To supply provider-level control information
| Position | Element | Name | Type | Min/Max | Repeat | |
|---|---|---|---|---|---|---|
| 1 | 127 | Reference Identification | Mandatory | Alphanumeric | 1/50 | 1 |
| 2 | 1331 | Facility Code Value | Mandatory | Alphanumeric | 1/2 | 1 |
| 3 | 373 | Date | Mandatory | Date | 8/8 | 1 |
| 4 | 380 | Quantity | Mandatory | Decimal | 1/15 | 1 |
| 5 | 782 | Monetary Amount | Mandatory | Decimal | 1/18 | 1 |
| 6 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 7 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 8 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 9 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 10 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 11 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 12 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 13 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 14 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 15 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 16 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 17 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 18 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 19 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 20 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 21 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 22 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |
| 23 | 380 | Quantity | Opt | Decimal | 1/15 | 1 |
| 24 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 |