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[LOOPS]
ISA
GS
ST
2000A
2000B
2000C
2000D
SE
GE
IEA
#--- start of loop details ---#
[ISA]
segment=ISA:::ISA:R:1
[GS]
segment=GS:::GS:R:1
#LOOP ID - HEADER
[ST]
segment=ST:::Transaction Set Header:R:1
segment=BHT:::Beginning of Hierarchical Transaction:R:1
#LOOP ID - 2000A INFORMATION SOURCE LEVEL >1
[2000A]
segment=HL:3:20:Information Source Level:R:1
loop=2100A
#LOOP ID - 2100A INFORMATION SOURCE NAME 1
[2100A]
segment=NM1:1:2B,36,GP,P5,PR:Information Source Name:R:1
#LOOP ID - 2000B INFORMATION RECEIVER LEVEL >1
[2000B]
segment=HL:3:21:Information Receiver Level:R:1
loop=2100B
#LOOP ID - 2100B INFORMATION RECEIVER NAME 1
[2100B]
segment=NM1:1:1P,2B,36,80,FA,GP,P5,PR:Information Receiver Name:R:1
segment=REF:::Information Receiver Additional Identification:S:9
segment=N3:::Information Receiver Address:S:1
segment=N4:::Information Receiver City/State/ZIP Code:S:1
segment=PER:::Information Receiver Contact Information:S:3
segment=PRV:::Information Receiver Provider Information:S:1
#LOOP ID - 2000C SUBSCRIBER LEVEL >1
[2000C]
segment=HL:3:22:Subscriber Level:R:1
segment=TRN:::Subscriber Trace Number:S:2
loop=2100C
#LOOP ID - 2100C SUBSCRIBER NAME 1
[2100C]
segment=NM1:1:IL:Subscriber Name:R:1
segment=REF:::Subscriber Additional Identification:S:9
segment=N3:::Subscriber Address:S:1
segment=N4:::Subscriber City/State/ZIP Code:S:1
segment=PRV:::Provider Information:S:1
segment=DMG:::Subscriber Demographic Information:S:1
segment=INS:::Subscriber Relationship:S:1
segment=DTP:::Subscriber Date:S:2
loop=2110C
#LOOP ID - 2110C SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY INFORMATION 99
[2110C]
segment=EQ:::Subscriber Eligibility or Benefit Inquiry Information:S:1
segment=AMT:::Subscriber Spend Down Amount:S:1
segment=III:::Subscriber Eligibility or Benefit Additional Inquiry Information:S:10
segment=REF:::Subscriber Additional Information:S:1
segment=DTP:::Subscriber Eligibility/Benefit Date:S:1
#LOOP ID - 2000D DEPENDENT LEVEL >1
[2000D]
segment=HL:3:23:Dependent Level:S:1
segment=TRN:::Dependent Trace Number:S:2
loop=2100D
#LOOP ID - 2100D DEPENDENT NAME 1
[2100D]
segment=NM1:1:03:Dependent Name:R:1
segment=REF:::Dependent Additional Identification:S:9
segment=N3:::Dependent Address:S:1
segment=N4:::Dependent City/State/ZIP Code:S:1
segment=PRV:::Provider Information:S:1
segment=DMG:::Dependent Demographic Information:S:1
segment=INS:::Dependent Relationship:S:1
segment=DTP:::Dependent Date:S:2
loop=2110D
#LOOP ID - 2110D DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY INFORMATION 99
[2110D]
segment=EQ:::Dependent Eligibility or Benefit Inquiry Information:R:1
segment=III:::Dependent Eligibility or Benefit Additional Inquiry Information:S:10
segment=REF:::Dependent Additional Information:S:1
segment=DTP:::Dependent Eligibility/Benefit Date:S:1
#LOOP ID - TRAILER
[SE]
segment=SE:::Transaction Set Trailer:R:1
[GE]
segment=GE:::GE:R:1
[IEA]
segment=IEA:::IEA:R:1
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