| <?xml version="1.0"?> |
| <!DOCTYPE HIPAA270> |
| <HIPAA270> |
| <ISA> |
| <_01_Authorization_Information_Qualifier_>00</_01_Authorization_Information_Qualifier_> |
| <_02_Authorization_Information_>1234567890</_02_Authorization_Information_> |
| <_03_Security_Information_Qualifier_>00</_03_Security_Information_Qualifier_> |
| <_04_Security_Information_>1234567890</_04_Security_Information_> |
| <_05_Interchange_ID_Qualifier_>ZZ</_05_Interchange_ID_Qualifier_> |
| <_06_Interchange_Sender_ID_>SUBMITTERS ID12</_06_Interchange_Sender_ID_> |
| <_07_Interchange_ID_Qualifier_>ZZ</_07_Interchange_ID_Qualifier_> |
| <_08_Interchange_Receiver_ID_>RECEIVERS ID123</_08_Interchange_Receiver_ID_> |
| <_09_Interchange_Date_>010122</_09_Interchange_Date_> |
| <_10_Interchange_Time_>1253</_10_Interchange_Time_> |
| <_11_Repetition_Separator_>U</_11_Repetition_Separator_> |
| <_12_Interchange_Control_Version_Number_>00401</_12_Interchange_Control_Version_Number_> |
| <_13_Interchange_Control_Number_>000000905</_13_Interchange_Control_Number_> |
| <_14_Acknowledgement_Requested_>1</_14_Acknowledgement_Requested_> |
| <_15_Usage_Indicator_>T</_15_Usage_Indicator_> |
| <_16_Component_Element_Separator_>:</_16_Component_Element_Separator_> |
| </ISA> |
| <GS> |
| <_01_Functional_Identifier_Code_>HS</_01_Functional_Identifier_Code_> |
| <_02_Application_Senders_Code_>SenderID</_02_Application_Senders_Code_> |
| <_03_Application_Receivers_Code_>ReceiverID</_03_Application_Receivers_Code_> |
| <_04_Date_>20010122</_04_Date_> |
| <_05_Time_>1310</_05_Time_> |
| <_06_Group_Control_Number_>1</_06_Group_Control_Number_> |
| <_07_Responsible_Agency_Code_>X</_07_Responsible_Agency_Code_> |
| <_08_Version__Release__Industry_Identifier_Code_>004010X092</_08_Version__Release__Industry_Identifier_Code_> |
| </GS> |
| <_270> |
| <ST> |
| <_01_Transaction_Set_Identifier_Code_>270</_01_Transaction_Set_Identifier_Code_> |
| <_02_Transaction_Set_Control_Number_>1234</_02_Transaction_Set_Control_Number_> |
| </ST> |
| <BHT> |
| <_01_Hierarchical_Structure_Code_>0022</_01_Hierarchical_Structure_Code_> |
| <_02_Transaction_Set_Purpose_Code_>13</_02_Transaction_Set_Purpose_Code_> |
| <_03_Reference_Identification_>10001234</_03_Reference_Identification_> |
| <_04_Date_>19990501</_04_Date_> |
| <_05_Time_>1319</_05_Time_> |
| <_06_Transaction_Type_Code_/> |
| </BHT> |
| <_2000A> |
| <HL> |
| <_01_Hierarchical_ID_Number_>1</_01_Hierarchical_ID_Number_> |
| <_02_Hierarchical_Parent_ID_Number_/> |
| <_03_Hierarchical_Level_Code_>20</_03_Hierarchical_Level_Code_> |
| <_04_Hierarchical_Child_Code_>1</_04_Hierarchical_Child_Code_> |
| </HL> |
| <_2100A> |
| <NM1> |
| <_01_Entity_Identifier_Code_>PR</_01_Entity_Identifier_Code_> |
| <_02_Entity_Type_Qualifier_>2</_02_Entity_Type_Qualifier_> |
| <_03_Name_Last_or_Organization_Name_>ABCCOMPANY</_03_Name_Last_or_Organization_Name_> |
| <_04_Name_First_/> |
| <_05_Name_Middle_/> |
| <_06_Name_Prefix_/> |
| <_07_Name_Suffix_/> |
| <_08_Identification_Code_Qualifier_>PI</_08_Identification_Code_Qualifier_> |
| <_09_Identification_Code_>842610001</_09_Identification_Code_> |
| </NM1> |
| </_2100A> |
| <_2000B> |
| <HL> |
| <_01_Hierarchical_ID_Number_>2</_01_Hierarchical_ID_Number_> |
| <_02_Hierarchical_Parent_ID_Number_>1</_02_Hierarchical_Parent_ID_Number_> |
| <_03_Hierarchical_Level_Code_>21</_03_Hierarchical_Level_Code_> |
| <_04_Hierarchical_Child_Code_>1</_04_Hierarchical_Child_Code_> |
| </HL> |
| <_2100B> |
| <NM1> |
| <_01_Entity_Identifier_Code_>1P</_01_Entity_Identifier_Code_> |
| <_02_Entity_Type_Qualifier_>1</_02_Entity_Type_Qualifier_> |
| <_03_Name_Last_or_Organization_Name_>JONES</_03_Name_Last_or_Organization_Name_> |
| <_04_Name_First_>MARCUS</_04_Name_First_> |
| <_05_Name_Middle_/> |
| <_06_Name_Prefix_/> |
| <_07_Name_Suffix_/> |
| <_08_Identification_Code_Qualifier_>SV</_08_Identification_Code_Qualifier_> |
| <_09_Identification_Code_>0202034</_09_Identification_Code_> |
| </NM1> |
| <REF> |
| <_01_Reference_Identification_Qualifier_>N5</_01_Reference_Identification_Qualifier_> |
| <_02_Reference_Identification_>129</_02_Reference_Identification_> |
| <_03_Description_/> |
| </REF> |
| <N3> |
| <_01_Address_Information_>55 HIGH STREET</_01_Address_Information_> |
| <_02_Address_Information_/> |
| </N3> |
| <N4> |
| <_01_City_Name_>SEATTLE</_01_City_Name_> |
| <_02_State_or_Province_Code_>WA</_02_State_or_Province_Code_> |
| <_03_Postal_Code_>98123</_03_Postal_Code_> |
| <_04_Country_Code_/> |
| </N4> |
| <PER> |
| <_01_Contact_Function_Code_>IC</_01_Contact_Function_Code_> |
| <_02_Name_>MARYMURPHY</_02_Name_> |
| <_03_Communication_Number_Qualifier_>TE</_03_Communication_Number_Qualifier_> |
| <_04_Communication_Number_>2065551212</_04_Communication_Number_> |
| <_05_Communication_Number_Qualifier_>EX</_05_Communication_Number_Qualifier_> |
| <_06_Communication_Number_>3694</_06_Communication_Number_> |
| <_07_Communication_Number_Qualifier_>FX</_07_Communication_Number_Qualifier_> |
| <_08_Communication_Number_>2065551214</_08_Communication_Number_> |
| </PER> |
| </_2100B> |
| <_2000C> |
| <HL> |
| <_01_Hierarchical_ID_Number_>3</_01_Hierarchical_ID_Number_> |
| <_02_Hierarchical_Parent_ID_Number_>2</_02_Hierarchical_Parent_ID_Number_> |
| <_03_Hierarchical_Level_Code_>22</_03_Hierarchical_Level_Code_> |
| <_04_Hierarchical_Child_Code_>1</_04_Hierarchical_Child_Code_> |
| </HL> |
| <TRN> |
| <_01_Trace_Type_Code_>1</_01_Trace_Type_Code_> |
| <_02_Reference_Identification_>93175-012547</_02_Reference_Identification_> |
| <_03_Originating_Company_Identifier_>9877281234</_03_Originating_Company_Identifier_> |
| <_04_Reference_Identification_/> |
| </TRN> |
| <_2100C> |
| <NM1> |
| <_01_Entity_Identifier_Code_>IL</_01_Entity_Identifier_Code_> |
| <_02_Entity_Type_Qualifier_>1</_02_Entity_Type_Qualifier_> |
| <_03_Name_Last_or_Organization_Name_>SMITH</_03_Name_Last_or_Organization_Name_> |
| <_04_Name_First_>ROBERT</_04_Name_First_> |
| <_05_Name_Middle_>B</_05_Name_Middle_> |
| <_06_Name_Prefix_/> |
| <_07_Name_Suffix_/> |
| <_08_Identification_Code_Qualifier_>MI</_08_Identification_Code_Qualifier_> |
| <_09_Identification_Code_>11122333301</_09_Identification_Code_> |
| </NM1> |
| <REF> |
| <_01_Reference_Identification_Qualifier_>1L</_01_Reference_Identification_Qualifier_> |
| <_02_Reference_Identification_>599119</_02_Reference_Identification_> |
| </REF> |
| <N3> |
| <_01_Address_Information_>29 FREMONT ST</_01_Address_Information_> |
| <_02_Address_Information_>APT# 1</_02_Address_Information_> |
| </N3> |
| <N4> |
| <_01_City_Name_>PEACE</_01_City_Name_> |
| <_02_State_or_Province_Code_>NY</_02_State_or_Province_Code_> |
| <_03_Postal_Code_>10023</_03_Postal_Code_> |
| <_04_Country_Code_/> |
| </N4> |
| <DMG> |
| <_01_Date_Time_Period_Format_Qualifier_>D8</_01_Date_Time_Period_Format_Qualifier_> |
| <_02_Date_Time_Period_>19430519</_02_Date_Time_Period_> |
| <_03_Gender_Code_>M</_03_Gender_Code_> |
| </DMG> |
| </_2100C> |
| <_2000D> |
| <HL> |
| <_01_Hierarchical_ID_Number_>4</_01_Hierarchical_ID_Number_> |
| <_02_Hierarchical_Parent_ID_Number_>3</_02_Hierarchical_Parent_ID_Number_> |
| <_03_Hierarchical_Level_Code_>23</_03_Hierarchical_Level_Code_> |
| <_04_Hierarchical_Child_Code_>0</_04_Hierarchical_Child_Code_> |
| </HL> |
| <TRN> |
| <_01_Trace_Type_Code_>1</_01_Trace_Type_Code_> |
| <_02_Reference_Identification_>93175-012547</_02_Reference_Identification_> |
| <_03_Originating_Company_Identifier_>9877281234</_03_Originating_Company_Identifier_> |
| <_04_Reference_Identification_>RADIOLOGY</_04_Reference_Identification_> |
| </TRN> |
| <_2100D> |
| <NM1> |
| <_01_Entity_Identifier_Code_>03</_01_Entity_Identifier_Code_> |
| <_02_Entity_Type_Qualifier_>1</_02_Entity_Type_Qualifier_> |
| <_03_Name_Last_or_Organization_Name_>SMITH</_03_Name_Last_or_Organization_Name_> |
| <_04_Name_First_>MARYLOU</_04_Name_First_> |
| <_05_Name_Middle_/> |
| <_06_Name_Prefix_/> |
| <_07_Name_Suffix_/> |
| </NM1> |
| <REF> |
| <_01_Reference_Identification_Qualifier_>SY</_01_Reference_Identification_Qualifier_> |
| <_02_Reference_Identification_>003221234</_02_Reference_Identification_> |
| </REF> |
| <N3> |
| <_01_Address_Information_>29 FREMONT ST</_01_Address_Information_> |
| <_02_Address_Information_>APT# 1</_02_Address_Information_> |
| </N3> |
| <N4> |
| <_01_City_Name_>PEACE</_01_City_Name_> |
| <_02_State_or_Province_Code_>NY</_02_State_or_Province_Code_> |
| <_03_Postal_Code_>10023</_03_Postal_Code_> |
| <_04_Country_Code_/> |
| </N4> |
| <DMG> |
| <_01_Date_Time_Period_Format_Qualifier_>D8</_01_Date_Time_Period_Format_Qualifier_> |
| <_02_Date_Time_Period_>19781014</_02_Date_Time_Period_> |
| <_03_Gender_Code_>F</_03_Gender_Code_> |
| </DMG> |
| <INS> |
| <_01_Yes_No_Condition_or_Response_Code_>N</_01_Yes_No_Condition_or_Response_Code_> |
| <_02_Individual_Relationship_Code_>19</_02_Individual_Relationship_Code_> |
| <_03_Maintenance_Type_Code_/> |
| <_04_Maintenance_Reason_Code_/> |
| <_05_Benefit_Status_Code_/> |
| <_06_Medicare_Status_Code_/> |
| <_07_Consolidated_Omnibus_Budget_Reconciliation_Act__COBRA__Qualifying_Event_Code_/> |
| <_08_Employment_Status_Code_/> |
| <_09_Student_Status_Code_/> |
| <_10_Yes_No_Condition_or_Response_Code_/> |
| <_11_Date_Time_Period_Format_Qualifier_/> |
| <_12_Date_Time_Period_/> |
| <_13_Confidentiality_Code_/> |
| <_14_City_Name_/> |
| <_15_State_or_Province_Code_/> |
| <_16_Country_Code_/> |
| <_17_Number_/> |
| </INS> |
| <DTP> |
| <_01_Date_Time_Qualifier_>472</_01_Date_Time_Qualifier_> |
| <_02_Date_Time_Period_Format_Qualifier_>D8</_02_Date_Time_Period_Format_Qualifier_> |
| <_03_Date_Time_Period_>19990501</_03_Date_Time_Period_> |
| </DTP> |
| <_2110D> |
| <EQ> |
| <_01_Service_Type_Code_>81</_01_Service_Type_Code_> |
| <_02_Composite_Medical_Procedure_Identifier_/> |
| <_03_Coverage_Level_Code_>FAM</_03_Coverage_Level_Code_> |
| <_04_Insurance_Type_Code_/> |
| </EQ> |
| </_2110D> |
| </_2100D> |
| </_2000D> |
| </_2000C> |
| </_2000B> |
| </_2000A> |
| <SE> |
| <_01_Number_of_Included_Segments_>28</_01_Number_of_Included_Segments_> |
| <_02_Transaction_Set_Control_Number_>1234</_02_Transaction_Set_Control_Number_> |
| </SE> |
| </_270> |
| <GE> |
| <_01_Number_of_Transaction_Sets_Included_>1</_01_Number_of_Transaction_Sets_Included_> |
| <_02_Group_Control_Number_>1</_02_Group_Control_Number_> |
| </GE> |
| <IEA> |
| <_01_Number_of_Included_Functional_Groups_>1</_01_Number_of_Included_Functional_Groups_> |
| <_02_Interchange_Control_Number_>000000905</_02_Interchange_Control_Number_> |
| </IEA> |
| </HIPAA270> |