Page #	Loop ID	Reference	Name	Codes	Notes/Comments
		ISA	Interchange Control Header
		ISA04			SENTARAADS
198 (B.4)		ISA07	Interchange ID Qualifier	ZZ
199		ISA08	Interchange Receiver ID	SUNTRUST
199		ISA16	Component Element Separator	>
202		GS	Functional Group Header
		GS03	Application Receiver Code	SUNTRUST
44		BPR	Financial Information
45		BPR01	Transaction Handling Code	D	D = Make Payment Only
46		BPR02	Monetary Amount		Check amount
46		BPR03	Credit/Debit Flag Code	C	Credit
46		BPR04	Payment Method Code	ACH	Automated Clearing House
47		BPR05	Payment Format Code	CTX	Corporate Trade Exchange
48		BPR06	(DFI) ID Number Qualifier	01	ABA Transit Routing Number including Check digits (9 digits)
48		BPR07	(DFI) ID Number		SUNTRUST Routing Number
49		BPR09	Account Number		Sender Bank Acct Number
49		BPR10	Originating Company Identifier		1+Tax ID number - must be identical to TRN03
49		BPR11	Originating Company Supplemental Code
49		BPR12	DFI ID No Qualifier	01	ABA Transit Routing Number Including Check Digits (9 digits)
50		BPR13	DFI ID Number		Provider Bank Routing #
50		BPR14	Account Number Qualifier	SG or DA	Provider Bank Account Type  DA = Demand Deposit;  SG = Savings
50		BPR15	Account Number		Provider Bank Account Number
50		BPR16	Date		Current Date (CCYYMMDD)
52		TRN	Reassociation Trace Number
52		TRN01	Trace Type Code	1	Current Transaction Trace Numbers
53		TRN02	Reference Ident		Optima Check Number
53		TRN03	Originating Company ID		1+Tax ID Number   Originating Co Tax ID Number preceded by 1
57		REF	Receiver Identification
57		REF01	Reference Ident Qual	EV	Receiver Identification Number
57		REF02	Reference Ident		VAN Indicator
60		DTM	Production Date
60		DTM01	Date/Time Qualifier	405	Production
61		DTM02	Date		Current Date (CCYYMMDD)
62	1000A	N1	Payer Identification
		N101	Payer	PR	Payer
		N102	Company name	Sentara	Payer Company Name
64	1000A	N3	Payer Address
		N301	Address Information	4417 Corporation Lane	Optima Address
65	1000A	N4	Payer City, State, Zip Code
65		N401	City Name	Virginia Beach
65		N402	State	VA
65		N403	Postal Code	23462
72	1000B	N1	Payee Identification
72		N101	Entity Identifier Code	PE	Payee
73		N102	Name		Vendor Name
73		N103	Identification Code Qualifier	FI	Federal Taxpayer's ID Number
73		N104	Identification Code		Actual Tax ID Number
77	1000B	REF	Payee Additional Identification
77		REF01	Reference Identification Qualifier	PQ	Payee Identification
77		REF02	Reference Identification		Optima Assigned Vendor Number
79	2000	LX	Header Number
		LX01	Assigned Number	1
89	2100	CLP	Claim Payment Information
89		CLP01	Claim Submitter's Identifier		Patient ID
90		CLP02	Claim Status Code	1,2 or 4	1 = Processed as Primary 2 = Processed as Secondary 4 = Denied
91		CLP03	Monetary Amount		Requested Amount
91		CLP04	Monetary Amount		Paid Amount
91		CLP05	Monetary Amount		Amount not allowed - Patient Responsible Amount
92		CLP06	Claim Filing Indicator Code	HM	Health Maintenance Organization
93		CLP07	Reference Identification		Optima Claim Number
93		CLP08	Facility Code Value		Bill Type - Number in the CLM05 of the 837 claims
93		CLP09	Claim Frequency Type Code		Claim Frequency Code - specific to institutional claims - Number in the CLM05-2 of the 837 claim
93		CLP11	Diagnosis Related Group (DRG) Code		Specific to institutional Claims.
102	2100	NM1	Patient Name
102		NM101	Entity Identifier Code	QC	QC = Patient
103		NM102	Entity Type Qualifier	1	Person
103		NM103	Name Last or Organization Name		Last name of Optima Member
103		NM104	Name First		First name of Optima Member
103		NM108	Identification Code Qualifier	MI
104		NM109	Identification Code		Optima member's number will include the asterisk to designate member
108	2100	NM1	Corrected Patient/Insured Name
		NM101	Entity Identifier Code	74	Corrected Insured
		NM102	Entity Type Qualifier	1
		NM103	Name Last or Organization Name		Corrected Member Last Name
		NM104	Name First		Corrected Member First Name
126	2100	REF	Other Claim Related Identification
126		REF01	Reference Identification Qualifier	IL	IL = Group or Policy Number
127		REF02	Reference Identification		Optima Plan code, Company, and Group Number EX:   OHIC#01#12345-ABC Company
135	2100	AMT	Claim Supplemental Information
		AMT01	Amount Qualifier Code	AU
		AMT02	Monetary Amount		Max amount allowed for claim
139	2110	SVC	Service Payment Information
141		SVC01-1	Product/Service ID Qualifier	HC or NU	HC = HCPCS code NU = CPT code
141		SVC01-2	Product/Service ID		HCPCS or CPT code
141		SCV01-3	Procedure Modifier		Modifier if present
142		SVC02	Monetary Amount		Requested Amount (COB Claim the SVC02 and SCV03 will be the same.  CAS segment will adjust amounts and match CLP04)
142		SVC03	Monetary Amount		Amount Paid
142		SVC05	Quantity		Unit of Service Paid Count
146	2110	DTM	Service Date
147		DTM01	Date/Time Qualifier	472, 150, or 151	If Single Day of Service then use 472;  otherwise use 150 (service begin) or 151 (service end)
		DTM02	Date		CCYYMMDD;  DOS, DTP=150 then DTP02 = Beginning DOS;  DTP = 151 then DTP02 = Ending DOS.
148	2110	CAS	Service Adjustment		Different Scenarios for Adjustment Group Codes (Example A)
150		CAS01	Claim Adjustment Group Code	OA
150		CAS02	Claim Adjustment Reason Code
150		CAS03	Monetary Amount		Amount not allowed
148	2110	CAS	Service Adjustment		Different Scenarios for Adjustment Group Codes (Example B)
150		CAS01	Claim Adjustment Group Code	PI
150		CAS02	Claim Adjustment Reason Code	104	Withhold
150		CAS03	Monetary Amount		Withhold amount
151		CAS05	Claim Adjustment Reason Code	41	Discount
151		CAS06	Monetary Amount
148	2110	CAS	Service Adjustment		Different Scenarios for Adjustment Group Codes (Example C)
150		CAS01	Claim Adjustment Group Code	PR
150		CAS02	Claim Adjustment Reason Code	2
150		CAS03	Monetary Amount		Withhold amount
151		CAS05	Claim Adjustment Reason Code	41	Discount
151		CAS06	Monetary Amount
148	2110	CAS	Service Adjustment		Different Scenarios for Adjustment Group Codes (Example D) COB Claim
150		CAS01	Claim Adjustment Group Code	CO
150		CAS02	Claim Adjustment Reason Code	23
150		CAS03	Monetary Amount		COB Amount from Primary Payer
151		CAS05	Claim Adjustment Reason Code	94	Processed in Excess of charges.
151		CAS06	Monetary Amount		Difference in COB amount and amount we pay
148	2110	CAS	Service Adjustment		Different Scenarios for Adjustment Group Codes (Example E)
150		CAS01	Claim Adjustment Group Code	OA
150		CAS02	Claim Adjustment Reason Code	24	Capitated Adjustment
150		CAS03	Monetary Amount		Capitated Amount + Amount not allowed
154	2100	REF	Service Identification
154		REF01	Reference Identification Qualifier	LU
155		REF02	Reference Identification		Place Code
154		REF01	Reference Identification Qualifier	6R	Provider Control Number
155		REF02	Reference Identification		PCP Number  - (Sentara 5 digit  provider numbers)
158	2110	AMT	Service Supplemental Amount
158		AMT01	Amount Qualifier Code	B6	Allowed Actual
159		AMT02	Monetary Amount		Max Allowed Amount for Service
162	2110	LQ	Health Care Remark Codes
162		LQ01	Code List Qualifier Code	HE	Claim Payment Remark Codes (Remittance Remark Codes)
163		LQ02	Industry Code		Remark Code