Loop 2000A Loop 2010AA PRV03 REF01 REF02

Loop 2010AA N301 N401 N402 N403 NM103 NM104 NM105 NM107 PER04

Loop 2310C NM109

CLM06 Loop 2300 Provider or Supplier Signature Indicator

CLM02 Loop 2300 Total Claim Charge Amount