" minOccurs="0" maxOccurs="0" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" maxOccurs="4" info="Other Payer Other Operating Physician Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Other Operating Physician Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2330F" minOccurs="0" info="Other Payer Service Facility Location">
<Segment name="NM1" info="Other Payer Service Facility Location">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="77" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_1" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" maxOccurs="0" />
<Data ref="F67" minOccurs="0" maxOccurs="0" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" maxOccurs="3" info="Other Payer Service Facility Location Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Service Facility Location Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2330G" minOccurs="0" info="Other Payer Rendering Provider Name">
<Segment name="NM1" info="Other Payer Rendering Provider Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="82" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_1" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" maxOccurs="0" />
<Data ref="F67" minOccurs="0" maxOccurs="0" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" maxOccurs="4" info="Other Payer Rendering Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Rendering Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2330H" minOccurs="0" info="Other Payer Referring Provider">
<Segment name="NM1" info="Other Payer Referring Provider">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="DN" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_1" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" maxOccurs="0" />
<Data ref="F67" minOccurs="0" maxOccurs="0" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" maxOccurs="3" info="Other Payer Referring Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Referring Provider Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2330I" minOccurs="0" info="Other Payer Billing Provider">
<Segment name="NM1" info="Other Payer Billing Provider">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="85" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="2" />
</Values>
</Data>
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_1" />
<Data ref="F1036" minOccurs="0" maxOccurs="0" />
<Data ref="F1037" minOccurs="0" maxOccurs="0" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" maxOccurs="0" />
<Data ref="F67" minOccurs="0" maxOccurs="0" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" maxOccurs="2" info="Other Payer Billing Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Billing Provider Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
</Group>
<Group name="Loop2400" maxOccurs="999" info="Service Line Number">
<Segment name="LX" info="Service Line Number">
<Data ref="F554" info="Assigned Number" />
</Segment>
<Segment name="SV2" info="Institutional Service Line">
<Data ref="F234" info="Service Line Revenue Code" />
<Composite name="C003" minOccurs="0" info="Composite Medical Procedure Identifier">
<Data ref="F235" info="Product or Service ID Qualifier">
<Values>
<Value Code="ER" />
<Value Code="HC" />
<Value Code="HP" />
<Value Code="IV" />
<Value Code="WK" />
</Values>
</Data>
<Data ref="F234" info="Procedure Code" />
<Data ref="F1339" minOccurs="0" info="Procedure Modifier" nodeName="F1339_1" />
<Data ref="F1339" minOccurs="0" info="Procedure Modifier" nodeName="F1339_2" />
<Data ref="F1339" minOccurs="0" info="Procedure Modifier" nodeName="F1339_3" />
<Data ref="F1339" minOccurs="0" info="Procedure Modifier" nodeName="F1339_4" />
<Data ref="F352" minOccurs="0" info="Description" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_2" />
</Composite>
<Data ref="F782" info="Line Item Charge Amount" nodeName="F782_1" />
<Data ref="F355" info="Unit or Basis for Measurement Code">
<Values>
<Value Code="DA" />
<Value Code="UN" />
</Values>
</Data>
<Data ref="F380" info="Service Unit Count" />
<Data ref="F1371" minOccurs="0" maxOccurs="0" />
<Data ref="F782" minOccurs="0" info="Line Item Denied Charge or Non-Covered Charge Amount" nodeName="F782_2" />
<Data ref="F1073" minOccurs="0" maxOccurs="0" />
<Data ref="F1345" minOccurs="0" maxOccurs="0" />
<Data ref="F1337" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="PWK" minOccurs="0" maxOccurs="10" info="Line Supplemental Information">
<Data ref="F755" info="Attachment Report Type Code">
<Values>
<Value Code="03" />
<Value Code="04" />
<Value Code="05" />
<Value Code="06" />
<Value Code="07" />
<Value Code="08" />
<Value Code="09" />
<Value Code="10" />
<Value Code="11" />
<Value Code="13" />
<Value Code="15" />
<Value Code="21" />
<Value Code="A3" />
<Value Code="A4" />
<Value Code="AM" />
<Value Code="AS" />
<Value Code="B2" />
<Value Code="B3" />
<Value Code="B4" />
<Value Code="BR" />
<Value Code="BS" />
<Value Code="BT" />
<Value Code="CB" />
<Value Code="CK" />
<Value Code="CT" />
<Value Code="D2" />
<Value Code="DA" />
<Value Code="DB" />
<Value Code="DG" />
<Value Code="DJ" />
<Value Code="DS" />
<Value Code="EB" />
<Value Code="HC" />
<Value Code="HR" />
<Value Code="I5" />
<Value Code="IR" />
<Value Code="LA" />
<Value Code="M1" />
<Value Code="MT" />
<Value Code="NN" />
<Value Code="OB" />
<Value Code="OC" />
<Value Code="OD" />
<Value Code="OE" />
<Value Code="OX" />
<Value Code="OZ" />
<Value Code="P4" />
<Value Code="P5" />
<Value Code="PE" />
<Value Code="PN" />
<Value Code="PO" />
<Value Code="PQ" />
<Value Code="PY" />
<Value Code="PZ" />
<Value Code="RB" />
<Value Code="RR" />
<Value Code="RT" />
<Value Code="RX" />
<Value Code="SG" />
<Value Code="V5" />
<Value Code="XP" />
</Values>
</Data>
<Data ref="F756" info="Attachment Transmission Code">
<Values>
<Value Code="AA" />
<Value Code="BM" />
<Value Code="EL" />
<Value Code="EM" />
<Value Code="FT" />
<Value Code="FX" />
</Values>
</Data>
<Data ref="F757" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="AC" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Attachment Control Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C002" minOccurs="0" maxOccurs="0" />
<Data ref="F1525" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="DTP" minOccurs="0" info="Date - Service Date">
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="472" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
<Value Code="RD8" />
</Values>
</Data>
<Data ref="F1251" info="Service Date" />
</Segment>
<Segment name="REF" minOccurs="0" info="Line Item Control Number" nodeName="REF_1">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="6R" />
</Values>
</Data>
<Data ref="F127" info="Line Item Control Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Repriced Line Item Reference Number" nodeName="REF_2">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="9B" />
</Values>
</Data>
<Data ref="F127" info="Repriced Line Item Reference Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Adjusted Repriced Line Item Reference Number" nodeName="REF_3">
<Condition path="F128" />
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="9D" />
</Values>
</Data>
<Data ref="F127" info="Adjusted Repriced Line Item Reference Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
              <Segment name="AMT" minOccurs="0" info="Line Item Paid Amount" nodeName="AMT_1">
<Condition path="F522" />
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="F5" />
                    <Value Code="ST" />
                    <Value Code="F9" />
</Values>
</Data>
<Data ref="F782" info="Paid Amount" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
              <Segment name="AMT" minOccurs="0" info="Maximum Amount" nodeName="AMT_2">
<Condition path="F522" />
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="MA" />
</Values>
</Data>
<Data ref="F782" info="Maximum Amount" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="AMT" minOccurs="0" info="Service Tax Amount" nodeName="AMT_3">
<Condition path="F522" />
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="GT" />
</Values>
</Data>
<Data ref="F782" info="Service Tax Amount" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="AMT" minOccurs="0" info="Facility Tax Amount" nodeName="AMT_4">
<Condition path="F522" />
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="N8" />
</Values>
</Data>
<Data ref="F782" info="Facility Tax Amount" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="NTE" minOccurs="0" info="Third Party Organization Notes">
<Data ref="F363" info="Note Reference Code">
<Values>
<Value Code="TPO" />
</Values>
</Data>
<Data ref="F352" info="Line Note Text" />
</Segment>
<Segment name="HCP" minOccurs="0" info="Line Pricing/Repricing Information">
<Data ref="F1473" info="Pricing Methodology">
<Values>
<Value Code="00" />
<Value Code="01" />
<Value Code="02" />
<Value Code="03" />
<Value Code="04" />
<Value Code="05" />
<Value Code="06" />
<Value Code="07" />
<Value Code="08" />
<Value Code="09" />
<Value Code="10" />
<Value Code="11" />
<Value Code="12" />
<Value Code="13" />
<Value Code="14" />
</Values>
</Data>
<Data ref="F782" info="Monetary Amount" mergedEntries="2" nodeName="F782_1" />
<Data ref="F127" minOccurs="0" info="Reference Identification" nodeName="F127_1" />
<Data ref="F118" minOccurs="0" info="Rate" />
<Data ref="F127" minOccurs="0" info="Reference Identification" nodeName="F127_2" />
<Data ref="F782" minOccurs="0" info="Monetary Amount" nodeName="F782_2" />
<Data ref="F234" minOccurs="0" info="Product or Service ID" nodeName="F234_1" />
<Data ref="F235" minOccurs="0" info="Product or Service ID Qualifier">
<Values>
<Value Code="ER" />
<Value Code="HC" />
<Value Code="HP" />
<Value Code="IV" />
<Value Code="WK" />
</Values>
</Data>
<Data ref="F234" minOccurs="0" info="Repriced Approved HCPCS Code" nodeName="F234_2" />
<Data ref="F355" minOccurs="0" info="Unit or Basis for Measurement Code">
<Values>
<Value Code="DA" />
<Value Code="UN" />
</Values>
</Data>
<Data ref="F380" minOccurs="0" info="Quantity" />
<Data ref="F901" minOccurs="0" info="Reject Reason Code">
<Values>
<Value Code="T1" />
<Value Code="T2" />
<Value Code="T3" />
<Value Code="T4" />
<Value Code="T5" />
<Value Code="T6" />
</Values>
</Data>
<Data ref="F1526" minOccurs="0" info="Policy Compliance Code">
<Values>
<Value Code="1" />
<Value Code="2" />
<Value Code="3" />
<Value Code="4" />
<Value Code="5" />
</Values>
</Data>
<Data ref="F1527" minOccurs="0" info="Exception Code">
<Values>
<Value Code="1" />
<Value Code="2" />
<Value Code="3" />
<Value Code="4" />
<Value Code="5" />
<Value Code="6" />
</Values>
</Data>
</Segment>
<Group name="Loop2410" minOccurs="0" info="Drug Identification">
<Segment name="LIN" info="Drug Identification">
<Data ref="F350" minOccurs="0" maxOccurs="0" />
<Data ref="F235" info="Product or Service ID Qualifier">
<Values>
<Value Code="N4" />
</Values>
</Data>
<Data ref="F234" info="National Drug Code" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_2" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_2" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_3" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_3" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_4" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_4" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_5" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_5" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_6" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_6" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_7" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_7" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_8" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_8" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_9" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_9" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_10" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_10" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_11" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_11" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_12" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_12" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_13" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_13" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_14" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_14" />
<Data ref="F235" minOccurs="0" maxOccurs="0" nodeName="F235_unused_15" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_15" />
</Segment>
<Segment name="CTP" info="Drug Quantity">
<Data ref="F687" minOccurs="0" maxOccurs="0" />
<Data ref="F236" minOccurs="0" maxOccurs="0" />
<Data ref="F212" minOccurs="0" maxOccurs="0" />
<Data ref="F380" info="National Drug Unit Count" />
<Composite name="C001" info="Composite Unit of Measure">
<Data ref="F355" info="Code Qualifier">
<Values>
<Value Code="F2" />
<Value Code="GR" />
<Value Code="ME" />
<Value Code="ML" />
<Value Code="UN" />
</Values>
</Data>
<Data ref="F1018" minOccurs="0" maxOccurs="0" nodeName="F1018_unused_1" />
<Data ref="F649" minOccurs="0" maxOccurs="0" nodeName="F649_unused_1" />
<Data ref="F355" minOccurs="0" maxOccurs="0" nodeName="F355_unused_2" />
<Data ref="F1018" minOccurs="0" maxOccurs="0" nodeName="F1018_unused_2" />
<Data ref="F649" minOccurs="0" maxOccurs="0" nodeName="F649_unused_2" />
<Data ref="F355" minOccurs="0" maxOccurs="0" nodeName="F355_unused_3" />
<Data ref="F1018" minOccurs="0" maxOccurs="0" nodeName="F1018_unused_3" />
<Data ref="F649" minOccurs="0" maxOccurs="0" nodeName="F649_unused_3" />
<Data ref="F355" minOccurs="0" maxOccurs="0" nodeName="F355_unused_4" />
<Data ref="F1018" minOccurs="0" maxOccurs="0" nodeName="F1018_unused_4" />
<Data ref="F649" minOccurs="0" maxOccurs="0" nodeName="F649_unused_4" />
<Data ref="F355" minOccurs="0" maxOccurs="0" nodeName="F355_unused_5" />
<Data ref="F1018" minOccurs="0" maxOccurs="0" nodeName="F1018_unused_5" />
<Data ref="F649" minOccurs="0" maxOccurs="0" nodeName="F649_unused_5" />
</Composite>
<Data ref="F648" minOccurs="0" maxOccurs="0" />
<Data ref="F649" minOccurs="0" maxOccurs="0" />
<Data ref="F782" minOccurs="0" maxOccurs="0" />
<Data ref="F639" minOccurs="0" maxOccurs="0" />
<Data ref="F499" minOccurs="0" maxOccurs="0" />
<Data ref="F289" minOccurs="0" maxOccurs="0" />
</Segment>
<Segment name="REF" minOccurs="0" info="Prescription or Compound Drug Association Number">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="VY" />
<Value Code="XZ" />
</Values>
</Data>
<Data ref="F127" info="Prescription Number" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
<Group name="Loop2420A" minOccurs="0" info="Operating Physician Name">
<Segment name="NM1" info="Operating Physician Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="72" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Operating Physician Last Name" />
<Data ref="F1036" minOccurs="0" info="Operating Physician First Name" />
<Data ref="F1037" minOccurs="0" info="Operating Physician Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Operating Physician Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Operating Physician Primary Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="20" info="Operating Physician Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Operating Physician Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" info="Reference Identifier">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="2U" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Primary Identifier" />
<Data ref="F128" minOccurs="0" maxOccurs="0" nodeName="F128_unused_2" />
<Data ref="F127" minOccurs="0" maxOccurs="0" nodeName="F127_unused_2" />
<Data ref="F128" minOccurs="0" maxOccurs="0" nodeName="F128_unused_3" />
<Data ref="F127" minOccurs="0" maxOccurs="0" nodeName="F127_unused_3" />
</Composite>
</Segment>
</Group>
<Group name="Loop2420B" minOccurs="0" info="Other Operating Physician Name">
<Segment name="NM1" info="Other Operating Physician Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="ZZ" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Other Operating Physician Last Name" />
<Data ref="F1036" minOccurs="0" info="Other Operating Physician First Name" />
<Data ref="F1037" minOccurs="0" info="Other Operating Physician Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Other Operating Physician Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Other Operating Physician Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="20" info="Other Operating Physician Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Other Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" info="Reference Identifier">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="2U" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Primary Identifier" />
<Data ref="F128" minOccurs="0" maxOccurs="0" nodeName="F128_unused_2" />
<Data ref="F127" minOccurs="0" maxOccurs="0" nodeName="F127_unused_2" />
<Data ref="F128" minOccurs="0" maxOccurs="0" nodeName="F128_unused_3" />
<Data ref="F127" minOccurs="0" maxOccurs="0" nodeName="F127_unused_3" />
</Composite>
</Segment>
</Group>
<Group name="Loop2420C" minOccurs="0" info="Rendering Provider Name">
<Segment name="NM1" info="Rendering Provider Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="82" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Rendering Provider Last Name" />
<Data ref="F1036" minOccurs="0" info="Rendering Provider First Name" />
<Data ref="F1037" minOccurs="0" info="Rendering Provider Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Rendering Provider Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Rendering Provider Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="20" info="Rendering Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
<Value Code="LU" />
</Values>
</Data>
<Data ref="F127" info="Rendering Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" info="Reference Identifier">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="2U" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Primary Identifier" />
<Data ref="F128" minOccurs="0" maxOccurs="0" nodeName="F128_unused_2" />
<Data ref="F127" minOccurs="0" maxOccurs="0" nodeName="F127_unused_2" />
<Data ref="F128" minOccurs="0" maxOccurs="0" nodeName="F128_unused_3" />
<Data ref="F127" minOccurs="0" maxOccurs="0" nodeName="F127_unused_3" />
</Composite>
</Segment>
</Group>
<Group name="Loop2420D" minOccurs="0" info="Referring Provider Name">
<Segment name="NM1" info="Referring Provider Name">
<Condition path="F98" />
<Data ref="F98" info="Entity Identifier Code">
<Values>
<Value Code="DN" />
</Values>
</Data>
<Data ref="F1065" info="Entity Type Qualifier">
<Values>
<Value Code="1" />
</Values>
</Data>
<Data ref="F1035" info="Referring Provider Last Name" />
<Data ref="F1036" minOccurs="0" info="Referring Provider First Name" />
<Data ref="F1037" minOccurs="0" info="Referring Provider Middle Name or Initial" />
<Data ref="F1038" minOccurs="0" maxOccurs="0" />
<Data ref="F1039" minOccurs="0" info="Referring Provider Name Suffix" />
<Data ref="F66" minOccurs="0" info="Identification Code Qualifier">
<Values>
<Value Code="XX" />
</Values>
</Data>
<Data ref="F67" minOccurs="0" info="Referring Provider Identifier" />
<Data ref="F706" minOccurs="0" maxOccurs="0" />
<Data ref="F98" minOccurs="0" maxOccurs="0" nodeName="F98_unused_2" />
<Data ref="F1035" minOccurs="0" maxOccurs="0" nodeName="F1035_unused_2" />
</Segment>
<Segment name="REF" minOccurs="0" maxOccurs="20" info="Referring Provider Secondary Identification">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="0B" />
<Value Code="1G" />
<Value Code="G2" />
</Values>
</Data>
<Data ref="F127" info="Referring Provider Secondary Identifier" />
<Data ref="F352" minOccurs="0" maxOccurs="0" />
<Composite name="C040" minOccurs="0" info="Reference Identifier">
<Data ref="F128" info="Reference Identification Qualifier">
<Values>
<Value Code="2U" />
</Values>
</Data>
<Data ref="F127" info="Other Payer Primary Identifier" />
<Data ref="F128" minOccurs="0" maxOccurs="0" nodeName="F128_unused_2" />
<Data ref="F127" minOccurs="0" maxOccurs="0" nodeName="F127_unused_2" />
<Data ref="F128" minOccurs="0" maxOccurs="0" nodeName="F128_unused_3" />
<Data ref="F127" minOccurs="0" maxOccurs="0" nodeName="F127_unused_3" />
</Composite>
</Segment>
</Group>
<Group name="Loop2430" maxOccurs="15" minOccurs="0" info="Line Adjudication Information">
<Segment name="SVD" info="Line Adjudication Information">
<Data ref="F67" info="Other Payer Primary Identifier" />
<Data ref="F782" info="Service Line Paid Amount" />
<Composite name="C003" minOccurs="0" info="Composite Medical Procedure Identifier">
<Data ref="F235" info="Product or Service ID Qualifier">
<Values>
<Value Code="ER" />
<Value Code="HC" />
<Value Code="HP" />
<Value Code="IV" />
<Value Code="WK" />
</Values>
</Data>
<Data ref="F234" info="Procedure Code" />
<Data ref="F1339" minOccurs="0" info="Procedure Modifier" nodeName="F1339_1" />
<Data ref="F1339" minOccurs="0" info="Procedure Modifier" nodeName="F1339_2" />
<Data ref="F1339" minOccurs="0" info="Procedure Modifier" nodeName="F1339_3" />
<Data ref="F1339" minOccurs="0" info="Procedure Modifier" nodeName="F1339_4" />
<Data ref="F352" minOccurs="0" info="Procedure Code Description" />
<Data ref="F234" minOccurs="0" maxOccurs="0" nodeName="F234_unused_2" />
</Composite>
<Data ref="F234" info="Service Line Revenue Code" />
<Data ref="F380" info="Paid Service Unit Count" />
<Data ref="F554" minOccurs="0" info="Bundled Line Number" />
</Segment>
<Segment name="CAS" minOccurs="0" maxOccurs="5" info="Line Adjustment">
<Data ref="F1033" info="Claim Adjustment Group Code">
<Values>
<Value Code="CO" />
<Value Code="CR" />
<Value Code="OA" />
<Value Code="PI" />
<Value Code="PR" />
</Values>
</Data>
<Data ref="F1034" info="Adjustment Reason Code" nodeName="F1034_1" />
<Data ref="F782" info="Adjustment Amount" nodeName="F782_1" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_1" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_2" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_2" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_2" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_3" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_3" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_3" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_4" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_4" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_4" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_5" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_5" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_5" />
<Data ref="F1034" minOccurs="0" info="Adjustment Reason Code" nodeName="F1034_6" />
<Data ref="F782" minOccurs="0" info="Adjustment Amount" nodeName="F782_6" />
<Data ref="F380" minOccurs="0" info="Adjustment Quantity" nodeName="F380_6" />
</Segment>
<Segment name="DTP" info="Line Check or Remittance Date">
<Data ref="F374" info="Date Time Qualifier">
<Values>
<Value Code="573" />
</Values>
</Data>
<Data ref="F1250" info="Date Time Period Format Qualifier">
<Values>
<Value Code="D8" />
</Values>
</Data>
<Data ref="F1251" info="Adjudication or Payment Date" />
</Segment>
<Segment name="AMT" minOccurs="0" info="Remaining Patient Liability">
<Data ref="F522" info="Amount Qualifier Code">
<Values>
<Value Code="EAF" />
</Values>
</Data>
<Data ref="F782" info="Remaining Patient Liability" />
<Data ref="F478" minOccurs="0" maxOccurs="0" />
</Segment>
</Group>
</Group>
</Group>
</Group>
</Group>
</Group>
<Segment name="SE" info="Transaction Set Trailer">
<Data ref="F96" info="Transaction Segment Count" />
<Data ref="F329" info="Transaction Set Control Number" />
</Segment>
</Group>
</Message>
</Config>

James

Rank: Member

Joined: 2/21/2017
Posts: 14

OK. The second one seems to have all I need so I'll go with that one.

Thank you.

JamesNT

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