5010 Payroll Deducted and Other Group Premium Payment for Insurance Products [S0]


Loop Qualifiers
xx - Loop Iteration Prefix
xxyy - Outer Loop Iteration and Inner Loop Iteration
yy / yyy - Loop Value Qualifier
xxyy / xxyyy - Loop Iteration and Value Qualifier
Segment Modifiers:
X - Distinguishing Identifier Suffix
nn - Segment Iteration (only after first iterartion)
nn - Element Repeat Iteration (only after first iterartion)

ISA - GROUP HEADERS
ISAISAInterchange Control Header
02ISA_ISA02_NO_AUTH_NFOStringNo Authorization Information Present
02ISA_ISA02_ADDL_DATA_IDStringAdditional Data Identification
04ISA_ISA04_NO_SEC_NFOStringNo Security Information Present
04ISA_ISA04_PSSWDStringPassword
06ISA_ISA06_DUN_BRDSTStringDun and Brandstreet
06ISA_ISA06_DUN_BRDST_SFXStringDuns Plus Suffix
06ISA_ISA06_HINStringHealth Industry Number
06ISA_ISA06_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_TAX_IDStringUS Federal Tax Identification Number
06ISA_ISA06_NAIC_CDStringNational Association of Insurance Commissioners Company Code
06ISA_ISA06_MUTLY_DEFStringMutually Defined
08ISA_ISA08_DUN_BRDSTStringDun and Brandstreet
08ISA_ISA08_DUN_BRDST_SFXStringDuns Plus Suffix
08ISA_ISA08_HINStringHealth Industry Number
08ISA_ISA08_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_TAX_IDStringUS Federal Tax Identification Number
08ISA_ISA08_NAIC_CDStringNational Association of Insurance Commissioners Company Code
08ISA_ISA08_MUTLY_DEFStringMutually Defined
09ISA_ISA09_INTCHG_DTDate (YYMMDD)Interchange Date
10ISA_ISA10_INTCHG_TMTime (HHMM)Interchange Time
11ISA_ISA11_REPTN_SEPStringRepetition Separator
12ISA_ISA12_ICN_VERS_NRStringInterchang Control Version Number
13ISA_ISA13_ICNIntegerInterchange Control Number
14ISA_ISA14_ACK_REQStringAcknowledgment Requested
15ISA_ISA15_ICN_USG_INDStringInterchange Usage Indicator
16ISA_ISA16_COMP_ELE_SEPStringComponent Element Separator
GSHDR - GROUP HEADER
GSHDRGSFunctional Group Header
02GSHDR_GS02_APP_SNDR_CDStringApplication Senders Code
03GSHDR_GS03_APP_RCV_CDStringApplication Receivers Code
04GSHDR_GS04_D8Date (YYYYMMDD)Date
05GSHDR_GS05_TMTime (HHMM)Time
05GSHDR_GS05_TM8Time (HHMMSSCC)Time
06GSHDR_GS06_GCNIntegerGroup Control Number
STHDR - TRANSACTION SET HEADER
STHDRST820 Header
02STHDR_ST02_TCNStringTransaction Set Control Number
03STHDR_ST03_IMP_CONV_REFStringImplementation Convention Reference
STHDRBPRFinancial Information
01STHDR_BPR01_TRANS_HANDL_CDStringTransaction Handling Code
02STHDR_BPR02_TOT_PRM_PMT_AMTNumberTotal Premium Payment Amount
04STHDR_BPR04_PMT_METHD_CDStringPayment Method Code
05STHDR_BPR05_PMT_FMT_CDStringPayment Format Code
06STHDR_BPR06_DFI_NRStringDepository Financial Institution (DFI) network. If not required by this implementation guide do not
07STHDR_BPR07_ORIG_DFIStringOriginating Depository Financial Institution (DFI)
09STHDR_BPR09_ALCStringAgency Location Code (ALC)
09STHDR_BPR09_DEMND_DEPSTStringDemand Deposit
10STHDR_BPR10_PYR_IDStringPayer Identifier
11STHDR_BPR11_ORG_CO_SUPP_CDStringOriginating Company Supplemental Code
12STHDR_BPR12_DFI_NRStringDepository Financial Institution (DFI) not required by this implementation guide, do not send.
13STHDR_BPR13_RCV_DFIStringReceiving Depository Financial Institution (DFI)
15STHDR_BPR15_DEMND_DEPSTStringDemand Deposit
15STHDR_BPR15_SAVNGSStringSavings
16STHDR_BPR16_CHK_EFT_EFDT_D8Date (YYYYMMDD)Check Issue or EFT Effective Date
STHDRTRNReassociation Trace Number
01STHDR_TRN01_TRAC_TYP_CDStringTrace Type Code
02STHDR_TRN02_CHK_EFT_TRC_NRStringCheck or EFT Trace Number
03STHDR_TRN03_ORG_CO_IDStringOriginating Company Identifier
04STHDR_TRN04_ORG_CO_SUPP_CDStringOriginating Company Supplemental Code
STHDRCURForeign Currency Information
01STHDR_CUR01_ENTY_ID_CDStringEntity Identifier Code
02STHDR_CUR02_CURRNCY_CDStringCurrency Code
STHDRREFPremium Receivers Identification KeyIterated: [01-99]
02STHDR_nnREF_MSTR_ACCT_NRStringMaster Account Number
02STHDR_nnREF_CLT_RPT_CATStringClient Reporting Category
02STHDR_nnREF_PLAN_NRStringPlan Number
02STHDR_nnREF_INVC_NRStringConsolidated Invoice Number
02STHDR_nnREF_MSTR_PLCY_NRStringMaster Policy Number
02STHDR_nnREF_SCH_REF_NRStringSchedule Reference Number
02STHDR_nnREF_LCKBXStringLockbox
STHDRDTMProcess Date
02STHDR_DTM02_PRCSDateTimeProcess
STHDRDTMDelivery Date
02STHDR_DTM02_DELVDDateTimeDelivered
STHDRDTMCoverage Period
02STHDR_DTM02_D8Date (YYYYMMDD)Date
STHDRDTMCreation Date
02STHDR_DTM02_TS_CREATNDateTimeTransaction Creation
L1000A - PREMIUM RECEIVERS NAME
L1000AN1Premium Receiver?s Name
02L1000A_N102_PREM_RCV_LNMStringPremium Receiver's Last or Organization Name
04L1000A_N104_DUNS_NRStringD-U-N-S Number, Dun and Bradstreet
04L1000A_N104_DUNS4_NRStringD-U-N-S+4, D-U-N-S Number with Four Character Suffix
04L1000A_N104_INS_ASGND_IDStringInsurance Company Assigned Identification Number
04L1000A_N104_TAX_IDStringFederal Taxpayer's Identification Number
04L1000A_N104_CMS_PLANIDStringCenters for Medicare and Medicaid Services PlanID
L1000AN2Premium Receiver Additional Name
01L1000A_N201_PRM_RCV_ADDL_NMStringPremium Receiver's Additional Name
L1000AN3Premium Receiver?s Address
01L1000A_N301_PREM_RCV_ADDRStringPremium Receiver's Address Line
02L1000A_N302_PREM_RCV_ADDRStringPremium Receiver's Address Line
L1000AN4Premium Receiver?s City, State, and ZIP Code
01L1000A_N401_PREM_RCV_CITY_NMStringPremium Receiver's City Name
02L1000A_N402_PRM_RCV_STATStringPremium Receiver's State Code
03L1000A_N403_PRM_RCV_ZIPStringPremium Receiver's Postal Zone or Zip Code
04L1000A_N404_CNTRY_CDStringCountry Code
07L1000A_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L1000ARDMPremium Receiver?s Remittance Delivery Method
01L1000A_RDM01_REMIT_DEL_MTH_CDStringRemittance Delivery Method Code
02L1000A_RDM02_PREM_RCV_LNMStringPremium Receiver's Last or Organization Name
03L1000A_RDM03_PREM_RCV_COMM_NRStringPremium Receiver's Communication Number
L1000B - PREMIUM PAYERS NAME
L1000BN1Premium Payer?s Name
02L1000B_N102_PREM_PYR_NMStringPremium Payer Name
04L1000B_N104_DUNS_NRStringD-U-N-S Number, Dun and Bradstreet
04L1000B_N104_DUNS4_NRStringD-U-N-S+4, D-U-N-S Number with Four Character Suffix
04L1000B_N104_EMP_ID_NRStringEmployer's Identification Number
04L1000B_N104_STAT_ASGND_NRStringState or Province Assigned Number
04L1000B_N104_INS_ASGND_IDStringInsurance Company Assigned Identification Number
04L1000B_N104_TAX_IDStringFederal Taxpayer's Identification Number
04L1000B_N104_PAYR_IDStringPayor Identification
L1000BN2Premium Payer Additional Name
01L1000B_N201_PREM_PYR_ADDL_NMStringPremium Payer Additional Name
L1000BN3Premium Payer?s Address
01L1000B_N301_PREM_PYR_ADDRStringPremium Payer Address Line
02L1000B_N302_PREM_PYR_ADDRStringPremium Payer Address Line
L1000BN4Premium Payer?s City, State, ZIP Code
01L1000B_N401_PREM_PYR_CITYStringPremium Payer City Name
02L1000B_N402_PREM_PYR_STATStringPremium Payer State Code
03L1000B_N403_PREM_PYR_ZIPStringPremium Payer Postal Zone or ZIP Code
04L1000B_N404_CNTRY_CDStringCountry Code
07L1000B_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L1000BPERPremium Payer?s Administrative ContactIterated: [01-99]
02L1000B_nnPER02_PREM_PYR_CON_NMStringPremium Payer Contact Name
04L1000B_nnPER04_EMAILStringElectronic Mail
04L1000B_nnPER04_FAXStringFacsimile
04L1000B_nnPER04_PHN_NRStringTelephone
06L1000B_nnPER06_EMAILStringElectronic Mail
06L1000B_nnPER06_PHN_EXTStringTelephone Extension
06L1000B_nnPER06_FAXStringFacsimile
06L1000B_nnPER06_PHN_NRStringTelephone
08L1000B_nnPER08_EMAILStringElectronic Mail
08L1000B_nnPER08_PHN_EXTStringTelephone Extension
08L1000B_nnPER08_FAXStringFacsimile
08L1000B_nnPER08_PHN_NRStringTelephone
L1000C - INTERMEDIARY BANK INFORMATION (Value Qualified)
Mapping Prefix: L1000C_04 - Asset Account Holder
Mapping Prefix: L1000C_0B - Interim Funding Organization
Mapping Prefix: L1000C_8W - Payment Address
Mapping Prefix: L1000C_AK - Party to Whom Acknowledgment Should Be Sent
Mapping Prefix: L1000C_BE - Beneficiary
Mapping Prefix: L1000C_BK - Bank
Mapping Prefix: L1000C_C1 - In Care Of Party no. 1
Mapping Prefix: L1000C_C2 - In Care Of Party no. 2
Mapping Prefix: L1000C_IAT - Party Executing and Verifying
Mapping Prefix: L1000C_MJ - Financial Institution
Mapping Prefix: L1000C_RB - Receiving Bank
Mapping Prefix: L1000C_Z6 - Transferring Party
Mapping Prefix: L1000C_ZB - Party to Receive Credit
Mapping Prefix: L1000C_ZL - Federal Medicare or Medicaid Payment Mandate - Category 2
L1000CN1Intermediary Bank Information
02L1000C_yy_N102_INTER_BANK_NMStringIntermediary Bank Name
04L1000C_yy_N104_BANK_ID_CDStringBank Identification Code
04L1000C_yy_N104_DEPTStringDepartment
04L1000C_yy_N104_ORG_CD_DEST_TSStringCode assigned by the organization that is the ultimate destination of the transaction set
04L1000C_yy_N104_ASGD_3RD_PTYStringAssigned by Third Party
04L1000C_yy_N104_ASGD_CLGHSStringAssigned by Clearinghouse
04L1000C_yy_N104_FINSStringFinancial Identification Numbering System (FINS)
04L1000C_yy_N104_CAN_INST_RT_NRStringCanadian Financial Institution Routing Number
04L1000C_yy_N104_PAYEE_ID_NRStringPayee Identification Number
04L1000C_yy_N104_2ND_AGNT_IDStringSecondary Agent Identification
L1000CN2Intermediary Bank Additional Name
01L1000C_yy_N201_INTR_BNK_ADL_NMStringIntermediary Bank Additional Name
L1000CN3Intermediary Bank?s Address
01L1000C_yy_N301_INTER_BNK_ADDRStringIntermediary Bank Address Line
02L1000C_yy_N302_INTER_BNK_ADDRStringIntermediary Bank Address Line
L1000CN4Intermediary Bank?s City, State, ZIP Code
01L1000C_yy_N401_INTER_BANK_CITYStringIntermediary Bank City Name
02L1000C_yy_N402_INTER_BANK_STATStringIntermediary Bank State Code
03L1000C_yy_N403_INTER_BANK_ZIPStringIntermediary Bank Postal Zone or ZIP Code
04L1000C_yy_N404_CNTRY_CDStringCountry Code
07L1000C_yy_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L1000CPERIntermediary Bank?s Administrative ContactIterated: [01-99]
02L1000C_yy_nnPER02_INTR_BNK_CONStringIntermediary Bank Contact Name
04L1000C_yy_nnPER04_EMAILStringElectronic Mail
04L1000C_yy_nnPER04_FAXStringFacsimile
04L1000C_yy_nnPER04_PHN_NRStringTelephone
06L1000C_yy_nnPER06_EMAILStringElectronic Mail
06L1000C_yy_nnPER06_PHN_EXTStringTelephone Extension
06L1000C_yy_nnPER06_FAXStringFacsimile
06L1000C_yy_nnPER06_PHN_NRStringTelephone
08L1000C_yy_nnPER08_EMAILStringElectronic Mail
08L1000C_yy_nnPER08_PHN_EXTStringTelephone Extension
08L1000C_yy_nnPER08_FAXStringFacsimile
08L1000C_yy_nnPER08_PHN_NRStringTelephone
L2000A - ORGANIZATION SUMMARY REMITTANCE (Value Qualified)
Mapping Prefix: L2000A_2L - Corporation
Mapping Prefix: L2000A_AG - Agent/Agency
Mapping Prefix: L2000A_NH - Association
Mapping Prefix: L2000A_RGA - Responsible Government Agency
Mapping Prefix: L2000A_UN - Union
L2000AENTOrganization Summary Remittance
01L2000A_yy_ENT01_ASSGD_NRIntegerAssigned Number
04L2000A_yy_ENT04_DUNS_NRStringD-U-N-S Number, Dun and Bradstreet
04L2000A_yy_ENT04_DUNS4_NRStringD-U-N-S+4, D-U-N-S Number with Four Character
04L2000A_yy_ENT04_EMP_ID_NRStringEmployer's Identification Number
04L2000A_yy_ENT04_TAX_IDStringFederal Taxpayer's Identification Number
L2200A - ORGANIZATION SUMMARY REMITTANCE LEVEL ADJUSTMENT FOR PREVIOUS PAYMENT
L2200AADXOrganization Summary Remittance Level Adjustment for Previous Payment
01L2200A_ADX01_PREM_PMT_ADJ_AMTNumberPremium Payment Adjustment Amount
02L2200A_ADX02_PREM_PMT_ADJ_RSNStringPremium Payment Adjustment Reason
L2300A - ORGANIZATION SUMMARY REMITTANCE DETAIL
L2300ARMROrganization Summary Remittance Detail
02L2300A_RMR02_ACCT_NRStringAccount Number
02L2300A_RMR02_GRP_POLCY_NRStringGroup or Policy Number
02L2300A_RMR02_CNTRCT_NRStringContract Number
02L2300A_RMR02_INVC_NRStringInvoice Number
03L2300A_RMR03_StringPayment Action Code
04L2300A_RMR04_DTL_PRM_PMT_AMTNumberDetail Premium Payment Amount
05L2300A_RMR05_BILL_PREM_AMTNumberBilled Premium Amount
L2300AREFReference InformationIterated: [01-99]
02L2300A_nnREF_MSTR_ACCT_NRStringMaster Account Number
02L2300A_nnREF_CLT_RPT_CATStringClient Reporting Category
02L2300A_nnREF_PLAN_NRStringPlan Number
02L2300A_nnREF_INVC_NRStringConsolidated Invoice Number
02L2300A_nnREF_MSTR_PLCY_NRStringMaster Policy Number
02L2300A_nnREF_ATTCH_CDStringAttachment Code
02L2300A_nnREF_LCKBXStringLockbox
02L2300A_nnREF_LOC_NRStringLocation Number
02L2300A_nnREF_MUTLY_DEFStringMutually Defined
L2300ADTMOrganizational Coverage Period
02L2300A_DTM02_D8Date (YYYYMMDD)Date
L2310A - SUMMARY LINE ITEM
L2310AIT1Summary Line Item
01L2310A_IT101_LIN_ITM_CTL_NRStringLine Item Control Number
L2312A - SERVICE, PROMOTION, ALLOWANCE, OR CHARGE INFORMATION (Single Iteration)
L2312ASACService, Promotion, Allowance, or Charge Information
02L2312A_xx_SAC02_SVC_PRM_CHG_CDStringService, Promotion, Allowance, or Charge Code
05L2312A_xx_SAC05_AMTStringAmount
L2315A - MEMBER COUNT (Single Iteration)
L2315ASLNMember Count
01L2315A_xx_SLN01_LIN_ITM_CTL_NRStringLine Item Control Number
04L2315A_xx_SLN04_HEAD_CTNumberHead Count
0501L2315A_xx_SLN0501_UNIT_MSMT_CDStringUnit or Basis for Measurement Code
L2320A - ORGANIZATION SUMMARY REMITTANCE LEVEL ADJUSTMENT FOR CURRENT PAYMENT
L2320AADXOrganization Summary Remittance Level Adjustment for Current Payment
01L2320A_ADX01_ADJ_AMTNumberAdjustment Amount
02L2320A_ADX02_ADJ_RSN_CDStringAdjustment Reason Code
L2000B - INDIVIDUAL REMITTANCE
L2000BENTIndividual Remittance
01L2000B_ENT01_ASSGD_NRIntegerAssigned Number
04L2000B_ENT04_SSNStringSocial Security Number
04L2000B_ENT04_EMP_IDStringEmployee Identification Number
04L2000B_ENT04_UNQ_IND_IDStringStandard Unique Health Identifier for each Individual in the United States
L2100BX - INDIVIDUAL NAME
L2100BXNM1Individual Name
03L2100BX_NM103_IND_LNMStringIndividual Last Name
04L2100BX_NM104_IND_FNMStringIndividual First Name
05L2100BX_NM105_IND_MNMStringIndividual Middle Name
06L2100BX_NM106_IND_PFXStringIndividual Name Prefix
07L2100BX_NM107_IND_SFXStringIndividual Name Suffix
09L2100BX_NM109_SSNStringSocial Security Number
09L2100BX_NM109_EMPLY_ID_NRStringEmployee Identification Number
09L2100BX_NM109_INSRD_UNQ_IDStringInsured's Unique Identification Number
L2200BX - INDIVIDUAL PREMIUM ADJUSTMENT FOR PREVIOUS PAYMENT
L2200BXADXIndividual Premium Adjustment for Previous Payment
01L2200BX_ADX01_PREM_PMT_ADJ_AMTNumberPremium Payment Adjustment Amount
02L2200BX_ADX02_PREM_PMT_ADJ_RSNStringPremium Payment Adjustment Reason
L2300B - INDIVIDUAL PREMIUM REMITTANCE DETAIL
L2300BRMRIndividual Premium Remittance Detail
02L2300B_RMR02_ACCT_NRStringAccount Number
02L2300B_RMR02_PENSN_CNTCTStringPension Contract
02L2300B_RMR02_HLTH_INS_PLCYStringHealth Insurance Policy Number
02L2300B_RMR02_LIF_INS_PLCYStringLife Insurance Policy Number
02L2300B_RMR02_CNTRCT_NRStringContract Number
02L2300B_RMR02_INS_CERT_NRStringInsurance Certificate Number
02L2300B_RMR02_INS_PLCY_NRStringInsurance Policy Number
02L2300B_RMR02_INVC_NRStringInvoice Number
02L2300B_RMR02_CERTFCTNStringCertification
04L2300B_RMR04_DTL_PRM_PMT_AMTNumberDetail Premium Payment Amount
05L2300B_RMR05_BILL_PREM_AMTNumberBilled Premium Amount
L2300BREFReference InformationIterated: [01-99]
02L2300B_nnREF_MSTR_ACCT_NRStringMaster Account Number
02L2300B_nnREF_PLAN_NRStringPlan Number
02L2300B_nnREF_INVC_NRStringConsolidated Invoice Number
02L2300B_nnREF_MSTR_PLCY_NRStringMaster Policy Number
02L2300B_nnREF_ATTCH_CDStringAttachment Code
02L2300B_nnREF_LOC_NRStringLocation Number
02L2300B_nnREF_MUTLY_DEFStringMutually Defined
L2300BDTMIndividual Coverage Period
02L2300B_DTM02_D8Date (YYYYMMDD)Date
L2320B - INDIVIDUAL PREMIUM ADJUSTMENT FOR CURRENT PAYMENT
L2320BADXIndividual Premium Adjustment for Current Payment
01L2320B_ADX01_ADJ_AMTNumberAdjustment Amount
02L2320B_ADX02_ADJ_RSN_CDStringAdjustment Reason Code
STHDRSETransaction Set Trailer
01STHDR_SE01_TS_SEG_CTIntegerTransaction Segment Count
02STHDR_SE02_TCNStringTransaction Set Control Number
GSHDRGEFunctional Group Trailer
01GSHDR_GE01_NR_TS_INCLUDEDIntegerNumber of Transaction Sets Included
02GSHDR_GE02_GCNIntegerGroup Control Number
ISAIEAInterchange Control Trailer
01ISA_IEA01_NR_INC_FUNC_GRPIntegerNumber of Included Functional Groups
02ISA_IEA02_ICNIntegerInterchange Control Number