v1/test/cases/schema/appview/HIPAA270.xml

<?xml version="1.0"?>
<!-- Copyright 2004 The Apache Software Foundation

     Licensed under the Apache License, Version 2.0 (the "License");
     you may not use this file except in compliance with the License.
     You may obtain a copy of the License at

         http://www.apache.org/licenses/LICENSE-2.0

     Unless required by applicable law or agreed to in writing, software
     distributed under the License is distributed on an "AS IS" BASIS,
     WITHOUT WARRANTIES OR CONDITIONS OF ANY KIND, either express or implied.
     See the License for the specific language governing permissions and
     limitations under the License. -->
<!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>