Anthem
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Benefit Enrollment and Maintenance (X220A1)
  • Specification
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X12 834 Benefit Enrollment and Maintenance (X220A1)

X12 Release 5010
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
ST
0100
Transaction Set Header
Max use 1
Required
BGN
0200
Beginning Segment
Max use 1
Required
REF
0300
Transaction Set Policy Number
Max use 1
Optional
DTP
0400
File Effective Date
Max use 1
Optional
QTY
0600
Transaction Set Control Totals
Max use 3
Optional
Sponsor Name Loop
N1
0700
Sponsor Name
Max use 1
Required
Payer Loop
N1
0700
Payer
Max use 1
Required
TPA/Broker Name Loop
N1
0700
TPA/Broker Name
Max use 1
Required
TPA/Broker Account Information Loop
ACT
1200
TPA/Broker Account Information
Max use 1
Required
detail
Member Level Detail Loop
INS
0100
Member Level Detail
Max use 1
Required
REF
0200
Member Policy Number
Max use 1
Optional
REF
0200
Member Supplemental Identifier
Max use 13
Optional
REF
0200
Subscriber Identifier
Max use 1
Required
DTP
0250
Member Level Dates
Max use 24
Optional
Member Name Loop
NM1
0300
Member Name
Max use 1
Required
PER
0400
Member Communications Numbers
Max use 1
Optional
N3
0500
Member Residence Street Address
Max use 1
Required
N4
0600
Member City, State, ZIP Code
Max use 1
Optional
DMG
0800
Member Demographics
Max use 1
Required
EC
1000
Employment Class
Max use 1
Optional
ICM
1100
Member Income
Max use 1
Optional
AMT
1200
Member Policy Amounts
Max use 7
Optional
HLH
1300
Member Health Information
Max use 1
Optional
LUI
1500
Member Language
Max use 1
Optional
Incorrect Member Name Loop
NM1
0300
Incorrect Member Name
Max use 1
Required
DMG
0800
Incorrect Member Demographics
Max use 1
Optional
Member Mailing Address Loop
NM1
0300
Member Mailing Address
Max use 1
Required
N3
0500
Member Mail Street Address
Max use 1
Required
N4
0600
Member Mail City, State, ZIP Code
Max use 1
Required
Member Employer Loop
NM1
0300
Member Employer
Max use 1
Required
PER
0400
Member Employer Communications Numbers
Max use 1
Optional
N3
0500
Member Employer Street Address
Max use 1
Optional
N4
0600
Member Employer City, State, ZIP Code
Max use 1
Optional
Member School Loop
NM1
0300
Member School
Max use 1
Required
PER
0400
Member School Commmunications Numbers
Max use 1
Optional
N3
0500
Member School Street Address
Max use 1
Optional
N4
0600
Member School City, State, ZIP Code
Max use 1
Optional
Custodial Parent Loop
NM1
0300
Custodial Parent
Max use 1
Required
PER
0400
Custodial Parent Communications Numbers
Max use 1
Optional
N3
0500
Custodial Parent Street Address
Max use 1
Optional
N4
0600
Custodial Parent City, State, ZIP Code
Max use 1
Optional
Responsible Person Loop
NM1
0300
Responsible Person
Max use 1
Required
PER
0400
Responsible Person Communications Numbers
Max use 1
Optional
N3
0500
Responsible Person Street Address
Max use 1
Optional
N4
0600
Responsible Person City, State, ZIP Code
Max use 1
Optional
Drop Off Location Loop
NM1
0300
Drop Off Location
Max use 1
Required
N3
0500
Drop Off Location Street Address
Max use 1
Optional
N4
0600
Drop Off Location City, State, ZIP Code
Max use 1
Optional
Disability Information Loop
DSB
2000
Disability Information
Max use 1
Required
DTP
2100
Disability Eligibility Dates
Max use 2
Optional
Health Coverage Loop
HD
2600
Health Coverage
Max use 1
Required
DTP
2700
Health Coverage Dates
Max use 6
Required
AMT
2800
Health Coverage Policy
Max use 9
Optional
REF
2900
Health Coverage Policy Number
Max use 14
Optional
REF
2900
Prior Coverage Months
Max use 1
Optional
IDC
3000
Identification Card
Max use 3
Optional
Provider Information Loop
LX
3100
Provider Information
Max use 1
Required
NM1
3200
Provider Name
Max use 1
Required
N3
3500
Provider Address
Max use 2
Optional
N4
3600
Provider City, State, ZIP Code
Max use 1
Optional
PER
3700
Provider Communications Numbers
Max use 2
Optional
PLA
3950
Provider Change Reason
Max use 1
Optional
Coordination of Benefits Loop
COB
4000
Coordination of Benefits
Max use 1
Required
REF
4050
Additional Coordination of Benefits Identifiers
Max use 4
Optional
DTP
4070
Coordination of Benefits Eligibility Dates
Max use 2
Optional
LS
4100
Loop Header
Max use 1
Required
Coordination of Benefits Related Entity Loop
NM1
4100
Coordination of Benefits Related Entity
Max use 1
Required
N3
4300
Coordination of Benefits Related Entity Address
Max use 1
Optional
N4
4400
Coordination of Benefits Other Insurance Company City, State, ZIP Code
Max use 1
Optional
PER
4500
Administrative Communications Contact
Max use 1
Optional
LE
4100
Loop Trailer
Max use 1
Required
Member Reporting Categories Loop
LX
6881
Member Reporting Categories
Max use 1
Required
Reporting Category Loop
N1
6882
Reporting Category
Max use 1
Required
REF
6883
Reporting Category Reference
Max use 1
Optional
DTP
6884
Reporting Category Date
Max use 1
Optional
SE
6900
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1
—
Example
ISA-01
I01
Authorization Information Qualifier
Required
Identifier (ID)
—
00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10
—
ISA-03
I03
Security Information Qualifier
Required
Identifier (ID)
—
00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10
—
ISA-05
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2
—
Codes
ISA-06
I06
Interchange Sender ID
Required
String (AN)
Min 15Max 15
—
ISA-07
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2
—
Codes
ISA-08
I07
Interchange Receiver ID
Required
String (AN)
Min 15Max 15
—
ISA-09
I08
Interchange Date
Required
Date (DT)
YYMMDD format
—
ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format
—
ISA-11
I65
Repetition Separator
Required
String (AN)
Min 1Max 1
—
^
Repetition Separator
ISA-12
I11
Interchange Control Version Number
Required
Identifier (ID)
—
00501
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA-13
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9
—
ISA-14
I13
Acknowledgment Requested
Required
Identifier (ID)
Min 1Max 1
—
0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1
—
I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1
—
>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1
—
Example
GS-01
479
Functional Identifier Code
Required
Identifier (ID)
—
BE
Benefit Enrollment and Maintenance (834)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15
—
GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15
—
GS-04
373
Date
Required
Date (DT)
CCYYMMDD format
—
GS-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
GS-06
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9
—
GS-07
455
Responsible Agency Code
Required
Identifier (ID)
Min 1Max 2
—
T
Transportation Data Coordinating Committee (TDCC)
X
Accredited Standards Committee X12
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)
—
005010X220A1

Heading

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1
—
Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)
—
834
Benefit Enrollment and Maintenance
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9
—
Usage notes
—
ST-03
1705
Implementation Convention Reference
Required
String (AN)
—
Usage notes
—
005010X220A1
BGN
0200
Heading > BGN

Beginning Segment

RequiredMax use 1
—
Example
BGN-01
353
Transaction Set Purpose Code
Required
Identifier (ID)
—
00
Original
—
15
Re-Submission
—
22
Information Copy
—
BGN-02
127
Transaction Set Reference Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
BGN-03
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format
—
Usage notes
—
BGN-04
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format
—
Usage notes
—
BGN-05
623
Time Zone Code
Optional
Identifier (ID)
—
01
Equivalent to ISO P01
02
Equivalent to ISO P02
03
Equivalent to ISO P03
04
Equivalent to ISO P04
05
Equivalent to ISO P05
06
Equivalent to ISO P06
07
Equivalent to ISO P07
08
Equivalent to ISO P08
09
Equivalent to ISO P09
10
Equivalent to ISO P10
11
Equivalent to ISO P11
12
Equivalent to ISO P12
13
Equivalent to ISO M12
14
Equivalent to ISO M11
15
Equivalent to ISO M10
16
Equivalent to ISO M09
17
Equivalent to ISO M08
18
Equivalent to ISO M07
19
Equivalent to ISO M06
20
Equivalent to ISO M05
21
Equivalent to ISO M04
22
Equivalent to ISO M03
23
Equivalent to ISO M02
24
Equivalent to ISO M01
AD
Alaska Daylight Time
AS
Alaska Standard Time
AT
Alaska Time
CD
Central Daylight Time
CS
Central Standard Time
CT
Central Time
ED
Eastern Daylight Time
ES
Eastern Standard Time
ET
Eastern Time
GM
Greenwich Mean Time
HD
Hawaii-Aleutian Daylight Time
HS
Hawaii-Aleutian Standard Time
HT
Hawaii-Aleutian Time
LT
Local Time
MD
Mountain Daylight Time
MS
Mountain Standard Time
MT
Mountain Time
ND
Newfoundland Daylight Time
NS
Newfoundland Standard Time
NT
Newfoundland Time
PD
Pacific Daylight Time
PS
Pacific Standard Time
PT
Pacific Time
TD
Atlantic Daylight Time
TS
Atlantic Standard Time
TT
Atlantic Time
UT
Universal Time Coordinate
BGN-06
127
Original Transaction Set Reference Number
Optional
String (AN)
Min 1Max 50
—
BGN-08
306
Action Code
Required
Identifier (ID)
—
2
Change (Update)
—
4
Verify
—
RX
Replace
—
REF
0300
Heading > REF

Transaction Set Policy Number

OptionalMax use 1
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
38
Master Policy Number
REF-02
127
Master Policy Number
Required
String (AN)
Min 1Max 50
—
DTP
0400
Heading > DTP

File Effective Date

OptionalMax use >1
—
Usage notes
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
007
Effective
090
Report Start
091
Report End
303
Maintenance Effective
382
Enrollment
388
Payment Commencement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Date Time Period
Required
String (AN)
Min 1Max 35
—
QTY
0600
Heading > QTY

Transaction Set Control Totals

OptionalMax use 3
—
Usage notes
—
Example
QTY-01
673
Quantity Qualifier
Required
Identifier (ID)
—
DT
Dependent Total
ET
Employee Total
TO
Total
QTY-02
380
Record Totals
Required
Decimal number (R)
Min 1Max 15
—
1000A Sponsor Name Loop
RequiredMax 1
Variants (all may be used)
Payer LoopTPA/Broker Name Loop
N1
0700
Heading > Sponsor Name Loop > N1

Sponsor Name

RequiredMax use 1
—
Usage notes
—
Example
N1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
P5
Plan Sponsor
N1-02
93
Plan Sponsor Name
Optional
String (AN)
Min 1Max 60
—
N1-03
66
Identification Code Qualifier
Required
Identifier (ID)
—
24
Employer's Identification Number
—
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
N1-04
67
Sponsor Identifier
Required
String (AN)
Min 2Max 80
—
1000A Sponsor Name Loop end
1000B Payer Loop
RequiredMax 1
Variants (all may be used)
Sponsor Name LoopTPA/Broker Name Loop
N1
0700
Heading > Payer Loop > N1

Payer

RequiredMax use 1
—
Usage notes
—
Example
N1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
IN
Insurer
N1-02
93
Insurer Name
Required
String (AN)
—
ANTHEM BLUE CROSS
N1-03
66
Identification Code Qualifier
Required
Identifier (ID)
—
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
XV
Centers for Medicare and Medicaid Services PlanID
—
N1-04
67
Insurer Identification Code
Required
String (AN)
—
953760001
1000B Payer Loop end
1000C TPA/Broker Name Loop
OptionalMax 2
Variants (all may be used)
Sponsor Name LoopPayer Loop
N1
0700
Heading > TPA/Broker Name Loop > N1

TPA/Broker Name

RequiredMax use 1
—
Usage notes
—
Example
N1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
BO
Broker or Sales Office
TV
Third Party Administrator (TPA)
N1-02
93
TPA or Broker Name
Required
String (AN)
Min 1Max 60
—
N1-03
66
Identification Code Qualifier
Required
Identifier (ID)
—
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
XV
Centers for Medicare and Medicaid Services PlanID
—
N1-04
67
TPA or Broker Identification Code
Required
String (AN)
Min 2Max 80
—
1100C TPA/Broker Account Information Loop
OptionalMax 1
ACT
1200
Heading > TPA/Broker Name Loop > TPA/Broker Account Information Loop > ACT

TPA/Broker Account Information

RequiredMax use 1
—
Usage notes
—
Example
ACT-01
508
TPA or Broker Account Number
Required
String (AN)
Min 1Max 35
—
ACT-06
508
TPA or Broker Account Number
Optional
String (AN)
Min 1Max 35
—
1100C TPA/Broker Account Information Loop end
1000C TPA/Broker Name Loop end
Heading end

Detail

2000 Member Level Detail Loop
RequiredMax >1
INS
0100
Detail > Member Level Detail Loop > INS

Member Level Detail

RequiredMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (INS-11) or Member Individual Death Date (INS-12) is present, then the other is required
INS-01
1073
Member Indicator
Required
Identifier (ID)
—
N
No
Y
Yes
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)
—
Usage notes
—
01
Spouse
03
Father or Mother
04
Grandfather or Grandmother
05
Grandson or Granddaughter
06
Uncle or Aunt
07
Nephew or Niece
08
Cousin
09
Adopted Child
10
Foster Child
11
Son-in-law or Daughter-in-law
12
Brother-in-law or Sister-in-law
13
Mother-in-law or Father-in-law
14
Brother or Sister
15
Ward
16
Stepparent
17
Stepson or Stepdaughter
18
Self
19
Child
23
Sponsored Dependent
—
24
Dependent of a Minor Dependent
25
Ex-spouse
26
Guardian
31
Court Appointed Guardian
38
Collateral Dependent
—
53
Life Partner
—
60
Annuitant
D2
Trustee
G8
Other Relationship
G9
Other Relative
INS-03
875
Maintenance Type Code
Required
Identifier (ID)
—
001
Change
—
021
Addition
—
024
Cancellation or Termination
—
025
Reinstatement
—
030
Audit or Compare
—
INS-04
1203
Maintenance Reason Code
Optional
Identifier (ID)
—
01
Divorce
02
Birth
03
Death
04
Retirement
05
Adoption
06
Strike
07
Termination of Benefits
08
Termination of Employment
09
Consolidation Omnibus Budget Reconciliation Act (COBRA)
10
Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
11
Surviving Spouse
14
Voluntary Withdrawal
15
Primary Care Provider (PCP) Change
16
Quit
17
Fired
18
Suspended
20
Active
21
Disability
22
Plan Change
—
25
Change in Identifying Data Elements
—
26
Declined Coverage
—
27
Pre-Enrollment
—
28
Initial Enrollment
—
29
Benefit Selection
—
31
Legal Separation
32
Marriage
33
Personnel Data
—
37
Leave of Absence with Benefits
38
Leave of Absence without Benefits
39
Lay Off with Benefits
40
Lay Off without Benefits
41
Re-enrollment
43
Change of Location
—
59
Non Payment
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
AJ
Appointment Times not Met in a Timely Manner
AL
Algorithm Assigned Benefit Selection
EC
Member Benefit Selection
—
XN
Notification Only
—
XT
Transfer
—
INS-05
1216
Benefit Status Code
Required
Identifier (ID)
—
A
Active
C
Consolidated Omnibus Budget Reconciliation Act (COBRA)
S
Surviving Insured
T
Tax Equity and Fiscal Responsibility Act (TEFRA)
INS-06
C052
Medicare Status Code
OptionalMax use 1
To provide Medicare coverage and associated reason for Medicare eligibility
Usage notes
—
C052-01
1218
Medicare Plan Code
Required
Identifier (ID)
—
A
Medicare Part A
B
Medicare Part B
C
Medicare Part A and B
D
Medicare
E
No Medicare
C052-02
1701
Medicare Eligibility Reason Code
Optional
Identifier (ID)
—
0
Age
1
Disability
2
End Stage Renal Disease (ESRD)
INS-07
1219
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code
Optional
Identifier (ID)
—
1
Termination of Employment
2
Reduction of work hours
3
Medicare
4
Death
5
Divorce
6
Separation
7
Ineligible Child
8
Bankruptcy of Retiree's Former Employer (26 U.S.C. 4980B(f)(3)(F))
9
Layoff
10
Leave of Absence
ZZ
Mutually Defined
INS-08
584
Employment Status Code
Optional
Identifier (ID)
—
Usage notes
—
AC
Active
AO
Active Military - Overseas
AU
Active Military - USA
FT
Full-time
—
L1
Leave of Absence
PT
Part-time
—
RT
Retired
TE
Terminated
INS-09
1220
Student Status Code
Optional
Identifier (ID)
—
F
Full-time
N
Not a Student
P
Part-time
INS-10
1073
Handicap Indicator
Optional
Identifier (ID)
—
N
No
Y
Yes
INS-11
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
INS-12
1251
Member Individual Death Date
Optional
String (AN)
Min 1Max 35
—
INS-13
1165
Confidentiality Code
Optional
Identifier (ID)
—
R
Restricted Access
U
Unrestricted Access
INS-17
1470
Birth Sequence Number
Optional
Numeric (N0)
Min 1Max 9
—
REF
0200
Detail > Member Level Detail Loop > REF

Member Policy Number

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFMember Supplemental IdentifierREFSubscriber Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
1L
Group or Policy Number
—
REF-02
127
Member Group or Policy Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
0200
Detail > Member Level Detail Loop > REF

Member Supplemental Identifier

OptionalMax use 13
—
Usage notes
—
Example
Variants (all may be used)
REFMember Policy NumberREFSubscriber Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
3H
Case Number
4A
Personal Identification Number (PIN)
—
6O
Cross Reference Number
—
17
Client Reporting Category
—
23
Client Number
—
ABB
Personal ID Number
D3
National Council for Prescription Drug Programs Pharmacy Number
DX
Department/Agency Number
—
F6
Health Insurance Claim (HIC) Number
—
P5
Position Code
—
Q4
Prior Identifier Number
—
QQ
Unit Number
—
ZZ
Mutually Defined
REF-02
127
Member Supplemental Identifier
Required
String (AN)
Min 1Max 50
—
REF
0200
Detail > Member Level Detail Loop > REF

Subscriber Identifier

RequiredMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFMember Policy NumberREFMember Supplemental Identifier
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
0F
Subscriber Number
—
REF-02
127
Subscriber Identifier
Required
String (AN)
Min 1Max 50
—
Usage notes
—
DTP
0250
Detail > Member Level Detail Loop > DTP

Member Level Dates

OptionalMax use 24
—
Usage notes
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
050
Received
—
286
Retirement
296
Initial Disability Period Return To Work
297
Initial Disability Period Last Day Worked
300
Enrollment Signature Date
301
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event
303
Maintenance Effective
—
336
Employment Begin
337
Employment End
338
Medicare Begin
339
Medicare End
340
Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
341
Consolidated Omnibus Budget Reconciliation Act (COBRA) End
350
Education Begin
—
351
Education End
—
356
Eligibility Begin
—
357
Eligibility End
—
383
Adjusted Hire
385
Credited Service Begin
—
386
Credited Service End
—
393
Plan Participation Suspension
394
Rehire
473
Medicaid Begin
474
Medicaid End
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Status Information Effective Date
Required
String (AN)
Min 1Max 35
—
2100A Member Name Loop
OptionalMax 1
Variants (all may be used)
Incorrect Member Name LoopMember Mailing Address LoopMember Employer LoopMember School LoopCustodial Parent LoopResponsible Person LoopDrop Off Location Loop
NM1
0300
Detail > Member Level Detail Loop > Member Name Loop > NM1

Member Name

RequiredMax use 1
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
Usage notes
—
74
Corrected Insured
—
IL
Insured or Subscriber
—
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Member Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Member First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Member Middle Name
Required
String (AN)
Min 1Max 25
—
Usage notes
—
NM1-06
1038
Member Name Prefix
Optional
String (AN)
Min 1Max 10
—
NM1-07
1039
Member Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)
—
34
Social Security Number
—
ZZ
Mutually Defined
—
NM1-09
67
Member Identifier
Required
String (AN)
Min 2Max 80
—
Usage notes
—
PER
0400
Detail > Member Level Detail Loop > Member Name Loop > PER

Member Communications Numbers

OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
IP
Insured Party
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
Usage notes
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
N3
0500
Detail > Member Level Detail Loop > Member Name Loop > N3

Member Residence Street Address

RequiredMax use 1
—
Usage notes
—
Example
N3-01
166
Member Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Member Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0600
Detail > Member Level Detail Loop > Member Name Loop > N4

Member City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Member State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Location Identifier (N4-06) is present, then Location Qualifier (N4-05) is required
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Member City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Member State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Member Postal Zone or Zip Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-05
309
Location Qualifier
Optional
Identifier (ID)
—
60
Area
CY
County/Parish
N4-06
310
Location Identifier
Optional
String (AN)
Min 1Max 30
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
DMG
0800
Detail > Member Level Detail Loop > Member Name Loop > DMG

Member Demographics

RequiredMax use 1
—
Usage notes
—
Example
If either Code List Qualifier Code (DMG-10) or Race or Ethnicity Collection Code (DMG-11) is present, then the other is required
If Race or Ethnicity Collection Code (DMG-11) is present, then Composite Race or Ethnicity Information (DMG-05) is required
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Member Birth Date
Required
String (AN)
Min 1Max 35
—
DMG-03
1068
Gender Code
Required
Identifier (ID)
—
F
Female
M
Male
DMG-04
1067
Marital Status Code
Optional
Identifier (ID)
—
B
Registered Domestic Partner
D
Divorced
I
Single
M
Married
R
Unreported
S
Separated
U
Unmarried (Single or Divorced or Widowed)
—
W
Widowed
X
Legally Separated
DMG-05
C056
Composite Race or Ethnicity Information
OptionalMax use 10
To send general and detailed information on race or ethnicity
Usage notes
—
If either Code List Qualifier Code (C056-02) or Race or Ethnicity Code (C056-03) is present, then the other is required
C056-01
1109
Race or Ethnicity Code
Optional
Identifier (ID)
—
7
Not Provided
8
Not Applicable
A
Asian or Pacific Islander
B
Black
C
Caucasian
D
Subcontinent Asian American
E
Other Race or Ethnicity
F
Asian Pacific American
G
Native American
H
Hispanic
I
American Indian or Alaskan Native
J
Native Hawaiian
N
Black (Non-Hispanic)
O
White (Non-Hispanic)
P
Pacific Islander
Z
Mutually Defined
C056-02
1270
Code List Qualifier Code
Optional
Identifier (ID)
—
RET
Classification of Race or Ethnicity
C056-03
1271
Race or Ethnicity Code
Optional
String (AN)
Min 1Max 30
—
Usage notes
—
DMG-06
1066
Citizenship Status Code
Optional
Identifier (ID)
—
1
U.S. Citizen
2
Non-Resident Alien
3
Resident Alien
4
Illegal Alien
5
Alien
6
U.S. Citizen - Non-Resident
7
U.S. Citizen - Resident
DMG-10
1270
Code List Qualifier Code
Optional
Identifier (ID)
—
REC
Race or Ethnicity Collection Code
DMG-11
1271
Race or Ethnicity Collection Code
Optional
String (AN)
Min 1Max 30
—
EC
1000
Detail > Member Level Detail Loop > Member Name Loop > EC

Employment Class

OptionalMax use >1
—
Usage notes
—
Example
EC-01
1176
Employment Class Code
Required
Identifier (ID)
—
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
EC-02
1176
Employment Class Code
Optional
Identifier (ID)
—
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
EC-03
1176
Employment Class Code
Optional
Identifier (ID)
—
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
ICM
1100
Detail > Member Level Detail Loop > Member Name Loop > ICM

Member Income

OptionalMax use 1
—
Usage notes
—
Example
ICM-01
594
Frequency Code
Required
Identifier (ID)
—
1
Weekly
2
Biweekly
3
Semimonthly
4
Monthly
6
Daily
7
Annual
8
Two Calendar Months
9
Lump-Sum Separation Allowance
B
Year-to-Date
C
Single
H
Hourly
Q
Quarterly
S
Semiannual
U
Unknown
ICM-02
782
Wage Amount
Required
Decimal number (R)
Min 1Max 15
—
ICM-03
380
Work Hours Count
Optional
Decimal number (R)
Min 1Max 15
—
ICM-04
310
Location Identification Code
Optional
String (AN)
Min 1Max 30
—
ICM-05
1214
Salary Grade Code
Optional
String (AN)
Min 1Max 5
—
AMT
1200
Detail > Member Level Detail Loop > Member Name Loop > AMT

Member Policy Amounts

OptionalMax use 7
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
B9
Co-insurance - Actual
—
C1
Co-Payment Amount
D2
Deductible Amount
EBA
Expected Expenditure Amount
FK
Other Unlisted Amount
P3
Premium Amount
R
Spend Down
AMT-02
782
Contract Amount
Required
Decimal number (R)
Min 1Max 15
—
HLH
1300
Detail > Member Level Detail Loop > Member Name Loop > HLH

Member Health Information

OptionalMax use 1
—
Usage notes
—
Example
HLH-01
1212
Health Related Code
Required
Identifier (ID)
—
N
None
S
Substance Abuse
T
Tobacco Use
U
Unknown
X
Tobacco Use and Substance Abuse
HLH-02
65
Member Height
Optional
Decimal number (R)
Min 1Max 8
—
Usage notes
—
HLH-03
81
Member Weight
Optional
Decimal number (R)
Min 1Max 10
—
LUI
1500
Detail > Member Level Detail Loop > Member Name Loop > LUI

Member Language

OptionalMax use >1
—
Usage notes
—
Example
If either Identification Code Qualifier (LUI-01) or Language Code (LUI-02) is present, then the other is required
If Language Use Indicator (LUI-04) is present, then at least one of Language Code (LUI-02) or Language Description (LUI-03) is required
LUI-01
66
Identification Code Qualifier
Optional
Identifier (ID)
—
LD
NISO Z39.53 Language Codes
LE
ISO 639 Language Codes
LUI-02
67
Language Code
Optional
String (AN)
Min 2Max 80
—
LUI-03
352
Language Description
Optional
String (AN)
Min 1Max 80
—
LUI-04
1303
Language Use Indicator
Optional
Identifier (ID)
—
5
Language Reading
6
Language Writing
7
Language Speaking
8
Native Language
2100A Member Name Loop end
2100B Incorrect Member Name Loop
OptionalMax 1
Variants (all may be used)
Member Name LoopMember Mailing Address LoopMember Employer LoopMember School LoopCustodial Parent LoopResponsible Person LoopDrop Off Location Loop
NM1
0300
Detail > Member Level Detail Loop > Incorrect Member Name Loop > NM1

Incorrect Member Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Prior Incorrect Insured Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
Usage notes
—
70
Prior Incorrect Insured
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Prior Incorrect Member Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Prior Incorrect Member First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Prior Incorrect Member Middle Name
Optional
String (AN)
Min 1Max 25
—
NM1-06
1038
Prior Incorrect Member Name Prefix
Optional
String (AN)
Min 1Max 10
—
NM1-07
1039
Prior Incorrect Member Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
34
Social Security Number
—
ZZ
Mutually Defined
—
NM1-09
67
Prior Incorrect Insured Identifier
Optional
String (AN)
Min 2Max 80
—
Usage notes
—
DMG
0800
Detail > Member Level Detail Loop > Incorrect Member Name Loop > DMG

Incorrect Member Demographics

OptionalMax use 1
—
Usage notes
—
Example
If either Date Time Period Format Qualifier (DMG-01) or Prior Incorrect Insured Birth Date (DMG-02) is present, then the other is required
If either Code List Qualifier Code (DMG-10) or Race or Ethnicity Collection Code (DMG-11) is present, then the other is required
If Race or Ethnicity Collection Code (DMG-11) is present, then Composite Race or Ethnicity Information (DMG-05) is required
DMG-01
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Prior Incorrect Insured Birth Date
Optional
String (AN)
Min 1Max 35
—
DMG-03
1068
Prior Incorrect Insured Gender Code
Optional
Identifier (ID)
—
F
Female
M
Male
U
Unknown
DMG-04
1067
Marital Status Code
Optional
Identifier (ID)
—
B
Registered Domestic Partner
D
Divorced
I
Single
M
Married
R
Unreported
S
Separated
U
Unmarried (Single or Divorced or Widowed)
—
W
Widowed
X
Legally Separated
DMG-05
C056
Composite Race or Ethnicity Information
OptionalMax use 10
To send general and detailed information on race or ethnicity
Usage notes
—
If either Code List Qualifier Code (C056-02) or Race or Ethnicity Code (C056-03) is present, then the other is required
C056-01
1109
Race or Ethnicity Code
Optional
Identifier (ID)
—
7
Not Provided
8
Not Applicable
A
Asian or Pacific Islander
B
Black
C
Caucasian
D
Subcontinent Asian American
E
Other Race or Ethnicity
F
Asian Pacific American
G
Native American
H
Hispanic
I
American Indian or Alaskan Native
J
Native Hawaiian
N
Black (Non-Hispanic)
O
White (Non-Hispanic)
P
Pacific Islander
Z
Mutually Defined
C056-02
1270
Code List Qualifier Code
Optional
Identifier (ID)
—
RET
Classification of Race or Ethnicity
C056-03
1271
Race or Ethnicity Code
Optional
String (AN)
Min 1Max 30
—
DMG-06
1066
Citizenship Status Code
Optional
Identifier (ID)
—
1
U.S. Citizen
2
Non-Resident Alien
3
Resident Alien
4
Illegal Alien
5
Alien
6
U.S. Citizen - Non-Resident
7
U.S. Citizen - Resident
DMG-10
1270
Code List Qualifier Code
Optional
Identifier (ID)
—
REC
Race or Ethnicity Collection Code
DMG-11
1271
Race or Ethnicity Collection Code
Optional
String (AN)
Min 1Max 30
—
2100B Incorrect Member Name Loop end
2100C Member Mailing Address Loop
OptionalMax 1
Variants (all may be used)
Member Name LoopIncorrect Member Name LoopMember Employer LoopMember School LoopCustodial Parent LoopResponsible Person LoopDrop Off Location Loop
NM1
0300
Detail > Member Level Detail Loop > Member Mailing Address Loop > NM1

Member Mailing Address

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
31
Postal Mailing Address
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
N3
0500
Detail > Member Level Detail Loop > Member Mailing Address Loop > N3

Member Mail Street Address

RequiredMax use 1
—
Example
N3-01
166
Member Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Member Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0600
Detail > Member Level Detail Loop > Member Mailing Address Loop > N4

Member Mail City, State, ZIP Code

RequiredMax use 1
—
Example
Only one of Member Mail State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Member Mail City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Member Mail State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Member Mail Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
2100C Member Mailing Address Loop end
2100D Member Employer Loop
OptionalMax 3
Variants (all may be used)
Member Name LoopIncorrect Member Name LoopMember Mailing Address LoopMember School LoopCustodial Parent LoopResponsible Person LoopDrop Off Location Loop
NM1
0300
Detail > Member Level Detail Loop > Member Employer Loop > NM1

Member Employer

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Member Employer Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
36
Employer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Member Employer Name
Optional
String (AN)
Min 1Max 60
—
NM1-04
1036
Member Employer First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Member Employer Middle Name
Optional
String (AN)
Min 1Max 25
—
NM1-06
1038
Member Employer Name Prefix
Optional
String (AN)
Min 1Max 10
—
NM1-07
1039
Member Employer Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
24
Employer's Identification Number
—
34
Social Security Number
NM1-09
67
Member Employer Identifier
Optional
String (AN)
Min 2Max 80
—
PER
0400
Detail > Member Level Detail Loop > Member Employer Loop > PER

Member Employer Communications Numbers

OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
EP
Employer Contact
PER-02
93
Member Employer Communications Contact Name
Optional
String (AN)
Min 1Max 60
—
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
N3
0500
Detail > Member Level Detail Loop > Member Employer Loop > N3

Member Employer Street Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Member Employer Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Member Employer Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0600
Detail > Member Level Detail Loop > Member Employer Loop > N4

Member Employer City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Member Employer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Member Employer City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Member Employer State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Member Employer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
2100D Member Employer Loop end
2100E Member School Loop
OptionalMax 3
Variants (all may be used)
Member Name LoopIncorrect Member Name LoopMember Mailing Address LoopMember Employer LoopCustodial Parent LoopResponsible Person LoopDrop Off Location Loop
NM1
0300
Detail > Member Level Detail Loop > Member School Loop > NM1

Member School

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
M8
Educational Institution
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
School Name
Required
String (AN)
Min 1Max 60
—
PER
0400
Detail > Member Level Detail Loop > Member School Loop > PER

Member School Commmunications Numbers

OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
SK
School Clerk
PER-02
93
Member School Communications Contact Name
Optional
String (AN)
Min 1Max 60
—
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
N3
0500
Detail > Member Level Detail Loop > Member School Loop > N3

Member School Street Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
School Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
School Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0600
Detail > Member Level Detail Loop > Member School Loop > N4

Member School City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Member School State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Member School City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Member School State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Member School Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
2100E Member School Loop end
2100F Custodial Parent Loop
OptionalMax 1
Variants (all may be used)
Member Name LoopIncorrect Member Name LoopMember Mailing Address LoopMember Employer LoopMember School LoopResponsible Person LoopDrop Off Location Loop
NM1
0300
Detail > Member Level Detail Loop > Custodial Parent Loop > NM1

Custodial Parent

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Custodial Parent Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
S3
Custodial Parent
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Custodial Parent Last Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Custodial Parent First Name
Required
String (AN)
Min 1Max 35
—
NM1-05
1037
Custodial Parent Middle Name
Optional
String (AN)
Min 1Max 25
—
NM1-06
1038
Custodial Parent Name Prefix
Optional
String (AN)
Min 1Max 10
—
NM1-07
1039
Custodial Parent Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
34
Social Security Number
—
ZZ
Mutually Defined
—
NM1-09
67
Custodial Parent Identifier
Optional
String (AN)
Min 2Max 80
—
PER
0400
Detail > Member Level Detail Loop > Custodial Parent Loop > PER

Custodial Parent Communications Numbers

OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
PQ
Parent or Guardian
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
N3
0500
Detail > Member Level Detail Loop > Custodial Parent Loop > N3

Custodial Parent Street Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Custodial Parent Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Custodial Parent Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0600
Detail > Member Level Detail Loop > Custodial Parent Loop > N4

Custodial Parent City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Custodial Parent State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Custodial Parent City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Custodial Parent State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Custodial Parent Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
2100F Custodial Parent Loop end
2100G Responsible Person Loop
OptionalMax 13
Variants (all may be used)
Member Name LoopIncorrect Member Name LoopMember Mailing Address LoopMember Employer LoopMember School LoopCustodial Parent LoopDrop Off Location Loop
NM1
0300
Detail > Member Level Detail Loop > Responsible Person Loop > NM1

Responsible Person

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Responsible Party Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
6Y
Case Manager
9K
Key Person
E1
Person or Other Entity Legally Responsible for a Child
—
EI
Executor of Estate
—
EXS
Ex-spouse
—
GB
Other Insured
GD
Guardian
J6
Power of Attorney
LR
Legal Representative
QD
Responsible Party
S1
Parent
TZ
Significant Other
X4
Spouse
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Responsible Party Last or Organization Name
Required
String (AN)
Min 1Max 60
—
NM1-04
1036
Responsible Party First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Responsible Party Middle Name
Optional
String (AN)
Min 1Max 25
—
NM1-06
1038
Responsible Party Name Prefix
Optional
String (AN)
Min 1Max 10
—
NM1-07
1039
Responsible Party Suffix Name
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
34
Social Security Number
—
ZZ
Mutually Defined
—
NM1-09
67
Responsible Party Identifier
Optional
String (AN)
Min 2Max 80
—
PER
0400
Detail > Member Level Detail Loop > Responsible Person Loop > PER

Responsible Person Communications Numbers

OptionalMax use 1
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
RP
Responsible Person
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
N3
0500
Detail > Member Level Detail Loop > Responsible Person Loop > N3

Responsible Person Street Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Responsible Party Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Responsible Party Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0600
Detail > Member Level Detail Loop > Responsible Person Loop > N4

Responsible Person City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Responsible Person State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Responsible Person City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Responsible Person State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Responsible Person Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
2100G Responsible Person Loop end
2100H Drop Off Location Loop
OptionalMax 1
Variants (all may be used)
Member Name LoopIncorrect Member Name LoopMember Mailing Address LoopMember Employer LoopMember School LoopCustodial Parent LoopResponsible Person Loop
NM1
0300
Detail > Member Level Detail Loop > Drop Off Location Loop > NM1

Drop Off Location

RequiredMax use 1
—
Usage notes
—
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
45
Drop-off Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
NM1-03
1035
Name Last or Organization Name
Optional
String (AN)
Min 1Max 60
—
NM1-04
1036
Name First
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Name Middle
Optional
String (AN)
Min 1Max 25
—
NM1-06
1038
Name Prefix
Optional
String (AN)
Min 1Max 10
—
NM1-07
1039
Name Suffix
Optional
String (AN)
Min 1Max 10
—
N3
0500
Detail > Member Level Detail Loop > Drop Off Location Loop > N3

Drop Off Location Street Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Drop Off Location Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Drop Off Location Address Line
Optional
String (AN)
Min 1Max 55
—
N4
0600
Detail > Member Level Detail Loop > Drop Off Location Loop > N4

Drop Off Location City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Drop Off Location State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Drop Off Location City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Drop Off Location State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Drop Off Location Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
2100H Drop Off Location Loop end
2200 Disability Information Loop
OptionalMax >1
DSB
2000
Detail > Member Level Detail Loop > Disability Information Loop > DSB

Disability Information

RequiredMax use 1
—
Usage notes
—
Example
If either Product or Service ID Qualifier (DSB-07) or Diagnosis Code (DSB-08) is present, then the other is required
DSB-01
1146
Disability Type Code
Required
Identifier (ID)
—
1
Short Term Disability
2
Long Term Disability
3
Permanent or Total Disability
4
No Disability
DSB-07
235
Product or Service ID Qualifier
Optional
Identifier (ID)
—
DX
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis
ZZ
Mutually Defined
—
DSB-08
1137
Diagnosis Code
Optional
String (AN)
Min 1Max 15
—
DTP
2100
Detail > Member Level Detail Loop > Disability Information Loop > DTP

Disability Eligibility Dates

OptionalMax use 2
—
Usage notes
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
360
Initial Disability Period Start
361
Initial Disability Period End
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Disability Eligibility Date
Required
String (AN)
Min 1Max 35
—
2200 Disability Information Loop end
2300 Health Coverage Loop
OptionalMax 99
HD
2600
Detail > Member Level Detail Loop > Health Coverage Loop > HD

Health Coverage

RequiredMax use 1
—
Usage notes
—
Example
HD-01
875
Maintenance Type Code
Required
Identifier (ID)
—
Usage notes
—
001
Change
002
Delete
—
021
Addition
024
Cancellation or Termination
—
025
Reinstatement
026
Correction
—
030
Audit or Compare
032
Employee Information Not Applicable
—
HD-03
1205
Insurance Line Code
Required
Identifier (ID)
—
AG
Preventative Care/Wellness
AH
24 Hour Care
AJ
Medicare Risk
AK
Mental Health
DCP
Dental Capitation
—
DEN
Dental
EPO
Exclusive Provider Organization
FAC
Facility
HE
Hearing
HLT
Health
—
HMO
Health Maintenance Organization
LTC
Long-Term Care
LTD
Long-Term Disability
MM
Major Medical
MOD
Mail Order Drug
PDG
Prescription Drug
POS
Point of Service
PPO
Preferred Provider Organization
PRA
Practitioners
STD
Short-Term Disability
UR
Utilization Review
VIS
Vision
HD-04
1204
Plan Coverage Description
Optional
String (AN)
Min 1Max 50
—
HD-05
1207
Coverage Level Code
Optional
Identifier (ID)
—
Usage notes
—
CHD
Children Only
DEP
Dependents Only
E1D
Employee and One Dependent
—
E2D
Employee and Two Dependents
E3D
Employee and Three Dependents
E5D
Employee and One or More Dependents
E6D
Employee and Two or More Dependents
E7D
Employee and Three or More Dependents
E8D
Employee and Four or More Dependents
E9D
Employee and Five or More Dependents
ECH
Employee and Children
EMP
Employee Only
ESP
Employee and Spouse
FAM
Family
IND
Individual
SPC
Spouse and Children
SPO
Spouse Only
TWO
Two Party
HD-09
1073
Late Enrollment Indicator
Optional
Identifier (ID)
—
N
No
Y
Yes
DTP
2700
Detail > Member Level Detail Loop > Health Coverage Loop > DTP

Health Coverage Dates

RequiredMax use 6
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
Usage notes
—
300
Enrollment Signature Date
303
Maintenance Effective
—
343
Premium Paid to Date End
348
Benefit Begin
—
349
Benefit End
—
543
Last Premium Paid Date
695
Previous Period
—
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
—
DTP-03
1251
Coverage Period
Required
String (AN)
Min 1Max 35
—
Usage notes
—
AMT
2800
Detail > Member Level Detail Loop > Health Coverage Loop > AMT

Health Coverage Policy

OptionalMax use 9
—
Usage notes
—
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)
—
B9
Co-insurance - Actual
—
C1
Co-Payment Amount
D2
Deductible Amount
EBA
Expected Expenditure Amount
FK
Other Unlisted Amount
P3
Premium Amount
R
Spend Down
AMT-02
782
Contract Amount
Required
Decimal number (R)
Min 1Max 15
—
REF
2900
Detail > Member Level Detail Loop > Health Coverage Loop > REF

Health Coverage Policy Number

OptionalMax use 14
—
Usage notes
—
Example
Variants (all may be used)
REFPrior Coverage Months
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
1L
Group or Policy Number
—
9V
Payment Category
17
Client Reporting Category
CE
Class of Contract Code
E8
Service Contract (Coverage) Number
M7
Medical Assistance Category
PID
Program Identification Number
RB
Rate code number
X9
Internal Control Number
XM
Issuer Number
XX1
Special Program Code
XX2
Service Area Code
ZX
County Code
ZZ
Mutually Defined
—
REF-02
127
Member Group or Policy Number
Required
String (AN)
Min 1Max 50
—
Usage notes
—
REF
2900
Detail > Member Level Detail Loop > Health Coverage Loop > REF

Prior Coverage Months

OptionalMax use 1
—
Usage notes
—
Example
Variants (all may be used)
REFHealth Coverage Policy Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
QQ
Unit Number
—
REF-02
127
Prior Coverage Month Count
Required
String (AN)
Min 1Max 50
—
Usage notes
—
IDC
3000
Detail > Member Level Detail Loop > Health Coverage Loop > IDC

Identification Card

OptionalMax use 3
—
Usage notes
—
Example
IDC-01
1204
Plan Coverage Description
Required
String (AN)
Min 1Max 50
—
Usage notes
—
IDC-02
1215
Identification Card Type Code
Required
Identifier (ID)
—
Usage notes
—
D
Dental Insurance
H
Health Insurance
P
Prescription Drug Service Drug Insurance
IDC-03
380
Identification Card Count
Optional
Decimal number (R)
Min 1Max 15
—
Usage notes
—
IDC-04
306
Action Code
Optional
Identifier (ID)
—
1
Add
2
Change (Update)
RX
Replace
—
2310 Provider Information Loop
OptionalMax 30
LX
3100
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > LX

Provider Information

RequiredMax use 1
—
Usage notes
—
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6
—
Usage notes
—
NM1
3200
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > NM1

Provider Name

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
1X
Laboratory
3D
Obstetrics and Gynecology Facility
80
Hospital
FA
Facility
OD
Doctor of Optometry
P3
Primary Care Provider
QA
Pharmacy
QN
Dentist
Y2
Managed Care Organization
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
1
Person
2
Non-Person Entity
NM1-03
1035
Provider Last or Organization Name
Optional
String (AN)
Min 1Max 60
—
NM1-04
1036
Provider First Name
Optional
String (AN)
Min 1Max 35
—
NM1-05
1037
Provider Middle Name
Optional
String (AN)
Min 1Max 25
—
NM1-06
1038
Provider Name Prefix
Optional
String (AN)
Min 1Max 10
—
NM1-07
1039
Provider Name Suffix
Optional
String (AN)
Min 1Max 10
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
34
Social Security Number
—
FI
Federal Taxpayer's Identification Number
SV
Service Provider Number
—
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Provider Identifier
Optional
String (AN)
Min 2Max 80
—
NM1-10
706
Entity Relationship Code
Required
Identifier (ID)
—
Usage notes
—
25
Established Patient
26
Not Established Patient
72
Unknown
N3
3500
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > N3

Provider Address

OptionalMax use 2
—
Usage notes
—
Example
N3-01
166
Provider Address Line
Required
String (AN)
Min 1Max 55
—
N3-02
166
Provider Address Line
Optional
String (AN)
Min 1Max 55
—
N4
3600
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > N4

Provider City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Provider State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Provider City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Provider State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Provider Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
PER
3700
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > PER

Provider Communications Numbers

OptionalMax use 2
—
Usage notes
—
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
IC
Information Contact
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)
—
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256
—
PLA
3950
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > PLA

Provider Change Reason

OptionalMax use 1
—
Usage notes
—
Example
PLA-01
306
Action Code
Required
Identifier (ID)
—
2
Change (Update)
PLA-02
98
Entity Identifier Code
Required
Identifier (ID)
—
1P
Provider
PLA-03
373
Provider Effective Date
Required
Date (DT)
CCYYMMDD format
—
Usage notes
—
PLA-05
1203
Maintenance Reason Code
Required
Identifier (ID)
—
Usage notes
—
14
Voluntary Withdrawal
22
Plan Change
46
Current Customer Information File in Error
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
AJ
Appointment Times not Met in a Timely Manner
2310 Provider Information Loop end
2320 Coordination of Benefits Loop
OptionalMax 5
COB
4000
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > COB

Coordination of Benefits

RequiredMax use 1
—
Usage notes
—
Example
COB-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)
—
P
Primary
S
Secondary
T
Tertiary
U
Unknown
COB-02
127
Member Group or Policy Number
Optional
String (AN)
Min 1Max 50
—
COB-03
1143
Coordination of Benefits Code
Required
Identifier (ID)
—
1
Coordination of Benefits
5
Unknown
6
No Coordination of Benefits
—
COB-04
1365
Service Type Code
Optional
Identifier (ID)
Max use 9
—
1
Medical Care
35
Dental Care
48
Hospital - Inpatient
50
Hospital - Outpatient
54
Long Term Care
89
Free Standing Prescription Drug
90
Mail Order Prescription Drug
A4
Psychiatric
AG
Skilled Nursing Care
AL
Vision (Optometry)
BB
Partial Hospitalization (Psychiatric)
REF
4050
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > REF

Additional Coordination of Benefits Identifiers

OptionalMax use 4
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Optional
Identifier (ID)
—
6P
Group Number
60
Account Suffix Code
SY
Social Security Number
—
ZZ
Mutually Defined
—
REF-02
127
Member Group or Policy Number
Required
String (AN)
Min 1Max 50
—
DTP
4070
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > DTP

Coordination of Benefits Eligibility Dates

OptionalMax use 2
—
Usage notes
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
344
Coordination of Benefits Begin
345
Coordination of Benefits End
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Coordination of Benefits Date
Required
String (AN)
Min 1Max 35
—
LS
4100
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > LS

Loop Header

RequiredMax use 1
—
Example
LS-01
447
Loop Identifier Code
Required
String (AN)
Min 1Max 6
—
2330 Coordination of Benefits Related Entity Loop
RequiredMax 3
NM1
4100
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > NM1

Coordination of Benefits Related Entity

RequiredMax use 1
—
Usage notes
—
Example
If either Identification Code Qualifier (NM1-08) or Coordination of Benefits Insurer Identification Code (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
36
Employer
GW
Group
IN
Insurer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)
—
2
Non-Person Entity
NM1-03
1035
Coordination of Benefits Insurer Name
Optional
String (AN)
Min 1Max 60
—
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)
—
FI
Federal Taxpayer's Identification Number
NI
National Association of Insurance Commissioners (NAIC) Identification
XV
Centers for Medicare and Medicaid Services PlanID
—
NM1-09
67
Coordination of Benefits Insurer Identification Code
Optional
String (AN)
Min 2Max 80
—
N3
4300
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > N3

Coordination of Benefits Related Entity Address

OptionalMax use 1
—
Usage notes
—
Example
N3-01
166
Address Information
Required
String (AN)
Min 1Max 55
—
N3-02
166
Address Information
Optional
String (AN)
Min 1Max 55
—
N4
4400
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > N4

Coordination of Benefits Other Insurance Company City, State, ZIP Code

OptionalMax use 1
—
Usage notes
—
Example
Only one of Coordination of Benefits Other Insurance Company State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Coordination of Benefits Other Insurance Company City Name
Required
String (AN)
Min 2Max 30
—
N4-02
156
Coordination of Benefits Other Insurance Company State Code
Optional
Identifier (ID)
Min 2Max 2
—
N4-03
116
Coordination of Benefits Other Insurance Company Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15
—
N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3
—
Usage notes
—
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3
—
Usage notes
—
PER
4500
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > PER

Administrative Communications Contact

OptionalMax use 1
—
Usage notes
—
Example
PER-01
366
Contact Function Code
Required
Identifier (ID)
—
CN
General Contact
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)
—
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256
—
2330 Coordination of Benefits Related Entity Loop end
LE
4100
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > LE

Loop Trailer

RequiredMax use 1
—
Example
LE-01
447
Loop Identifier Code
Required
String (AN)
Min 1Max 6
—
2320 Coordination of Benefits Loop end
2300 Health Coverage Loop end
2700 Member Reporting Categories Loop
OptionalMax >1
LX
6881
Detail > Member Level Detail Loop > Member Reporting Categories Loop > LX

Member Reporting Categories

RequiredMax use 1
—
Usage notes
—
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6
—
Usage notes
—
2750 Reporting Category Loop
RequiredMax 1
N1
6882
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > N1

Reporting Category

RequiredMax use 1
—
Usage notes
—
Example
N1-01
98
Entity Identifier Code
Required
Identifier (ID)
—
75
Participant
N1-02
93
Member Reporting Category Name
Required
String (AN)
Min 1Max 60
—
REF
6883
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > REF

Reporting Category Reference

OptionalMax use 1
—
Usage notes
—
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)
—
00
Contracting District Number
3L
Branch Identifier
6M
Application Number
9V
Payment Category
9X
Account Category
17
Client Reporting Category
18
Plan Number
19
Division Identifier
26
Union Number
GE
Geographic Number
LU
Location Number
PID
Program Identification Number
XX1
Special Program Code
XX2
Service Area Code
YY
Geographic Key
ZZ
Mutually Defined
REF-02
127
Member Reporting Category Reference ID
Required
String (AN)
Min 1Max 50
—
DTP
6884
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > DTP

Reporting Category Date

OptionalMax use 1
—
Usage notes
—
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)
—
007
Effective
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)
—
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
—
DTP-03
1251
Member Reporting Category Effective Date(s)
Required
String (AN)
Min 1Max 35
—
2750 Reporting Category Loop end
2700 Member Reporting Categories Loop end
2000 Member Level Detail Loop end
SE
6900
Detail > SE

Transaction Set Trailer

RequiredMax use 1
—
Example
SE-01
96
Transaction Segment Count
Required
Numeric (N0)
Min 1Max 10
—
SE-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9
—
Usage notes
—
Detail end
GE

Functional Group Trailer

RequiredMax use 1
—
Example
GE-01
97
Number of Transaction Sets Included
Required
Numeric (N0)
Min 1Max 6
—
GE-02
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9
—
IEA

Interchange Control Trailer

RequiredMax use 1
—
Example
IEA-01
I16
Number of Included Functional Groups
Required
Numeric (N0)
Min 1Max 5
—
IEA-02
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9
—
EDI Samples

Example 1: Enrolling a subscriber effective 10/01/2010

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240119*1852*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185224*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*22*X*20240120*2105*08*X**2~
N1*IN*ANTHEM BLUE CROSS*94*953760001~
N1*P5*XXXXXX*24*XXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20101001~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*IND~
DTP*348*D8*20101001~
GE*1*000000001~
IEA*1*000000001~

Example 2: Enrolling a family effective 10/01/2010

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240119*1853*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185343*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*22*XXXXX*20240120*1854*02*X**4~
N1*IN*ANTHEM BLUE CROSS*XV*953760001~
N1*P5*XXXX*24*XXXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*FAM~
DTP*348*D8*20101001~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19820303*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20101001~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
NM1*IL*1*TestName*Dependent2*MIDDLENAME***34*888888888~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19920620*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20101001~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
NM1*IL*1*TestName*Dependent3*MIDDLENAME***34*777777777~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19930913*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20101001~
INS*N*01*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20100601~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20101001~
GE*1*000000001~
IEA*1*000000001~

Example 3: Term a spouse effective 12/31/2010; change status from F to S and D

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240119*1854*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185419*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*22*XX*20240120*1708*ET*XX**4~
N1*IN*ANTHEM BLUE CROSS*94*953760001~
N1*P5*XXX*24*XXXXXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050601~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*ECH~
DTP*348*D8*20060101~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050601~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19820303*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20060101~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050601~
NM1*IL*1*TestName*Dependent2*MIDDLENAME***34*888888888~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19920620*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20060101~
INS*N*01*024**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050601~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*024**HLT*HEALTH 1~
DTP*348*D8*20051001~
DTP*349*D8*20101231~
GE*1*000000001~
IEA*1*000000001~

Example 4: Add dependent to a subscriber and spouse contract effective 06/25/2006

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240119*1855*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185500*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*15*XXXXX*20240120*2009*14*XXX**RX~
N1*IN*ANTHEM BLUE CROSS*XV*953760001~
N1*P5*XX*FI*XXXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*FAM~
DTP*348*D8*20060625~
INS*N*01*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20060601~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060625~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*20060625*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20060625~
GE*1*000000001~
IEA*1*000000001~

Example 5: Term family effective 12/31/2006. Family has been effective since 01/01/2006

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240119*1855*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185548*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*00*XXXX*20240120*1210*NS*XXXXX**2~
N1*IN*ANTHEM BLUE CROSS*FI*953760001~
N1*P5*XXX*24*XXXXX~
INS*Y*18*024**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060101~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*024**HLT*HEALTH 1*FAM~
DTP*348*D8*20060101~
DTP*349*D8*20061231~
INS*N*19*024**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060101~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19820303*F~
HD*024**HLT*HEALTH 1~
DTP*348*D8*20060101~
DTP*349*D8*20061231~
INS*N*19*024**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060101~
NM1*IL*1*TestName*Dependent2*MIDDLENAME***34*888888888~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19920620*M~
HD*024**HLT*HEALTH 1~
DTP*348*D8*20060101~
DTP*349*D8*20061231~
INS*N*01*024**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20060101~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*024**HLT*HEALTH 1~
DTP*348*D8*20060101~
DTP*349*D8*20061231~
GE*1*000000001~
IEA*1*000000001~

Example 6: For family, add medical coverage effective 1/1/05 + dental coverage effective 2/1/05

ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *240119*1856*^*00501*000000001*0*T*>~
GS*BE*SENDERGS*RECEIVERGS*20240119*185621*000000001*X*005010X220A1~
ST*834*0001*005010X220A1~
BGN*22*X*20240120*1429*CS*XX**2~
N1*IN*ANTHEM BLUE CROSS*FI*953760001~
N1*P5*XXXXXX*24*XXXXX~
INS*Y*18*001**A***PT~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
DTP*336*D8*19930103~
NM1*IL*1*TestName*Subscriber*M***34*987654321~
PER*IP**HP*8129345656~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19600115*F*M~
HD*001**HLT*HEALTH 1*FAM~
DTP*348*D8*20050101~
HD*001**DEN*DENTAL 1~
DTP*348*D8*20050201~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
NM1*IL*1*TestName*Dependent1*MIDDLENAME***34*999999999~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19820303*F~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20050101~
HD*001**DEN*DENTAL 1~
DTP*348*D8*20050201~
INS*N*19*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
NM1*IL*1*TestName*Dependent2*MIDDLENAME***34*888888888~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19920620*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20050101~
HD*001**DEN*DENTAL 1~
DTP*348*D8*20050201~
INS*N*01*001**A~
REF*0F*987654321~
REF*1L*00012345~
REF*DX*0000~
REF*17*001~
DTP*356*D8*20050101~
NM1*IL*1*TestName*Husband*MIDDLENAME***34*666666666~
N3*100 Test Blvd~
N4*Batesville*IN*47006*US*CY*Franklin~
DMG*D8*19550527*M*M~
HD*001**HLT*HEALTH 1~
DTP*348*D8*20050101~
HD*001**DEN*DENTAL 1~
DTP*348*D8*20050201~
GE*1*000000001~
IEA*1*000000001~

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