x12 0.1.0

data/cf/277_004010X092.cf

@@ -0,0 +1,122 @@
+[LOOPS]
+ISA
+GS
+ST
+2000A
+2000B
+2000C
+2000D
+2000E
+SE
+GE
+IEA
+
+#--- start of loop details ---#
+
+[ISA]
+segment=ISA:::ISA:R:1
+
+[GS]
+segment=GS:::GS:R:1
+
+#LOOP ID - HEADER
+[ST]
+segment=ST:::Transaction Set Header:R:1
+segment=BHT:::Beginning of Hierarchical Transaction:R:1
+
+#LOOP ID - 2000A INFORMATION SOURCE LEVEL >1
+[2000A]
+segment=HL:3:20:Information Source Level:R:1
+loop=2100A
+
+#LOOP ID - 2100A PAYER NAME >1
+[2100A]
+segment=NM1:1:PR:Payer Name:R:1
+segment=PER:::Payer Contact Information:S:1
+
+#LOOP ID - 2000B INFORMATION RECEIVER LEVEL >1
+[2000B]
+segment=HL:3:21:Information Receiver Level:R:1
+loop=2100B
+
+#LOOP ID - 2100B INFORMATION RECEIVER NAME >1
+[2100B]
+segment=NM1:1:41:Information Receiver Name:R:1
+
+#LOOP ID - 2000C SERVICE PROVIDER LEVEL >1
+[2000C]
+segment=HL:3:19:Service Provider Level:R:1
+loop=2100C
+
+#LOOP ID - 2100C PROVIDER NAME >1
+[2100C]
+segment=NM1:1:1P:Provider Name:R:1
+
+#LOOP ID - 2000D SUBSCRIBER LEVEL >1
+[2000D]
+segment=HL:3:22:Subscriber Level:R:1
+segment=DMG:::Subscriber Demographic Information:R:1
+loop=2100D
+loop=2200D
+
+#LOOP ID - 2100D SUBSCRIBER NAME >1
+[2100D]
+segment=NM1:1:IL,QC:Subscriber Name:R:1
+
+#LOOP ID - 2200D CLAIM SUBMITTER TRACE NUMBER >1
+[2200D]
+segment=TRN:::Claim Submitter Trace Number:R:1
+segment=STC:::Claim Level Status Information:R:1
+segment=REF:::Payer Claim Identification Number:S:1
+segment=REF:::Institutional Bill Type Identification:S:1
+segment=REF:::Medical Record Identification:S:1
+segment=DTP:::Claim Service Date:S:1
+loop=2220D
+
+#LOOP ID - 2220D SERVICE LINE INFORMATION >1
+[2220D]
+segment=SVC:::Service Line Information:S:1
+segment=STC:::Service Line Status Information:S:1
+segment=REF:::Service Line Item Identification:S:1
+segment=DTP:::Service Line Date:S:1
+
+#LOOP ID - 2000E DEPENDENT LEVEL >1
+[2000E]
+segment=HL:3:23:Dependent Level:S:1
+segment=DMG:::Dependent Demographic Information:R:1
+loop=2100E
+loop=2200E
+
+#LOOP ID - 2100E DEPENDENT NAME >1
+[2100E]
+segment=NM1:1:QC:Dependent Name:R:1
+
+#LOOP ID - 2200E CLAIM SUBMITTER TRACE NUMBER >1
+[2200E]
+segment=TRN:::Claim Submitter Trace Number:R:1
+segment=STC:::Claim Level Status Information:R:1
+segment=REF:::Payer Claim Identification Number:R:1
+segment=REF:::Institutional Bill Type Identification:S:1
+segment=REF:::Medical Record Identification:S:1
+segment=DTP:::Claim Service Date:S:1
+loop=2220E
+
+#LOOP ID - 2220E SERVICE LINE INFORMATION >1
+[2220E]
+segment=SVC:::Service Line Information:S:1
+segment=STC:::Service Line Status Information:S:1
+segment=REF:::Service Line Item Identification:S:1
+segment=DTP:::Service Line Date:S:1
+
+#LOOP ID - TRAILER
+[SE]
+segment=SE:::Transaction Set Trailer:R:1
+
+[GE]
+segment=GE:::GE:R:1
+
+[IEA]
+segment=IEA:::IEA:R:1
+
+
+

data/cf/278_004010X094_Req.cf

@@ -0,0 +1,130 @@
+[LOOPS]
+ISA
+GS
+ST
+2000A
+2000B
+2000C
+2000D
+2000E
+2000F
+SE
+GE
+IEA
+
+#--- start of loop details ---#
+
+[ISA]
+segment=ISA:::ISA:R:1
+
+[GS]
+segment=GS:::GS:R:1
+
+#LOOP ID - HEADER
+[ST]
+segment=ST:::Transaction Set Header:R:1
+segment=BHT:::Beginning of Hierarchical Transaction:R:1
+
+#LOOP ID - 2000A UTILIZATION MANAGEMENT ORGANIZATION (UMO) LEVEL 1
+[2000A]
+segment=HL:3:20:Utilization Management Organization (UMO) Level:R:1
+loop=2010A
+
+#LOOP ID - 2010A UTILIZATION MANAGEMENT ORGANIZATION (UMO) NAME 1
+[2010A]
+segment=NM1:1:X3:Utilization Management Organization (UMO) Name:R:1
+
+#LOOP ID - 2000B REQUESTER LEVEL 1
+[2000B]
+segment=HL:3:21:Requester Level:R:1
+loop=2010B
+
+#LOOP ID - 2010B REQUESTER NAME 1
+[2010B]
+segment=NM1:1:1P,FA:Requester Name:R:1
+segment=REF:::Requester Supplemental Identification:S:8
+segment=N3:::Requester Address:S:1
+segment=N4:::Requester City/State/ZIP Code:S:1
+segment=PER:::Requester Contact Information:S:1
+segment=PRV:::Requester Provider Information:S:1
+
+#LOOP ID - 2000C SUBSCRIBER LEVEL 1
+[2000C]
+segment=HL:3:22:Subscriber Level:R:1
+segment=DTP:::Accident Date:S:1
+segment=DTP:::Last Menstrual Period Date:S:1
+segment=DTP:::Estimated Date of Birth:S:1
+segment=DTP:::Onset of Current Symptoms or Illness Date:S:1
+segment=HI:::Subscriber Diagnosis:S:1
+loop=2010C
+
+#LOOP ID - 2010C SUBSCRIBER NAME 1
+[2010C]
+segment=NM1:1:IL:Subscriber Name:R:1
+segment=REF:::Subscriber Supplemental Identification:S:9
+segment=DMG:::Subscriber Demographic Information:S:1
+
+#LOOP ID - 2000D DEPENDENT LEVEL 1
+[2000D]
+segment=HL:3:23:Dependent Level:S:1
+segment=DTP:::Accident Date:S:1
+segment=DTP:::Last Menstrual Period Date:S:1
+segment=DTP:::Estimated Date of Birth:S:1
+segment=DTP:::Onset of Current Symptoms or Illness Date:S:1
+segment=HI:::Dependent Diagnosis:S:1
+loop=2010D
+
+#LOOP ID - 2010D DEPENDENT NAME 1
+[2010D]
+segment=NM1:1:QD:Dependent Name:R:1
+segment=REF:::Dependent Supplemental Identification:S:3
+segment=DMG:::Dependent Demographic Information:S:1
+segment=INS:::Dependent Relationship:S:1
+
+#LOOP ID - 2000E SERVICE PROVIDER LEVEL >1
+[2000E]
+segment=HL:3:19:Service Provider Level:R:1
+segment=MSG:::Message Text:S:1
+loop=2010E
+
+#LOOP ID - 2010E SERVICE PROVIDER NAME 3
+[2010E]
+segment=NM1:1:1T,FA,SJ:Service Provider Name:R:1
+segment=REF:::Service Provider Supplemental Identification:S:7
+segment=N3:::Service Provider Address:S:1
+segment=N4:::Service Provider City/State/ZIP Code:S:1
+segment=PER:::Service Provider Contact Information:S:1
+segment=PRV:::Service Provider Information:S:1
+
+#LOOP ID - 2000F SERVICE LEVEL >1
+[2000F]
+segment=HL:3:SS:Service Level:R:1
+segment=TRN:::Service Trace Number:S:2
+segment=UM:::Health Care Services Review Information:R:1
+segment=REF:::Previous Certification Identification:S:1
+segment=DTP:::Service Date:S:1
+segment=DTP:::Admission Date:S:1
+segment=DTP:::Discharge Date:S:1
+segment=DTP:::Surgery Date:S:1
+segment=HI:::Procedures:S:1
+segment=HSD:::Health Care Services Delivery:S:1
+segment=CRC:::Patient Condition Information:S:6
+segment=CL1:::Institutional Claim Code:S:1
+segment=CR1:::Ambulance Transport Information:S:1
+segment=CR2:::Spinal Manipulation Service Information:S:1
+segment=CR5:::Home Oxygen Therapy Information:S:1
+segment=CR6:::Home Health Care Information:S:1
+segment=MSG:::Message Text:S:1
+
+#LOOP ID - TRAILER
+[SE]
+segment=SE:::Transaction Set Trailer:R:1
+
+[GE]
+segment=GE:::GE:R:1
+
+[IEA]
+segment=IEA:::IEA:R:1
+
+
+

data/cf/278_004010X094_Res.cf

@@ -0,0 +1,139 @@
+[LOOPS]
+ISA
+GS
+ST
+2000A
+2000B
+2000C
+2000D
+2000E
+2000F
+SE
+GE
+IEA
+
+#--- start of loop details ---#
+
+[ISA]
+segment=ISA:::ISA:R:1
+
+[GS]
+segment=GS:::GS:R:1
+
+#LOOP ID - HEADER
+[ST]
+segment=ST:::Transaction Set Header:R:1
+segment=BHT:::Beginning of Hierarchical Transaction:R:1
+
+#LOOP ID - 2000A UTILIZATION MANAGEMENT ORGANIZATION (UMO) LEVEL 1
+[2000A]
+segment=HL:3:20:Utilization Management Organization (UMO) Level:R:1
+segment=AAA:::Request Validation:S:9
+loop=2010A
+
+#LOOP ID - 2010A UTILIZATION MANAGEMENT ORGANIZATION (UMO) NAME 1
+[2010A]
+segment=NM1:1:X3:Utilization Management Organization (UMO) Name:R:1
+segment=PER:::Utilization Management Organization (UMO) Contact Information:S:1
+segment=AAA:::Utilization Management Organization (UMO) Request Validation:S:9
+
+#LOOP ID - 2000B REQUESTER LEVEL 1
+[2000B]
+segment=HL:3:21:Requester Level:R:1
+loop=2010B
+
+#LOOP ID - 2010B REQUESTER NAME 1
+[2010B]
+segment=NM1:1:1P,FA:Requester Name:R:1
+segment=REF:::Requester Supplemental Identification:S:8
+segment=AAA:::Requester Request Validation:S:9
+segment=PRV:::Requester Provider Information:S:1
+
+#LOOP ID - 2000C SUBSCRIBER LEVEL 1
+[2000C]
+segment=HL:3:22:Subscriber Level:R:1
+segment=AAA:::Subscriber Request Validation:S:9
+segment=DTP:::Accident Date:S:1
+segment=DTP:::Last Menstrual Period Date:S:1
+segment=DTP:::Estimated Date of Birth:S:1
+segment=DTP:::Onset of Current Symptoms or Illness Date:S:1
+segment=HI:::Subscriber Diagnosis:S:1
+loop=2010C
+
+#LOOP ID - 2010C SUBSCRIBER NAME 1
+[2010C]
+segment=NM1:1:IL:Subscriber Name:R:1
+segment=REF:::Subscriber Supplemental Identification:S:9
+segment=AAA:::Subscriber Request Validation:S:9
+segment=DMG:::Subscriber Demographic Information:S:1
+
+#LOOP ID - 2000D DEPENDENT LEVEL 1
+[2000D]
+segment=HL:3:23:Dependent Level:S:1
+segment=AAA:::Dependent Request Validation:S:9
+segment=DTP:::Accident Date:S:1
+segment=DTP:::Last Menstrual Period Date:S:1
+segment=DTP:::Estimated Date of Birth:S:1
+segment=DTP:::Onset of Current Symptoms or Illness Date:S:1
+segment=HI:::Dependent Diagnosis:S:1
+loop=2010D
+
+#LOOP ID - 2010D DEPENDENT NAME 1
+[2010D]
+segment=NM1:1:QC:Dependent Name:R:1
+segment=REF:::Dependent Supplemental Identification:S:3
+segment=AAA:::Dependent Request Validation:S:9
+segment=DMG:::Dependent Demographic Information:S:1
+segment=INS:::Dependent Relationship:S:1
+
+#LOOP ID - 2000E SERVICE PROVIDER LEVEL >1
+[2000E]
+segment=HL:3:19:Service Provider Level:R:1
+segment=MSG:::Message Text:S:1
+
+#LOOP ID - 2010E SERVICE PROVIDER NAME 3
+[2010E]
+segment=NM1:1:1T,FA,SJ:Service Provider Name:R:1
+segment=REF:::Service Provider Supplemental Identification:S:7
+segment=N3:::Service Provider Address:S:1
+segment=N4:::Service Provider City/State/ZIP Code:S:1
+segment=PER:::Service Provider Contact Information:S:1
+segment=AAA:::Service Provider Request Validation:S:9
+segment=PRV:::Service Provider Information:S:1
+
+#LOOP ID - 2000F SERVICE LEVEL >1
+[2000F]
+segment=HL:3:SS:Service Level:R:1
+segment=TRN:::Service Trace Number:S:3
+segment=AAA:::Service Request Validation:S:9
+segment=UM:::Health Care Services Review Information:R:1
+segment=HCR:::Health Care Services Review:S:1
+segment=REF:::Previous Certification Identification:S:1
+segment=DTP:::Service Date:S:1
+segment=DTP:::Admission Date:S:1
+segment=DTP:::Discharge Date:S:1
+segment=DTP:::Surgery Date:S:1
+segment=DTP:::Certification Issue Date:S:1
+segment=DTP:::Certification Expiration Date:S:1
+segment=DTP:::Certification Effective Date:S:1
+segment=HI:::Procedures:S:1
+segment=HSD:::Health Care Services Delivery:S:1
+segment=CL1:::Institutional Claim Code:S:1
+segment=CR1:::Ambulance Transport Information:S:1
+segment=CR2:::Spinal Manipulation Service Information:S:1
+segment=CR5:::Home Oxygen Therapy Information:S:1
+segment=CR6:::Home Health Care Information:S:1
+segment=MSG:::Message Text:S:1
+
+#LOOP ID - TRAILER
+[SE]
+segment=SE:::Transaction Set Trailer:R:1
+
+[GE]
+segment=GE:::GE:R:1
+
+[IEA]
+segment=IEA:::IEA:R:1
+
+
+

data/cf/810.cf

@@ -0,0 +1,100 @@
+[LOOPS]
+ISA
+GS
+ST-H
+BIG-H
+N1-H
+ITD-H
+IT1-D
+TDS-S
+TXI-S
+SAC-S
+CTT-S
+SE-S
+GE
+IEA
+
+#--- start of loop details ---#
+
+[ISA]
+segment=ISA:::ISA:R:1
+
+[GS]
+segment=GS:::GE:R:1
+
+[ST-H]
+segment=ST:1:810:Transaction Set Header:R:1
+
+[BIG-H]
+segment=BIG:7:DI,PR:Credit Invoice:R:1
+
+[N1-H]
+segment=N1:1:BS,BT,RE,RI,SD,SF,ST,VN:Ship To:S:1
+loop=N1_LOOP-H
+loop=REF_LOOP-H
+
+[N1_LOOP-H]
+segment=N3:::Address Information:S:1
+segment=N4:::Geographic Location:S:1
+
+[REF_LOOP-H]
+segment=REF:::Reference Identification:S:1
+
+[ITD-H]
+segment=ITD:1:03:Terms of Sale:S:1
+
+[IT1-D]
+segment=IT1:::Baseline Item Data:S:1
+loop=QTY_LOOP-D
+loop=TXI_LOOP-D
+loop=CTP_LOOP-D
+loop=MEA_LOOP-D
+loop=PID_LOOP-D
+loop=PKG_LOOP-D
+loop=PO4_LOOP-D
+loop=REF_LOOP-D
+
+[QTY_LOOP-D]
+segment=QTY:::Quantity:S:1
+
+[TXI_LOOP-D]
+segment=TXI:::Taxes:S:1
+
+[CTP_LOOP-D]
+segment=CTP:::Pricing information:S:1
+
+[MEA_LOOP-D]
+segment=MEA:::Measurements:S:1
+
+[PID_LOOP-D]
+segment=PID:::Free Form Product/Item/Description:S:1
+
+[PKG_LOOP-D]
+segment=PKG:::Packaging:S:1
+
+[PO4_LOOP-D]
+segment=PO4:::Item physical details:S:1
+
+[REF_LOOP-D]
+segment=REF:::Reference:S:1
+
+[TDS-S]
+segment=TDS:::Monetary Value Summary:S:1
+
+[TXI-S]
+segment=TXI:1:LS:Tax Information:S:1
+
+[SAC-S]
+segment=SAC:1:C:Service,Promotion,Allowance, or Charge:S:1
+
+[CTT-S]
+segment=CTT:::Transaction Totals:S:1
+
+[SE-S]
+segment=SE:::Transaction Set Trailer:R:1
+
+[GE]
+segment=GE:::GE:R:1
+
+[IEA]
+segment=IEA:::IEA:R:1