<?xml version="1.0"?>
<!--
######################################################################
# Copyright (c) 2001-2005 Kalamazoo Community Mental Health Services,
#   John Holland <jholland@kazoocmh.org> <john@zoner.org>
# All rights reserved.
#
# This software is licensed as described in the file LICENSE.txt, which
# you should have received as part of this distribution.
#
######################################################################

#    $Id: 835.4010.X091.A1.xml,v 1.10 2004/12/30 04:54:19 johnholland Exp $
-->
<transaction>
  <id>835</id>
  <name>HIPAA Health Care Claim Payment/Advice X091-835</name>
  <loop xid="ISA_LOOP" type="explicit">
    <name>Interchange Control Header</name>
    <usage>R</usage>
    <pos>001</pos>
    <repeat>&gt;1</repeat>
    <segment xid="ISA">
      <name>Interchange Control Header</name>
      <usage>R</usage>
      <pos>010</pos>
      <max_use>1</max_use>
      <element xid="ISA01">
        <data_ele>I01</data_ele>
        <name>Authorization Information Qualifier</name>
        <usage>R</usage>
        <seq>01</seq>
        <data_type>ID</data_type>
        <min_len>2</min_len>
        <max_len>2</max_len>
        <valid_codes>
          <code>00</code>
          <code>03</code>
        </valid_codes>
      </element>
      <element xid="ISA02">
        <data_ele>I02</data_ele>
        <name>Authorization Information</name>
        <usage>R</usage>
        <seq>02</seq>
        <data_type>AN</data_type>
        <min_len>10</min_len>
        <max_len>10</max_len>
      </element>
      <element xid="ISA03">
        <data_ele>I03</data_ele>
        <name>Security Information Qualifier</name>
        <usage>R</usage>
        <seq>03</seq>
        <data_type>ID</data_type>
        <min_len>2</min_len>
        <max_len>2</max_len>
        <valid_codes>
          <code>00</code>
          <code>01</code>
        </valid_codes>
      </element>
      <element xid="ISA04">
        <data_ele>I04</data_ele>
        <name>Security Information</name>
        <usage>R</usage>
        <seq>04</seq>
        <data_type>AN</data_type>
        <min_len>10</min_len>
        <max_len>10</max_len>
      </element>
      <element xid="ISA05">
        <data_ele>I05</data_ele>
        <name>Interchange ID Qualifier</name>
        <usage>R</usage>
        <seq>05</seq>
        <data_type>ID</data_type>
        <min_len>2</min_len>
        <max_len>2</max_len>
        <valid_codes>
          <code>01</code>
          <code>14</code>
          <code>20</code>
          <code>27</code>
          <code>28</code>
          <code>29</code>
          <code>30</code>
          <code>33</code>
          <code>ZZ</code>
        </valid_codes>
      </element>
      <element xid="ISA06">
        <data_ele>I06</data_ele>
        <name>Interchange Sender ID</name>
        <usage>R</usage>
        <seq>06</seq>
        <data_type>AN</data_type>
        <min_len>15</min_len>
        <max_len>15</max_len>
      </element>
      <element xid="ISA07">
        <data_ele>I05</data_ele>
        <name>Interchange ID Qualifier</name>
        <usage>R</usage>
        <seq>07</seq>
        <data_type>ID</data_type>
        <min_len>2</min_len>
        <max_len>2</max_len>
        <valid_codes>
          <code>01</code>
          <code>14</code>
          <code>20</code>
          <code>27</code>
          <code>28</code>
          <code>29</code>
          <code>30</code>
          <code>33</code>
          <code>ZZ</code>
        </valid_codes>
      </element>
      <element xid="ISA08">
        <data_ele>I07</data_ele>
        <name>Interchange Receiver ID</name>
        <usage>R</usage>
        <seq>08</seq>
        <data_type>AN</data_type>
        <min_len>15</min_len>
        <max_len>15</max_len>
      </element>
      <element xid="ISA09">
        <data_ele>I08</data_ele>
        <name>Interchange Date</name>
        <usage>R</usage>
        <seq>09</seq>
        <data_type>DT</data_type>
        <min_len>6</min_len>
        <max_len>6</max_len>
        <valid_codes>
      </valid_codes>
      </element>
      <element xid="ISA10">
        <data_ele>I09</data_ele>
        <name>Interchange Time</name>
        <usage>R</usage>
        <seq>10</seq>
        <data_type>TM</data_type>
        <min_len>4</min_len>
        <max_len>4</max_len>
        <valid_codes>
      </valid_codes>
      </element>
      <element xid="ISA11">
        <data_ele>I10</data_ele>
        <name>Interchange Control Standards Identifier</name>
        <usage>R</usage>
        <seq>11</seq>
        <data_type>ID</data_type>
        <min_len>1</min_len>
        <max_len>1</max_len>
        <valid_codes>
          <code>U</code>
        </valid_codes>
      </element>
      <element xid="ISA12">
        <data_ele>I11</data_ele>
        <name>Interchange Control Version Number</name>
        <usage>R</usage>
        <seq>12</seq>
        <data_type>ID</data_type>
        <min_len>5</min_len>
        <max_len>5</max_len>
        <valid_codes>
          <code>00401</code>
        </valid_codes>
      </element>
      <element xid="ISA13">
        <data_ele>I12</data_ele>
        <name>Interchange Control Number</name>
        <usage>R</usage>
        <seq>13</seq>
        <data_type>N0</data_type>
        <min_len>9</min_len>
        <max_len>9</max_len>
      </element>
      <element xid="ISA14">
        <data_ele>I13</data_ele>
        <name>Acknowledgment Requested</name>
        <usage>R</usage>
        <seq>14</seq>
        <data_type>ID</data_type>
        <min_len>1</min_len>
        <max_len>1</max_len>
        <valid_codes>
          <code>0</code>
          <code>1</code>
        </valid_codes>
      </element>
      <element xid="ISA15">
        <data_ele>I14</data_ele>
        <name>Usage Indicator</name>
        <usage>R</usage>
        <seq>15</seq>
        <data_type>ID</data_type>
        <min_len>1</min_len>
        <max_len>1</max_len>
        <valid_codes>
          <code>P</code>
          <code>T</code>
        </valid_codes>
      </element>
      <element xid="ISA16">
        <data_ele>I15</data_ele>
        <name>Component Element Separator</name>
        <usage>R</usage>
        <seq>16</seq>
        <data_type>AN</data_type>
        <min_len>1</min_len>
        <max_len>1</max_len>
      </element>
    </segment>
<!--End of ISA segment-->
    <loop xid="GS_LOOP" type="explicit">
      <name>Functional Group Header</name>
      <usage>R</usage>
      <pos>020</pos>
      <repeat>&gt;1</repeat>
      <segment xid="GS">
        <name>Functional Group Header</name>
        <usage>R</usage>
        <pos>010</pos>
        <max_use>1</max_use>
        <element xid="GS01">
          <data_ele>479</data_ele>
          <name>Functional Identifier Code</name>
          <usage>R</usage>
          <seq>01</seq>
          <data_type>ID</data_type>
          <min_len>2</min_len>
          <max_len>2</max_len>
          <valid_codes>
            <code>HP</code>
          </valid_codes>
        </element>
        <element xid="GS02">
          <data_ele>142</data_ele>
          <name>Application Sender's Code</name>
          <usage>R</usage>
          <seq>02</seq>
          <data_type>AN</data_type>
          <min_len>2</min_len>
          <max_len>15</max_len>
        </element>
        <element xid="GS03">
          <data_ele>124</data_ele>
          <name>Application Receiver's Code</name>
          <usage>R</usage>
          <seq>03</seq>
          <data_type>AN</data_type>
          <min_len>2</min_len>
          <max_len>15</max_len>
        </element>
        <element xid="GS04">
          <data_ele>373</data_ele>
          <name>Date</name>
          <usage>R</usage>
          <seq>04</seq>
          <data_type>DT</data_type>
          <min_len>8</min_len>
          <max_len>8</max_len>
          <valid_codes>
      </valid_codes>
        </element>
        <element xid="GS05">
          <data_ele>337</data_ele>
          <name>Time</name>
          <usage>R</usage>
          <seq>05</seq>
          <data_type>TM</data_type>
          <min_len>4</min_len>
          <max_len>8</max_len>
          <valid_codes>
      </valid_codes>
        </element>
        <element xid="GS06">
          <data_ele>28</data_ele>
          <name>Group Control Number</name>
          <usage>R</usage>
          <seq>06</seq>
          <data_type>N0</data_type>
          <min_len>1</min_len>
          <max_len>9</max_len>
        </element>
        <element xid="GS07">
          <data_ele>455</data_ele>
          <name>Responsible Agency Code</name>
          <usage>R</usage>
          <seq>07</seq>
          <data_type>ID</data_type>
          <min_len>1</min_len>
          <max_len>2</max_len>
          <valid_codes>
            <code>X</code>
          </valid_codes>
        </element>
        <element xid="GS08">
          <data_ele>480</data_ele>
          <name>Version / Release / Industry Identifier Code</name>
          <usage>R</usage>
          <seq>08</seq>
          <data_type>AN</data_type>
          <min_len>1</min_len>
          <max_len>12</max_len>
          <valid_codes>
            <code>004010X091A1</code>
          </valid_codes>
        </element>
      </segment>
<!--End of GS segment-->
      <loop xid="ST_LOOP" type="explicit">
        <name>Transaction Set Header</name>
        <usage>R</usage>
        <pos>020</pos>
        <repeat>&gt;1</repeat>
        <segment xid="ST">
          <name>Transaction Set Header</name>
          <usage>R</usage>
          <pos>010</pos>
          <max_use>1</max_use>
          <element xid="ST01">
            <data_ele>143</data_ele>
            <name>Transaction Set Identifier Code</name>
            <usage>R</usage>
            <seq>01</seq>
            <data_type>ID</data_type>
            <min_len>3</min_len>
            <max_len>3</max_len>
            <valid_codes>
              <code>835</code>
            </valid_codes>
          </element>
          <element xid="ST02">
            <data_ele>329</data_ele>
            <name>Transaction Set Control Number</name>
            <usage>R</usage>
            <seq>02</seq>
            <data_type>AN</data_type>
            <min_len>4</min_len>
            <max_len>9</max_len>
          </element>
        </segment>
<!--End of ST segment-->
        <loop xid="HEADER" type="wrapper">
          <name>Table 1 - Header</name>
          <usage>R</usage>
          <pos>015</pos>
          <repeat>1</repeat>
          <segment xid="BPR">
            <name>Financial Information</name>
            <usage>R</usage>
            <pos>020</pos>
            <max_use>1</max_use>
            <element xid="BPR01">
              <data_ele>305</data_ele>
              <name>Transaction Handling Code</name>
              <usage>R</usage>
              <seq>01</seq>
              <data_type>ID</data_type>
              <min_len>1</min_len>
              <max_len>2</max_len>
              <valid_codes>
                <code>C</code>
                <code>D</code>
                <code>H</code>
                <code>I</code>
                <code>P</code>
                <code>U</code>
                <code>X</code>
              </valid_codes>
            </element>
            <element xid="BPR02">
              <data_ele>782</data_ele>
              <name>Total Actual Provider Payment Amount</name>
              <usage>R</usage>
              <seq>02</seq>
              <data_type>R</data_type>
              <min_len>1</min_len>
              <max_len>18</max_len>
            </element>
            <element xid="BPR03">
              <data_ele>478</data_ele>
              <name>Credit or Debit Flag Code</name>
              <usage>R</usage>
              <seq>03</seq>
              <data_type>ID</data_type>
              <min_len>1</min_len>
              <max_len>1</max_len>
              <valid_codes>
                <code>C</code>
                <code>D</code>
              </valid_codes>
            </element>
            <element xid="BPR04">
              <data_ele>591</data_ele>
              <name>Payment Method Code</name>
              <usage>R</usage>
              <seq>04</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
              <valid_codes>
                <code>ACH</code>
                <code>BOP</code>
                <code>CHK</code>
                <code>FWT</code>
                <code>NON</code>
              </valid_codes>
            </element>
            <element xid="BPR05">
              <data_ele>812</data_ele>
              <name>Payment Format Code</name>
              <usage>S</usage>
              <seq>05</seq>
              <data_type>ID</data_type>
              <min_len>1</min_len>
              <max_len>10</max_len>
              <valid_codes>
                <code>CCP</code>
                <code>CTX</code>
              </valid_codes>
            </element>
            <element xid="BPR06">
              <data_ele>506</data_ele>
              <name>Depository Financial Institution (DFI) Identification Number Qualifier</name>
              <usage>S</usage>
              <seq>06</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>2</max_len>
              <valid_codes>
                <code>01</code>
                <code>04</code>
              </valid_codes>
            </element>
            <element xid="BPR07">
              <data_ele>507</data_ele>
              <name>Sender DFI Identifier</name>
              <usage>S</usage>
              <seq>07</seq>
              <data_type>AN</data_type>
              <min_len>3</min_len>
              <max_len>12</max_len>
            </element>
            <element xid="BPR08">
              <data_ele>569</data_ele>
              <name>Account Number Qualifier</name>
              <usage>S</usage>
              <seq>08</seq>
              <data_type>ID</data_type>
              <min_len>1</min_len>
              <max_len>3</max_len>
              <valid_codes>
                <code>DA</code>
              </valid_codes>
            </element>
            <element xid="BPR09">
              <data_ele>508</data_ele>
              <name>Sender Bank Account Number</name>
              <usage>S</usage>
              <seq>09</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>35</max_len>
            </element>
            <element xid="BPR10">
              <data_ele>509</data_ele>
              <name>Payer Identifier</name>
              <usage>S</usage>
              <seq>10</seq>
              <data_type>AN</data_type>
              <min_len>10</min_len>
              <max_len>10</max_len>
            </element>
            <element xid="BPR11">
              <data_ele>510</data_ele>
              <name>Originating Company Supplemental Code</name>
              <usage>S</usage>
              <seq>11</seq>
              <data_type>AN</data_type>
              <min_len>9</min_len>
              <max_len>9</max_len>
            </element>
            <element xid="BPR12">
              <data_ele>506</data_ele>
              <name>Depository Financial Institution (DFI) Identification Number Qualifier</name>
              <usage>S</usage>
              <seq>12</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>2</max_len>
              <valid_codes>
                <code>01</code>
                <code>04</code>
              </valid_codes>
            </element>
            <element xid="BPR13">
              <data_ele>507</data_ele>
              <name>Receiver or Provider Bank ID Number</name>
              <usage>S</usage>
              <seq>13</seq>
              <data_type>AN</data_type>
              <min_len>3</min_len>
              <max_len>12</max_len>
            </element>
            <element xid="BPR14">
              <data_ele>569</data_ele>
              <name>Account Number Qualifier</name>
              <usage>S</usage>
              <seq>14</seq>
              <data_type>ID</data_type>
              <min_len>1</min_len>
              <max_len>3</max_len>
              <valid_codes>
                <code>DA</code>
                <code>SG</code>
              </valid_codes>
            </element>
            <element xid="BPR15">
              <data_ele>508</data_ele>
              <name>Receiver or Provider Account Number</name>
              <usage>S</usage>
              <seq>15</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>35</max_len>
            </element>
            <element xid="BPR16">
              <data_ele>373</data_ele>
              <name>Check Issue or EFT Effective Date</name>
              <usage>R</usage>
              <seq>16</seq>
              <data_type>DT</data_type>
              <min_len>8</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="BPR17">
              <data_ele>1048</data_ele>
              <name>Business Function Code</name>
              <usage>N</usage>
              <seq>17</seq>
              <data_type>ID</data_type>
              <min_len>1</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="BPR18">
              <data_ele>506</data_ele>
              <name>(DFI) ID Number Qualifier</name>
              <usage>N</usage>
              <seq>18</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>2</max_len>
            </element>
            <element xid="BPR19">
              <data_ele>507</data_ele>
              <name>(DFI) Identification Number</name>
              <usage>N</usage>
              <seq>19</seq>
              <data_type>AN</data_type>
              <min_len>3</min_len>
              <max_len>12</max_len>
            </element>
            <element xid="BPR20">
              <data_ele>569</data_ele>
              <name>Account Number Qualifier</name>
              <usage>N</usage>
              <seq>20</seq>
              <data_type>ID</data_type>
              <min_len>1</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="BPR21">
              <data_ele>508</data_ele>
              <name>Account Number</name>
              <usage>N</usage>
              <seq>21</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>35</max_len>
            </element>
          </segment>
<!--End of BPR segment-->
          <segment xid="TRN">
            <name>Reassociation Trace Number</name>
            <usage>R</usage>
            <pos>040</pos>
            <max_use>1</max_use>
            <element xid="TRN01">
              <data_ele>481</data_ele>
              <name>Trace Type Code</name>
              <usage>R</usage>
              <seq>01</seq>
              <data_type>ID</data_type>
              <min_len>1</min_len>
              <max_len>2</max_len>
              <valid_codes>
                <code>1</code>
              </valid_codes>
            </element>
            <element xid="TRN02">
              <data_ele>127</data_ele>
              <name>Check or EFT Trace Number</name>
              <usage>R</usage>
              <seq>02</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>30</max_len>
            </element>
            <element xid="TRN03">
              <data_ele>509</data_ele>
              <name>Payer Identifier</name>
              <usage>R</usage>
              <seq>03</seq>
              <data_type>AN</data_type>
              <min_len>10</min_len>
              <max_len>10</max_len>
            </element>
            <element xid="TRN04">
              <data_ele>127</data_ele>
              <name>Originating Company Supplemental Code</name>
              <usage>S</usage>
              <seq>04</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>30</max_len>
            </element>
          </segment>
<!--End of TRN segment-->
          <segment xid="CUR">
            <name>Foreign Currency Information</name>
            <usage>S</usage>
            <pos>050</pos>
            <max_use>1</max_use>
            <element xid="CUR01">
              <data_ele>98</data_ele>
              <name>Entity Identifier Code</name>
              <usage>R</usage>
              <seq>01</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>3</max_len>
              <valid_codes>
                <code>PR</code>
              </valid_codes>
            </element>
            <element xid="CUR02">
              <data_ele>100</data_ele>
              <name>Currency Code</name>
              <usage>R</usage>
              <seq>02</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR03">
              <data_ele>280</data_ele>
              <name>Exchange Rate</name>
              <usage>S</usage>
              <seq>03</seq>
              <data_type>R</data_type>
              <min_len>4</min_len>
              <max_len>10</max_len>
            </element>
            <element xid="CUR04">
              <data_ele>98</data_ele>
              <name>Entity Identifier Code</name>
              <usage>N</usage>
              <seq>04</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR05">
              <data_ele>100</data_ele>
              <name>Currency Code</name>
              <usage>N</usage>
              <seq>05</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR06">
              <data_ele>669</data_ele>
              <name>Currency Market/Exchange Code</name>
              <usage>N</usage>
              <seq>06</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR07">
              <data_ele>374</data_ele>
              <name>Date/Time Qualifier</name>
              <usage>N</usage>
              <seq>07</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR08">
              <data_ele>373</data_ele>
              <name>Date</name>
              <usage>N</usage>
              <seq>08</seq>
              <data_type>DT</data_type>
              <min_len>8</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR09">
              <data_ele>337</data_ele>
              <name>Time</name>
              <usage>N</usage>
              <seq>09</seq>
              <data_type>TM</data_type>
              <min_len>4</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR10">
              <data_ele>374</data_ele>
              <name>Date/Time Qualifier</name>
              <usage>N</usage>
              <seq>10</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR11">
              <data_ele>373</data_ele>
              <name>Date</name>
              <usage>N</usage>
              <seq>11</seq>
              <data_type>DT</data_type>
              <min_len>8</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR12">
              <data_ele>337</data_ele>
              <name>Time</name>
              <usage>N</usage>
              <seq>12</seq>
              <data_type>TM</data_type>
              <min_len>4</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR13">
              <data_ele>374</data_ele>
              <name>Date/Time Qualifier</name>
              <usage>N</usage>
              <seq>13</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR14">
              <data_ele>373</data_ele>
              <name>Date</name>
              <usage>N</usage>
              <seq>14</seq>
              <data_type>DT</data_type>
              <min_len>8</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR15">
              <data_ele>337</data_ele>
              <name>Time</name>
              <usage>N</usage>
              <seq>15</seq>
              <data_type>TM</data_type>
              <min_len>4</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR16">
              <data_ele>374</data_ele>
              <name>Date/Time Qualifier</name>
              <usage>N</usage>
              <seq>16</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR17">
              <data_ele>373</data_ele>
              <name>Date</name>
              <usage>N</usage>
              <seq>17</seq>
              <data_type>DT</data_type>
              <min_len>8</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR18">
              <data_ele>337</data_ele>
              <name>Time</name>
              <usage>N</usage>
              <seq>18</seq>
              <data_type>TM</data_type>
              <min_len>4</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR19">
              <data_ele>374</data_ele>
              <name>Date/Time Qualifier</name>
              <usage>N</usage>
              <seq>19</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="CUR20">
              <data_ele>373</data_ele>
              <name>Date</name>
              <usage>N</usage>
              <seq>20</seq>
              <data_type>DT</data_type>
              <min_len>8</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="CUR21">
              <data_ele>337</data_ele>
              <name>Time</name>
              <usage>N</usage>
              <seq>21</seq>
              <data_type>TM</data_type>
              <min_len>4</min_len>
              <max_len>8</max_len>
            </element>
          </segment>
<!--End of CUR segment-->
          <segment xid="REF">
            <name>Receiver Identification</name>
            <usage>S</usage>
            <pos>060</pos>
            <max_use>1</max_use>
            <element xid="REF01">
              <data_ele>128</data_ele>
              <name>Reference Identification Qualifier</name>
              <usage>R</usage>
              <seq>01</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>3</max_len>
              <valid_codes>
                <code>EV</code>
              </valid_codes>
            </element>
            <element xid="REF02">
              <data_ele>127</data_ele>
              <name>Receiver Identifier</name>
              <usage>R</usage>
              <seq>02</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>30</max_len>
            </element>
            <element xid="REF03">
              <data_ele>352</data_ele>
              <name>Description</name>
              <usage>N</usage>
              <seq>03</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>80</max_len>
            </element>
            <composite>
              <data_ele>C040</data_ele>
              <name>Reference Identifier</name>
              <usage>N</usage>
              <seq>04</seq>
            </composite>
          </segment>
<!--End of REF segment-->
          <segment xid="REF">
            <name>Version Identification</name>
            <usage>S</usage>
            <pos>060</pos>
            <max_use>1</max_use>
            <element xid="REF01">
              <data_ele>128</data_ele>
              <name>Reference Identification Qualifier</name>
              <usage>R</usage>
              <seq>01</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>3</max_len>
              <valid_codes>
                <code>F2</code>
              </valid_codes>
            </element>
            <element xid="REF02">
              <data_ele>127</data_ele>
              <name>Version Identification Code</name>
              <usage>R</usage>
              <seq>02</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>30</max_len>
            </element>
            <element xid="REF03">
              <data_ele>352</data_ele>
              <name>Description</name>
              <usage>N</usage>
              <seq>03</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>80</max_len>
            </element>
            <composite>
              <data_ele>C040</data_ele>
              <name>Reference Identifier</name>
              <usage>N</usage>
              <seq>04</seq>
            </composite>
          </segment>
<!--End of REF segment-->
          <segment xid="DTM">
            <name>Production Date</name>
            <usage>S</usage>
            <pos>070</pos>
            <max_use>1</max_use>
            <element xid="DTM01">
              <data_ele>374</data_ele>
              <name>Date Time Qualifier</name>
              <usage>R</usage>
              <seq>01</seq>
              <data_type>ID</data_type>
              <min_len>3</min_len>
              <max_len>3</max_len>
              <valid_codes>
                <code>405</code>
              </valid_codes>
            </element>
            <element xid="DTM02">
              <data_ele>373</data_ele>
              <name>Production Date</name>
              <usage>R</usage>
              <seq>02</seq>
              <data_type>DT</data_type>
              <min_len>8</min_len>
              <max_len>8</max_len>
              <valid_codes>
      </valid_codes>
            </element>
            <element xid="DTM03">
              <data_ele>337</data_ele>
              <name>Time</name>
              <usage>N</usage>
              <seq>03</seq>
              <data_type>TM</data_type>
              <min_len>4</min_len>
              <max_len>8</max_len>
            </element>
            <element xid="DTM04">
              <data_ele>623</data_ele>
              <name>Time Code</name>
              <usage>N</usage>
              <seq>04</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>2</max_len>
            </element>
            <element xid="DTM05">
              <data_ele>1250</data_ele>
              <name>Date Time Period Format Qualifier</name>
              <usage>N</usage>
              <seq>05</seq>
              <data_type>ID</data_type>
              <min_len>2</min_len>
              <max_len>3</max_len>
            </element>
            <element xid="DTM06">
              <data_ele>1251</data_ele>
              <name>Date Time Period</name>
              <usage>N</usage>
              <seq>06</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>35</max_len>
            </element>
          </segment>
<!--End of DTM segment-->
          <loop xid="1000A">
            <name>Payer Identification</name>
            <usage>R</usage>
            <pos>080</pos>
            <repeat>1</repeat>
            <segment xid="N1">
              <name>Payer Identification</name>
              <usage>R</usage>
              <pos>080</pos>
              <max_use>1</max_use>
              <element xid="N101">
                <data_ele>98</data_ele>
                <name>Entity Identifier Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>3</max_len>
                <valid_codes>
                  <code>PR</code>
                </valid_codes>
              </element>
              <element xid="N102">
                <data_ele>93</data_ele>
                <name>Payer Name</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>60</max_len>
              </element>
              <element xid="N103">
                <data_ele>66</data_ele>
                <name>Identification Code Qualifier</name>
                <usage>S</usage>
                <seq>03</seq>
                <data_type>ID</data_type>
                <min_len>1</min_len>
                <max_len>2</max_len>
                <valid_codes>
                  <code>XV</code>
                </valid_codes>
              </element>
              <element xid="N104">
                <data_ele>67</data_ele>
                <name>Payer Identifier</name>
                <usage>S</usage>
                <seq>04</seq>
                <data_type>AN</data_type>
                <min_len>2</min_len>
                <max_len>80</max_len>
              </element>
              <element xid="N105">
                <data_ele>706</data_ele>
                <name>Entity Relationship Code</name>
                <usage>N</usage>
                <seq>05</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
              </element>
              <element xid="N106">
                <data_ele>98</data_ele>
                <name>Entity Identifier Code</name>
                <usage>N</usage>
                <seq>06</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>3</max_len>
              </element>
            </segment>
<!--End of N1 segment-->
            <segment xid="N3">
              <name>Payer Address</name>
              <usage>R</usage>
              <pos>100</pos>
              <max_use>1</max_use>
              <element xid="N301">
                <data_ele>166</data_ele>
                <name>Payer Address Line</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>55</max_len>
              </element>
              <element xid="N302">
                <data_ele>166</data_ele>
                <name>Payer Address Line</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>55</max_len>
              </element>
            </segment>
<!--End of N3 segment-->
            <segment xid="N4">
              <name>Payer City, State, ZIP Code</name>
              <usage>R</usage>
              <pos>110</pos>
              <max_use>1</max_use>
              <element xid="N401">
                <data_ele>19</data_ele>
                <name>Payer City Name</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>AN</data_type>
                <min_len>2</min_len>
                <max_len>30</max_len>
              </element>
              <element xid="N402">
                <data_ele>156</data_ele>
                <name>Payer State Code</name>
                <usage>R</usage>
                <seq>02</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes external="states"/>
              </element>
              <element xid="N403">
                <data_ele>116</data_ele>
                <name>Payer Postal Zone or ZIP Code</name>
                <usage>R</usage>
                <seq>03</seq>
                <data_type>ID</data_type>
                <min_len>3</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="N404">
                <data_ele>26</data_ele>
                <name>Country Code</name>
                <usage>N</usage>
                <seq>04</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>3</max_len>
              </element>
              <element xid="N405">
                <data_ele>309</data_ele>
                <name>Location Qualifier</name>
                <usage>N</usage>
                <seq>05</seq>
                <data_type>ID</data_type>
                <min_len>1</min_len>
                <max_len>2</max_len>
              </element>
              <element xid="N406">
                <data_ele>310</data_ele>
                <name>Location Identifier</name>
                <usage>N</usage>
                <seq>06</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
            </segment>
<!--End of N4 segment-->
            <segment xid="REF">
              <name>Additional Payer Identification</name>
              <usage>S</usage>
              <pos>120</pos>
              <max_use>4</max_use>
              <element xid="REF01">
                <data_ele>128</data_ele>
                <name>Reference Identification Qualifier</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>3</max_len>
                <valid_codes>
                  <code>2U</code>
                  <code>EO</code>
                  <code>HI</code>
                  <code>NF</code>
                </valid_codes>
              </element>
              <element xid="REF02">
                <data_ele>127</data_ele>
                <name>Additional Payer Identifier</name>
                <usage>R</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
              <element xid="REF03">
                <data_ele>352</data_ele>
                <name>Description</name>
                <usage>N</usage>
                <seq>03</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>80</max_len>
              </element>
              <composite>
                <data_ele>C040</data_ele>
                <name>Reference Identifier</name>
                <usage>N</usage>
                <seq>04</seq>
              </composite>
            </segment>
<!--End of REF segment-->
            <segment xid="PER">
              <name>Payer Contact Information</name>
              <usage>S</usage>
              <pos>130</pos>
              <max_use>1</max_use>
              <element xid="PER01">
                <data_ele>366</data_ele>
                <name>Contact Function Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes>
                  <code>CX</code>
                </valid_codes>
              </element>
              <element xid="PER02">
                <data_ele>93</data_ele>
                <name>Payer Contact Name</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>60</max_len>
              </element>
              <element xid="PER03">
                <data_ele>365</data_ele>
                <name>Communication Number Qualifier</name>
                <usage>S</usage>
                <seq>03</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes>
                  <code>EM</code>
                  <code>FX</code>
                  <code>TE</code>
                </valid_codes>
              </element>
              <element xid="PER04">
                <data_ele>364</data_ele>
                <name>Payer Contact Communication Number</name>
                <usage>S</usage>
                <seq>04</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>80</max_len>
              </element>
              <element xid="PER05">
                <data_ele>365</data_ele>
                <name>Communication Number Qualifier</name>
                <usage>S</usage>
                <seq>05</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes>
                  <code>EM</code>
                  <code>EX</code>
                  <code>FX</code>
                  <code>TE</code>
                </valid_codes>
              </element>
              <element xid="PER06">
                <data_ele>364</data_ele>
                <name>Payer Contact Communication Number</name>
                <usage>S</usage>
                <seq>06</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>80</max_len>
              </element>
              <element xid="PER07">
                <data_ele>365</data_ele>
                <name>Communication Number Qualifier</name>
                <usage>S</usage>
                <seq>07</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes>
                  <code>EX</code>
                </valid_codes>
              </element>
              <element xid="PER08">
                <data_ele>364</data_ele>
                <name>Payer Contact Communication Number</name>
                <usage>S</usage>
                <seq>08</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>80</max_len>
              </element>
              <element xid="PER09">
                <data_ele>443</data_ele>
                <name>Contact Inquiry Reference</name>
                <usage>N</usage>
                <seq>09</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>20</max_len>
              </element>
            </segment>
<!--End of PER segment-->
          </loop>
<!--End of 1000A loop-->
          <loop xid="1000B">
            <name>Payee Identification</name>
            <usage>R</usage>
            <pos>080</pos>
            <repeat>1</repeat>
            <segment xid="N1">
              <name>Payee Identification</name>
              <usage>R</usage>
              <pos>080</pos>
              <max_use>1</max_use>
              <element xid="N101">
                <data_ele>98</data_ele>
                <name>Entity Identifier Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>3</max_len>
                <valid_codes>
                  <code>PE</code>
                </valid_codes>
              </element>
              <element xid="N102">
                <data_ele>93</data_ele>
                <name>Payee Name</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>60</max_len>
              </element>
              <element xid="N103">
                <data_ele>66</data_ele>
                <name>Identification Code Qualifier</name>
                <usage>R</usage>
                <seq>03</seq>
                <data_type>ID</data_type>
                <min_len>1</min_len>
                <max_len>2</max_len>
                <valid_codes>
                  <code>FI</code>
                  <code>XX</code>
                </valid_codes>
              </element>
              <element xid="N104">
                <data_ele>67</data_ele>
                <name>Payee Identification Code</name>
                <usage>R</usage>
                <seq>04</seq>
                <data_type>AN</data_type>
                <min_len>2</min_len>
                <max_len>80</max_len>
              </element>
              <element xid="N105">
                <data_ele>706</data_ele>
                <name>Entity Relationship Code</name>
                <usage>N</usage>
                <seq>05</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
              </element>
              <element xid="N106">
                <data_ele>98</data_ele>
                <name>Entity Identifier Code</name>
                <usage>N</usage>
                <seq>06</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>3</max_len>
              </element>
            </segment>
<!--End of N1 segment-->
            <segment xid="N3">
              <name>Payee Address</name>
              <usage>S</usage>
              <pos>100</pos>
              <max_use>1</max_use>
              <element xid="N301">
                <data_ele>166</data_ele>
                <name>Payee Address Line</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>55</max_len>
              </element>
              <element xid="N302">
                <data_ele>166</data_ele>
                <name>Payee Address Line</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>55</max_len>
              </element>
            </segment>
<!--End of N3 segment-->
            <segment xid="N4">
              <name>Payee City, State, ZIP Code</name>
              <usage>S</usage>
              <pos>110</pos>
              <max_use>1</max_use>
              <element xid="N401">
                <data_ele>19</data_ele>
                <name>Payee City Name</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>AN</data_type>
                <min_len>2</min_len>
                <max_len>30</max_len>
              </element>
              <element xid="N402">
                <data_ele>156</data_ele>
                <name>Payee State Code</name>
                <usage>R</usage>
                <seq>02</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes external="states"/>
              </element>
              <element xid="N403">
                <data_ele>116</data_ele>
                <name>Payee Postal Zone or ZIP Code</name>
                <usage>R</usage>
                <seq>03</seq>
                <data_type>ID</data_type>
                <min_len>3</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="N404">
                <data_ele>26</data_ele>
                <name>Country Code</name>
                <usage>S</usage>
                <seq>04</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>3</max_len>
                <valid_codes external="country"/>
              </element>
              <element xid="N405">
                <data_ele>309</data_ele>
                <name>Location Qualifier</name>
                <usage>N</usage>
                <seq>05</seq>
                <data_type>ID</data_type>
                <min_len>1</min_len>
                <max_len>2</max_len>
              </element>
              <element xid="N406">
                <data_ele>310</data_ele>
                <name>Location Identifier</name>
                <usage>N</usage>
                <seq>06</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
            </segment>
<!--End of N4 segment-->
            <segment xid="REF">
              <name>Payee Additional Identification</name>
              <usage>S</usage>
              <pos>120</pos>
              <max_use>&gt;1</max_use>
              <element xid="REF01">
                <data_ele>128</data_ele>
                <name>Reference Identification Qualifier</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>3</max_len>
                <valid_codes>
                  <code>0B</code>
                  <code>1A</code>
                  <code>1B</code>
                  <code>1C</code>
                  <code>1D</code>
                  <code>1E</code>
                  <code>1F</code>
                  <code>1G</code>
                  <code>1H</code>
                  <code>D3</code>
                  <code>G2</code>
                  <code>N5</code>
                  <code>PQ</code>
                  <code>TJ</code>
                </valid_codes>
              </element>
              <element xid="REF02">
                <data_ele>127</data_ele>
                <name>Additional Payee Identifier</name>
                <usage>R</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
              <element xid="REF03">
                <data_ele>352</data_ele>
                <name>Description</name>
                <usage>N</usage>
                <seq>03</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>80</max_len>
              </element>
              <composite>
                <data_ele>C040</data_ele>
                <name>Reference Identifier</name>
                <usage>N</usage>
                <seq>04</seq>
              </composite>
            </segment>
<!--End of REF segment-->
          </loop>
<!--End of 1000B loop-->
        </loop>
<!--End of HEADER loop-->
        <loop xid="DETAIL" type="wrapper">
          <name>Table 2 - Detail</name>
          <usage>S</usage>
          <pos>020</pos>
          <repeat>&gt;1</repeat>
          <loop xid="2000">
            <name>Header Number</name>
            <usage>S</usage>
            <pos>003</pos>
            <repeat>&gt;1</repeat>
            <segment xid="LX">
              <name>Header Number</name>
              <usage>R</usage>
              <pos>003</pos>
              <max_use>1</max_use>
              <element xid="LX01">
                <data_ele>554</data_ele>
                <name>Assigned Number</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>N0</data_type>
                <min_len>1</min_len>
                <max_len>6</max_len>
              </element>
            </segment>
<!--End of LX segment-->
            <segment xid="TS3">
              <name>Provider Summary Information</name>
              <usage>S</usage>
              <pos>005</pos>
              <max_use>1</max_use>
              <element xid="TS301">
                <data_ele>127</data_ele>
                <name>Provider Identifier</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
              <element xid="TS302">
                <data_ele>1331</data_ele>
                <name>Facility Type Code</name>
                <usage>R</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>2</max_len>
              </element>
              <element xid="TS303">
                <data_ele>373</data_ele>
                <name>Fiscal Period Date</name>
                <usage>R</usage>
                <seq>03</seq>
                <data_type>DT</data_type>
                <min_len>8</min_len>
                <max_len>8</max_len>
                <valid_codes>
        </valid_codes>
              </element>
              <element xid="TS304">
                <data_ele>380</data_ele>
                <name>Total Claim Count</name>
                <usage>R</usage>
                <seq>04</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS305">
                <data_ele>782</data_ele>
                <name>Total Claim Charge Amount</name>
                <usage>R</usage>
                <seq>05</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS306">
                <data_ele>782</data_ele>
                <name>Total Covered Charge Amount</name>
                <usage>S</usage>
                <seq>06</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS307">
                <data_ele>782</data_ele>
                <name>Total Noncovered Charge Amount</name>
                <usage>S</usage>
                <seq>07</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS308">
                <data_ele>782</data_ele>
                <name>Total Denied Charge Amount</name>
                <usage>S</usage>
                <seq>08</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS309">
                <data_ele>782</data_ele>
                <name>Total Provider Payment Amount</name>
                <usage>S</usage>
                <seq>09</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS310">
                <data_ele>782</data_ele>
                <name>Total Interest Amount</name>
                <usage>S</usage>
                <seq>10</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS311">
                <data_ele>782</data_ele>
                <name>Total Contractual Adjustment Amount</name>
                <usage>S</usage>
                <seq>11</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS312">
                <data_ele>782</data_ele>
                <name>Total Gramm-Rudman Reduction Amount</name>
                <usage>S</usage>
                <seq>12</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS313">
                <data_ele>782</data_ele>
                <name>Total MSP Payer Amount</name>
                <usage>S</usage>
                <seq>13</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS314">
                <data_ele>782</data_ele>
                <name>Total Blood Deductible Amount</name>
                <usage>S</usage>
                <seq>14</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS315">
                <data_ele>782</data_ele>
                <name>Total Non-Lab Charge Amount</name>
                <usage>S</usage>
                <seq>15</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS316">
                <data_ele>782</data_ele>
                <name>Total Coinsurance Amount</name>
                <usage>S</usage>
                <seq>16</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS317">
                <data_ele>782</data_ele>
                <name>Total HCPCS Reported Charge Amount</name>
                <usage>S</usage>
                <seq>17</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS318">
                <data_ele>782</data_ele>
                <name>Total HCPCS Payable Amount</name>
                <usage>S</usage>
                <seq>18</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS319">
                <data_ele>782</data_ele>
                <name>Total Deductible Amount</name>
                <usage>S</usage>
                <seq>19</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS320">
                <data_ele>782</data_ele>
                <name>Total Professional Component Amount</name>
                <usage>S</usage>
                <seq>20</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS321">
                <data_ele>782</data_ele>
                <name>Total MSP Patient Liability Met Amount</name>
                <usage>S</usage>
                <seq>21</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS322">
                <data_ele>782</data_ele>
                <name>Total Patient Reimbursement Amount</name>
                <usage>S</usage>
                <seq>22</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS323">
                <data_ele>380</data_ele>
                <name>Total PIP Claim Count</name>
                <usage>S</usage>
                <seq>23</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS324">
                <data_ele>782</data_ele>
                <name>Total PIP Adjustment Amount</name>
                <usage>S</usage>
                <seq>24</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
            </segment>
<!--End of TS3 segment-->
            <segment xid="TS2">
              <name>Provider Supplemental Summary Information</name>
              <usage>S</usage>
              <pos>007</pos>
              <max_use>1</max_use>
              <element xid="TS201">
                <data_ele>782</data_ele>
                <name>Total DRG Amount</name>
                <usage>S</usage>
                <seq>01</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS202">
                <data_ele>782</data_ele>
                <name>Total Federal Specific Amount</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS203">
                <data_ele>782</data_ele>
                <name>Total Hospital Specific Amount</name>
                <usage>S</usage>
                <seq>03</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS204">
                <data_ele>782</data_ele>
                <name>Total Disproportionate Share Amount</name>
                <usage>S</usage>
                <seq>04</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS205">
                <data_ele>782</data_ele>
                <name>Total Capital Amount</name>
                <usage>S</usage>
                <seq>05</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS206">
                <data_ele>782</data_ele>
                <name>Total Indirect Medical Education Amount</name>
                <usage>S</usage>
                <seq>06</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS207">
                <data_ele>380</data_ele>
                <name>Total Outlier Day Count</name>
                <usage>S</usage>
                <seq>07</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS208">
                <data_ele>782</data_ele>
                <name>Total Day Outlier Amount</name>
                <usage>S</usage>
                <seq>08</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS209">
                <data_ele>782</data_ele>
                <name>Total Cost Outlier Amount</name>
                <usage>S</usage>
                <seq>09</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS210">
                <data_ele>380</data_ele>
                <name>Average DRG Length of Stay</name>
                <usage>S</usage>
                <seq>10</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS211">
                <data_ele>380</data_ele>
                <name>Total Discharge Count</name>
                <usage>S</usage>
                <seq>11</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS212">
                <data_ele>380</data_ele>
                <name>Total Cost Report Day Count</name>
                <usage>S</usage>
                <seq>12</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS213">
                <data_ele>380</data_ele>
                <name>Total Covered Day Count</name>
                <usage>S</usage>
                <seq>13</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS214">
                <data_ele>380</data_ele>
                <name>Total Noncovered Day Count</name>
                <usage>S</usage>
                <seq>14</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS215">
                <data_ele>782</data_ele>
                <name>Total MSP Pass-Through Amount</name>
                <usage>S</usage>
                <seq>15</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS216">
                <data_ele>380</data_ele>
                <name>Average DRG weight</name>
                <usage>S</usage>
                <seq>16</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>15</max_len>
              </element>
              <element xid="TS217">
                <data_ele>782</data_ele>
                <name>Total PPS Capital FSP DRG Amount</name>
                <usage>S</usage>
                <seq>17</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS218">
                <data_ele>782</data_ele>
                <name>Total PPS Capital HSP DRG Amount</name>
                <usage>S</usage>
                <seq>18</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
              <element xid="TS219">
                <data_ele>782</data_ele>
                <name>Total PPS DSH DRG Amount</name>
                <usage>S</usage>
                <seq>19</seq>
                <data_type>R</data_type>
                <min_len>1</min_len>
                <max_len>18</max_len>
              </element>
            </segment>
<!--End of TS2 segment-->
            <loop xid="2100">
              <name>Claim Payment Information</name>
              <usage>R</usage>
              <pos>010</pos>
              <repeat>&gt;1</repeat>
              <segment xid="CLP">
                <name>Claim Payment Information</name>
                <usage>R</usage>
                <pos>010</pos>
                <max_use>1</max_use>
                <element xid="CLP01">
                  <data_ele>1028</data_ele>
                  <name>Patient Control Number</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>38</max_len>
                </element>
                <element xid="CLP02">
                  <data_ele>1029</data_ele>
                  <name>Claim Status Code</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes external="claim_status"/>
                </element>
                <element xid="CLP03">
                  <data_ele>782</data_ele>
                  <name>Total Claim Charge Amount</name>
                  <usage>R</usage>
                  <seq>03</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CLP04">
                  <data_ele>782</data_ele>
                  <name>Claim Payment Amount</name>
                  <usage>R</usage>
                  <seq>04</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CLP05">
                  <data_ele>782</data_ele>
                  <name>Patient Responsibility Amount</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CLP06">
                  <data_ele>1032</data_ele>
                  <name>Claim Filing Indicator Code</name>
                  <usage>R</usage>
                  <seq>06</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>12</code>
                    <code>13</code>
                    <code>14</code>
                    <code>15</code>
                    <code>16</code>
                    <code>AM</code>
                    <code>CH</code>
                    <code>DS</code>
                    <code>HM</code>
                    <code>LM</code>
                    <code>MA</code>
                    <code>MB</code>
                    <code>MC</code>
                    <code>OF</code>
                    <code>TV</code>
                    <code>VA</code>
                    <code>WC</code>
                  </valid_codes>
                </element>
                <element xid="CLP07">
                  <data_ele>127</data_ele>
                  <name>Payer Claim Control Number</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                </element>
                <element xid="CLP08">
                  <data_ele>1331</data_ele>
                  <name>Facility Type Code</name>
                  <usage>S</usage>
                  <seq>08</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="CLP09">
                  <data_ele>1325</data_ele>
                  <name>Claim Frequency Code</name>
                  <usage>S</usage>
                  <seq>09</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>1</max_len>
                  <valid_codes>
                    <code>0</code>
                    <code>1</code>
                    <code>2</code>
                    <code>3</code>
                    <code>4</code>
                    <code>5</code>
                    <code>6</code>
                    <code>7</code>
                    <code>8</code>
                    <code>9</code>
                    <code>A</code>
                    <code>B</code>
                    <code>C</code>
                    <code>D</code>
                    <code>E</code>
                    <code>F</code>
                    <code>G</code>
                    <code>H</code>
                    <code>I</code>
                    <code>J</code>
                    <code>K</code>
                    <code>L</code>
                    <code>M</code>
                    <code>N</code>
                    <code>O</code>
                    <code>X</code>
                    <code>Y</code>
                    <code>Z</code>
                  </valid_codes>
                </element>
                <element xid="CLP10">
                  <data_ele>1352</data_ele>
                  <name>Patient Status Code</name>
                  <usage>N</usage>
                  <seq>10</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="CLP11">
                  <data_ele>1354</data_ele>
                  <name>Diagnosis Related Group (DRG) Code</name>
                  <usage>S</usage>
                  <seq>11</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>4</max_len>
                </element>
                <element xid="CLP12">
                  <data_ele>380</data_ele>
                  <name>Diagnosis Related Group (DRG) Weight</name>
                  <usage>S</usage>
                  <seq>12</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="CLP13">
                  <data_ele>954</data_ele>
                  <name>Discharge Fraction</name>
                  <usage>S</usage>
                  <seq>13</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
              </segment>
<!--End of CLP segment-->
              <segment xid="CAS">
                <name>Claim Adjustment</name>
                <usage>S</usage>
                <pos>020</pos>
                <max_use>99</max_use>
                <element xid="CAS01">
                  <data_ele>1033</data_ele>
                  <name>Claim Adjustment Group Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>CO</code>
                    <code>CR</code>
                    <code>OA</code>
                    <code>PI</code>
                    <code>PR</code>
                  </valid_codes>
                </element>
                <element xid="CAS02">
                  <data_ele>1034</data_ele>
                  <name>Adjustment Reason Code</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>5</max_len>
                  <valid_codes external="adjustment_reason"/>
                </element>
                <element xid="CAS03">
                  <data_ele>782</data_ele>
                  <name>Adjustment Amount</name>
                  <usage>R</usage>
                  <seq>03</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CAS04">
                  <data_ele>380</data_ele>
                  <name>Adjustment Quantity</name>
                  <usage>S</usage>
                  <seq>04</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="CAS05">
                  <data_ele>1034</data_ele>
                  <name>Adjustment Reason Code</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>5</max_len>
                  <valid_codes external="adjustment_reason"/>
                </element>
                <element xid="CAS06">
                  <data_ele>782</data_ele>
                  <name>Adjustment Amount</name>
                  <usage>S</usage>
                  <seq>06</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CAS07">
                  <data_ele>380</data_ele>
                  <name>Adjustment Quantity</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="CAS08">
                  <data_ele>1034</data_ele>
                  <name>Adjustment Reason Code</name>
                  <usage>S</usage>
                  <seq>08</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>5</max_len>
                  <valid_codes external="adjustment_reason"/>
                </element>
                <element xid="CAS09">
                  <data_ele>782</data_ele>
                  <name>Adjustment Amount</name>
                  <usage>S</usage>
                  <seq>09</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CAS10">
                  <data_ele>380</data_ele>
                  <name>Adjustment Quantity</name>
                  <usage>S</usage>
                  <seq>10</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="CAS11">
                  <data_ele>1034</data_ele>
                  <name>Adjustment Reason Code</name>
                  <usage>S</usage>
                  <seq>11</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>5</max_len>
                  <valid_codes external="adjustment_reason"/>
                </element>
                <element xid="CAS12">
                  <data_ele>782</data_ele>
                  <name>Adjustment Amount</name>
                  <usage>S</usage>
                  <seq>12</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CAS13">
                  <data_ele>380</data_ele>
                  <name>Adjustment Quantity</name>
                  <usage>S</usage>
                  <seq>13</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="CAS14">
                  <data_ele>1034</data_ele>
                  <name>Adjustment Reason Code</name>
                  <usage>S</usage>
                  <seq>14</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>5</max_len>
                  <valid_codes external="adjustment_reason"/>
                </element>
                <element xid="CAS15">
                  <data_ele>782</data_ele>
                  <name>Adjustment Amount</name>
                  <usage>S</usage>
                  <seq>15</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CAS16">
                  <data_ele>380</data_ele>
                  <name>Adjustment Quantity</name>
                  <usage>S</usage>
                  <seq>16</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="CAS17">
                  <data_ele>1034</data_ele>
                  <name>Adjustment Reason Code</name>
                  <usage>S</usage>
                  <seq>17</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>5</max_len>
                  <valid_codes external="adjustment_reason"/>
                </element>
                <element xid="CAS18">
                  <data_ele>782</data_ele>
                  <name>Adjustment Amount</name>
                  <usage>S</usage>
                  <seq>18</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="CAS19">
                  <data_ele>380</data_ele>
                  <name>Adjustment Quantity</name>
                  <usage>S</usage>
                  <seq>19</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
              </segment>
<!--End of CAS segment-->
              <segment xid="NM1">
                <name>Patient Name</name>
                <usage>R</usage>
                <pos>030</pos>
                <max_use>1</max_use>
                <element xid="NM101">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>QC</code>
                  </valid_codes>
                </element>
                <element xid="NM102">
                  <data_ele>1065</data_ele>
                  <name>Entity Type Qualifier</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>1</max_len>
                  <valid_codes>
                    <code>1</code>
                  </valid_codes>
                </element>
                <element xid="NM103">
                  <data_ele>1035</data_ele>
                  <name>Patient Last Name</name>
                  <usage>R</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>35</max_len>
                </element>
                <element xid="NM104">
                  <data_ele>1036</data_ele>
                  <name>Patient First Name</name>
                  <usage>R</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM105">
                  <data_ele>1037</data_ele>
                  <name>Patient Middle Name</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM106">
                  <data_ele>1038</data_ele>
                  <name>Name Prefix</name>
                  <usage>N</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM107">
                  <data_ele>1039</data_ele>
                  <name>Patient Name Suffix</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM108">
                  <data_ele>66</data_ele>
                  <name>Identification Code Qualifier</name>
                  <usage>S</usage>
                  <seq>08</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>34</code>
                    <code>HN</code>
                    <code>II</code>
                    <code>MI</code>
                    <code>MR</code>
                  </valid_codes>
                </element>
                <element xid="NM109">
                  <data_ele>67</data_ele>
                  <name>Patient Identifier</name>
                  <usage>S</usage>
                  <seq>09</seq>
                  <data_type>AN</data_type>
                  <min_len>2</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="NM110">
                  <data_ele>706</data_ele>
                  <name>Entity Relationship Code</name>
                  <usage>N</usage>
                  <seq>10</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="NM111">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>N</usage>
                  <seq>11</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                </element>
              </segment>
<!--End of NM1 segment-->
              <segment xid="NM1">
                <name>Insured Name</name>
                <usage>S</usage>
                <pos>030</pos>
                <max_use>1</max_use>
                <element xid="NM101">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>IL</code>
                  </valid_codes>
                </element>
                <element xid="NM102">
                  <data_ele>1065</data_ele>
                  <name>Entity Type Qualifier</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>1</max_len>
                  <valid_codes>
                    <code>1</code>
                    <code>2</code>
                  </valid_codes>
                </element>
                <element xid="NM103">
                  <data_ele>1035</data_ele>
                  <name>Subscriber Last Name</name>
                  <usage>S</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>35</max_len>
                </element>
                <element xid="NM104">
                  <data_ele>1036</data_ele>
                  <name>Subscriber First Name</name>
                  <usage>S</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM105">
                  <data_ele>1037</data_ele>
                  <name>Subscriber Middle Name</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM106">
                  <data_ele>1038</data_ele>
                  <name>Name Prefix</name>
                  <usage>N</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM107">
                  <data_ele>1039</data_ele>
                  <name>Subscriber Name Suffix</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM108">
                  <data_ele>66</data_ele>
                  <name>Identification Code Qualifier</name>
                  <usage>R</usage>
                  <seq>08</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>34</code>
                    <code>HN</code>
                    <code>MI</code>
                  </valid_codes>
                </element>
                <element xid="NM109">
                  <data_ele>67</data_ele>
                  <name>Subscriber Identifier</name>
                  <usage>R</usage>
                  <seq>09</seq>
                  <data_type>AN</data_type>
                  <min_len>2</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="NM110">
                  <data_ele>706</data_ele>
                  <name>Entity Relationship Code</name>
                  <usage>N</usage>
                  <seq>10</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="NM111">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>N</usage>
                  <seq>11</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                </element>
              </segment>
<!--End of NM1 segment-->
              <segment xid="NM1">
                <name>Corrected Patient/Insured Name</name>
                <usage>S</usage>
                <pos>030</pos>
                <max_use>1</max_use>
                <element xid="NM101">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>74</code>
                  </valid_codes>
                </element>
                <element xid="NM102">
                  <data_ele>1065</data_ele>
                  <name>Entity Type Qualifier</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>1</max_len>
                  <valid_codes>
                    <code>1</code>
                    <code>2</code>
                  </valid_codes>
                </element>
                <element xid="NM103">
                  <data_ele>1035</data_ele>
                  <name>Corrected Patient or Insured Last Name</name>
                  <usage>S</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>35</max_len>
                </element>
                <element xid="NM104">
                  <data_ele>1036</data_ele>
                  <name>Corrected Patient or Insured First Name</name>
                  <usage>S</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM105">
                  <data_ele>1037</data_ele>
                  <name>Corrected Patient or Insured Middle Name</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM106">
                  <data_ele>1038</data_ele>
                  <name>Name Prefix</name>
                  <usage>N</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM107">
                  <data_ele>1039</data_ele>
                  <name>Corrected Patient or Insured Name Suffix</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM108">
                  <data_ele>66</data_ele>
                  <name>Identification Code Qualifier</name>
                  <usage>S</usage>
                  <seq>08</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>C</code>
                  </valid_codes>
                </element>
                <element xid="NM109">
                  <data_ele>67</data_ele>
                  <name>Corrected Insured Identification Indicator</name>
                  <usage>S</usage>
                  <seq>09</seq>
                  <data_type>AN</data_type>
                  <min_len>2</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="NM110">
                  <data_ele>706</data_ele>
                  <name>Entity Relationship Code</name>
                  <usage>N</usage>
                  <seq>10</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="NM111">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>N</usage>
                  <seq>11</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                </element>
              </segment>
<!--End of NM1 segment-->
              <segment xid="NM1">
                <name>Service Provider Name</name>
                <usage>S</usage>
                <pos>030</pos>
                <max_use>1</max_use>
                <element xid="NM101">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>82</code>
                  </valid_codes>
                </element>
                <element xid="NM102">
                  <data_ele>1065</data_ele>
                  <name>Entity Type Qualifier</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>1</max_len>
                  <valid_codes>
                    <code>1</code>
                    <code>2</code>
                  </valid_codes>
                </element>
                <element xid="NM103">
                  <data_ele>1035</data_ele>
                  <name>Rendering Provider Last or Organization Name</name>
                  <usage>S</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>35</max_len>
                </element>
                <element xid="NM104">
                  <data_ele>1036</data_ele>
                  <name>Rendering Provider First Name</name>
                  <usage>S</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM105">
                  <data_ele>1037</data_ele>
                  <name>Rendering Provider Middle Name</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM106">
                  <data_ele>1038</data_ele>
                  <name>Name Prefix</name>
                  <usage>N</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM107">
                  <data_ele>1039</data_ele>
                  <name>Rendering Provider Name Suffix</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM108">
                  <data_ele>66</data_ele>
                  <name>Identification Code Qualifier</name>
                  <usage>R</usage>
                  <seq>08</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>BD</code>
                    <code>BS</code>
                    <code>FI</code>
                    <code>MC</code>
                    <code>PC</code>
                    <code>SL</code>
                    <code>UP</code>
                    <code>XX</code>
                  </valid_codes>
                </element>
                <element xid="NM109">
                  <data_ele>67</data_ele>
                  <name>Rendering Provider Identifier</name>
                  <usage>R</usage>
                  <seq>09</seq>
                  <data_type>AN</data_type>
                  <min_len>2</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="NM110">
                  <data_ele>706</data_ele>
                  <name>Entity Relationship Code</name>
                  <usage>N</usage>
                  <seq>10</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="NM111">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>N</usage>
                  <seq>11</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                </element>
              </segment>
<!--End of NM1 segment-->
              <segment xid="NM1">
                <name>Crossover Carrier Name</name>
                <usage>S</usage>
                <pos>030</pos>
                <max_use>1</max_use>
                <element xid="NM101">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>TT</code>
                  </valid_codes>
                </element>
                <element xid="NM102">
                  <data_ele>1065</data_ele>
                  <name>Entity Type Qualifier</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>1</max_len>
                  <valid_codes>
                    <code>2</code>
                  </valid_codes>
                </element>
                <element xid="NM103">
                  <data_ele>1035</data_ele>
                  <name>Coordination of Benefits Carrier Name</name>
                  <usage>R</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>35</max_len>
                </element>
                <element xid="NM104">
                  <data_ele>1036</data_ele>
                  <name>Name First</name>
                  <usage>N</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM105">
                  <data_ele>1037</data_ele>
                  <name>Name Middle</name>
                  <usage>N</usage>
                  <seq>05</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM106">
                  <data_ele>1038</data_ele>
                  <name>Name Prefix</name>
                  <usage>N</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM107">
                  <data_ele>1039</data_ele>
                  <name>Name Suffix</name>
                  <usage>N</usage>
                  <seq>07</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM108">
                  <data_ele>66</data_ele>
                  <name>Identification Code Qualifier</name>
                  <usage>R</usage>
                  <seq>08</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>AD</code>
                    <code>FI</code>
                    <code>NI</code>
                    <code>PI</code>
                    <code>PP</code>
                    <code>XV</code>
                  </valid_codes>
                </element>
                <element xid="NM109">
                  <data_ele>67</data_ele>
                  <name>Coordination of Benefits Carrier Identifier</name>
                  <usage>R</usage>
                  <seq>09</seq>
                  <data_type>AN</data_type>
                  <min_len>2</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="NM110">
                  <data_ele>706</data_ele>
                  <name>Entity Relationship Code</name>
                  <usage>N</usage>
                  <seq>10</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="NM111">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>N</usage>
                  <seq>11</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                </element>
              </segment>
<!--End of NM1 segment-->
              <segment xid="NM1">
                <name>Corrected Priority Payer Name</name>
                <usage>S</usage>
                <pos>030</pos>
                <max_use>2</max_use>
                <element xid="NM101">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>PR</code>
                  </valid_codes>
                </element>
                <element xid="NM102">
                  <data_ele>1065</data_ele>
                  <name>Entity Type Qualifier</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>1</max_len>
                  <valid_codes>
                    <code>2</code>
                  </valid_codes>
                </element>
                <element xid="NM103">
                  <data_ele>1035</data_ele>
                  <name>Corrected Priority Payer Name</name>
                  <usage>R</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>35</max_len>
                </element>
                <element xid="NM104">
                  <data_ele>1036</data_ele>
                  <name>Name First</name>
                  <usage>N</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM105">
                  <data_ele>1037</data_ele>
                  <name>Name Middle</name>
                  <usage>N</usage>
                  <seq>05</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>25</max_len>
                </element>
                <element xid="NM106">
                  <data_ele>1038</data_ele>
                  <name>Name Prefix</name>
                  <usage>N</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM107">
                  <data_ele>1039</data_ele>
                  <name>Name Suffix</name>
                  <usage>N</usage>
                  <seq>07</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="NM108">
                  <data_ele>66</data_ele>
                  <name>Identification Code Qualifier</name>
                  <usage>R</usage>
                  <seq>08</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>AD</code>
                    <code>FI</code>
                    <code>NI</code>
                    <code>PI</code>
                    <code>PP</code>
                    <code>XV</code>
                  </valid_codes>
                </element>
                <element xid="NM109">
                  <data_ele>67</data_ele>
                  <name>Corrected Priority Payer Identification Number</name>
                  <usage>R</usage>
                  <seq>09</seq>
                  <data_type>AN</data_type>
                  <min_len>2</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="NM110">
                  <data_ele>706</data_ele>
                  <name>Entity Relationship Code</name>
                  <usage>N</usage>
                  <seq>10</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="NM111">
                  <data_ele>98</data_ele>
                  <name>Entity Identifier Code</name>
                  <usage>N</usage>
                  <seq>11</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                </element>
              </segment>
<!--End of NM1 segment-->
              <segment xid="MIA">
                <name>Inpatient Adjudication Information</name>
                <usage>S</usage>
                <pos>033</pos>
                <max_use>1</max_use>
                <element xid="MIA01">
                  <data_ele>380</data_ele>
                  <name>Covered Days or Visits Count</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="MIA02">
                  <data_ele>380</data_ele>
                  <name>PPS Operating Outlier Amount</name>
                  <usage>S</usage>
                  <seq>02</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="MIA03">
                  <data_ele>380</data_ele>
                  <name>Lifetime Psychiatric Days Count</name>
                  <usage>S</usage>
                  <seq>03</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="MIA04">
                  <data_ele>782</data_ele>
                  <name>Claim DRG Amount</name>
                  <usage>S</usage>
                  <seq>04</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA05">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MIA06">
                  <data_ele>782</data_ele>
                  <name>Claim Disproportionate Share Amount</name>
                  <usage>S</usage>
                  <seq>06</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA07">
                  <data_ele>782</data_ele>
                  <name>Claim MSP Pass-through Amount</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA08">
                  <data_ele>782</data_ele>
                  <name>Claim PPS Capital Amount</name>
                  <usage>S</usage>
                  <seq>08</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA09">
                  <data_ele>782</data_ele>
                  <name>PPS-Capital FSP DRG Amount</name>
                  <usage>S</usage>
                  <seq>09</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA10">
                  <data_ele>782</data_ele>
                  <name>PPS-Capital HSP DRG Amount</name>
                  <usage>S</usage>
                  <seq>10</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA11">
                  <data_ele>782</data_ele>
                  <name>PPS-Capital DSH DRG Amount</name>
                  <usage>S</usage>
                  <seq>11</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA12">
                  <data_ele>782</data_ele>
                  <name>Old Capital Amount</name>
                  <usage>S</usage>
                  <seq>12</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA13">
                  <data_ele>782</data_ele>
                  <name>PPS-Capital IME Amount</name>
                  <usage>S</usage>
                  <seq>13</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA14">
                  <data_ele>782</data_ele>
                  <name>PPS-Operating Hospital Specific DRG Amount</name>
                  <usage>S</usage>
                  <seq>14</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA15">
                  <data_ele>380</data_ele>
                  <name>Cost Report Day Count</name>
                  <usage>S</usage>
                  <seq>15</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <element xid="MIA16">
                  <data_ele>782</data_ele>
                  <name>PPS-Operating Federal Specific DRG Amount</name>
                  <usage>S</usage>
                  <seq>16</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA17">
                  <data_ele>782</data_ele>
                  <name>Claim PPS Capital Outlier Amount</name>
                  <usage>S</usage>
                  <seq>17</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA18">
                  <data_ele>782</data_ele>
                  <name>Claim Indirect Teaching Amount</name>
                  <usage>S</usage>
                  <seq>18</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA19">
                  <data_ele>782</data_ele>
                  <name>Nonpayable Professional Component Amount</name>
                  <usage>S</usage>
                  <seq>19</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MIA20">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>20</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MIA21">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>21</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MIA22">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>22</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MIA23">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>23</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MIA24">
                  <data_ele>782</data_ele>
                  <name>PPS-Capital Exception Amount</name>
                  <usage>S</usage>
                  <seq>24</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
              </segment>
<!--End of MIA segment-->
              <segment xid="MOA">
                <name>Outpatient Adjudication Information</name>
                <usage>S</usage>
                <pos>035</pos>
                <max_use>1</max_use>
                <element xid="MOA01">
                  <data_ele>954</data_ele>
                  <name>Reimbursement Rate</name>
                  <usage>S</usage>
                  <seq>01</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>10</max_len>
                </element>
                <element xid="MOA02">
                  <data_ele>782</data_ele>
                  <name>Claim HCPCS Payable Amount</name>
                  <usage>S</usage>
                  <seq>02</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MOA03">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MOA04">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MOA05">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MOA06">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MOA07">
                  <data_ele>127</data_ele>
                  <name>Remark Code</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                  <valid_codes external="remark_code"/>
                </element>
                <element xid="MOA08">
                  <data_ele>782</data_ele>
                  <name>Claim ESRD Payment Amount</name>
                  <usage>S</usage>
                  <seq>08</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="MOA09">
                  <data_ele>782</data_ele>
                  <name>Nonpayable Professional Component Amount</name>
                  <usage>S</usage>
                  <seq>09</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
              </segment>
<!--End of MOA segment-->
              <segment xid="REF">
                <name>Other Claim Related Identification</name>
                <usage>S</usage>
                <pos>040</pos>
                <max_use>5</max_use>
                <element xid="REF01">
                  <data_ele>128</data_ele>
                  <name>Reference Identification Qualifier</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>1L</code>
                    <code>1W</code>
                    <code>9A</code>
                    <code>9C</code>
                    <code>A6</code>
                    <code>BB</code>
                    <code>CE</code>
                    <code>EA</code>
                    <code>F8</code>
                    <code>G1</code>
                    <code>G3</code>
                    <code>IG</code>
                    <code>SY</code>
                  </valid_codes>
                </element>
                <element xid="REF02">
                  <data_ele>127</data_ele>
                  <name>Other Claim Related Identifier</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                </element>
                <element xid="REF03">
                  <data_ele>352</data_ele>
                  <name>Description</name>
                  <usage>N</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>80</max_len>
                </element>
                <composite>
                  <data_ele>C040</data_ele>
                  <name>Reference Identifier</name>
                  <usage>N</usage>
                  <seq>04</seq>
                </composite>
              </segment>
<!--End of REF segment-->
              <segment xid="REF">
                <name>Rendering Provider Identification</name>
                <usage>S</usage>
                <pos>040</pos>
                <max_use>10</max_use>
                <element xid="REF01">
                  <data_ele>128</data_ele>
                  <name>Reference Identification Qualifier</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>1A</code>
                    <code>1B</code>
                    <code>1C</code>
                    <code>1D</code>
                    <code>1G</code>
                    <code>1H</code>
                    <code>D3</code>
                    <code>G2</code>
                  </valid_codes>
                </element>
                <element xid="REF02">
                  <data_ele>127</data_ele>
                  <name>Rendering Provider Secondary Identifier</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                </element>
                <element xid="REF03">
                  <data_ele>352</data_ele>
                  <name>Description</name>
                  <usage>N</usage>
                  <seq>03</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>80</max_len>
                </element>
                <composite>
                  <data_ele>C040</data_ele>
                  <name>Reference Identifier</name>
                  <usage>N</usage>
                  <seq>04</seq>
                </composite>
              </segment>
<!--End of REF segment-->
              <segment xid="DTM">
                <name>Claim Date</name>
                <usage>S</usage>
                <pos>050</pos>
                <max_use>4</max_use>
                <element xid="DTM01">
                  <data_ele>374</data_ele>
                  <name>Date Time Qualifier</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>3</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>036</code>
                    <code>050</code>
                    <code>232</code>
                    <code>233</code>
                  </valid_codes>
                </element>
                <element xid="DTM02">
                  <data_ele>373</data_ele>
                  <name>Claim Date</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>DT</data_type>
                  <min_len>8</min_len>
                  <max_len>8</max_len>
                  <valid_codes>
          </valid_codes>
                </element>
                <element xid="DTM03">
                  <data_ele>337</data_ele>
                  <name>Time</name>
                  <usage>N</usage>
                  <seq>03</seq>
                  <data_type>TM</data_type>
                  <min_len>4</min_len>
                  <max_len>8</max_len>
                </element>
                <element xid="DTM04">
                  <data_ele>623</data_ele>
                  <name>Time Code</name>
                  <usage>N</usage>
                  <seq>04</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                </element>
                <element xid="DTM05">
                  <data_ele>1250</data_ele>
                  <name>Date Time Period Format Qualifier</name>
                  <usage>N</usage>
                  <seq>05</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>3</max_len>
                </element>
                <element xid="DTM06">
                  <data_ele>1251</data_ele>
                  <name>Date Time Period</name>
                  <usage>N</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>35</max_len>
                </element>
              </segment>
<!--End of DTM segment-->
              <segment xid="PER">
                <name>Claim Contact Information</name>
                <usage>S</usage>
                <pos>060</pos>
                <max_use>3</max_use>
                <element xid="PER01">
                  <data_ele>366</data_ele>
                  <name>Contact Function Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>CX</code>
                  </valid_codes>
                </element>
                <element xid="PER02">
                  <data_ele>93</data_ele>
                  <name>Claim Contact Name</name>
                  <usage>S</usage>
                  <seq>02</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>60</max_len>
                </element>
                <element xid="PER03">
                  <data_ele>365</data_ele>
                  <name>Communication Number Qualifier</name>
                  <usage>S</usage>
                  <seq>03</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>EM</code>
                    <code>FX</code>
                    <code>TE</code>
                  </valid_codes>
                </element>
                <element xid="PER04">
                  <data_ele>364</data_ele>
                  <name>Claim Contact Communications Number</name>
                  <usage>S</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="PER05">
                  <data_ele>365</data_ele>
                  <name>Communication Number Qualifier</name>
                  <usage>S</usage>
                  <seq>05</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>EM</code>
                    <code>EX</code>
                    <code>FX</code>
                    <code>TE</code>
                  </valid_codes>
                </element>
                <element xid="PER06">
                  <data_ele>364</data_ele>
                  <name>Claim Contact Communications Number</name>
                  <usage>S</usage>
                  <seq>06</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="PER07">
                  <data_ele>365</data_ele>
                  <name>Communication Number Qualifier</name>
                  <usage>S</usage>
                  <seq>07</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>EX</code>
                  </valid_codes>
                </element>
                <element xid="PER08">
                  <data_ele>364</data_ele>
                  <name>Communication Number Extension</name>
                  <usage>S</usage>
                  <seq>08</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>80</max_len>
                </element>
                <element xid="PER09">
                  <data_ele>443</data_ele>
                  <name>Contact Inquiry Reference</name>
                  <usage>N</usage>
                  <seq>09</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>20</max_len>
                </element>
              </segment>
<!--End of PER segment-->
              <segment xid="AMT">
                <name>Claim Supplemental Information</name>
                <usage>S</usage>
                <pos>062</pos>
                <max_use>14</max_use>
                <element xid="AMT01">
                  <data_ele>522</data_ele>
                  <name>Amount Qualifier Code</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>3</max_len>
                  <valid_codes>
                    <code>I</code>
                    <code>T</code>
                    <code>AU</code>
                    <code>D8</code>
                    <code>DY</code>
                    <code>F5</code>
                    <code>NL</code>
                    <code>T2</code>
                    <code>ZK</code>
                    <code>ZL</code>
                    <code>ZM</code>
                    <code>ZN</code>
                    <code>ZO</code>
                    <code>ZZ</code>
                  </valid_codes>
                </element>
                <element xid="AMT02">
                  <data_ele>782</data_ele>
                  <name>Claim Supplemental Information Amount</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>18</max_len>
                </element>
                <element xid="AMT03">
                  <data_ele>478</data_ele>
                  <name>Credit/Debit Flag Code</name>
                  <usage>N</usage>
                  <seq>03</seq>
                  <data_type>ID</data_type>
                  <min_len>1</min_len>
                  <max_len>1</max_len>
                </element>
              </segment>
<!--End of AMT segment-->
              <segment xid="QTY">
                <name>Claim Supplemental Information Quantity</name>
                <usage>S</usage>
                <pos>064</pos>
                <max_use>15</max_use>
                <element xid="QTY01">
                  <data_ele>673</data_ele>
                  <name>Quantity Qualifier</name>
                  <usage>R</usage>
                  <seq>01</seq>
                  <data_type>ID</data_type>
                  <min_len>2</min_len>
                  <max_len>2</max_len>
                  <valid_codes>
                    <code>CA</code>
                    <code>CD</code>
                    <code>LA</code>
                    <code>LE</code>
                    <code>NA</code>
                    <code>NE</code>
                    <code>NR</code>
                    <code>OU</code>
                    <code>PS</code>
                    <code>VS</code>
                    <code>ZK</code>
                    <code>ZL</code>
                    <code>ZM</code>
                    <code>ZN</code>
                    <code>ZO</code>
                  </valid_codes>
                </element>
                <element xid="QTY02">
                  <data_ele>380</data_ele>
                  <name>Claim Supplemental Information Quantity</name>
                  <usage>R</usage>
                  <seq>02</seq>
                  <data_type>R</data_type>
                  <min_len>1</min_len>
                  <max_len>15</max_len>
                </element>
                <composite>
                  <data_ele>C001</data_ele>
                  <name>Composite Unit of Measure</name>
                  <usage>N</usage>
                  <seq>03</seq>
                </composite>
                <element xid="QTY04">
                  <data_ele>61</data_ele>
                  <name>Free-Form Message</name>
                  <usage>N</usage>
                  <seq>04</seq>
                  <data_type>AN</data_type>
                  <min_len>1</min_len>
                  <max_len>30</max_len>
                </element>
              </segment>
<!--End of QTY segment-->
              <loop xid="2110">
                <name>Service Payment Information</name>
                <usage>S</usage>
                <pos>070</pos>
                <repeat>999</repeat>
                <segment xid="SVC">
                  <name>Service Payment Information</name>
                  <usage>R</usage>
                  <pos>070</pos>
                  <max_use>1</max_use>
                  <composite>
                    <data_ele>C003</data_ele>
                    <name>Composite Medical Procedure Identifier</name>
                    <usage>R</usage>
                    <seq>01</seq>
                    <element xid="SVC01-01">
                      <data_ele>235</data_ele>
                      <name>Product or Service ID Qualifier</name>
                      <usage>R</usage>
                      <seq>01</seq>
                      <data_type>ID</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                      <valid_codes>
                        <code>AD</code>
                        <code>ER</code>
                        <code>HC</code>
                        <code>ID</code>
                        <code>IV</code>
                        <code>N4</code>
                        <code>NU</code>
                        <code>RB</code>
                        <code>ZZ</code>
                      </valid_codes>
                    </element>
                    <element xid="SVC01-02">
                      <data_ele>234</data_ele>
                      <name>Procedure Code</name>
                      <usage>R</usage>
                      <seq>02</seq>
                      <data_type>AN</data_type>
                      <min_len>1</min_len>
                      <max_len>48</max_len>
                    </element>
                    <element xid="SVC01-03">
                      <data_ele>1339</data_ele>
                      <name>Procedure Modifier</name>
                      <usage>S</usage>
                      <seq>03</seq>
                      <data_type>AN</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                    </element>
                    <element xid="SVC01-04">
                      <data_ele>1339</data_ele>
                      <name>Procedure Modifier</name>
                      <usage>S</usage>
                      <seq>04</seq>
                      <data_type>AN</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                    </element>
                    <element xid="SVC01-05">
                      <data_ele>1339</data_ele>
                      <name>Procedure Modifier</name>
                      <usage>S</usage>
                      <seq>05</seq>
                      <data_type>AN</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                    </element>
                    <element xid="SVC01-06">
                      <data_ele>1339</data_ele>
                      <name>Procedure Modifier</name>
                      <usage>S</usage>
                      <seq>06</seq>
                      <data_type>AN</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                    </element>
                    <element xid="SVC01-07">
                      <data_ele>352</data_ele>
                      <name>Procedure Code Description</name>
                      <usage>S</usage>
                      <seq>07</seq>
                      <data_type>AN</data_type>
                      <min_len>1</min_len>
                      <max_len>80</max_len>
                    </element>
                  </composite>
                  <element xid="SVC02">
                    <data_ele>782</data_ele>
                    <name>Line Item Charge Amount</name>
                    <usage>R</usage>
                    <seq>02</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="SVC03">
                    <data_ele>782</data_ele>
                    <name>Line Item Provider Payment Amount</name>
                    <usage>R</usage>
                    <seq>03</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="SVC04">
                    <data_ele>234</data_ele>
                    <name>National Uniform Billing Committee Revenue Code</name>
                    <usage>S</usage>
                    <seq>04</seq>
                    <data_type>AN</data_type>
                    <min_len>1</min_len>
                    <max_len>48</max_len>
                  </element>
                  <element xid="SVC05">
                    <data_ele>380</data_ele>
                    <name>Units of Service Paid Count</name>
                    <usage>S</usage>
                    <seq>05</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                  <composite>
                    <data_ele>C003</data_ele>
                    <name>Composite Medical Procedure Identifier</name>
                    <usage>S</usage>
                    <seq>06</seq>
                    <element xid="SVC06-01">
                      <data_ele>235</data_ele>
                      <name>Product or Service ID Qualifier</name>
                      <usage>R</usage>
                      <seq>01</seq>
                      <data_type>ID</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                      <valid_codes>
                        <code>AD</code>
                        <code>ER</code>
                        <code>HC</code>
                        <code>ID</code>
                        <code>IV</code>
                        <code>N4</code>
                        <code>NU</code>
                        <code>RB</code>
                        <code>ZZ</code>
                      </valid_codes>
                    </element>
                    <element xid="SVC06-02">
                      <data_ele>234</data_ele>
                      <name>Procedure Code</name>
                      <usage>R</usage>
                      <seq>02</seq>
                      <data_type>AN</data_type>
                      <min_len>1</min_len>
                      <max_len>48</max_len>
                    </element>
                    <element xid="SVC06-03">
                      <data_ele>1339</data_ele>
                      <name>Procedure Modifier</name>
                      <usage>S</usage>
                      <seq>03</seq>
                      <data_type>AN</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                    </element>
                    <element xid="SVC06-04">
                      <data_ele>1339</data_ele>
                      <name>Procedure Modifier</name>
                      <usage>S</usage>
                      <seq>04</seq>
                      <data_type>AN</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                    </element>
                    <element xid="SVC06-05">
                      <data_ele>1339</data_ele>
                      <name>Procedure Modifier</name>
                      <usage>S</usage>
                      <seq>05</seq>
                      <data_type>AN</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                    </element>
                    <element xid="SVC06-06">
                      <data_ele>1339</data_ele>
                      <name>Procedure Modifier</name>
                      <usage>S</usage>
                      <seq>06</seq>
                      <data_type>AN</data_type>
                      <min_len>2</min_len>
                      <max_len>2</max_len>
                    </element>
                    <element xid="SVC06-07">
                      <data_ele>352</data_ele>
                      <name>Procedure Code Description</name>
                      <usage>S</usage>
                      <seq>07</seq>
                      <data_type>AN</data_type>
                      <min_len>1</min_len>
                      <max_len>80</max_len>
                    </element>
                  </composite>
                  <element xid="SVC07">
                    <data_ele>380</data_ele>
                    <name>Original Units of Service Count</name>
                    <usage>S</usage>
                    <seq>07</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                </segment>
<!--End of SVC segment-->
                <segment xid="DTM">
                  <name>Service Date</name>
                  <usage>S</usage>
                  <pos>080</pos>
                  <max_use>3</max_use>
                  <element xid="DTM01">
                    <data_ele>374</data_ele>
                    <name>Date Time Qualifier</name>
                    <usage>R</usage>
                    <seq>01</seq>
                    <data_type>ID</data_type>
                    <min_len>3</min_len>
                    <max_len>3</max_len>
                    <valid_codes>
                      <code>150</code>
                      <code>151</code>
                      <code>472</code>
                    </valid_codes>
                  </element>
                  <element xid="DTM02">
                    <data_ele>373</data_ele>
                    <name>Service Date</name>
                    <usage>R</usage>
                    <seq>02</seq>
                    <data_type>DT</data_type>
                    <min_len>8</min_len>
                    <max_len>8</max_len>
                    <valid_codes>
            </valid_codes>
                  </element>
                  <element xid="DTM03">
                    <data_ele>337</data_ele>
                    <name>Time</name>
                    <usage>N</usage>
                    <seq>03</seq>
                    <data_type>TM</data_type>
                    <min_len>4</min_len>
                    <max_len>8</max_len>
                  </element>
                  <element xid="DTM04">
                    <data_ele>623</data_ele>
                    <name>Time Code</name>
                    <usage>N</usage>
                    <seq>04</seq>
                    <data_type>ID</data_type>
                    <min_len>2</min_len>
                    <max_len>2</max_len>
                  </element>
                  <element xid="DTM05">
                    <data_ele>1250</data_ele>
                    <name>Date Time Period Format Qualifier</name>
                    <usage>N</usage>
                    <seq>05</seq>
                    <data_type>ID</data_type>
                    <min_len>2</min_len>
                    <max_len>3</max_len>
                  </element>
                  <element xid="DTM06">
                    <data_ele>1251</data_ele>
                    <name>Date Time Period</name>
                    <usage>N</usage>
                    <seq>06</seq>
                    <data_type>AN</data_type>
                    <min_len>1</min_len>
                    <max_len>35</max_len>
                  </element>
                </segment>
<!--End of DTM segment-->
                <segment xid="CAS">
                  <name>Service Adjustment</name>
                  <usage>S</usage>
                  <pos>090</pos>
                  <max_use>99</max_use>
                  <element xid="CAS01">
                    <data_ele>1033</data_ele>
                    <name>Claim Adjustment Group Code</name>
                    <usage>R</usage>
                    <seq>01</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>2</max_len>
                    <valid_codes>
                      <code>CO</code>
                      <code>CR</code>
                      <code>OA</code>
                      <code>PI</code>
                      <code>PR</code>
                    </valid_codes>
                  </element>
                  <element xid="CAS02">
                    <data_ele>1034</data_ele>
                    <name>Adjustment Reason Code</name>
                    <usage>R</usage>
                    <seq>02</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>5</max_len>
                    <valid_codes external="adjustment_reason"/>
                  </element>
                  <element xid="CAS03">
                    <data_ele>782</data_ele>
                    <name>Adjustment Amount</name>
                    <usage>R</usage>
                    <seq>03</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="CAS04">
                    <data_ele>380</data_ele>
                    <name>Adjustment Quantity</name>
                    <usage>S</usage>
                    <seq>04</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                  <element xid="CAS05">
                    <data_ele>1034</data_ele>
                    <name>Adjustment Reason Code</name>
                    <usage>S</usage>
                    <seq>05</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>5</max_len>
                    <valid_codes external="adjustment_reason"/>
                  </element>
                  <element xid="CAS06">
                    <data_ele>782</data_ele>
                    <name>Adjustment Amount</name>
                    <usage>S</usage>
                    <seq>06</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="CAS07">
                    <data_ele>380</data_ele>
                    <name>Adjustment Quantity</name>
                    <usage>S</usage>
                    <seq>07</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                  <element xid="CAS08">
                    <data_ele>1034</data_ele>
                    <name>Adjustment Reason Code</name>
                    <usage>S</usage>
                    <seq>08</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>5</max_len>
                    <valid_codes external="adjustment_reason"/>
                  </element>
                  <element xid="CAS09">
                    <data_ele>782</data_ele>
                    <name>Adjustment Amount</name>
                    <usage>S</usage>
                    <seq>09</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="CAS10">
                    <data_ele>380</data_ele>
                    <name>Adjustment Quantity</name>
                    <usage>S</usage>
                    <seq>10</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                  <element xid="CAS11">
                    <data_ele>1034</data_ele>
                    <name>Adjustment Reason Code</name>
                    <usage>S</usage>
                    <seq>11</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>5</max_len>
                    <valid_codes external="adjustment_reason"/>
                  </element>
                  <element xid="CAS12">
                    <data_ele>782</data_ele>
                    <name>Adjustment Amount</name>
                    <usage>S</usage>
                    <seq>12</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="CAS13">
                    <data_ele>380</data_ele>
                    <name>Adjustment Quantity</name>
                    <usage>S</usage>
                    <seq>13</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                  <element xid="CAS14">
                    <data_ele>1034</data_ele>
                    <name>Adjustment Reason Code</name>
                    <usage>S</usage>
                    <seq>14</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>5</max_len>
                    <valid_codes external="adjustment_reason"/>
                  </element>
                  <element xid="CAS15">
                    <data_ele>782</data_ele>
                    <name>Adjustment Amount</name>
                    <usage>S</usage>
                    <seq>15</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="CAS16">
                    <data_ele>380</data_ele>
                    <name>Adjustment Quantity</name>
                    <usage>S</usage>
                    <seq>16</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                  <element xid="CAS17">
                    <data_ele>1034</data_ele>
                    <name>Adjustment Reason Code</name>
                    <usage>S</usage>
                    <seq>17</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>5</max_len>
                    <valid_codes external="adjustment_reason"/>
                  </element>
                  <element xid="CAS18">
                    <data_ele>782</data_ele>
                    <name>Adjustment Amount</name>
                    <usage>S</usage>
                    <seq>18</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="CAS19">
                    <data_ele>380</data_ele>
                    <name>Adjustment Quantity</name>
                    <usage>S</usage>
                    <seq>19</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                </segment>
<!--End of CAS segment-->
                <segment xid="REF">
                  <name>Service Identification</name>
                  <usage>S</usage>
                  <pos>100</pos>
                  <max_use>7</max_use>
                  <element xid="REF01">
                    <data_ele>128</data_ele>
                    <name>Reference Identification Qualifier</name>
                    <usage>R</usage>
                    <seq>01</seq>
                    <data_type>ID</data_type>
                    <min_len>2</min_len>
                    <max_len>3</max_len>
                    <valid_codes>
                      <code>1S</code>
                      <code>6R</code>
                      <code>BB</code>
                      <code>E9</code>
                      <code>G1</code>
                      <code>G3</code>
                      <code>LU</code>
                      <code>RB</code>
                    </valid_codes>
                  </element>
                  <element xid="REF02">
                    <data_ele>127</data_ele>
                    <name>Provider Identifier</name>
                    <usage>R</usage>
                    <seq>02</seq>
                    <data_type>AN</data_type>
                    <min_len>1</min_len>
                    <max_len>30</max_len>
                  </element>
                  <element xid="REF03">
                    <data_ele>352</data_ele>
                    <name>Description</name>
                    <usage>N</usage>
                    <seq>03</seq>
                    <data_type>AN</data_type>
                    <min_len>1</min_len>
                    <max_len>80</max_len>
                  </element>
                  <composite>
                    <data_ele>C040</data_ele>
                    <name>Reference Identifier</name>
                    <usage>N</usage>
                    <seq>04</seq>
                  </composite>
                </segment>
<!--End of REF segment-->
                <segment xid="REF">
                  <name>Rendering Provider Information</name>
                  <usage>S</usage>
                  <pos>100</pos>
                  <max_use>10</max_use>
                  <element xid="REF01">
                    <data_ele>128</data_ele>
                    <name>Reference Identification Qualifier</name>
                    <usage>R</usage>
                    <seq>01</seq>
                    <data_type>ID</data_type>
                    <min_len>2</min_len>
                    <max_len>3</max_len>
                    <valid_codes>
                      <code>1A</code>
                      <code>1B</code>
                      <code>1C</code>
                      <code>1D</code>
                      <code>1G</code>
                      <code>1H</code>
                      <code>1J</code>
                      <code>HPI</code>
                      <code>SY</code>
                      <code>TJ</code>
                    </valid_codes>
                  </element>
                  <element xid="REF02">
                    <data_ele>127</data_ele>
                    <name>Rendering Provider Identifier</name>
                    <usage>R</usage>
                    <seq>02</seq>
                    <data_type>AN</data_type>
                    <min_len>1</min_len>
                    <max_len>30</max_len>
                  </element>
                  <element xid="REF03">
                    <data_ele>352</data_ele>
                    <name>Description</name>
                    <usage>N</usage>
                    <seq>03</seq>
                    <data_type>AN</data_type>
                    <min_len>1</min_len>
                    <max_len>80</max_len>
                  </element>
                  <composite>
                    <data_ele>C040</data_ele>
                    <name>Reference Identifier</name>
                    <usage>N</usage>
                    <seq>04</seq>
                  </composite>
                </segment>
<!--End of REF segment-->
                <segment xid="AMT">
                  <name>Service Supplemental Amount</name>
                  <usage>S</usage>
                  <pos>110</pos>
                  <max_use>12</max_use>
                  <element xid="AMT01">
                    <data_ele>522</data_ele>
                    <name>Amount Qualifier Code</name>
                    <usage>R</usage>
                    <seq>01</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>3</max_len>
                    <valid_codes>
                      <code>B6</code>
                      <code>DY</code>
                      <code>KH</code>
                      <code>NE</code>
                      <code>T</code>
                      <code>T2</code>
                      <code>ZK</code>
                      <code>ZL</code>
                      <code>ZM</code>
                      <code>ZN</code>
                      <code>ZO</code>
                    </valid_codes>
                  </element>
                  <element xid="AMT02">
                    <data_ele>782</data_ele>
                    <name>Service Supplemental Amount</name>
                    <usage>R</usage>
                    <seq>02</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>18</max_len>
                  </element>
                  <element xid="AMT03">
                    <data_ele>478</data_ele>
                    <name>Credit/Debit Flag Code</name>
                    <usage>N</usage>
                    <seq>03</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>1</max_len>
                  </element>
                </segment>
<!--End of AMT segment-->
                <segment xid="QTY">
                  <name>Service Supplemental Quantity</name>
                  <usage>S</usage>
                  <pos>120</pos>
                  <max_use>6</max_use>
                  <element xid="QTY01">
                    <data_ele>673</data_ele>
                    <name>Quantity Qualifier</name>
                    <usage>R</usage>
                    <seq>01</seq>
                    <data_type>ID</data_type>
                    <min_len>2</min_len>
                    <max_len>2</max_len>
                    <valid_codes>
                      <code>NE</code>
                      <code>ZK</code>
                      <code>ZL</code>
                      <code>ZM</code>
                      <code>ZN</code>
                      <code>ZO</code>
                    </valid_codes>
                  </element>
                  <element xid="QTY02">
                    <data_ele>380</data_ele>
                    <name>Service Supplemental Quantity Count</name>
                    <usage>R</usage>
                    <seq>02</seq>
                    <data_type>R</data_type>
                    <min_len>1</min_len>
                    <max_len>15</max_len>
                  </element>
                  <composite>
                    <data_ele>C001</data_ele>
                    <name>Composite Unit of Measure</name>
                    <usage>N</usage>
                    <seq>03</seq>
                  </composite>
                  <element xid="QTY04">
                    <data_ele>61</data_ele>
                    <name>Free-Form Message</name>
                    <usage>N</usage>
                    <seq>04</seq>
                    <data_type>AN</data_type>
                    <min_len>1</min_len>
                    <max_len>30</max_len>
                  </element>
                </segment>
<!--End of QTY segment-->
                <segment xid="LQ">
                  <name>Health Care Remark Codes</name>
                  <usage>S</usage>
                  <pos>130</pos>
                  <max_use>99</max_use>
                  <element xid="LQ01">
                    <data_ele>1270</data_ele>
                    <name>Code List Qualifier Code</name>
                    <usage>R</usage>
                    <seq>01</seq>
                    <data_type>ID</data_type>
                    <min_len>1</min_len>
                    <max_len>3</max_len>
                    <valid_codes>
                      <code>HE</code>
                      <code>RX</code>
                    </valid_codes>
                  </element>
                  <element xid="LQ02">
                    <data_ele>1271</data_ele>
                    <name>Remark Code</name>
                    <usage>R</usage>
                    <seq>02</seq>
                    <data_type>AN</data_type>
                    <min_len>1</min_len>
                    <max_len>30</max_len>
                  </element>
                </segment>
<!--End of LQ segment-->
              </loop>
<!--End of 2110 loop-->
            </loop>
<!--End of 2100 loop-->
          </loop>
<!--End of 2000 loop-->
        </loop>
<!--End of DETAIL loop-->
        <loop xid="FOOTER" type="wrapper">
          <name>Table 3 - Footer</name>
          <usage>S</usage>
          <pos>030</pos>
          <repeat>1</repeat>
          <segment xid="PLB">
            <name>Provider Adjustment</name>
            <usage>S</usage>
            <pos>010</pos>
            <max_use>&gt;1</max_use>
            <element xid="PLB01">
              <data_ele>127</data_ele>
              <name>Provider Identifier</name>
              <usage>R</usage>
              <seq>01</seq>
              <data_type>AN</data_type>
              <min_len>1</min_len>
              <max_len>30</max_len>
            </element>
            <element xid="PLB02">
              <data_ele>373</data_ele>
              <name>Fiscal Period Date</name>
              <usage>R</usage>
              <seq>02</seq>
              <data_type>DT</data_type>
              <min_len>8</min_len>
              <max_len>8</max_len>
            </element>
            <composite>
              <data_ele>C042</data_ele>
              <name>Adjustment Identifier</name>
              <usage>R</usage>
              <seq>03</seq>
              <element xid="PLB03-01">
                <data_ele>426</data_ele>
                <name>Adjustment Reason Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes external="adjustment_reason"/>
              </element>
              <element xid="PLB03-02">
                <data_ele>127</data_ele>
                <name>Provider Adjustment Identifier</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
            </composite>
            <element xid="PLB04">
              <data_ele>782</data_ele>
              <name>Provider Adjustment Amount</name>
              <usage>R</usage>
              <seq>04</seq>
              <data_type>R</data_type>
              <min_len>1</min_len>
              <max_len>18</max_len>
            </element>
            <composite>
              <data_ele>C042</data_ele>
              <name>Adjustment Identifier</name>
              <usage>S</usage>
              <seq>05</seq>
              <element xid="PLB05-01">
                <data_ele>426</data_ele>
                <name>Adjustment Reason Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes external="adjustment_reason"/>
              </element>
              <element xid="PLB05-02">
                <data_ele>127</data_ele>
                <name>Provider Adjustment Identifier</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
            </composite>
            <element xid="PLB06">
              <data_ele>782</data_ele>
              <name>Provider Adjustment Amount</name>
              <usage>S</usage>
              <seq>06</seq>
              <data_type>R</data_type>
              <min_len>1</min_len>
              <max_len>18</max_len>
            </element>
            <composite>
              <data_ele>C042</data_ele>
              <name>Adjustment Identifier</name>
              <usage>S</usage>
              <seq>07</seq>
              <element xid="PLB07-01">
                <data_ele>426</data_ele>
                <name>Adjustment Reason Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes external="adjustment_reason"/>
              </element>
              <element xid="PLB07-02">
                <data_ele>127</data_ele>
                <name>Provider Adjustment Identifier</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
            </composite>
            <element xid="PLB08">
              <data_ele>782</data_ele>
              <name>Provider Adjustment Amount</name>
              <usage>S</usage>
              <seq>08</seq>
              <data_type>R</data_type>
              <min_len>1</min_len>
              <max_len>18</max_len>
            </element>
            <composite>
              <data_ele>C042</data_ele>
              <name>Adjustment Identifier</name>
              <usage>S</usage>
              <seq>09</seq>
              <element xid="PLB09-01">
                <data_ele>426</data_ele>
                <name>Adjustment Reason Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes external="adjustment_reason"/>
              </element>
              <element xid="PLB09-02">
                <data_ele>127</data_ele>
                <name>Provider Adjustment Identifier</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
            </composite>
            <element xid="PLB10">
              <data_ele>782</data_ele>
              <name>Provider Adjustment Amount</name>
              <usage>S</usage>
              <seq>10</seq>
              <data_type>R</data_type>
              <min_len>1</min_len>
              <max_len>18</max_len>
            </element>
            <composite>
              <data_ele>C042</data_ele>
              <name>Adjustment Identifier</name>
              <usage>S</usage>
              <seq>11</seq>
              <element xid="PLB11-01">
                <data_ele>426</data_ele>
                <name>Adjustment Reason Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes external="adjustment_reason"/>
              </element>
              <element xid="PLB11-02">
                <data_ele>127</data_ele>
                <name>Provider Adjustment Identifier</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
            </composite>
            <element xid="PLB12">
              <data_ele>782</data_ele>
              <name>Provider Adjustment Amount</name>
              <usage>S</usage>
              <seq>12</seq>
              <data_type>R</data_type>
              <min_len>1</min_len>
              <max_len>18</max_len>
            </element>
            <composite>
              <data_ele>C042</data_ele>
              <name>Adjustment Identifier</name>
              <usage>S</usage>
              <seq>13</seq>
              <element xid="PLB13-01">
                <data_ele>426</data_ele>
                <name>Adjustment Reason Code</name>
                <usage>R</usage>
                <seq>01</seq>
                <data_type>ID</data_type>
                <min_len>2</min_len>
                <max_len>2</max_len>
                <valid_codes external="adjustment_reason"/>
              </element>
              <element xid="PLB13-02">
                <data_ele>127</data_ele>
                <name>Provider Adjustment Identifier</name>
                <usage>S</usage>
                <seq>02</seq>
                <data_type>AN</data_type>
                <min_len>1</min_len>
                <max_len>30</max_len>
              </element>
            </composite>
            <element xid="PLB14">
              <data_ele>782</data_ele>
              <name>Provider Adjustment Amount</name>
              <usage>S</usage>
              <seq>14</seq>
              <data_type>R</data_type>
              <min_len>1</min_len>
              <max_len>18</max_len>
            </element>
          </segment>
<!--End of PLB segment-->
        </loop>
<!--End of FOOTER loop-->
        <segment xid="SE">
          <name>Transaction Set Trailer</name>
          <usage>R</usage>
          <pos>050</pos>
          <max_use>1</max_use>
          <element xid="SE01">
            <data_ele>96</data_ele>
            <name>Transaction Segment Count</name>
            <usage>R</usage>
            <seq>01</seq>
            <data_type>N0</data_type>
            <min_len>1</min_len>
            <max_len>10</max_len>
          </element>
          <element xid="SE02">
            <data_ele>329</data_ele>
            <name>Transaction Set Control Number</name>
            <usage>R</usage>
            <seq>02</seq>
            <data_type>AN</data_type>
            <min_len>4</min_len>
            <max_len>9</max_len>
          </element>
        </segment>
<!--End of SE segment-->
      </loop>
<!--End of ST loop-->
      <segment xid="GE">
        <name>Functional Group Trailer</name>
        <usage>R</usage>
        <pos>030</pos>
        <max_use>1</max_use>
        <element xid="GE01">
          <data_ele>97</data_ele>
          <name>Number of Transaction Sets Included</name>
          <usage>R</usage>
          <seq>01</seq>
          <data_type>N0</data_type>
          <min_len>1</min_len>
          <max_len>6</max_len>
        </element>
        <element xid="GE02">
          <data_ele>28</data_ele>
          <name>Group Control Number</name>
          <usage>R</usage>
          <seq>02</seq>
          <data_type>N0</data_type>
          <min_len>1</min_len>
          <max_len>9</max_len>
        </element>
      </segment>
<!--End of GE segment-->
    </loop>
<!--End of GS loop-->
    <segment xid="TA1">
      <name>Interchange Achnowledgement</name>
      <usage>S</usage>
      <pos>020</pos>
      <element xid="TA101">
        <data_ele>I12</data_ele>
        <name>Interchange Control Number</name>
        <usage>R</usage>
        <seq>01</seq>
        <data_type>N0</data_type>
        <min_len>9</min_len>
        <max_len>9</max_len>
      </element>
      <element xid="TA102">
        <data_ele>I08</data_ele>
        <name>Interchange Date</name>
        <usage>R</usage>
        <seq>02</seq>
        <data_type>DT</data_type>
        <min_len>6</min_len>
        <max_len>6</max_len>
      </element>
      <element xid="TA103">
        <data_ele>I09</data_ele>
        <name>Interchange Time</name>
        <usage>R</usage>
        <seq>03</seq>
        <data_type>TM</data_type>
        <min_len>4</min_len>
        <max_len>4</max_len>
      </element>
      <element xid="TA104">
        <data_ele>I17</data_ele>
        <name>Interchange Achnowledgement Code</name>
        <usage>R</usage>
        <seq>04</seq>
        <data_type>ID</data_type>
        <min_len>1</min_len>
        <max_len>1</max_len>
        <valid_codes>
          <code>A</code>
          <code>E</code>
          <code>R</code>
        </valid_codes>
      </element>
      <element xid="TA105">
        <data_ele>I18</data_ele>
        <name>Interchange Note Code</name>
        <usage>R</usage>
        <seq>05</seq>
        <data_type>ID</data_type>
        <min_len>3</min_len>
        <max_len>3</max_len>
        <valid_codes>
          <code>000</code>
          <code>001</code>
          <code>002</code>
          <code>003</code>
          <code>004</code>
          <code>005</code>
          <code>006</code>
          <code>007</code>
          <code>008</code>
          <code>009</code>
          <code>010</code>
          <code>011</code>
          <code>012</code>
          <code>013</code>
          <code>014</code>
          <code>015</code>
          <code>016</code>
          <code>017</code>
          <code>018</code>
          <code>019</code>
          <code>020</code>
          <code>021</code>
          <code>022</code>
          <code>023</code>
          <code>024</code>
          <code>025</code>
          <code>026</code>
          <code>027</code>
          <code>028</code>
          <code>029</code>
          <code>030</code>
          <code>031</code>
        </valid_codes>
      </element>
    </segment>
<!--End of TA1 segment-->
    <segment xid="IEA">
      <name>Interchange Control Trailer</name>
      <usage>R</usage>
      <pos>030</pos>
      <max_use>1</max_use>
      <element xid="IEA01">
        <data_ele>I16</data_ele>
        <name>Number of Included Functional Groups</name>
        <usage>R</usage>
        <seq>01</seq>
        <data_type>N0</data_type>
        <min_len>1</min_len>
        <max_len>5</max_len>
      </element>
      <element xid="IEA02">
        <data_ele>I12</data_ele>
        <name>Interchange Control Number</name>
        <usage>R</usage>
        <seq>02</seq>
        <data_type>N0</data_type>
        <min_len>9</min_len>
        <max_len>9</max_len>
      </element>
    </segment>
<!--End of IEA segment-->
  </loop>
<!--End of ISA loop-->
</transaction>
