Sample Output XML Document

The following is the XML file that results from inbound processing of the preceding HIPAA document.

<?xml version="1.0" encoding="ISO-8859-1" ?>
<documents>
    <ValidationReport>
        <Report>
            <Success/>
        </Report>
    </ValidationReport>
    <input>
<![CDATA[ISA*00*..........*01*SECRET....*ZZ*SUBMITTERS.ID..*ZZ*
RECEIVERS.ID...*030101*1253*^*00501*000000905*0*T*:~
        GS*HR*SENDER CODE*RECEIVER CODE*19991231*0802*1*X*005010X212~
        ST*276*0001*005010X212~
        BHT*0010*13*ABC276XXX*20050915*1425~
        HL*1**20*1~
        NM1*PR*2*ABC INSURANCE*****PI*12345~
        HL*2*1*21*1~
        NM1*41*2*XYZ SERVICE*****46*X67E~
        HL*3*2*19*1~
        NM1*1P*2*HOME HOSPITAL*****XX*1666666668~
        HL*4*3*22*0~
        DMG*D8*19301210*M~
        NM1*IL*1*SMITH*FRED****MI*123456789A~
        TRN*1*ABCXYZ1~
        REF*BLT*111~
        REF*EJ*SM123456~
        AMT*T3*8513.88~
        DTP*472*RD8*20050831-20050906~
        HL*5*3*22*0~
        DMG*D8*19301115*F~
        NM1*IL*1*JONES*MARY****MI*234567890A~
        TRN*1*ABCXYZ2~
        REF*BLT*111~
        REF*EJ*JO234567~
        AMT*T3*7599~
        DTP*472*RD8*20050731-20050809~
        HL*6*2*19*1~
        NM1*1P*2*HOME HOSPITAL PHYSICIANS*****XX*1666666668~
        HL*7*6*22*1~
        NM1*IL*1*MANN*JOHN****MI*345678901~
        HL*8*7*23~
        DMG*D8*19951101*M~
        NM1*QC*1*MANN*JOSEPH~
        TRN*1*ABCXYZ3~
        REF*EJ*MA345678~
        SVC*HC:99203*150*****1~
        DTP*472*D8*20050501~
        SE*36*0001~
        GE*1*1~
        IEA*1*000000905~]]>
    </input>
    <output>
        <HIPAA_276_005010X212>
            <ISA>
<_01_Authorization_Information_Qualifier>00
</_01_Authorization_Information_Qualifier>
<_02_Authorization_Information>..........
</_02_Authorization_Information>
<_03_Security_Information_Qualifier>01
</_03_Security_Information_Qualifier>
<_04_Security_Information>SECRET....</_04_Security_Information>
<_05_Interchange_ID_Qualifier>ZZ</_05_Interchange_ID_Qualifier>
<_06_Interchange_Sender_ID>SUBMITTERS.ID..</_06_Interchange_Sender_ID>
<_07_Interchange_ID_Qualifier>ZZ</_07_Interchange_ID_Qualifier>
<_08_Interchange_Receiver_ID>RECEIVERS.ID...
</_08_Interchange_Receiver_ID>
<_09_Interchange_Date>030101</_09_Interchange_Date>
<_10_Interchange_Time>1253</_10_Interchange_Time>
<_11_Repetition_Separator>^</_11_Repetition_Separator>
<_12_Interchange_Control_Version_Number>00501
</_12_Interchange_Control_Version_Number>
    <_13_Interchange_Control_Number>000000905
    </_13_Interchange_Control_Number>
    <_14_Acknowledgement_Requested>0</_14_Acknowledgement_Requested>
     <_15_Usage_Indicator>T</_15_Usage_Indicator>
     <_16_Component_Element_Separator>:</_16_Component_Element_Separator>
            </ISA>
            <GS>
<_01_Functional_Identifier_Code>HR</_01_Functional_Identifier_Code>
<_02_Application_Senders_Code>SENDER CODE</_02_Application_Senders_Code>
<_03_Application_Receivers_Code>RECEIVER
CODE</_03_Application_Receivers_Code>
        <_04_Date>19991231</_04_Date>
        <_05_Time>0802</_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>005010X212</_08_Version__
Release__Industry_Identifier_Code>
            </GS>
            <_276>
                <ST>
<_01_Transaction_Set_Identifier_Code>276
</_01_Transaction_Set_Identifier_Code>
<_02_Transaction_Set_Control_Number>0001
</_02_Transaction_Set_Control_Number>
<_03_Implementation_Convention_Reference>005010X212
</_03_Implementation_Convention_Reference>
                </ST>
                <BHT>
<_01_Hierarchical_Structure_Code>0010
</_01_Hierarchical_Structure_Code>
<_02_Transaction_Set_Purpose_Code>13
</_02_Transaction_Set_Purpose_Code>
<_03_Reference_Identification>ABC276XXX
</_03_Reference_Identification>
<_04_Date>20050915</_04_Date>
<_05_Time>1425</_05_Time>
                </BHT>
                <_2000A>
                    <HL>
<_01_Hierarchical_ID_Number>1</_01_Hierarchical_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>ABC INSURANCE
</_03_Name_Last_or_Organization_Name>
<_08_Identification_Code_Qualifier>PI
</_08_Identification_Code_Qualifier>   
<_09_Identification_Code>12345</_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>41</_01_Entity_Identifier_Code>
<_02_Entity_Type_Qualifier>2</_02_Entity_Type_Qualifier>
<_03_Name_Last_or_Organization_Name>XYZ SERVICE
</_03_Name_Last_or_Organization_Name>
<_08_Identification_Code_Qualifier>46</_08_Identification_Code_Qualifier>
<_09_Identification_Code>X67E</_09_Identification_Code>
                          </NM1>
                        </_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>19</_03_Hierarchical_Level_Code>
<_04_Hierarchical_Child_Code>1</_04_Hierarchical_Child_Code>
                            </HL>
                            <_2100C>
                                <NM1>
<_01_Entity_Identifier_Code>1P</_01_Entity_Identifier_Code>
<_02_Entity_Type_Qualifier>2</_02_Entity_Type_Qualifier>
<_03_Name_Last_or_Organization_Name>HOME HOSPITAL
</_03_Name_Last_or_Organization_Name>
<_08_Identification_Code_Qualifier>XX</_08_Identification_Code_Qualifier>
<_09_Identification_Code>1666666668</_09_Identification_Code>
                                </NM1>
                            </_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>22</_03_Hierarchical_Level_Code>
<_04_Hierarchical_Child_Code>0</_04_Hierarchical_Child_Code>
                                </HL>
                                <DMG>                                <_01_Date_Time_Period_Format_Qualifier>D8
</_01_Date_Time_Period_Format_Qualifier>
<_02_Date_Time_Period>19301210</_02_Date_Time_Period>
<_03_Gender_Code>M</_03_Gender_Code>
                                </DMG>
                                <_2100D>
                                    <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>FRED</_04_Name_First>
<_08_Identification_Code_Qualifier>MI
</_08_Identification_Code_Qualifier>
<_09_Identification_Code>123456789A</_09_Identification_Code>
                                    </NM1>
                                </_2100D>
                                <_2200D>
                                    <TRN>
<_01_Trace_Type_Code>1</_01_Trace_Type_Code>
<_02_Reference_Identification>ABCXYZ1</_02_Reference_Identification>
                                    </TRN>
                                    <REF>
<_01_Reference_Identification_Qualifier>BLT</_01_Reference_Identification_Qualifier>                          <_02_Reference_Identification>111</_02_Reference_Identification>
                                    </REF>
                                    <REF>
<_01_Reference_Identification_Qualifier>EJ</_01_Reference_Identification_Qualifier>
<_02_Reference_Identification>SM123456</_02_Reference_Identification>
                                    </REF>
                                    <AMT>
<_01_Amount_Qualifier_Code>T3</_01_Amount_Qualifier_Code>
<_02_Monetary_Amount>8513.88</_02_Monetary_Amount>
                                    </AMT>
                                    <DTP>
<_01_Date_Time_Qualifier>472</_01_Date_Time_Qualifier>
<_02_Date_Time_Period_Format_Qualifier>RD8
</_02_Date_Time_Period_Format_Qualifier>
<_03_Date_Time_Period>20050831-20050906</_03_Date_Time_Period>
                                    </DTP>
                                </_2200D>
                            </_2000D>
                            <_2000D>
                                <HL>
<_01_Hierarchical_ID_Number>5</_01_Hierarchical_ID_Number>
<_02_Hierarchical_Parent_ID_Number>3</_02_Hierarchical_Parent_ID_Number>
<_03_Hierarchical_Level_Code>22</_03_Hierarchical_Level_Code>
<_04_Hierarchical_Child_Code>0</_04_Hierarchical_Child_Code>
                                </HL>
                                <DMG>
<_01_Date_Time_Period_Format_Qualifier>D8
</_01_Date_Time_Period_Format_Qualifier>
<_02_Date_Time_Period>19301115</_02_Date_Time_Period>
<_03_Gender_Code>F</_03_Gender_Code>
                                </DMG>
                                <_2100D>
                                    <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>JONES
</_03_Name_Last_or_Organization_Name>
<_04_Name_First>MARY</_04_Name_First>
<_08_Identification_Code_Qualifier>MI</_08_Identification_Code_Qualifier>
<_09_Identification_Code>234567890A</_09_Identification_Code>
                                    </NM1>
                                </_2100D>
                                <_2200D>
                                    <TRN>
<_01_Trace_Type_Code>1</_01_Trace_Type_Code>
<_02_Reference_Identification>ABCXYZ2</_02_Reference_Identification>
                                    </TRN>
                                    <REF>
  <_01_Reference_Identification_Qualifier>BLT
</_01_Reference_Identification_Qualifier>                        <_02_Reference_Identification>111</_02_Reference_Identification>
                                    </REF>
                                    <REF>
<_01_Reference_Identification_Qualifier>EJ
</_01_Reference_Identification_Qualifier>
<_02_Reference_Identification>JO234567</_02_Reference_Identification>
                                    </REF>
                                    <AMT>                                        <_01_Amount_Qualifier_Code>T3</_01_Amount_Qualifier_Code>
<_02_Monetary_Amount>7599</_02_Monetary_Amount>
                                    </AMT>
                                    <DTP>
<_01_Date_Time_Qualifier>472</_01_Date_Time_Qualifier>
<_02_Date_Time_Period_Format_Qualifier>RD8
</_02_Date_Time_Period_Format_Qualifier>
<_03_Date_Time_Period>20050731-20050809</_03_Date_Time_Period>
                                    </DTP>
                                </_2200D>
                            </_2000D>
                        </_2000C>
                        <_2000C>
                            <HL>
<_01_Hierarchical_ID_Number>6</_01_Hierarchical_ID_Number>
_02_Hierarchical_Parent_ID_Number>2</_02_Hierarchical_Parent_ID_Number>
<_03_Hierarchical_Level_Code>19</_03_Hierarchical_Level_Code>
<_04_Hierarchical_Child_Code>1</_04_Hierarchical_Child_Code>
                            </HL>
                            <_2100C>
                                <NM1>
<_01_Entity_Identifier_Code>1P</_01_Entity_Identifier_Code>
<_02_Entity_Type_Qualifier>2</_02_Entity_Type_Qualifier>
<_03_Name_Last_or_Organization_Name>HOME HOSPITAL PHYSICIANS</_03_Name_Last_or_Organization_Name>
<_08_Identification_Code_Qualifier>XX</_08_Identification_Code_Qualifier>
<_09_Identification_Code>1666666668</_09_Identification_Code>
                                </NM1>
                            </_2100C>
                            <_2000D>
                                <HL>
<_01_Hierarchical_ID_Number>7</_01_Hierarchical_ID_Number>
<_02_Hierarchical_Parent_ID_Number>6</_02_Hierarchical_Parent_ID_Number>
<_03_Hierarchical_Level_Code>22</_03_Hierarchical_Level_Code>
<_04_Hierarchical_Child_Code>1</_04_Hierarchical_Child_Code>
                                </HL>
                                <_2100D>
                                    <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>MANN
</_03_Name_Last_or_Organization_Name>
<_04_Name_First>JOHN</_04_Name_First>
<_08_Identification_Code_Qualifier>MI</_08_Identification_Code_Qualifier>
<_09_Identification_Code>345678901</_09_Identification_Code>
                                    </NM1>
                                </_2100D>
                                <_2000E>
                                    <HL>                                        <_01_Hierarchical_ID_Number>8</_01_Hierarchical_ID_Number>
<_02_Hierarchical_Parent_ID_Number>7</_02_Hierarchical_Parent_ID_Number>
<_03_Hierarchical_Level_Code>23</_03_Hierarchical_Level_Code>
                                    </HL>
                                    <DMG>
<_01_Date_Time_Period_Format_Qualifier>D8
</_01_Date_Time_Period_Format_Qualifier>                                        <_02_Date_Time_Period>19951101</_02_Date_Time_Period>
<_03_Gender_Code>M</_03_Gender_Code>
                                    </DMG>
                                    <_2100E>
                                        <NM1>
<_01_Entity_Identifier_Code>QC</_01_Entity_Identifier_Code>
<_02_Entity_Type_Qualifier>1</_02_Entity_Type_Qualifier>
<_03_Name_Last_or_Organization_Name>MANN</_03_Name_Last_or_Organization_Name>
<_04_Name_First>JOSEPH</_04_Name_First>
                                        </NM1>
                                    </_2100E>
                                    <_2200E>
                                        <TRN>                                         <_01_Trace_Type_Code>1</_01_Trace_Type_Code>
<_02_Reference_Identification>ABCXYZ3</_02_Reference_Identification>
                                        </TRN>
                                        <REF>
<_01_Reference_Identification_Qualifier>EJ
</_01_Reference_Identification_Qualifier>
<_02_Reference_Identification>MA345678</_02_Reference_Identification>
                                        </REF>
                                        <_2210E>
                                            <SVC>
                                                <C003>
                                                    <_01_Product_Service_ID_Qualifier>HC</_01_Product_Service_ID_Qualifier>
<_02_Product_Service_ID>99203</_02_Product_Service_ID>
                                                </C003>
                                              <_02_Monetary_Amount>150</_02_Monetary_Amount>
<_07_Quantity>1</_07_Quantity>
                                            </SVC>
                                            <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>20050501</_03_Date_Time_Period>
                                            </DTP>
                                        </_2210E>
                                    </_2200E>
                                </_2000E>
                            </_2000D>
                        </_2000C>
                    </_2000B>
                </_2000A>
                <SE>
<_01_Number_of_Included_Segments>36</_01_Number_of_Included_Segments>
<_02_Transaction_Set_Control_Number>0001
</_02_Transaction_Set_Control_Number>
                </SE>
            </_276>
            <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>
        </HIPAA_276_005010X212>
    </output>
</documents>

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