# Additional name information (Applies in every case !)
N2*		N2*n Associates, Inc

# Address (Applies in every case !)
N3*		N3*225 Main Street*Barkley Building

# City, State, ZIP (Applies in every case !)
N4*		N4*Centerville*PA*17111*US

# Contact person and number (Applies in every case.  You may need to customize this.)
PER*		PER**Jane Doe**9005555555**8005551212**8775551212

# Subscriber information (Group name and number)
SBR*		SBR***G01020102*Group Name

# Subscriber Name (Name and ID number)
NM1*IL*2*	NM1***John T Doe Liability Co.******123456
NM1*IL*1*	NM1***Doe*John*T**Jr**123456

# Corrected Insured Name (Name and ID number)
NM1*74*2*	NM1***Shepard Liability Co.******666666666A
NM1*74*1*	NM1***Right*Samuel*O**Sr**666666666A

# Prior Incorrect Insured (Name and ID number)
NM1*70*2*	NM1***Shepard Liability Co.******666666666A
NM1*70*1*	NM1***Prior*Samuel*O**Sr**666666666A

# Dependent Name
NM1*03*1*	NM1***Smith*MaryLou*R****777777777A

# Employee Name
NM1*EY*1*	NM1***Shepard*Jessica*S****999887777A

# Demographic information (DOB)
DMG*		DMG**19330706

# Patient information (DOD)
PAT*		PAT******19970314

# Patient Name
NM1*QC*1*	NM1***Doe*Sally*J****SJD11111

# Custodial Parent
NM1*S3*1*	NM1***Jones*Mary*R****777777777A

# Responsible Person
NM1*E1*1*	NM1***Case*John*R****777777777A
NM1*EI*1*	NM1***Case*John*R****777777777A
NM1*EXS*1*	NM1***Case*John*R****777777777A
NM1*GD*1*	NM1***Case*John*R****777777777A
NM1*J6*1*	NM1***Case*John*R****777777777A
NM1*QD*1*	NM1***Case*John*R****777777777A

# Responsible Party name
NM1*QD*2*	NM1***Estate of Lisa Jones
NM1*QD*1*	NM1***Jones*Lisa*J**Sr

# Legal Representative
NM1*LR*2*	NM1***Mary Jones Executor******123456
NM1*LR*1*	NM1***Jones*James*J**Jr**123456

# Credit/Debit Cardholder name
NM1*AO*2*	NM1***Smith Enterprises******370000000000000
NM1*AO*1*	NM1***Smith*Jane*L****370000000000000

# 0F - Subscriber Number
REF*0F*		REF**920399398
# 1K - Payor's Claim Number
REF*1K*		REF**9918046987
# 1L - Group or Policy Number
REF*1L*		REF**666123
# 1W - Member Identification Number
REF*1W*		REF**528446666
# 17 - Client Reporting Category
REF*17*		REF**920399398
# 23 - Client Number
REF*23*		REF**528446666
# 2U - Payer Identification Number
REF*2U*		REF**465980789
# 3H - Case Number
REF*3H*		REF**660415
# 49 - Family Unit Number
REF*49*		REF**660415
# 4A - Personal Identification Number (PIN)
REF*4A*		REF**477563928
# 60 - Account Suffix Code
REF*60*		REF**AZ12345
# 6P - Group Number
REF*6P*		REF**660415
# 6R - Provider Control Number
REF*6R*		REF**54321
# 9A - Repriced Claim Reference Number
REF*9A*		REF**RJ55555
# 9B - Repriced Line Item Reference Number
REF*9B*		REF**444444
# 9C - Adjusted Repriced Claim Reference Number
REF*9C*		REF**RP44444444
# 9D - Adjusted Repriced Line Item Reference Number
REF*9D*		REF**444444
# 9F - Referral Number
REF*9F*		REF**13579
# A6 - Employee Identification Number
REF*A6*		REF**666123
# AB - Acceptable Source Purchaser ID
REF*AB*		REF**111222333334
# BB - Authorization Number
REF*BB*		REF**111222333334
# CE - Class of Contract Code
REF*CE*		REF**666123
# CT - Contract Number
REF*CT*		REF**477563928
# D9 - Claim Number
REF*D9*		REF**TJ98UU321
# DD - Document Identification Code
REF*DD*		REF**96234007932
# E9 - Attachment Code
REF*E9*		REF**4445555
# EA - Medical Record Identification Number
REF*EA*		REF**44444TH56
# EJ - Patient Account Number
REF*EJ*		REF**660415
# F6 - Health Insurance Claim (HIC) Number
REF*F6*		REF**660415
# F8 - Original Reference Number
REF*F8*		REF**R555588
# FJ - Line Item Control Number
REF*FJ*		REF**6042201
# G1 - Prior Authorization Number
REF*G1*		REF**13579
# G3 - Predetermination of Benefits Identification Number
REF*G3*		REF**13579
# G4 - Peer Review Organization (PRO) Approval Number
REF*G4*		REF**284746
# GH - Identification Card Serial Number
REF*GH*		REF**660415
# HJ - Identity Card Number
REF*HJ*		REF**660415
# IF - Issue Number
REF*IF*		REF**660415
# IG - Insurance Policy Number
REF*IG*		REF**528446666
# JD - User Identification
REF*JD*		REF**477563928
# M7 - Medical Assistance Category
REF*M7*		REF**660415
# ML - Military Rank/Civilian Pay Grade Number
REF*ML*		REF**G12
# N6 - Plan Network Identification Number
REF*N6*		REF**660415
# NQ - Medicaid Recipient Identification Number
REF*NQ*		REF**660415
# Q4 - Prior Identifier Number
REF*Q4*		REF**477563928
# SY - Social Security Number
REF*SY*		REF**528446666
# Y4 - Agency Claim Number
REF*Y4*		REF**4445555
# ZZ - Mutually Defined
REF*ZZ*		REF**123456

# Claim information
CLM*		CLM*A37YH556

# Service line adjudication
SVD*		SVD*NR002

# Paperwork
PWK*		PWK******DMN0012

# Prescription NUmber
SV4*		SV4*4466777TJ

# Trace number
TRN*		TRN**12345*1512345678*199999999

# Discharge Date  (be careful, as this could mask a data error)
DTP*096*D8*	DTP***19970115
# Discharge Hour
DTP*096*TM*	DTP***1130

# Issue Date  (be careful, as this could mask a data error)
DTP*102*D8*	DTP***19970114
DTP*102*RD8*	DTP***19970607-19970608

# Eligibility Date  (be careful, as this could mask a data error)
DTP*307*D8*	DTP***19970114
DTP*307*RD8*	DTP***19970607-19970608

# Admission Date  (be careful, as this could mask a data error)
DTP*435*D8*	DTP***19970114
DTP*435*DT*	DTP***199610131242
DTP*435*RD8*	DTP***19961013-19971231

# Date of Death  (be careful, as this could mask a data error)
DTP*442*D8*	DTP***19991231

# Service Date  (be careful, as this could mask a data error)
DTP*472*D8*	DTP***19970114
DTP*472*RD8*	DTP***19970607-19970608

# Financial Information
BPR*		BPR*******999999992**123456*1512345678*1999999999**999988880**98765

# Claim payment information
CLP*		CLP*7722337******119932404007801

# Individual Remittance (820)
ENT*		ENT****030668776

# Remittance Advice Accounts Receivable Open Item Reference
RMR*		RMR**123456789


# Submitter Name
# NM1*41*2*	NM1***Crammer, Dole, Palmer, and Johanson******W7933THU
# NM1*41*1*	NM1***Crammer*Robert*A****W7933THU

# Receiver Name
# NM1*40*2*	NM1***Union Mutual of Oregon******11122333
# NM1*40*1*	NM1***Dole*John*B****11122333

# Payer Name
# NM1*PR*2*	NM1***Union Mutual of Oregon******11122333

# Crossover Carrier Name
# NM1*TT*2*	NM1***ACME Insurance******123456789

# Third Party Administrator
# NM1*2B*2*	NM1***Ace Insurance Company******87728

# Prior Insurance Carrier
# NM1*P4*2*	NM1***Prior Insurance Company******87728

# Employer Name
# NM1*ES*2*	NM1***Ace Company******87728
# NM1*ES*1*	NM1***Jones*Fred*S****87728

# Employer
# NM1*36*2*	NM1***Ace Company******87728

# Plan Sponsor
# NM1*P5*2*	NM1***Ace Company******87728

# Educational Institution
# NM1*M8*2*	NM1***State University******87728

# Primary Payer
# NM1*PRP*2*	NM1***First Mutual of Oregon******11122333

# Secondary Payer
# NM1*SEP*2*	NM1***Second Mutual of Oregon******11122333

# Tertiary Payer
# NM1*TTP*2*	NM1***Third Mutual of Oregon******11122333

# Vendor
# NM1*VN*2*	NM1***Integrated Medical Service******11122333

# Facility
# NM1*FA*2*	NM1***Medical Arts******201749586

# Hospital
# NM1*80*2*	NM1**2*Community Hospital******444332222

# Physician, Clinic or Group Practice
# NM1*1T*2*	NM1***Crammer, Dole, and Johansen******111223333
# NM1*1T*1*	NM1***Palmer*James*C****111223333

# Service Provider
# NM1*SJ*2*	NM1***Crammer, Dole, and Johansen******111223333
# NM1*SJ*1*	NM1***Palmer*James*C****111223333

# Provider Name
# NM1*1P*2*	NM1***Crammer, Dole, and Johansen******111223333
# NM1*1P*1*	NM1***Palmer*James*C****111223333

# Gateway Provider Name
# NM1*GP*2*	NM1***Crammer, Dole, and Johansen******111223333
# NM1*GP*1*	NM1***Palmer*James*C****111223333

# Rendering Provider
# NM1*82*2*	NM1***Medical Laboratory******12345678
# NM1*82*1*	NM1***Watkins*Larry*C**Sr**12345678

# Billing Provider Name
# NM1*85*2*	NM1***Crammer, Dole, and Johansen******111223333
# NM1*85*1*	NM1***Palmer*James*C****111223333

# Pay-to Provider Name
# NM1*87*2*	NM1***Crammer Lockbox******09876543
# NM1*87*1*	NM1***Crammer*Joseph*D****09876543

# Operating Provider
# NM1*72*1*	NM1***Meyers*Jane*A**Jr**12345678

# Ordering Provider
# NM1*DK*1*	NM1**1*Richardson*Trent*D**Sr**555667778

# Supervising Provider
# NM1*DQ*1*	NM1***Killian*Bart*B**II**222334444

# Attending Provider
# NM1*71*2*	NM1***Attending Provider******12345678
# NM1*71*1*	NM1***Jones*John*B**Sr**12345678

# Other Provider Name
# NM1*73*2*	NM1***Medical Arts******201749586
# NM1*73*1*	NM1***Doe*John*A**Sr**201749586

# Referring Provider
# NM1*DN*2*	NM1**2*Community Hospital******444332222
# NM1*DN*1*	NM1**1*Welby*Marcus*W**Jr**444332222

# Primary Care Provider
# NM1*P3*2*	NM1**2*Community Hospital******444332222
# NM1*P3*1*	NM1**1*Welby*Marcus*W**Jr**444332222

# Purchased Service Provider
# NM1*QB*2*	NM1***Medical Services******111223333
# NM1*QB*1*	NM1***Good*Phil*I**Jr**111223333

# Contracted Service Provider
# NM1*13*2*	NM1***Jones, and Johansen******111223333
# NM1*13*1*	NM1***Jones*Marcus*D**MD**111223333

# Service Facility
# NM1*77*2*	NM1***A-OK Service Location******11122333
# NM1*FA*2*	NM1***A-OK Facility******11122333
# NM1*LI*2*	NM1***A-OK Independent Lab******11122333
# NM1*TL*2*	NM1***A-OK Testing Laboratory******11122333

# Pharmacy
# NM1*QA*2*	NM1**2*ABC Drugs******444332222

# Obstetrics and Gynecology Facility
# NM1*3D*2*	NM1**2*Womens Clinic******444332222

# Managed Care Organization
# NM1*Y2*2*	NM1**2*Progressive HMO******444332222

# Dentist
# NM1*QN*2*	NM1***Tooth Services******111223333
# NM1*QN*1*	NM1***Floss*James*I**Jr**111223333

# Doctor of Optometry
# NM1*OD*2*	NM1***Vision Services******111223333
# NM1*OD*1*	NM1***Good*Cecil*I**Jr**111223333

# Utilization Management Organization
# NM1*X3*2*	NM1***PRO-R-US******11122333
# NM1*X3*1*	NM1***Good*Umo*I**Jr**111223333

# Broker or Sales Office
# N1*BO*	N1**Independent Brokers of Nevada**12356799

# Insurer
# N1*IN*	N1**Best Rates Co**12356799

# Plan Sponsor
# N1*P5*	N1**ACME Brick**12356799

# Payee
# N1*PE*	N1**Cybils Mental Hospital**12345678

# Payer
# N1*PR*	N1**Insurance Company of Timbucktu**88888888

# Third Party Administrator (TPA)
# N1*TV*	N1**Benefit Consultants of Nevada**12356799

# Referring Provider Taxonomy
# PRV*RF*	PRV***363LP0200N

# Provider Taxonomy or Identifier
# PRV*		PRV***203BA0200N

# Purchased Service
# PS1*		PS1*PN222222

# Repricing
# HCP*		HCP****RPO12345

# Provider summary information
# TS3*		TS3*123456

# Provider adjustment
# PLB*		PLB*123456

# Here are a bunch of REF possibilities
# 06 - System Number
# REF*06*		REF**1112223333
# 0B - State License Number
# REF*0B*		REF**98765
# 14 - Master Account Number
# REF*14*		REF**123456789
# 18 - Plan Number
# REF*18*		REF**660415
# 1A - Blue Cross Provider Number
# REF*1A*		REF**98765
# 1B - Blue Shield Provider Number
# REF*1B*		REF**98765
# 1C - Medicare Provider Number
# REF*1C*		REF**98765
# 1D - Medicaid Provider Number
# REF*1D*		REF**98765
# 1E - Dentist License Number
# REF*1E*		REF**98765
# 1F - Anesthesia License Number
# REF*1F*		REF**12345678
# 1G - Provider UPIN Number
# REF*1G*		REF**98765
# 1H - CHAMPUS Identification Number
# REF*1H*		REF**98765
# 1J - Facility ID Number
# REF*1J*		REF**98765
# 2F - Consolidated Invoice Number
# REF*2F*		REF**123456789
# 2U - Payer Identification Number
# REF*2U*		REF**435261708
# 38 - Master Policy Number
# REF*38*		REF**123456
# 72 - Schedule Reference Number
# REF*72*		REF**123456789
# 8U - Bank Assigned Security Identifier
# REF*8U*		REF**1112223333
# B3 - Preferred Provider Organization Number
# REF*B3*		REF**98765
# BQ - Health Maintenance Organization Code Number
# REF*BQ*		REF**98765
# D3 - National Association of Boards of Pharmacy Number
# REF*D3*		REF**12345678
# EI - Employer s Identification Number
# REF*EI*		REF**98765
# EL - Electronic device pin number
# REF*EL*		REF**477563928
# EM - Electronic Payment Reference Number
# REF*EM*		REF**1112223333
# EO - Submitter Identification Number
# REF*EO*		REF**477563928
# EV - Receiver Identification Number
# REF*EV*		REF**12345678
# EW - Mammography Certification NUmber
# REF*EW*		REF**T554
# F4 - Facility Certification Number
# REF*F4*		REF**34D1234567
# FH - Clinic Number
# REF*FH*		REF**98765
# FY - Claim Office Number
# REF*FY*		REF**435261708
# G2 - Provider Commercial Number
# REF*G2*		REF**98765
# G5 - Provider Site Number
# REF*G5*		REF**98765
# IJ - Standard Industry Classification (SIC) Code
# REF*IJ*		REF**1112223333
# LU - Location Number
# REF*LU*		REF**98765
# LX - Qualified Products List
# REF*LX*		REF**TG334
# N5 - Provider Plan Network Identification Number
# REF*N5*		REF**A12345
# N7 - Facility Network Identification Number
# REF*N7*		REF**477563928
# NF - National Association of Insurance Commissioners (NAIC) Code
# REF*NF*		REF**435261708
# P4 - Project Code
# REF*P4*		REF**THJ1222
# PQ - Payee Identification
# REF*PQ*		REF**12345678
# RB - Rate code number
# REF*RB*		REF**1112223333
# ST - Store Number
# REF*ST*		REF**1112223333
# TT - Terminal Code
# REF*TT*		REF**1112223333
# TJ - Federal Taxpayer s Identification Number
# REF*TJ*		REF**435261708
# U3 - Unique Supplier Identification Number (USIN)
# REF*U3*		REF**98765
# X4 - Clinical Laboratory Improvement Amendment Number
# REF*X4*		REF**12D4567890
# X5 - State Industrial Accident Provider Number
# REF*X5*		REF**98765
# ZH - Carrier Assigned Reference Number
# REF*ZH*		REF**1112223333
# HPI - Health Care Financing Administration National Provider Identifier
# REF*HPI*		REF**12345678

# Here are a bunch of dates
# 007 - Effective
# DTP*007*D8*		DTP***19961001
# 011 - Shipped
# DTP*011*D8*		DTP***19970526
# 036 - Expiration
# DTP*036*D8*		DTP***19980731
# 090 - Report Start
# DTP*090*D8*		DTP***19970214
# 091 - Report End
# DTP*091*D8*		DTP***19970217
# 119 - Test Performed
# DTP*119*D8*		DTP***19970615
# 152 - Effective Date of Change
# DTP*152*D8*		DTP***19950818
# 193 - Period Start
# DTP*193*D8*		DTP***19960624
# 194 - Period End
# DTP*194*D8*		DTP***19960724
# 198 - Completion
# DTP*198*D8*		DTP***19960624
# 232 - Claim Statement Period Start
# DTP*232*D8*		DTP***19970114
# DTP*232*RD8*		DTP***19970607-19970608
# 286 - Retirement
# DTP*286*D8*		DTP***19960705
# 290 - Coordination of Benefits
# DTP*290*D8*		DTP***19960624
# 291 - Plan Date
# DTP*291*D8*		DTP***19950818
# 292 - Benefit
# DTP*292*D8*		DTP***19960624
# 295 - Primary Care Provider
# DTP*295*D8*		DTP***19960624
# 296 - Return to Work
# DTP*296*D8*		DTP***19970620
# 297 - Date Last Worked
# DTP*297*D8*		DTP***19970114
# 300 - Enrollment Signature Date
# DTP*300*D8*		DTP***19960705
# 301 - COBRA Qualifying Event
# DTP*301*D8*		DTP***19960705
# 303 - Maintenance Effective
# DTP*303*D8*		DTP***19961001
# 304 - Latest Visit or Consultation
# DTP*304*D8*		DTP***19970115
# 307 - Eligibility
# DTP*307*D8*		DTP***19960624
# 318 - Date Added
# DTP*318*D8*		DTP***19950818
# 330 - Referral Date
# DTP*330*D8*		DTP***19970617
# 336 - Employment Begin
# DTP*336*D8*		DTP***19960705
# 337 - Employment End
# DTP*337*D8*		DTP***19960805
# 338 - Medicare Begin
# DTP*338*D8*		DTP***19960705
# 339 - Medicare End
# DTP*339*D8*		DTP***19960805
# 340 - COBRA Begin
# DTP*340*D8*		DTP***19950818
# 341 - COBRA End
# DTP*341*D8*		DTP***19950918
# 342 - Premium Paid to Date Begin
# DTP*342*D8*		DTP***19950818
# 343 - Premium Paid to Date End
# DTP*343*D8*		DTP***19950918
# 344 - Coordination of Benefits Begin
# DTP*344*D8*		DTP***19950818
# 345 - Coordination of Benefits End
# DTP*345*D8*		DTP***19950918
# 346 - Plan Begin
# DTP*346*D8*		DTP***19950818
# 347 - Plan End
# DTP*347*D8*		DTP***19950918
# 348 - Benefit Begin
# DTP*348*D8*		DTP***19960624
# 349 - Benefit End
# DTP*349*D8*		DTP***19960724
# 350 - Education Begin
# DTP*350*D8*		DTP***19960705
# 351 - Education End
# DTP*351*D8*		DTP***19960805
# 356 - Eligibility Begin
# DTP*356*D8*		DTP***19950818
# 357 - Eligibility End
# DTP*357*D8*		DTP***19950918
# 360 - Disability Begin
# DTP*360*D8*		DTP***19970114
# 361 - Disability End
# DTP*361*D8*		DTP***19970613
# 382 - Enrollment
# DTP*382*D8*		DTP***19950818
# 383 - Adjusted Hire
# DTP*383*D8*		DTP***19960705
# 388 - Payment Commencement
# DTP*388*D8*		DTP***19961001
# 393 - Plan Participation Suspension
# DTP*393*D8*		DTP***19960705
# 394 - Rehire
# DTP*394*D8*		DTP***19960705
# 405 - Production
# DTP*405*D8*		DTP***19960317
# 431 - Onset of Current Symptoms or Illness
# DTP*431*D8*		DTP***19970115
# 438 - Onset of Similar Symptoms or Illness
# DTP*438*D8*		DTP***19970115
# 439 - Accident
# DTP*439*D8*		DTP***19970114
# DTP*439*DT*		DTP***199701141405
# 441 - Prior Placement
# DTP*441*D8*		DTP***19980108
# 446 - Replacement
# DTP*446*D8*		DTP***19980108
# 452 - Appliance Placement
# DTP*452*D8*		DTP***19980108
# 453 - Acute Manifestation of a Chronic Condition
# DTP*453*D8*		DTP***19970115
# 454 - Initial Treatment
# DTP*454*D8*		DTP***19970115
# 455 - Last X-Ray
# DTP*455*D8*		DTP***19970114
# 456 - Surgery
# DTP*456*D8*		DTP***19980723
# 458 - Certification
# DTP*458*D8*		DTP***19950818
# 461 - Last Certification
# DTP*461*D8*		DTP***19970519
# 463 - Begin Therapy
# DTP*463*D8*		DTP***19970519
# 471 - Prescription
# DTP*471*D8*		DTP***19970115
# 473 - Medicaid Begin
# DTP*473*D8*		DTP***19960705
# 474 - Medicaid End
# DTP*474*D8*		DTP***19960805
# 480 - Arterial Blood Gas Test
# DTP*480*D8*		DTP***19970615
# 481 - Oxygen Saturation Test
# DTP*481*D8*		DTP***19970615
# 484 - Last Menstrual Period
# DTP*484*D8*		DTP***19961113
# 539 - Policy Effective
# DTP*539*D8*		DTP***19950818
# 540 - Policy Expiration
# DTP*540*D8*		DTP***19950918
# 573 - Date Claim Paid
# DTP*573*D8*		DTP***19980314
# 607 - Certification Revision
# DTP*607*D8*		DTP***19970519
# 636 - Date of Last Update
# DTP*636*D8*		DTP***19950818
# 738 - Most Recent Hemoglobin or Hematocrit or Both
# DTP*738*D8*		DTP***19970615
# 739 - Most Recent Serum Creatine (should be creatinine - KZ)
# DTP*739*D8*		DTP***19970615
# 771 - Status
# DTP*771*D8*		DTP***19950818
# 866 - Examination
# DTP*866*D8*		DTP***19981210
# 938 - Order
# DTP*938*D8*		DTP***19970617
# ABC - Estimated Date of Birth
# DTP*ABC*D8*		DTP***19970617

# And some DTM segments also
# 009 - Process
# DTM*009*		DTM**19970101
# 035 - Delivered
# DTM*035*		DTM**19970101
# 036 - Expiration
# DTM*036*		DTM**19960916
# 050 - Received
# DTM*050*		DTM**19960916
# 150 - Service Period Start
# DTM*150*		DTM**19961031
# 151 - Service Period End
# DTM*151*		DTM**19961031
# 232 - Claim Statement Period Start
# DTM*232*		DTM**19960916
# 233 - Claim Statement Period End
# DTM*233*		DTM**19960916
# 472 - Service
# DTM*472*		DTM**19961031
# 582 - Report Period
# DTM*582*		DTM**19970101****19970101-19970130
