X12 271 Health Care Eligibility Benefit Response (X279A1)

X12 Release 5010

Delimiters

• ~ Segment
• * Element
• > Component
• ^ Repetition

ISA Interchange Control Header

Required · Max use 1

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 10 Max 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 10 Max 10

ISA-05 · I05 · Interchange ID Qualifier · Required · Identifier (ID)

• ZZ: Mutually Defined

ISA-06 · I06 · Interchange Sender ID · Required · String (AN) · Min 15 Max 15

ISA-07 · I05 · Interchange ID Qualifier · Required · Identifier (ID)

• 01: Duns (Dun & Bradstreet)

ISA-08 · I07 · Interchange Receiver ID · Required · String (AN) · Min 15 Max 15

Example values

• BCCA           

• DEN            

• 030240928      

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 1 Max 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 9 Max 9

ISA-14 · I13 · Acknowledgment Requested · Required · Identifier (ID) · Min 1 Max 1

• 0: No Interchange Acknowledgment Requested
• 1: Interchange Acknowledgment Requested (TA1)

ISA-15 · I14 · Interchange Usage Indicator · Required · Identifier (ID) · Min 1 Max 1

• I: Information
• P: Production Data
• T: Test Data

ISA-16 · I15 · Component Element Separator · Required · String (AN) · Min 1 Max 1

• >: Component Element Separator

GS Functional Group Header

Required · Max use 1

GS-01 · 479 · Functional Identifier Code · Required · Identifier (ID)

• HB: Eligibility, Coverage or Benefit Information (271)

GS-02 · 142 · Application Sender's Code · Required · String (AN) · Min 2 Max 15

GS-03 · 124 · Application Receiver's Code · Required · String (AN) · Min 2 Max 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 1 Max 9

GS-07 · 455 · Responsible Agency Code · Required · Identifier (ID) · Min 1 Max 2

• T: Transportation Data Coordinating Committee (TDCC)
• X: Accredited Standards Committee X12

GS-08 · 480 · Version / Release / Industry Identifier Code · Required · String (AN)

• 005010X279A1: ANSI ASC X12.281 Eligibility, Coverage, or Benefit Inquiry (270) and ANSI ASC X12.282 Eligibility, Coverage, or Benefit Information (271) mandated under HIPAA through June 2010

Heading

0100 Heading > ST

ST Transaction Set Header

Required · Max use 1

ST-01 · 143 · Transaction Set Identifier Code · Required · Identifier (ID)

• 271: Eligibility, Coverage or Benefit Information

ST-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

ST-03 · 1705 · Implementation Convention Reference · Required · String (AN)

005010X279A1

0200 Heading > BHT

BHT Beginning of Hierarchical Transaction

Required · Max use 1

BHT-01 · 1005 · Hierarchical Structure Code · Required · Identifier (ID)

• 0022: Information Source, Information Receiver, Subscriber, Dependent

BHT-02 · 353 · Transaction Set Purpose Code · Required · Identifier (ID)

• 06: Confirmation
• 11: Response

BHT-03 · 127 · Submitter Transaction Identifier · Optional · String (AN) · Min 1 Max 50

BHT-04 · 373 · Transaction Set Creation Date · Required · Date (DT) · CCYYMMDD format

BHT-05 · 337 · Transaction Set Creation Time · Required · Time (TM) · HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

Detail

2000A Information Source Level Loop Required Max >1

0100 Detail > Information Source Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 20: Information Source

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 0: No Subordinate HL Segment in This Hierarchical Structure.
• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

0250 Detail > Information Source Level Loop > AAA

AAA Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 04: Authorized Quantity Exceeded
• 41: Authorization/Access Restrictions
• 42: Unable to Respond at Current Time
• 79: Invalid Participant Identification

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• P: Please Resubmit Original Transaction
• R: Resubmission Allowed
• S: Do Not Resubmit; Inquiry Initiated to a Third Party
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

2100A Information Source Name Loop Required Max 1

0300 Detail > Information Source Level Loop > Information Source Name Loop > NM1

NM1 Information Source Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• PR: Payer

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 2: Non-Person Entity

NM1-03 · 1035 · Information Source Last or Organization Name · Required · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Information Source First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Information Source Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Information Source Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• PI: Payor Identification

NM1-09 · 67 · Information Source Primary Identifier · Required · String (AN)

• 040: Anthem Blue Cross

0800 Detail > Information Source Level Loop > Information Source Name Loop > PER

PER Information Source Contact Information

Optional · Max use 3

If either Communication Number Qualifier (PER-03) or Information Source Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Information Source Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Information Source Communication Number (PER-08) is present, then the other is required

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• IC: Information Contact

PER-02 · 93 · Information Source Contact Name · Optional · String (AN) · Min 1 Max 60

PER-03 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-04 · 364 · Information Source Communication Number · Optional · String (AN) · Min 1 Max 256

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-06 · 364 · Information Source Communication Number · Optional · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)

PER-08 · 364 · Information Source Communication Number · Optional · String (AN) · Min 1 Max 256

0850 Detail > Information Source Level Loop > Information Source Name Loop > AAA

AAA Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 04: Authorized Quantity Exceeded
• 41: Authorization/Access Restrictions
• 42: Unable to Respond at Current Time
• 79: Invalid Participant Identification
• 80: No Response received - Transaction Terminated
• T4: Payer Name or Identifier Missing

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• P: Please Resubmit Original Transaction
• R: Resubmission Allowed
• S: Do Not Resubmit; Inquiry Initiated to a Third Party
• W: Please Wait 30 Days and Resubmit
• X: Please Wait 10 Days and Resubmit
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

2000B Information Receiver Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 21: Information Receiver

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 0: No Subordinate HL Segment in This Hierarchical Structure.
• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

2100B Information Receiver Name Loop Required Max 1

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1

NM1 Information Receiver Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 1P: Provider
• 2B: Third-Party Administrator
• 36: Employer
• 80: Hospital
• FA: Facility
• GP: Gateway Provider
• P5: Plan Sponsor
• PR: Payer

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Information Receiver Last or Organization Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Information Receiver First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Information Receiver Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Information Receiver Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Required · Identifier (ID)

• 24: Employer's Identification Number
• 34: Social Security Number
• FI: Federal Taxpayer's Identification Number
• PI: Payor Identification
• PP: Pharmacy Processor Number
• SV: Service Provider Number
• XV: Centers for Medicare and Medicaid Services PlanID
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

NM1-09 · 67 · Information Receiver Identification Number · Required · String (AN) · Min 2 Max 80

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > REF

REF Information Receiver Additional Identification

Optional · Max use 9

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 0B: State License Number
• 1C: Medicare Provider Number
• 1D: Medicaid Provider Number
• 1J: Facility ID Number
• 4A: Personal Identification Number (PIN)
• CT: Contract Number
• EL: Electronic device pin number
• EO: Submitter Identification Number
• HPI: Centers for Medicare and Medicaid Services National Provider Identifier
• JD: User Identification
• N5: Provider Plan Network Identification Number
• N7: Facility Network Identification Number
• Q4: Prior Identifier Number
• SY: Social Security Number
• TJ: Federal Taxpayer's Identification Number

REF-02 · 127 · Information Receiver Additional Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · Information Receiver Additional Identifier State · Optional · String (AN) · Min 1 Max 80

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > N3

N3 Information Receiver Address

Optional · Max use 1

N3-01 · 166 · Information Receiver Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Information Receiver Additional Address Line · Optional · String (AN) · Min 1 Max 55

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > N4

N4 Information Receiver City, State, ZIP Code

Optional · Max use 1

Only one of Information Receiver 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 · Information Receiver City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Information Receiver State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Information Receiver Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

0850 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > AAA

AAA Information Receiver Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 41: Authorization/Access Restrictions
• 43: Invalid/Missing Provider Identification
• 44: Invalid/Missing Provider Name
• 45: Invalid/Missing Provider Specialty
• 46: Invalid/Missing Provider Phone Number
• 47: Invalid/Missing Provider State
• 48: Invalid/Missing Referring Provider Identification Number
• 50: Provider Ineligible for Inquiries
• 51: Provider Not on File
• 79: Invalid Participant Identification
• 97: Invalid or Missing Provider Address
• T4: Payer Name or Identifier Missing

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• R: Resubmission Allowed
• S: Do Not Resubmit; Inquiry Initiated to a Third Party
• W: Please Wait 30 Days and Resubmit
• X: Please Wait 10 Days and Resubmit
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > PRV

PRV Information Receiver Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Information Receiver Provider Taxonomy Code (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AT: Attending
• BI: Billing
• CO: Consulting
• CV: Covering
• H: Hospital
• HH: Home Health Care
• LA: Laboratory
• OT: Other Physician
• P1: Pharmacist
• P2: Pharmacy
• PC: Primary Care Physician
• PE: Performing
• R: Rural Health Clinic
• RF: Referring
• SB: Submitting
• SK: Skilled Nursing Facility
• SU: Supervising

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Information Receiver Provider Taxonomy Code · Optional · String (AN) · Min 1 Max 50

2000C Subscriber Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 22: Subscriber

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 0: No Subordinate HL Segment in This Hierarchical Structure.
• 1: Additional Subordinate HL Data Segment in This Hierarchical Structure.

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > TRN

TRN Subscriber Trace Number

Optional · Max use 3

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 1: Current Transaction Trace Numbers
• 2: Referenced Transaction Trace Numbers

TRN-02 · 127 · Trace Number · Required · String (AN) · Min 1 Max 50

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

2100C Subscriber Name Loop Required Max 1

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

NM1 Subscriber Name

Required · Max use 1

If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• IL: Insured or Subscriber

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Subscriber Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Subscriber First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Subscriber Middle Name or Initial · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Subscriber Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• II: Standard Unique Health Identifier for each Individual in the United States
• MI: Member Identification Number

NM1-09 · 67 · Subscriber Primary Identifier · Optional · String (AN) · Min 2 Max 80

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

REF Subscriber Additional Identification

Optional · Max use 9

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1L: Group or Policy Number
• 1W: Member Identification Number
• 3H: Case Number
• 6P: Group Number
• 18: Plan Number
• 49: Family Unit Number
• CE: Class of Contract Code
• CT: Contract Number
• EA: Medical Record Identification Number
• EJ: Patient Account Number
• F6: Health Insurance Claim (HIC) Number
• GH: Identification Card Serial Number
• HJ: Identity Card Number
• IF: Issue Number
• IG: Insurance Policy Number
• N6: Plan Network Identification Number
• NQ: Medicaid Recipient Identification Number
• Q4: Prior Identifier Number
• SY: Social Security Number
• Y4: Agency Claim Number

REF-02 · 127 · Subscriber Supplemental Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · Plan, Group or Plan Network Name · Optional · String (AN) · Min 1 Max 80

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N3

N3 Subscriber Address

Optional · Max use 1

N3-01 · 166 · Subscriber Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Subscriber Address Line · Optional · String (AN) · Min 1 Max 55

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N4

N4 Subscriber City, State, ZIP Code

Optional · Max use 1

Only one of Subscriber State Code (N4-02) or Subscriber Country Subdivision Code (N4-07) may be present

If Subscriber Country Subdivision Code (N4-07) is present, then Subscriber Country Code (N4-04) is required

N4-01 · 19 · Subscriber City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Subscriber State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Subscriber Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Subscriber Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Subscriber Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

0850 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > AAA

AAA Subscriber Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 35: Out of Network
• 42: Unable to Respond at Current Time
• 43: Invalid/Missing Provider Identification
• 45: Invalid/Missing Provider Specialty
• 47: Invalid/Missing Provider State
• 48: Invalid/Missing Referring Provider Identification Number
• 49: Provider is Not Primary Care Physician
• 51: Provider Not on File
• 52: Service Dates Not Within Provider Plan Enrollment
• 56: Inappropriate Date
• 57: Invalid/Missing Date(s) of Service
• 58: Invalid/Missing Date-of-Birth
• 60: Date of Birth Follows Date(s) of Service
• 61: Date of Death Precedes Date(s) of Service
• 62: Date of Service Not Within Allowable Inquiry Period
• 63: Date of Service in Future
• 71: Patient Birth Date Does Not Match That for the Patient on the Database
• 72: Invalid/Missing Subscriber/Insured ID
• 73: Invalid/Missing Subscriber/Insured Name
• 74: Invalid/Missing Subscriber/Insured Gender Code
• 75: Subscriber/Insured Not Found
• 76: Duplicate Subscriber/Insured ID Number
• 78: Subscriber/Insured Not in Group/Plan Identified

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• R: Resubmission Allowed
• S: Do Not Resubmit; Inquiry Initiated to a Third Party
• W: Please Wait 30 Days and Resubmit
• X: Please Wait 10 Days and Resubmit
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > PRV

PRV Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Provider Identifier (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AT: Attending
• BI: Billing
• CO: Consulting
• CV: Covering
• H: Hospital
• HH: Home Health Care
• LA: Laboratory
• OT: Other Physician
• P1: Pharmacist
• P2: Pharmacy
• PC: Primary Care Physician
• PE: Performing
• R: Rural Health Clinic
• RF: Referring
• SK: Skilled Nursing Facility
• SU: Supervising

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Provider Identifier · Optional · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

DMG Subscriber Demographic Information

Optional · Max use 1

If either Date Time Period Format Qualifier (DMG-01) or Subscriber Birth Date (DMG-02) is present, then the other is required

DMG-01 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Subscriber Birth Date · Optional · String (AN) · Min 1 Max 35

DMG-03 · 1068 · Subscriber Gender Code · Optional · Identifier (ID)

• F: Female
• M: Male
• U: Unknown

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

INS Subscriber Relationship

Optional · Max use 1

INS-01 · 1073 · Insured Indicator · Required · Identifier (ID)

• Y: Yes

INS-02 · 1069 · Individual Relationship Code · Required · Identifier (ID)

• 18: Self

INS-03 · 875 · Maintenance Type Code · Optional · Identifier (ID)

• 001: Change

INS-04 · 1203 · Maintenance Reason Code · Optional · Identifier (ID)

• 25: Change in Identifying Data Elements

INS-17 · 1470 · Birth Sequence Number · Optional · Numeric (N0) · Min 1 Max 9

1150 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > HI

HI Subscriber Health Care Diagnosis Code

Optional · Max use 1

HI-01 · C022 · Health Care Code Information · Required Max use 1 · To send health care codes and their associated dates, amounts and quantities

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
• BK: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-02 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-03 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-04 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-05 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-06 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-07 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-08 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

1200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DTP

DTP Subscriber Date

Optional · Max use 9

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 096: Discharge
• 102: Issue
• 152: Effective Date of Change
• 291: Plan
• 307: Eligibility
• 318: Added
• 340: Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
• 341: Consolidated Omnibus Budget Reconciliation Act (COBRA) End
• 342: Premium Paid to Date Begin
• 343: Premium Paid to Date End
• 346: Plan Begin
• 347: Plan End
• 356: Eligibility Begin
• 357: Eligibility End
• 382: Enrollment
• 435: Admission
• 442: Date of Death
• 458: Certification
• 472: Service
• 539: Policy Effective
• 540: Policy Expiration
• 636: Date of Last Update
• 771: Status

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 · Date Time Period · Required · String (AN) · Min 1 Max 35

1275 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > MPI

MPI Subscriber Military Personnel Information

Optional · Max use 1

If either Date Time Period Format Qualifier (MPI-06) or Date Time Period (MPI-07) is present, then the other is required

MPI-01 · 1201 · Information Status Code · Required · Identifier (ID)

• A: Partial
• C: Current
• L: Latest
• O: Oldest
• P: Prior
• S: Second Most Current
• T: Third Most Current

MPI-02 · 584 · Employment Status Code · Required · Identifier (ID)

• AE: Active Reserve
• AO: Active Military - Overseas
• AS: Academy Student
• AT: Presidential Appointee
• AU: Active Military - USA
• CC: Contractor
• DD: Dishonorably Discharged
• HD: Honorably Discharged
• IR: Inactive Reserves
• LX: Leave of Absence: Military
• PE: Plan to Enlist
• RE: Recommissioned
• RM: Retired Military - Overseas
• RR: Retired Without Recall
• RU: Retired Military - USA

MPI-03 · 1595 · Government Service Affiliation Code · Required · Identifier (ID)

• A: Air Force
• B: Air Force Reserves
• C: Army
• D: Army Reserves
• E: Coast Guard
• F: Marine Corps
• G: Marine Corps Reserves
• H: National Guard
• I: Navy
• J: Navy Reserves
• K: Other
• L: Peace Corp
• M: Regular Armed Forces
• N: Reserves
• O: U.S. Public Health Service
• Q: Foreign Military
• R: American Red Cross
• S: Department of Defense
• U: United Services Organization
• W: Military Sealift Command

MPI-04 · 352 · Description · Optional · String (AN) · Min 1 Max 80

MPI-05 · 1596 · Military Service Rank Code · Optional · Identifier (ID)

• A1: Admiral
• A2: Airman
• A3: Airman First Class
• B1: Basic Airman
• B2: Brigadier General
• C1: Captain
• C2: Chief Master Sergeant
• C3: Chief Petty Officer
• C4: Chief Warrant
• C5: Colonel
• C6: Commander
• C7: Commodore
• C8: Corporal
• C9: Corporal Specialist 4
• E1: Ensign
• F1: First Lieutenant
• F2: First Sergeant
• F3: First Sergeant-Master Sergeant
• F4: Fleet Admiral
• G1: General
• G4: Gunnery Sergeant
• L1: Lance Corporal
• L2: Lieutenant
• L3: Lieutenant Colonel
• L4: Lieutenant Commander
• L5: Lieutenant General
• L6: Lieutenant Junior Grade
• M1: Major
• M2: Major General
• M3: Master Chief Petty Officer
• M4: Master Gunnery Sergeant Major
• M5: Master Sergeant
• M6: Master Sergeant Specialist 8
• P1: Petty Officer First Class
• P2: Petty Officer Second Class
• P3: Petty Officer Third Class
• P4: Private
• P5: Private First Class
• R1: Rear Admiral
• R2: Recruit
• S1: Seaman
• S2: Seaman Apprentice
• S3: Seaman Recruit
• S4: Second Lieutenant
• S5: Senior Chief Petty Officer
• S6: Senior Master Sergeant
• S7: Sergeant
• S8: Sergeant First Class Specialist 7
• S9: Sergeant Major Specialist 9
• SA: Sergeant Specialist 5
• SB: Staff Sergeant
• SC: Staff Sergeant Specialist 6
• T1: Technical Sergeant
• V1: Vice Admiral
• W1: Warrant Officer

MPI-06 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD
• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

MPI-07 · 1251 · Date Time Period · Optional · String (AN) · Min 1 Max 35

2110C Subscriber Eligibility or Benefit Information Loop Optional Max >1

1300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > EB

EB Subscriber Eligibility or Benefit Information

Required · Max use 1

If either Quantity Qualifier (EB-09) or Benefit Quantity (EB-10) is present, then the other is required

EB-01 · 1390 · Eligibility or Benefit Information · Required · Identifier (ID)

• 1: Active Coverage
• 2: Active - Full Risk Capitation
• 3: Active - Services Capitated
• 4: Active - Services Capitated to Primary Care Physician
• 5: Active - Pending Investigation
• 6: Inactive
• 7: Inactive - Pending Eligibility Update
• 8: Inactive - Pending Investigation
• A: Co-Insurance
• B: Co-Payment
• C: Deductible
• CB: Coverage Basis
• D: Benefit Description
• E: Exclusions
• F: Limitations
• G: Out of Pocket (Stop Loss)
• H: Unlimited
• I: Non-Covered
• J: Cost Containment
• K: Reserve
• L: Primary Care Provider
• M: Pre-existing Condition
• MC: Managed Care Coordinator
• N: Services Restricted to Following Provider
• O: Not Deemed a Medical Necessity
• P: Benefit Disclaimer
• Q: Second Surgical Opinion Required
• R: Other or Additional Payor
• S: Prior Year(s) History
• T: Card(s) Reported Lost/Stolen
• U: Contact Following Entity for Eligibility or Benefit Information
• V: Cannot Process
• W: Other Source of Data
• X: Health Care Facility
• Y: Spend Down

EB-02 · 1207 · Benefit Coverage Level Code · Optional · Identifier (ID)

• CHD: Children Only
• DEP: Dependents Only
• ECH: Employee and Children
• EMP: Employee Only
• ESP: Employee and Spouse
• FAM: Family
• IND: Individual
• SPC: Spouse and Children
• SPO: Spouse Only

EB-03 · 1365 · Service Type Code · Optional · Identifier (ID) · Max use 99

• 1: Medical Care
• 2: Surgical
• 3: Consultation
• 4: Diagnostic X-Ray
• 5: Diagnostic Lab
• 6: Radiation Therapy
• 7: Anesthesia
• 8: Surgical Assistance
• 9: Other Medical
• 10: Blood Charges
• 11: Used Durable Medical Equipment
• 12: Durable Medical Equipment Purchase
• 13: Ambulatory Service Center Facility
• 14: Renal Supplies in the Home
• 15: Alternate Method Dialysis
• 16: Chronic Renal Disease (CRD) Equipment
• 17: Pre-Admission Testing
• 18: Durable Medical Equipment Rental
• 19: Pneumonia Vaccine
• 20: Second Surgical Opinion
• 21: Third Surgical Opinion
• 22: Social Work
• 23: Diagnostic Dental
• 24: Periodontics
• 25: Restorative
• 26: Endodontics
• 27: Maxillofacial Prosthetics
• 28: Adjunctive Dental Services
• 30: Health Benefit Plan Coverage
• 32: Plan Waiting Period
• 33: Chiropractic
• 34: Chiropractic Office Visits
• 35: Dental Care
• 36: Dental Crowns
• 37: Dental Accident
• 38: Orthodontics
• 39: Prosthodontics
• 40: Oral Surgery
• 41: Routine (Preventive) Dental
• 42: Home Health Care
• 43: Home Health Prescriptions
• 44: Home Health Visits
• 45: Hospice
• 46: Respite Care
• 47: Hospital
• 48: Hospital - Inpatient
• 49: Hospital - Room and Board
• 50: Hospital - Outpatient
• 51: Hospital - Emergency Accident
• 52: Hospital - Emergency Medical
• 53: Hospital - Ambulatory Surgical
• 54: Long Term Care
• 55: Major Medical
• 56: Medically Related Transportation
• 57: Air Transportation
• 58: Cabulance
• 59: Licensed Ambulance
• 60: General Benefits
• 61: In-vitro Fertilization
• 62: MRI/CAT Scan
• 63: Donor Procedures
• 64: Acupuncture
• 65: Newborn Care
• 66: Pathology
• 67: Smoking Cessation
• 68: Well Baby Care
• 69: Maternity
• 70: Transplants
• 71: Audiology Exam
• 72: Inhalation Therapy
• 73: Diagnostic Medical
• 74: Private Duty Nursing
• 75: Prosthetic Device
• 76: Dialysis
• 77: Otological Exam
• 78: Chemotherapy
• 79: Allergy Testing
• 80: Immunizations
• 81: Routine Physical
• 82: Family Planning
• 83: Infertility
• 84: Abortion
• 85: AIDS
• 86: Emergency Services
• 87: Cancer
• 88: Pharmacy
• 89: Free Standing Prescription Drug
• 90: Mail Order Prescription Drug
• 91: Brand Name Prescription Drug
• 92: Generic Prescription Drug
• 93: Podiatry
• 94: Podiatry - Office Visits
• 95: Podiatry - Nursing Home Visits
• 96: Professional (Physician)
• 97: Anesthesiologist
• 98: Professional (Physician) Visit - Office
• 99: Professional (Physician) Visit - Inpatient
• A0: Professional (Physician) Visit - Outpatient
• A1: Professional (Physician) Visit - Nursing Home
• A2: Professional (Physician) Visit - Skilled Nursing Facility
• A3: Professional (Physician) Visit - Home
• A4: Psychiatric
• A5: Psychiatric - Room and Board
• A6: Psychotherapy
• A7: Psychiatric - Inpatient
• A8: Psychiatric - Outpatient
• A9: Rehabilitation
• AA: Rehabilitation - Room and Board
• AB: Rehabilitation - Inpatient
• AC: Rehabilitation - Outpatient
• AD: Occupational Therapy
• AE: Physical Medicine
• AF: Speech Therapy
• AG: Skilled Nursing Care
• AH: Skilled Nursing Care - Room and Board
• AI: Substance Abuse
• AJ: Alcoholism
• AK: Drug Addiction
• AL: Vision (Optometry)
• AM: Frames
• AN: Routine Exam
• AO: Lenses
• AQ: Nonmedically Necessary Physical
• AR: Experimental Drug Therapy
• B1: Burn Care
• B2: Brand Name Prescription Drug - Formulary
• B3: Brand Name Prescription Drug - Non-Formulary
• BA: Independent Medical Evaluation
• BB: Partial Hospitalization (Psychiatric)
• BC: Day Care (Psychiatric)
• BD: Cognitive Therapy
• BE: Massage Therapy
• BF: Pulmonary Rehabilitation
• BG: Cardiac Rehabilitation
• BH: Pediatric
• BI: Nursery
• BJ: Skin
• BK: Orthopedic
• BL: Cardiac
• BM: Lymphatic
• BN: Gastrointestinal
• BP: Endocrine
• BQ: Neurology
• BR: Eye
• BS: Invasive Procedures
• BT: Gynecological
• BU: Obstetrical
• BV: Obstetrical/Gynecological
• BW: Mail Order Prescription Drug: Brand Name
• BX: Mail Order Prescription Drug: Generic
• BY: Physician Visit - Office: Sick
• BZ: Physician Visit - Office: Well
• C1: Coronary Care
• CA: Private Duty Nursing - Inpatient
• CB: Private Duty Nursing - Home
• CC: Surgical Benefits - Professional (Physician)
• CD: Surgical Benefits - Facility
• CE: Mental Health Provider - Inpatient
• CF: Mental Health Provider - Outpatient
• CG: Mental Health Facility - Inpatient
• CH: Mental Health Facility - Outpatient
• CI: Substance Abuse Facility - Inpatient
• CJ: Substance Abuse Facility - Outpatient
• CK: Screening X-ray
• CL: Screening laboratory
• CM: Mammogram, High Risk Patient
• CN: Mammogram, Low Risk Patient
• CO: Flu Vaccination
• CP: Eyewear and Eyewear Accessories
• CQ: Case Management
• DG: Dermatology
• DM: Durable Medical Equipment
• DS: Diabetic Supplies
• GF: Generic Prescription Drug - Formulary
• GN: Generic Prescription Drug - Non-Formulary
• GY: Allergy
• IC: Intensive Care
• MH: Mental Health
• NI: Neonatal Intensive Care
• ON: Oncology
• PT: Physical Therapy
• PU: Pulmonary
• RN: Renal
• RT: Residential Psychiatric Treatment
• TC: Transitional Care
• TN: Transitional Nursery Care
• UC: Urgent Care

EB-04 · 1336 · Insurance Type Code · Optional · Identifier (ID)

• 12: Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
• 13: Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
• 14: Medicare Secondary, No-fault Insurance including Auto is Primary
• 15: Medicare Secondary Worker's Compensation
• 16: Medicare Secondary Public Health Service (PHS)or Other Federal Agency
• 41: Medicare Secondary Black Lung
• 42: Medicare Secondary Veteran's Administration
• 43: Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
• 47: Medicare Secondary, Other Liability Insurance is Primary
• AP: Auto Insurance Policy
• C1: Commercial
• CO: Consolidated Omnibus Budget Reconciliation Act (COBRA)
• CP: Medicare Conditionally Primary
• D: Disability
• DB: Disability Benefits
• EP: Exclusive Provider Organization
• FF: Family or Friends
• GP: Group Policy
• HM: Health Maintenance Organization (HMO)
• HN: Health Maintenance Organization (HMO) - Medicare Risk
• HS: Special Low Income Medicare Beneficiary
• IN: Indemnity
• IP: Individual Policy
• LC: Long Term Care
• LD: Long Term Policy
• LI: Life Insurance
• LT: Litigation
• MA: Medicare Part A
• MB: Medicare Part B
• MC: Medicaid
• MH: Medigap Part A
• MI: Medigap Part B
• MP: Medicare Primary
• OT: Other
• PE: Property Insurance - Personal
• PL: Personal
• PP: Personal Payment (Cash - No Insurance)
• PR: Preferred Provider Organization (PPO)
• PS: Point of Service (POS)
• QM: Qualified Medicare Beneficiary
• RP: Property Insurance - Real
• SP: Supplemental Policy
• TF: Tax Equity Fiscal Responsibility Act (TEFRA)
• WC: Workers Compensation
• WU: Wrap Up Policy

EB-05 · 1204 · Plan Coverage Description · Optional · String (AN) · Min 1 Max 50

EB-06 · 615 · Time Period Qualifier · Optional · Identifier (ID)

• 6: Hour
• 7: Day
• 13: 24 Hours
• 21: Years
• 22: Service Year
• 23: Calendar Year
• 24: Year to Date
• 25: Contract
• 26: Episode
• 27: Visit
• 28: Outlier
• 29: Remaining
• 30: Exceeded
• 31: Not Exceeded
• 32: Lifetime
• 33: Lifetime Remaining
• 34: Month
• 35: Week
• 36: Admission

EB-07 · 782 · Benefit Amount · Optional · Decimal number (R) · Min 1 Max 15

EB-08 · 954 · Benefit Percent · Optional · Decimal number (R) · Min 1 Max 10

EB-09 · 673 · Quantity Qualifier · Optional · Identifier (ID)

• 8H: Minimum
• 99: Quantity Used
• CA: Covered - Actual
• CE: Covered - Estimated
• D3: Number of Co-insurance Days
• DB: Deductible Blood Units
• DY: Days
• HS: Hours
• LA: Life-time Reserve - Actual
• LE: Life-time Reserve - Estimated
• M2: Maximum
• MN: Month
• P6: Number of Services or Procedures
• QA: Quantity Approved
• S7: Age, High Value
• S8: Age, Low Value
• VS: Visits
• YY: Years

EB-10 · 380 · Benefit Quantity · Optional · Decimal number (R) · Min 1 Max 15

EB-11 · 1073 · Authorization or Certification Indicator · Optional · Identifier (ID)

• N: No
• U: Unknown
• Y: Yes

EB-12 · 1073 · In Plan Network Indicator · Optional · Identifier (ID)

• N: No
• U: Unknown
• W: Not Applicable
• Y: Yes

EB-13 · C003 · Composite Medical Procedure Identifier · Optional Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers · Usage notes

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• AD: American Dental Association Codes
• CJ: Current Procedural Terminology (CPT) Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• ZZ: Mutually Defined

C003-02 · 234 · Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-08 · 234 · Product or Service ID · Optional · String (AN) · Min 1 Max 48

EB-14 · C004 · Composite Diagnosis Code Pointer · Optional Max use 1 · To identify one or more diagnosis code pointers · Usage notes

C004-01 · 1328 · Diagnosis Code Pointer · Required · Numeric (N0) · Min 1 Max 2

C004-02 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-03 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-04 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

1350 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > HSD

HSD Health Care Services Delivery

Optional · Max use 9

If either Quantity Qualifier (HSD-01) or Benefit Quantity (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

HSD-01 · 673 · Quantity Qualifier · Optional · Identifier (ID)

• DY: Days
• FL: Units
• HS: Hours
• MN: Month
• VS: Visits

HSD-02 · 380 · Benefit Quantity · Optional · Decimal number (R) · Min 1 Max 15

HSD-03 · 355 · Unit or Basis for Measurement Code · Optional · Identifier (ID)

• DA: Days
• MO: Months
• VS: Visit
• WK: Week
• YR: Years

HSD-04 · 1167 · Sample Selection Modulus · Optional · Decimal number (R) · Min 1 Max 6

HSD-05 · 615 · Time Period Qualifier · Optional · Identifier (ID)

• 6: Hour
• 7: Day
• 21: Years
• 22: Service Year
• 23: Calendar Year
• 24: Year to Date
• 25: Contract
• 26: Episode
• 27: Visit
• 28: Outlier
• 29: Remaining
• 30: Exceeded
• 31: Not Exceeded
• 32: Lifetime
• 33: Lifetime Remaining
• 34: Month
• 35: Week

HSD-06 · 616 · Period Count · Optional · Numeric (N0) · Min 1 Max 3

HSD-07 · 678 · Delivery Frequency Code · Optional · Identifier (ID)

• 1: 1st Week of the Month
• 2: 2nd Week of the Month
• 3: 3rd Week of the Month
• 4: 4th Week of the Month
• 5: 5th Week of the Month
• 6: 1st & 3rd Weeks of the Month
• 7: 2nd & 4th Weeks of the Month
• 8: 1st Working Day of Period
• 9: Last Working Day of Period
• A: Monday through Friday
• B: Monday through Saturday
• C: Monday through Sunday
• D: Monday
• E: Tuesday
• F: Wednesday
• G: Thursday
• H: Friday
• J: Saturday
• K: Sunday
• L: Monday through Thursday
• M: Immediately
• N: As Directed
• O: Daily Mon. through Fri.
• P: 1/2 Mon. & 1/2 Thurs.
• Q: 1/2 Tues. & 1/2 Thurs.
• R: 1/2 Wed. & 1/2 Fri.
• S: Once Anytime Mon. through Fri.
• SG: Tuesday through Friday
• SL: Monday, Tuesday and Thursday
• SP: Monday, Tuesday and Friday
• SX: Wednesday and Thursday
• SY: Monday, Wednesday and Thursday
• SZ: Tuesday, Thursday and Friday
• T: 1/2 Tue. & 1/2 Fri.
• U: 1/2 Mon. & 1/2 Wed.
• V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
• W: Whenever Necessary
• X: 1/2 By Wed., Bal. By Fri.
• Y: None (Also Used to Cancel or Override a Previous Pattern)

HSD-08 · 679 · Delivery Pattern Time Code · Optional · Identifier (ID)

• A: 1st Shift (Normal Working Hours)
• B: 2nd Shift
• C: 3rd Shift
• D: A.M.
• E: P.M.
• F: As Directed
• G: Any Shift
• Y: None (Also Used to Cancel or Override a Previous Pattern)

1400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > REF

REF Subscriber Additional Identification

Optional · Max use 9

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1L: Group or Policy Number
• 1W: Member Identification Number
• 6P: Group Number
• 9F: Referral Number
• 18: Plan Number
• 49: Family Unit Number
• ALS: Alternative List ID
• CLI: Coverage List ID
• F6: Health Insurance Claim (HIC) Number
• FO: Drug Formulary Number
• G1: Prior Authorization Number
• IG: Insurance Policy Number
• M7: Medical Assistance Category
• N6: Plan Network Identification Number
• NQ: Medicaid Recipient Identification Number

REF-02 · 127 · Subscriber Eligibility or Benefit Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · Plan, Group or Plan Network Name · Optional · String (AN) · Min 1 Max 80

1500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > DTP

DTP Subscriber Eligibility/Benefit Date

Optional · Max use 20

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 096: Discharge
• 193: Period Start
• 194: Period End
• 198: Completion
• 290: Coordination of Benefits
• 291: Plan
• 292: Benefit
• 295: Primary Care Provider
• 304: Latest Visit or Consultation
• 307: Eligibility
• 318: Added
• 346: Plan Begin
• 348: Benefit Begin
• 349: Benefit End
• 356: Eligibility Begin
• 357: Eligibility End
• 435: Admission
• 472: Service
• 636: Date of Last Update
• 771: Status

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 · Eligibility or Benefit Date Time Period · Required · String (AN) · Min 1 Max 35

1600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > AAA

AAA Subscriber Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 52: Service Dates Not Within Provider Plan Enrollment
• 53: Inquired Benefit Inconsistent with Provider Type
• 54: Inappropriate Product/Service ID Qualifier
• 55: Inappropriate Product/Service ID
• 56: Inappropriate Date
• 57: Invalid/Missing Date(s) of Service
• 60: Date of Birth Follows Date(s) of Service
• 61: Date of Death Precedes Date(s) of Service
• 62: Date of Service Not Within Allowable Inquiry Period
• 63: Date of Service in Future
• 69: Inconsistent with Patient's Age
• 70: Inconsistent with Patient's Gender
• 98: Experimental Service or Procedure
• AA: Authorization Number Not Found
• AE: Requires Primary Care Physician Authorization
• AF: Invalid/Missing Diagnosis Code(s)
• AG: Invalid/Missing Procedure Code(s)
• AO: Additional Patient Condition Information Required
• CI: Certification Information Does Not Match Patient
• E8: Requires Medical Review
• IA: Invalid Authorization Number Format
• MA: Missing Authorization Number

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• R: Resubmission Allowed
• W: Please Wait 30 Days and Resubmit
• X: Please Wait 10 Days and Resubmit
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

2500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > MSG

MSG Message Text

Optional · Max use 10

MSG-01 · 933 · Free Form Message Text · Required · String (AN) · Min 1 Max 264

2115C Subscriber Eligibility or Benefit Additional Information Loop Optional Max 10

2600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Eligibility or Benefit Additional Information Loop > III

III Subscriber Eligibility or Benefit Additional Information

Required · Max use 1

If either Code List Qualifier Code (III-01) or Industry Code (III-02) is present, then the other is required

If Code Category (III-03) is present, then Injured Body Part Name (III-04) is required

III-01 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• GR: National Council on Compensation Insurance (NCCI) Nature of Injury Code
• NI: Nature of Injury Code
• ZZ: Mutually Defined

III-02 · 1271 · Industry Code · Optional · String (AN) · Min 1 Max 30

III-03 · 1136 · Code Category · Optional · Identifier (ID)

• 44: Nature of Injury

III-04 · 933 · Injured Body Part Name · Optional · String (AN) · Min 1 Max 264

3300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > LS

LS Loop Header

Optional · Max use 1

LS-01 · 447 · Loop Identifier Code · Required · String (AN) · Min 1 Max 6

2120C Subscriber Benefit Related Entity Name Loop Optional Max 23

3400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > NM1

NM1 Subscriber Benefit Related Entity Name

Required · Max use 1

If either Identification Code Qualifier (NM1-08) or Benefit Related Entity Identifier (NM1-09) is present, then the other is required

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 1I: Preferred Provider Organization (PPO)
• 1P: Provider
• 2B: Third-Party Administrator
• 13: Contracted Service Provider
• 36: Employer
• 73: Other Physician
• FA: Facility
• GP: Gateway Provider
• GW: Group
• I3: Independent Physicians Association (IPA)
• IL: Insured or Subscriber
• LR: Legal Representative
• OC: Origin Carrier
• P3: Primary Care Provider
• P4: Prior Insurance Carrier
• P5: Plan Sponsor
• PR: Payer
• PRP: Primary Payer
• SEP: Secondary Payer
• TTP: Tertiary Payer
• VER: Party Performing Verification
• VN: Vendor
• VY: Organization Completing Configuration Change
• X3: Utilization Management Organization
• Y2: Managed Care Organization

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Benefit Related Entity Last or Organization Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Benefit Related Entity First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Benefit Related Entity Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Benefit Related Entity Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• 24: Employer's Identification Number
• 34: Social Security Number
• 46: Electronic Transmitter Identification Number (ETIN)
• FA: Facility Identification
• FI: Federal Taxpayer's Identification Number
• II: Standard Unique Health Identifier for each Individual in the United States
• MI: Member Identification Number
• NI: National Association of Insurance Commissioners (NAIC) Identification
• PI: Payor Identification
• PP: Pharmacy Processor Number
• SV: Service Provider Number
• XV: Centers for Medicare and Medicaid Services PlanID
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

NM1-09 · 67 · Benefit Related Entity Identifier · Optional · String (AN) · Min 2 Max 80

NM1-10 · 706 · Benefit Related Entity Relationship Code · Optional · Identifier (ID)

• 01: Parent
• 02: Child
• 27: Domestic Partner
• 41: Spouse
• 48: Employee
• 65: Other
• 72: Unknown

3600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > N3

N3 Subscriber Benefit Related Entity Address

Optional · Max use 1

N3-01 · 166 · Benefit Related Entity Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Benefit Related Entity Address Line · Optional · String (AN) · Min 1 Max 55

3700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > N4

N4 Subscriber Benefit Related Entity City, State, ZIP Code

Optional · Max use 1

Only one of Benefit Related Entity State Code (N4-02) or Benefit Related Entity Country Subdivision Code (N4-07) may be present

If Benefit Related Entity DOD Health Service Region (N4-06) is present, then Benefit Related Entity Location Qualifier (N4-05) is required

If Benefit Related Entity Country Subdivision Code (N4-07) is present, then Benefit Related Entity Country Code (N4-04) is required

N4-01 · 19 · Benefit Related Entity City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Benefit Related Entity State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Benefit Related Entity Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Benefit Related Entity Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-05 · 309 · Benefit Related Entity Location Qualifier · Optional · Identifier (ID)

• RJ: Region

N4-06 · 310 · Benefit Related Entity DOD Health Service Region · Optional · String (AN) · Min 1 Max 30

N4-07 · 1715 · Benefit Related Entity Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

3800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > PER

PER Subscriber Benefit Related Entity Contact Information

Optional · Max use 3

If either Communication Number Qualifier (PER-03) or Benefit Related Entity Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Benefit Related Entity Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Benefit Related Entity Communication Number (PER-08) is present, then the other is required

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• IC: Information Contact

PER-02 · 93 · Benefit Related Entity Contact Name · Optional · String (AN) · Min 1 Max 60

PER-03 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)
• WP: Work Phone Number

PER-04 · 364 · Benefit Related Entity Communication Number · Optional · String (AN) · Min 1 Max 256

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)
• WP: Work Phone Number

PER-06 · 364 · Benefit Related Entity Communication Number · Optional · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)
• WP: Work Phone Number

PER-08 · 364 · Benefit Related Entity Communication Number · Optional · String (AN) · Min 1 Max 256

3900 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > PRV

PRV Subscriber Benefit Related Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Benefit Related Entity Provider Taxonomy Code (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AT: Attending
• BI: Billing
• CO: Consulting
• CV: Covering
• H: Hospital
• HH: Home Health Care
• LA: Laboratory
• OT: Other Physician
• P1: Pharmacist
• P2: Pharmacy
• PC: Primary Care Physician
• PE: Performing
• R: Rural Health Clinic
• RF: Referring
• SB: Submitting
• SK: Skilled Nursing Facility
• SU: Supervising

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Benefit Related Entity Provider Taxonomy Code · Optional · String (AN) · Min 1 Max 50

4000 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > LE

LE Loop Trailer

Optional · Max use 1

LE-01 · 447 · Loop Identifier Code · Required · String (AN) · Min 1 Max 6

2000D Dependent Level Loop Optional Max >1

0100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

HL Hierarchical Level

Required · Max use 1

HL-01 · 628 · Hierarchical ID Number · Required · String (AN) · Min 1 Max 12

HL-02 · 734 · Hierarchical Parent ID Number · Required · String (AN) · Min 1 Max 12

HL-03 · 735 · Hierarchical Level Code · Required · Identifier (ID)

• 23: Dependent

HL-04 · 736 · Hierarchical Child Code · Optional · Identifier (ID)

• 0: No Subordinate HL Segment in This Hierarchical Structure.

0200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > TRN

TRN Dependent Trace Number

Optional · Max use 3

TRN-01 · 481 · Trace Type Code · Required · Identifier (ID)

• 1: Current Transaction Trace Numbers
• 2: Referenced Transaction Trace Numbers

TRN-02 · 127 · Trace Number · Required · String (AN) · Min 1 Max 50

TRN-03 · 509 · Trace Assigning Entity Identifier · Required · String (AN) · Min 10 Max 10

TRN-04 · 127 · Trace Assigning Entity Additional Identifier · Optional · String (AN) · Min 1 Max 50

2100D Dependent Name Loop Required Max 1

0300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

NM1 Dependent Name

Required · Max use 1

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 03: Dependent

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person

NM1-03 · 1035 · Dependent Last Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Dependent First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Dependent Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Dependent Name Suffix · Optional · String (AN) · Min 1 Max 10

0400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

REF Dependent Additional Identification

Optional · Max use 9

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1L: Group or Policy Number
• 1W: Member Identification Number
• 6P: Group Number
• 18: Plan Number
• 49: Family Unit Number
• CE: Class of Contract Code
• CT: Contract Number
• EA: Medical Record Identification Number
• EJ: Patient Account Number
• F6: Health Insurance Claim (HIC) Number
• GH: Identification Card Serial Number
• HJ: Identity Card Number
• IF: Issue Number
• IG: Insurance Policy Number
• MRC: Eligibility Category
• N6: Plan Network Identification Number
• NQ: Medicaid Recipient Identification Number
• Q4: Prior Identifier Number
• SY: Social Security Number
• Y4: Agency Claim Number

REF-02 · 127 · Dependent Supplemental Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · Plan, Group or Plan Network Name · Optional · String (AN) · Min 1 Max 80

0600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N3

N3 Dependent Address

Optional · Max use 1

N3-01 · 166 · Dependent Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Dependent Address Line · Optional · String (AN) · Min 1 Max 55

0700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N4

N4 Dependent City, State, ZIP Code

Optional · Max use 1

Only one of Dependent State Code (N4-02) or Dependent Country Subdivision Code (N4-07) may be present

If Dependent Country Subdivision Code (N4-07) is present, then Dependent Country Code (N4-04) is required

N4-01 · 19 · Dependent City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Dependent State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Dependent Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Dependent Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-07 · 1715 · Dependent Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

0850 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > AAA

AAA Dependent Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 35: Out of Network
• 42: Unable to Respond at Current Time
• 43: Invalid/Missing Provider Identification
• 45: Invalid/Missing Provider Specialty
• 47: Invalid/Missing Provider State
• 48: Invalid/Missing Referring Provider Identification Number
• 49: Provider is Not Primary Care Physician
• 51: Provider Not on File
• 52: Service Dates Not Within Provider Plan Enrollment
• 56: Inappropriate Date
• 57: Invalid/Missing Date(s) of Service
• 58: Invalid/Missing Date-of-Birth
• 60: Date of Birth Follows Date(s) of Service
• 61: Date of Death Precedes Date(s) of Service
• 62: Date of Service Not Within Allowable Inquiry Period
• 63: Date of Service in Future
• 64: Invalid/Missing Patient ID
• 65: Invalid/Missing Patient Name
• 66: Invalid/Missing Patient Gender Code
• 67: Patient Not Found
• 68: Duplicate Patient ID Number
• 71: Patient Birth Date Does Not Match That for the Patient on the Database
• 77: Subscriber Found, Patient Not Found

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• R: Resubmission Allowed
• S: Do Not Resubmit; Inquiry Initiated to a Third Party
• W: Please Wait 30 Days and Resubmit
• X: Please Wait 10 Days and Resubmit
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

0900 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > PRV

PRV Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Provider Identifier (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AT: Attending
• BI: Billing
• CO: Consulting
• CV: Covering
• H: Hospital
• HH: Home Health Care
• LA: Laboratory
• OT: Other Physician
• P1: Pharmacist
• P2: Pharmacy
• PC: Primary Care Physician
• PE: Performing
• R: Rural Health Clinic
• RF: Referring
• SK: Skilled Nursing Facility
• SU: Supervising

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Provider Identifier · Optional · String (AN) · Min 1 Max 50

1000 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

DMG Dependent Demographic Information

Optional · Max use 1

If either Date Time Period Format Qualifier (DMG-01) or Dependent Birth Date (DMG-02) is present, then the other is required

DMG-01 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD

DMG-02 · 1251 · Dependent Birth Date · Optional · String (AN) · Min 1 Max 35

DMG-03 · 1068 · Dependent Gender Code · Optional · Identifier (ID)

• F: Female
• M: Male
• U: Unknown

1100 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

INS Dependent Relationship

Optional · Max use 1

INS-01 · 1073 · Insured Indicator · Required · Identifier (ID)

• N: No

INS-02 · 1069 · Individual Relationship Code · Required · Identifier (ID)

• 01: Spouse
• 19: Child
• 20: Employee
• 21: Unknown
• 39: Organ Donor
• 40: Cadaver Donor
• 53: Life Partner
• G8: Other Relationship

INS-03 · 875 · Maintenance Type Code · Optional · Identifier (ID)

• 001: Change

INS-04 · 1203 · Maintenance Reason Code · Optional · Identifier (ID)

• 25: Change in Identifying Data Elements

INS-17 · 1470 · Birth Sequence Number · Optional · Numeric (N0) · Min 1 Max 9

1150 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > HI

HI Dependent Health Care Diagnosis Code

Optional · Max use 1

HI-01 · C022 · Health Care Code Information · Required Max use 1 · To send health care codes and their associated dates, amounts and quantities

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABK: International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
• BK: International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-02 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-03 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-04 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-05 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-06 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-07 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

HI-08 · C022 · Health Care Code Information · Optional Max use 1 · To send health care codes and their associated dates, amounts and quantities · Usage notes

C022-01 · 1270 · Diagnosis Type Code · Required · Identifier (ID)

• ABF: International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
• BF: International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis

C022-02 · 1271 · Diagnosis Code · Required · String (AN) · Min 1 Max 30

1200 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DTP

DTP Dependent Date

Optional · Max use 9

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 096: Discharge
• 102: Issue
• 152: Effective Date of Change
• 291: Plan
• 307: Eligibility
• 318: Added
• 340: Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
• 341: Consolidated Omnibus Budget Reconciliation Act (COBRA) End
• 342: Premium Paid to Date Begin
• 343: Premium Paid to Date End
• 346: Plan Begin
• 347: Plan End
• 356: Eligibility Begin
• 357: Eligibility End
• 382: Enrollment
• 435: Admission
• 442: Date of Death
• 458: Certification
• 472: Service
• 539: Policy Effective
• 540: Policy Expiration
• 636: Date of Last Update
• 771: Status

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 · Date Time Period · Required · String (AN) · Min 1 Max 35

1275 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > MPI

MPI Dependent Military Personnel Information

Optional · Max use 1

If either Date Time Period Format Qualifier (MPI-06) or Date Time Period (MPI-07) is present, then the other is required

MPI-01 · 1201 · Information Status Code · Required · Identifier (ID)

• A: Partial
• C: Current
• L: Latest
• O: Oldest
• P: Prior
• S: Second Most Current
• T: Third Most Current

MPI-02 · 584 · Employment Status Code · Required · Identifier (ID)

• AE: Active Reserve
• AO: Active Military - Overseas
• AS: Academy Student
• AT: Presidential Appointee
• AU: Active Military - USA
• CC: Contractor
• DD: Dishonorably Discharged
• HD: Honorably Discharged
• IR: Inactive Reserves
• LX: Leave of Absence: Military
• PE: Plan to Enlist
• RE: Recommissioned
• RM: Retired Military - Overseas
• RR: Retired Without Recall
• RU: Retired Military - USA

MPI-03 · 1595 · Government Service Affiliation Code · Required · Identifier (ID)

• A: Air Force
• B: Air Force Reserves
• C: Army
• D: Army Reserves
• E: Coast Guard
• F: Marine Corps
• G: Marine Corps Reserves
• H: National Guard
• I: Navy
• J: Navy Reserves
• K: Other
• L: Peace Corp
• M: Regular Armed Forces
• N: Reserves
• O: U.S. Public Health Service
• Q: Foreign Military
• R: American Red Cross
• S: Department of Defense
• U: United Services Organization
• W: Military Sealift Command

MPI-04 · 352 · Description · Optional · String (AN) · Min 1 Max 80

MPI-05 · 1596 · Military Service Rank Code · Optional · Identifier (ID)

• A1: Admiral
• A2: Airman
• A3: Airman First Class
• B1: Basic Airman
• B2: Brigadier General
• C1: Captain
• C2: Chief Master Sergeant
• C3: Chief Petty Officer
• C4: Chief Warrant
• C5: Colonel
• C6: Commander
• C7: Commodore
• C8: Corporal
• C9: Corporal Specialist 4
• E1: Ensign
• F1: First Lieutenant
• F2: First Sergeant
• F3: First Sergeant-Master Sergeant
• F4: Fleet Admiral
• G1: General
• G4: Gunnery Sergeant
• L1: Lance Corporal
• L2: Lieutenant
• L3: Lieutenant Colonel
• L4: Lieutenant Commander
• L5: Lieutenant General
• L6: Lieutenant Junior Grade
• M1: Major
• M2: Major General
• M3: Master Chief Petty Officer
• M4: Master Gunnery Sergeant Major
• M5: Master Sergeant
• M6: Master Sergeant Specialist 8
• P1: Petty Officer First Class
• P2: Petty Officer Second Class
• P3: Petty Officer Third Class
• P4: Private
• P5: Private First Class
• R1: Rear Admiral
• R2: Recruit
• S1: Seaman
• S2: Seaman Apprentice
• S3: Seaman Recruit
• S4: Second Lieutenant
• S5: Senior Chief Petty Officer
• S6: Senior Master Sergeant
• S7: Sergeant
• S8: Sergeant First Class Specialist 7
• S9: Sergeant Major Specialist 9
• SA: Sergeant Specialist 5
• SB: Staff Sergeant
• SC: Staff Sergeant Specialist 6
• T1: Technical Sergeant
• V1: Vice Admiral
• W1: Warrant Officer

MPI-06 · 1250 · Date Time Period Format Qualifier · Optional · Identifier (ID)

• D8: Date Expressed in Format CCYYMMDD
• RD8: Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

MPI-07 · 1251 · Date Time Period · Optional · String (AN) · Min 1 Max 35

2110D Dependent Eligibility or Benefit Information Loop Optional Max >1

1300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > EB

EB Dependent Eligibility or Benefit Information

Required · Max use 1

If either Quantity Qualifier (EB-09) or Benefit Quantity (EB-10) is present, then the other is required

EB-01 · 1390 · Eligibility or Benefit Information · Required · Identifier (ID)

• 1: Active Coverage
• 2: Active - Full Risk Capitation
• 3: Active - Services Capitated
• 4: Active - Services Capitated to Primary Care Physician
• 5: Active - Pending Investigation
• 6: Inactive
• 7: Inactive - Pending Eligibility Update
• 8: Inactive - Pending Investigation
• A: Co-Insurance
• B: Co-Payment
• C: Deductible
• CB: Coverage Basis
• D: Benefit Description
• E: Exclusions
• F: Limitations
• G: Out of Pocket (Stop Loss)
• H: Unlimited
• I: Non-Covered
• J: Cost Containment
• K: Reserve
• L: Primary Care Provider
• M: Pre-existing Condition
• MC: Managed Care Coordinator
• N: Services Restricted to Following Provider
• O: Not Deemed a Medical Necessity
• P: Benefit Disclaimer
• Q: Second Surgical Opinion Required
• R: Other or Additional Payor
• S: Prior Year(s) History
• T: Card(s) Reported Lost/Stolen
• U: Contact Following Entity for Eligibility or Benefit Information
• V: Cannot Process
• W: Other Source of Data
• X: Health Care Facility
• Y: Spend Down

EB-02 · 1207 · Benefit Coverage Level Code · Optional · Identifier (ID)

• CHD: Children Only
• DEP: Dependents Only
• ECH: Employee and Children
• ESP: Employee and Spouse
• FAM: Family
• IND: Individual
• SPC: Spouse and Children
• SPO: Spouse Only

EB-03 · 1365 · Service Type Code · Optional · Identifier (ID) · Max use 99

• 1: Medical Care
• 2: Surgical
• 3: Consultation
• 4: Diagnostic X-Ray
• 5: Diagnostic Lab
• 6: Radiation Therapy
• 7: Anesthesia
• 8: Surgical Assistance
• 9: Other Medical
• 10: Blood Charges
• 11: Used Durable Medical Equipment
• 12: Durable Medical Equipment Purchase
• 13: Ambulatory Service Center Facility
• 14: Renal Supplies in the Home
• 15: Alternate Method Dialysis
• 16: Chronic Renal Disease (CRD) Equipment
• 17: Pre-Admission Testing
• 18: Durable Medical Equipment Rental
• 19: Pneumonia Vaccine
• 20: Second Surgical Opinion
• 21: Third Surgical Opinion
• 22: Social Work
• 23: Diagnostic Dental
• 24: Periodontics
• 25: Restorative
• 26: Endodontics
• 27: Maxillofacial Prosthetics
• 28: Adjunctive Dental Services
• 30: Health Benefit Plan Coverage
• 32: Plan Waiting Period
• 33: Chiropractic
• 34: Chiropractic Office Visits
• 35: Dental Care
• 36: Dental Crowns
• 37: Dental Accident
• 38: Orthodontics
• 39: Prosthodontics
• 40: Oral Surgery
• 41: Routine (Preventive) Dental
• 42: Home Health Care
• 43: Home Health Prescriptions
• 44: Home Health Visits
• 45: Hospice
• 46: Respite Care
• 47: Hospital
• 48: Hospital - Inpatient
• 49: Hospital - Room and Board
• 50: Hospital - Outpatient
• 51: Hospital - Emergency Accident
• 52: Hospital - Emergency Medical
• 53: Hospital - Ambulatory Surgical
• 54: Long Term Care
• 55: Major Medical
• 56: Medically Related Transportation
• 57: Air Transportation
• 58: Cabulance
• 59: Licensed Ambulance
• 60: General Benefits
• 61: In-vitro Fertilization
• 62: MRI/CAT Scan
• 63: Donor Procedures
• 64: Acupuncture
• 65: Newborn Care
• 66: Pathology
• 67: Smoking Cessation
• 68: Well Baby Care
• 69: Maternity
• 70: Transplants
• 71: Audiology Exam
• 72: Inhalation Therapy
• 73: Diagnostic Medical
• 74: Private Duty Nursing
• 75: Prosthetic Device
• 76: Dialysis
• 77: Otological Exam
• 78: Chemotherapy
• 79: Allergy Testing
• 80: Immunizations
• 81: Routine Physical
• 82: Family Planning
• 83: Infertility
• 84: Abortion
• 85: AIDS
• 86: Emergency Services
• 87: Cancer
• 88: Pharmacy
• 89: Free Standing Prescription Drug
• 90: Mail Order Prescription Drug
• 91: Brand Name Prescription Drug
• 92: Generic Prescription Drug
• 93: Podiatry
• 94: Podiatry - Office Visits
• 95: Podiatry - Nursing Home Visits
• 96: Professional (Physician)
• 97: Anesthesiologist
• 98: Professional (Physician) Visit - Office
• 99: Professional (Physician) Visit - Inpatient
• A0: Professional (Physician) Visit - Outpatient
• A1: Professional (Physician) Visit - Nursing Home
• A2: Professional (Physician) Visit - Skilled Nursing Facility
• A3: Professional (Physician) Visit - Home
• A4: Psychiatric
• A5: Psychiatric - Room and Board
• A6: Psychotherapy
• A7: Psychiatric - Inpatient
• A8: Psychiatric - Outpatient
• A9: Rehabilitation
• AA: Rehabilitation - Room and Board
• AB: Rehabilitation - Inpatient
• AC: Rehabilitation - Outpatient
• AD: Occupational Therapy
• AE: Physical Medicine
• AF: Speech Therapy
• AG: Skilled Nursing Care
• AH: Skilled Nursing Care - Room and Board
• AI: Substance Abuse
• AJ: Alcoholism
• AK: Drug Addiction
• AL: Vision (Optometry)
• AM: Frames
• AN: Routine Exam
• AO: Lenses
• AQ: Nonmedically Necessary Physical
• AR: Experimental Drug Therapy
• B1: Burn Care
• B2: Brand Name Prescription Drug - Formulary
• B3: Brand Name Prescription Drug - Non-Formulary
• BA: Independent Medical Evaluation
• BB: Partial Hospitalization (Psychiatric)
• BC: Day Care (Psychiatric)
• BD: Cognitive Therapy
• BE: Massage Therapy
• BF: Pulmonary Rehabilitation
• BG: Cardiac Rehabilitation
• BH: Pediatric
• BI: Nursery
• BJ: Skin
• BK: Orthopedic
• BL: Cardiac
• BM: Lymphatic
• BN: Gastrointestinal
• BP: Endocrine
• BQ: Neurology
• BR: Eye
• BS: Invasive Procedures
• BT: Gynecological
• BU: Obstetrical
• BV: Obstetrical/Gynecological
• BW: Mail Order Prescription Drug: Brand Name
• BX: Mail Order Prescription Drug: Generic
• BY: Physician Visit - Office: Sick
• BZ: Physician Visit - Office: Well
• C1: Coronary Care
• CA: Private Duty Nursing - Inpatient
• CB: Private Duty Nursing - Home
• CC: Surgical Benefits - Professional (Physician)
• CD: Surgical Benefits - Facility
• CE: Mental Health Provider - Inpatient
• CF: Mental Health Provider - Outpatient
• CG: Mental Health Facility - Inpatient
• CH: Mental Health Facility - Outpatient
• CI: Substance Abuse Facility - Inpatient
• CJ: Substance Abuse Facility - Outpatient
• CK: Screening X-ray
• CL: Screening laboratory
• CM: Mammogram, High Risk Patient
• CN: Mammogram, Low Risk Patient
• CO: Flu Vaccination
• CP: Eyewear and Eyewear Accessories
• CQ: Case Management
• DG: Dermatology
• DM: Durable Medical Equipment
• DS: Diabetic Supplies
• GF: Generic Prescription Drug - Formulary
• GN: Generic Prescription Drug - Non-Formulary
• GY: Allergy
• IC: Intensive Care
• MH: Mental Health
• NI: Neonatal Intensive Care
• ON: Oncology
• PT: Physical Therapy
• PU: Pulmonary
• RN: Renal
• RT: Residential Psychiatric Treatment
• TC: Transitional Care
• TN: Transitional Nursery Care
• UC: Urgent Care

EB-04 · 1336 · Insurance Type Code · Optional · Identifier (ID)

• 12: Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
• 13: Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
• 14: Medicare Secondary, No-fault Insurance including Auto is Primary
• 15: Medicare Secondary Worker's Compensation
• 16: Medicare Secondary Public Health Service (PHS)or Other Federal Agency
• 41: Medicare Secondary Black Lung
• 42: Medicare Secondary Veteran's Administration
• 43: Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
• 47: Medicare Secondary, Other Liability Insurance is Primary
• AP: Auto Insurance Policy
• C1: Commercial
• CO: Consolidated Omnibus Budget Reconciliation Act (COBRA)
• CP: Medicare Conditionally Primary
• D: Disability
• DB: Disability Benefits
• EP: Exclusive Provider Organization
• FF: Family or Friends
• GP: Group Policy
• HM: Health Maintenance Organization (HMO)
• HN: Health Maintenance Organization (HMO) - Medicare Risk
• HS: Special Low Income Medicare Beneficiary
• IN: Indemnity
• IP: Individual Policy
• LC: Long Term Care
• LD: Long Term Policy
• LI: Life Insurance
• LT: Litigation
• MA: Medicare Part A
• MB: Medicare Part B
• MC: Medicaid
• MH: Medigap Part A
• MI: Medigap Part B
• MP: Medicare Primary
• OT: Other
• PE: Property Insurance - Personal
• PL: Personal
• PP: Personal Payment (Cash - No Insurance)
• PR: Preferred Provider Organization (PPO)
• PS: Point of Service (POS)
• QM: Qualified Medicare Beneficiary
• RP: Property Insurance - Real
• SP: Supplemental Policy
• TF: Tax Equity Fiscal Responsibility Act (TEFRA)
• WC: Workers Compensation
• WU: Wrap Up Policy

EB-05 · 1204 · Plan Coverage Description · Optional · String (AN) · Min 1 Max 50

EB-06 · 615 · Time Period Qualifier · Optional · Identifier (ID)

• 6: Hour
• 7: Day
• 13: 24 Hours
• 21: Years
• 22: Service Year
• 23: Calendar Year
• 24: Year to Date
• 25: Contract
• 26: Episode
• 27: Visit
• 28: Outlier
• 29: Remaining
• 30: Exceeded
• 31: Not Exceeded
• 32: Lifetime
• 33: Lifetime Remaining
• 34: Month
• 35: Week
• 36: Admission

EB-07 · 782 · Benefit Amount · Optional · Decimal number (R) · Min 1 Max 15

EB-08 · 954 · Benefit Percent · Optional · Decimal number (R) · Min 1 Max 10

EB-09 · 673 · Quantity Qualifier · Optional · Identifier (ID)

• 8H: Minimum
• 99: Quantity Used
• CA: Covered - Actual
• CE: Covered - Estimated
• D3: Number of Co-insurance Days
• DB: Deductible Blood Units
• DY: Days
• HS: Hours
• LA: Life-time Reserve - Actual
• LE: Life-time Reserve - Estimated
• M2: Maximum
• MN: Month
• P6: Number of Services or Procedures
• QA: Quantity Approved
• S7: Age, High Value
• S8: Age, Low Value
• VS: Visits
• YY: Years

EB-10 · 380 · Benefit Quantity · Optional · Decimal number (R) · Min 1 Max 15

EB-11 · 1073 · Authorization or Certification Indicator · Optional · Identifier (ID)

• N: No
• U: Unknown
• Y: Yes

EB-12 · 1073 · In Plan Network Indicator · Optional · Identifier (ID)

• N: No
• U: Unknown
• W: Not Applicable
• Y: Yes

EB-13 · C003 · Composite Medical Procedure Identifier · Optional Max use 1 · To identify a medical procedure by its standardized codes and applicable modifiers · Usage notes

C003-01 · 235 · Product or Service ID Qualifier · Required · Identifier (ID)

• AD: American Dental Association Codes
• CJ: Current Procedural Terminology (CPT) Codes
• HC: Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
• ID: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
• IV: Home Infusion EDI Coalition (HIEC) Product/Service Code
• N4: National Drug Code in 5-4-2 Format
• ZZ: Mutually Defined

C003-02 · 234 · Procedure Code · Required · String (AN) · Min 1 Max 48

C003-03 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-04 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-05 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-06 · 1339 · Procedure Modifier · Optional · String (AN) · Min 2 Max 2

C003-08 · 234 · Product or Service ID · Optional · String (AN) · Min 1 Max 48

EB-14 · C004 · Composite Diagnosis Code Pointer · Optional Max use 1 · To identify one or more diagnosis code pointers · Usage notes

C004-01 · 1328 · Diagnosis Code Pointer · Required · Numeric (N0) · Min 1 Max 2

C004-02 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-03 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

C004-04 · 1328 · Diagnosis Code Pointer · Optional · Numeric (N0) · Min 1 Max 2

1350 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > HSD

HSD Health Care Services Delivery

Optional · Max use 9

If either Quantity Qualifier (HSD-01) or Benefit Quantity (HSD-02) is present, then the other is required

If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required

HSD-01 · 673 · Quantity Qualifier · Optional · Identifier (ID)

• DY: Days
• FL: Units
• HS: Hours
• MN: Month
• VS: Visits

HSD-02 · 380 · Benefit Quantity · Optional · Decimal number (R) · Min 1 Max 15

HSD-03 · 355 · Unit or Basis for Measurement Code · Optional · Identifier (ID)

• DA: Days
• MO: Months
• VS: Visit
• WK: Week
• YR: Years

HSD-04 · 1167 · Sample Selection Modulus · Optional · Decimal number (R) · Min 1 Max 6

HSD-05 · 615 · Time Period Qualifier · Optional · Identifier (ID)

• 6: Hour
• 7: Day
• 21: Years
• 22: Service Year
• 23: Calendar Year
• 24: Year to Date
• 25: Contract
• 26: Episode
• 27: Visit
• 28: Outlier
• 29: Remaining
• 30: Exceeded
• 31: Not Exceeded
• 32: Lifetime
• 33: Lifetime Remaining
• 34: Month
• 35: Week

HSD-06 · 616 · Period Count · Optional · Numeric (N0) · Min 1 Max 3

HSD-07 · 678 · Delivery Frequency Code · Optional · Identifier (ID)

• 1: 1st Week of the Month
• 2: 2nd Week of the Month
• 3: 3rd Week of the Month
• 4: 4th Week of the Month
• 5: 5th Week of the Month
• 6: 1st & 3rd Weeks of the Month
• 7: 2nd & 4th Weeks of the Month
• 8: 1st Working Day of Period
• 9: Last Working Day of Period
• A: Monday through Friday
• B: Monday through Saturday
• C: Monday through Sunday
• D: Monday
• E: Tuesday
• F: Wednesday
• G: Thursday
• H: Friday
• J: Saturday
• K: Sunday
• L: Monday through Thursday
• M: Immediately
• N: As Directed
• O: Daily Mon. through Fri.
• P: 1/2 Mon. & 1/2 Thurs.
• Q: 1/2 Tues. & 1/2 Thurs.
• R: 1/2 Wed. & 1/2 Fri.
• S: Once Anytime Mon. through Fri.
• SG: Tuesday through Friday
• SL: Monday, Tuesday and Thursday
• SP: Monday, Tuesday and Friday
• SX: Wednesday and Thursday
• SY: Monday, Wednesday and Thursday
• SZ: Tuesday, Thursday and Friday
• T: 1/2 Tue. & 1/2 Fri.
• U: 1/2 Mon. & 1/2 Wed.
• V: 1/3 Mon., 1/3 Wed., 1/3 Fri.
• W: Whenever Necessary
• X: 1/2 By Wed., Bal. By Fri.
• Y: None (Also Used to Cancel or Override a Previous Pattern)

HSD-08 · 679 · Delivery Pattern Time Code · Optional · Identifier (ID)

• A: 1st Shift (Normal Working Hours)
• B: 2nd Shift
• C: 3rd Shift
• D: A.M.
• E: P.M.
• F: As Directed
• G: Any Shift
• Y: None (Also Used to Cancel or Override a Previous Pattern)

1400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > REF

REF Dependent Additional Identification

Optional · Max use 9

REF-01 · 128 · Reference Identification Qualifier · Required · Identifier (ID)

• 1L: Group or Policy Number
• 1W: Member Identification Number
• 6P: Group Number
• 9F: Referral Number
• 18: Plan Number
• 49: Family Unit Number
• ALS: Alternative List ID
• CLI: Coverage List ID
• F6: Health Insurance Claim (HIC) Number
• FO: Drug Formulary Number
• G1: Prior Authorization Number
• IG: Insurance Policy Number
• N6: Plan Network Identification Number
• NQ: Medicaid Recipient Identification Number

REF-02 · 127 · Dependent Eligibility or Benefit Identifier · Required · String (AN) · Min 1 Max 50

REF-03 · 352 · Plan, Group or Plan Network Name · Optional · String (AN) · Min 1 Max 80

1500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > DTP

DTP Dependent Eligibility/Benefit Date

Optional · Max use 20

DTP-01 · 374 · Date Time Qualifier · Required · Identifier (ID)

• 096: Discharge
• 193: Period Start
• 194: Period End
• 198: Completion
• 290: Coordination of Benefits
• 291: Plan
• 292: Benefit
• 295: Primary Care Provider
• 304: Latest Visit or Consultation
• 307: Eligibility
• 318: Added
• 346: Plan Begin
• 348: Benefit Begin
• 349: Benefit End
• 356: Eligibility Begin
• 357: Eligibility End
• 435: Admission
• 472: Service
• 636: Date of Last Update
• 771: Status

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 · Eligibility or Benefit Date Time Period · Required · String (AN) · Min 1 Max 35

1600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > AAA

AAA Dependent Request Validation

Optional · Max use 9

AAA-01 · 1073 · Valid Request Indicator · Required · Identifier (ID)

• N: No
• Y: Yes

AAA-03 · 901 · Reject Reason Code · Required · Identifier (ID)

• 15: Required application data missing
• 33: Input Errors
• 52: Service Dates Not Within Provider Plan Enrollment
• 53: Inquired Benefit Inconsistent with Provider Type
• 54: Inappropriate Product/Service ID Qualifier
• 55: Inappropriate Product/Service ID
• 56: Inappropriate Date
• 57: Invalid/Missing Date(s) of Service
• 60: Date of Birth Follows Date(s) of Service
• 61: Date of Death Precedes Date(s) of Service
• 62: Date of Service Not Within Allowable Inquiry Period
• 63: Date of Service in Future
• 69: Inconsistent with Patient's Age
• 70: Inconsistent with Patient's Gender
• 98: Experimental Service or Procedure
• AA: Authorization Number Not Found
• AE: Requires Primary Care Physician Authorization
• AF: Invalid/Missing Diagnosis Code(s)
• AG: Invalid/Missing Procedure Code(s)
• AO: Additional Patient Condition Information Required
• CI: Certification Information Does Not Match Patient
• E8: Requires Medical Review
• IA: Invalid Authorization Number Format
• MA: Missing Authorization Number

AAA-04 · 889 · Follow-up Action Code · Required · Identifier (ID)

• C: Please Correct and Resubmit
• N: Resubmission Not Allowed
• R: Resubmission Allowed
• W: Please Wait 30 Days and Resubmit
• X: Please Wait 10 Days and Resubmit
• Y: Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

2500 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > MSG

MSG Message Text

Optional · Max use 10

MSG-01 · 933 · Free Form Message Text · Required · String (AN) · Min 1 Max 264

2115D Dependent Eligibility or Benefit Additional Information Loop Optional Max 10

2600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Eligibility or Benefit Additional Information Loop > III

III Dependent Eligibility or Benefit Additional Information

Required · Max use 1

If either Code List Qualifier Code (III-01) or Industry Code (III-02) is present, then the other is required

If Code Category (III-03) is present, then Injured Body Part Name (III-04) is required

III-01 · 1270 · Code List Qualifier Code · Optional · Identifier (ID)

• GR: National Council on Compensation Insurance (NCCI) Nature of Injury Code
• NI: Nature of Injury Code
• ZZ: Mutually Defined

III-02 · 1271 · Industry Code · Optional · String (AN) · Min 1 Max 30

III-03 · 1136 · Code Category · Optional · Identifier (ID)

• 44: Nature of Injury

III-04 · 933 · Injured Body Part Name · Optional · String (AN) · Min 1 Max 264

3300 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > LS

LS Loop Header

Optional · Max use 1

LS-01 · 447 · Loop Identifier Code · Required · String (AN) · Min 1 Max 6

2120D Dependent Benefit Related Entity Name Loop Optional Max 23

3400 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > NM1

NM1 Dependent Benefit Related Entity Name

Required · Max use 1

If either Identification Code Qualifier (NM1-08) or Benefit Related Entity Identifier (NM1-09) is present, then the other is required

NM1-01 · 98 · Entity Identifier Code · Required · Identifier (ID)

• 1I: Preferred Provider Organization (PPO)
• 1P: Provider
• 2B: Third-Party Administrator
• 13: Contracted Service Provider
• 36: Employer
• 73: Other Physician
• FA: Facility
• GP: Gateway Provider
• GW: Group
• I3: Independent Physicians Association (IPA)
• IL: Insured or Subscriber
• LR: Legal Representative
• OC: Origin Carrier
• P3: Primary Care Provider
• P4: Prior Insurance Carrier
• P5: Plan Sponsor
• PR: Payer
• PRP: Primary Payer
• SEP: Secondary Payer
• TTP: Tertiary Payer
• VER: Party Performing Verification
• VN: Vendor
• VY: Organization Completing Configuration Change
• X3: Utilization Management Organization
• Y2: Managed Care Organization

NM1-02 · 1065 · Entity Type Qualifier · Required · Identifier (ID)

• 1: Person
• 2: Non-Person Entity

NM1-03 · 1035 · Benefit Related Entity Last or Organization Name · Optional · String (AN) · Min 1 Max 60

NM1-04 · 1036 · Benefit Related Entity First Name · Optional · String (AN) · Min 1 Max 35

NM1-05 · 1037 · Benefit Related Entity Middle Name · Optional · String (AN) · Min 1 Max 25

NM1-07 · 1039 · Benefit Related Entity Name Suffix · Optional · String (AN) · Min 1 Max 10

NM1-08 · 66 · Identification Code Qualifier · Optional · Identifier (ID)

• 24: Employer's Identification Number
• 34: Social Security Number
• 46: Electronic Transmitter Identification Number (ETIN)
• FA: Facility Identification
• FI: Federal Taxpayer's Identification Number
• II: Standard Unique Health Identifier for each Individual in the United States
• MI: Member Identification Number
• NI: National Association of Insurance Commissioners (NAIC) Identification
• PI: Payor Identification
• PP: Pharmacy Processor Number
• SV: Service Provider Number
• XV: Centers for Medicare and Medicaid Services PlanID
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

NM1-09 · 67 · Benefit Related Entity Identifier · Optional · String (AN) · Min 2 Max 80

NM1-10 · 706 · Benefit Related Entity Relationship Code · Optional · Identifier (ID)

• 01: Parent
• 02: Child
• 27: Domestic Partner
• 41: Spouse
• 48: Employee
• 65: Other
• 72: Unknown

3600 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > N3

N3 Dependent Benefit Related Entity Address

Optional · Max use 1

N3-01 · 166 · Benefit Related Entity Address Line · Required · String (AN) · Min 1 Max 55

N3-02 · 166 · Benefit Related Entity Address Line · Optional · String (AN) · Min 1 Max 55

3700 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > N4

N4 Dependent Benefit Related Entity City, State, ZIP Code

Optional · Max use 1

Only one of Benefit Related Entity State Code (N4-02) or Benefit Related Entity Country Subdivision Code (N4-07) may be present

If Benefit Related Entity DOD Health Service Region (N4-06) is present, then Benefit Related Entity Location Qualifier (N4-05) is required

If Benefit Related Entity Country Subdivision Code (N4-07) is present, then Benefit Related Entity Country Code (N4-04) is required

N4-01 · 19 · Benefit Related Entity City Name · Required · String (AN) · Min 2 Max 30

N4-02 · 156 · Benefit Related Entity State Code · Optional · Identifier (ID) · Min 2 Max 2

N4-03 · 116 · Benefit Related Entity Postal Zone or ZIP Code · Optional · Identifier (ID) · Min 3 Max 15

N4-04 · 26 · Benefit Related Entity Country Code · Optional · Identifier (ID) · Min 2 Max 3

N4-05 · 309 · Benefit Related Entity Location Qualifier · Optional · Identifier (ID)

• RJ: Region

N4-06 · 310 · Benefit Related Entity DOD Health Service Region · Optional · String (AN) · Min 1 Max 30

N4-07 · 1715 · Benefit Related Entity Country Subdivision Code · Optional · Identifier (ID) · Min 1 Max 3

3800 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > PER

PER Dependent Benefit Related Entity Contact Information

Optional · Max use 3

If either Communication Number Qualifier (PER-03) or Benefit Related Entity Communication Number (PER-04) is present, then the other is required

If either Communication Number Qualifier (PER-05) or Benefit Related Entity Communication Number (PER-06) is present, then the other is required

If either Communication Number Qualifier (PER-07) or Benefit Related Entity Communication Number (PER-08) is present, then the other is required

PER-01 · 366 · Contact Function Code · Required · Identifier (ID)

• IC: Information Contact

PER-02 · 93 · Benefit Related Entity Contact Name · Optional · String (AN) · Min 1 Max 60

PER-03 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)
• WP: Work Phone Number

PER-04 · 364 · Benefit Related Entity Communication Number · Optional · String (AN) · Min 1 Max 256

PER-05 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)
• WP: Work Phone Number

PER-06 · 364 · Benefit Related Entity Communication Number · Optional · String (AN) · Min 1 Max 256

PER-07 · 365 · Communication Number Qualifier · Optional · Identifier (ID)

• ED: Electronic Data Interchange Access Number
• EM: Electronic Mail
• EX: Telephone Extension
• FX: Facsimile
• TE: Telephone
• UR: Uniform Resource Locator (URL)
• WP: Work Phone Number

PER-08 · 364 · Benefit Related Entity Communication Number · Optional · String (AN) · Min 1 Max 256

3900 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > Dependent Benefit Related Entity Name Loop > PRV

PRV Dependent Benefit Related Provider Information

Optional · Max use 1

If either Reference Identification Qualifier (PRV-02) or Benefit Related Entity Provider Taxonomy Code (PRV-03) is present, then the other is required

PRV-01 · 1221 · Provider Code · Required · Identifier (ID)

• AD: Admitting
• AT: Attending
• BI: Billing
• CO: Consulting
• CV: Covering
• H: Hospital
• HH: Home Health Care
• LA: Laboratory
• OT: Other Physician
• P1: Pharmacist
• P2: Pharmacy
• PC: Primary Care Physician
• PE: Performing
• R: Rural Health Clinic
• RF: Referring
• SB: Submitting
• SK: Skilled Nursing Facility
• SU: Supervising

PRV-02 · 128 · Reference Identification Qualifier · Optional · Identifier (ID)

• PXC: Health Care Provider Taxonomy Code

PRV-03 · 127 · Benefit Related Entity Provider Taxonomy Code · Optional · String (AN) · Min 1 Max 50

4000 Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > LE

LE Loop Trailer

Optional · Max use 1

LE-01 · 447 · Loop Identifier Code · Required · String (AN) · Min 1 Max 6

4100 Detail > SE

SE Transaction Set Trailer

Required · Max use 1

SE-01 · 96 · Transaction Segment Count · Required · Numeric (N0) · Min 1 Max 10

SE-02 · 329 · Transaction Set Control Number · Required · Numeric (N) · Min 4 Max 9

GE Functional Group Trailer

Required · Max use 1

GE-01 · 97 · Number of Transaction Sets Included · Required · Numeric (N0) · Min 1 Max 6

GE-02 · 28 · Group Control Number · Required · Numeric (N0) · Min 1 Max 9

IEA Interchange Control Trailer

Required · Max use 1

IEA-01 · I16 · Number of Included Functional Groups · Required · Numeric (N0) · Min 1 Max 5

IEA-02 · I12 · Interchange Control Number · Required · Numeric (N0) · Min 9 Max 9

EDI Samples

Example 1a: Response to a Generic Request by a Clinic for the Patient’s (Subscriber) Eligibility

ST*271*4321*005010X279A1~
BHT*0022*11*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
HL*3*2*22*0~
TRN*2*93175-012547*9877281234~
NM1*IL*1*SMITH*JOHN****MI*123456789~
N3*15197 BROADWAY AVENUE*APT 215~
N4*KANSAS CITY*MO*64108~
DMG*D8*19630519*M~
DTP*346*D8*20060101~
EB*1**30**GOLD 123 PLAN~
EB*L~
EB*1**1^33^35^47^86^88^98^AL^MH^UC~
EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*10*****Y~
EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*30*****N~
LS*2120~
NM1*P3*1*JONES*MARCUS****SV*0202034~
LE*2120~
SE*22*4321~

Example 1b: Error Response from Payer to Clinic Not Eligible for Inquiries with Payer

ST*271*4323*005010X279A1~
BHT*0022*11*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
AAA*Y**50*N~
SE*8*4323~

Example 2: Response to a Generic Request by a Physician for the Patient’s (Dependent) Eligibility

ST*271*4322*005010X279A1~
BHT*0022*11*10001235*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
HL*3*2*22*1~
NM1*IL*1*SMITH*JOHN****MI*123456789~
N3*15197 BROADWAY AVENUE*APT 215~
N4*KANSAS CITY*MO*64108~
DMG*D8*19630519*M~
HL*4*3*23*0~
TRN*2*93175-012547*9877281234~
NM1*03*1*SMITH*MARY~
N3*15197 BROADWAY AVENUE*APT 215~
N4*KANSAS CITY*MO*64108~
DMG*D8*19981014*F~
INS*N*19~
DTP*346*D8*20060101~
EB*1**30**GOLD 123 PLAN~
EB*L~
EB*1**1^33^35^47^86^88^98^AL^MH^UC~
EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*10*****Y~
EB*B**1^33^35^47^86^88^98^AL^MH^UC*HM*GOLD 123 PLAN*27*30*****N~
LS*2120~
NM1*P3*1*JONES*MARCUS****SV*0202034~
LE*2120~
SE*28*4322~

sample 1

ISA*00*          *00*          *01*030240928      *ZZ*AV09311993     *221206*2245*^*00501*500292536*0*P*:~
GS*HB*030240928*AV01101957*20221206*2245*375976250*X*005010X279A1~
ST*271*1001*005010X279A1~
BHT*0022*11*10001234*20221206*2237~
HL*1**20*1~
NM1*PR*2*ANTHEM BLUE CROSS*****PI*040~
HL*2*1*21*1~
NM1*1P*2*PLACEHOLDER*****XX*1234567890~
HL*3*2*22*0~
TRN*2*A11A1111-A1A1-1A1A-A1A1-11AAA1AAAA1A*1111111111~
NM1*IL*1*SMITH*JOHN****MI*AAA000A00000~
REF*3H*1AAA~
REF*6P*00000A000*TECH BENEFITS PROGRAM COBRA~
REF*18*040*TECH BENEFITS PROGRAM COBRA~
N3*111 MARKET ST~
N4*BROOKLYN*NY*11111~
DMG*D8*19990909*M~
INS*Y*18~
DTP*291*RD8*20210701-20221231~
EB*1*IND*30*PR*CA GENERIC HLTH SAVINGS ACCT~
EB*D~
DTP*292*RD8*20221001-20221231~
MSG*FOR ALL SERVICES WITH HSA PLANS, THE DEDUCTIBLE MUST BE MET PRIOR TO APPLYING ANY COPAYMENT. REMINDER, PATIENT MAY HAVE HRA/HSA DOLLARS THAT CAN BE APPLIED TOWARDS THEIR DEDUCTIBLE AND OUT OF POCKET EXPENSES.~
EB*D***********Y~
DTP*292*RD8*20221001-20221231~
MSG*THIS MEMBER HAS CHRONIC PREVENTATIVE BENEFIT SERVICES FOR DIABETES, HYPERTENSION, ASTHMA, AND LIVER DISEASE/BLEEDING DISORDERS, WHICH MAY HAVE LOWER MEMBER COST SHARES.  CALL ANTHEM FOR MORE DETAILS.~
EB*D~
DTP*292*RD8*20221001-20221231~
MSG*INTERPROFESSIONAL CONSULTATION~
EB*1**AL^BZ^MH^UC^1^33^47^48^50^51^52^86^88^98*********W~
DTP*292*RD8*20221001-20221231~
EB*A*IND*BZ^UC^33^98*****.3****N~
DTP*292*RD8*20221001-20221231~
EB*A*IND*BZ^UC^33^98*****0****Y~
DTP*292*RD8*20221001-20221231~
EB*C*IND*BZ***23*0*****Y~
DTP*292*RD8*20221001-20221231~
EB*A*IND*98*****.3****N~
DTP*292*RD8*20221001-20221231~
MSG*SPECIALIST~
EB*A*IND*98*****0****Y~
DTP*292*RD8*20221001-20221231~
MSG*SPECIALIST~
EB*1**98*********W~
DTP*292*RD8*20221001-20221231~
MSG*SPECIALIST~
EB*C*IND*30***23*1111*****W~
DTP*291*RD8*20221001-20221231~
EB*C*IND*30***29*1111*****W~
DTP*291*RD8*20221001-20221231~
EB*G*IND*30***23*1111*****N~
DTP*292*RD8*20221001-20221231~
EB*G*IND*30***29*1111*****N~
EB*G*IND*30***23*1111*****Y~
DTP*292*RD8*20221001-20221231~
EB*G*IND*30***29*1111*****Y~
EB*F**33***23***VS*30**W~
DTP*292*RD8*20221001-20221231~
EB*F**33***29***VS*30**W~
EB*A*IND*47*****.3****N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*19~
EB*A*IND*47*****.3****N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*22~
EB*A*IND*47*****.3***U*N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM MUSCULOSKELETAL PROGRAM PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*21~
EB*A*IND*47*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM MUSCULOSKELETAL PROGRAM PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*21~
LS*2120~
NM1*X3*2*AIM SPECIALTY HEALTH~
PER*IC**TE*8000000000~
NM1*X3*2*UTILIZATION MANAGEMENT~
PER*IC**TE*8000000000~
LE*2120~
EB*A*IND*47*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*19~
EB*A*IND*47*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
III*ZZ*22~
EB*A*IND*48*****.3***U*N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM MUSCULOSKELETAL PROGRAM PROCEDURES ON ANTHEM.COM CONTACT AIM~
EB*A*IND*48*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM MUSCULOSKELETAL PROGRAM PROCEDURES ON ANTHEM.COM CONTACT AIM~
LS*2120~
NM1*X3*2*AIM SPECIALTY HEALTH~
PER*IC**TE*8000000000~
NM1*X3*2*UTILIZATION MANAGEMENT~
PER*IC**TE*8000000000~
LE*2120~
EB*A*IND*50*****.3****N~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
EB*A*IND*50*****0***U*Y~
DTP*292*RD8*20221001-20221231~
MSG*IF AIM SURGICAL UM REVIEW PROCEDURES ON ANTHEM.COM CONTACT AIM~
LS*2120~
NM1*X3*2*AIM SPECIALTY HEALTH~
PER*IC**TE*8000000000~
LE*2120~
EB*A*IND*51^52^86*****0****W~
DTP*292*RD8*20221001-20221231~
EB*P~
MSG*UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITS AND THE MEMBER'S STATUS ON THE DATE OF SERVICE. ACCUMULATED AMOUNTS SUCH AS DEDUCTIBLE MAY CHANGE AS ADDITIONAL CLAIMS ARE PROCESSED.~
SE*114*1001~
GE*1*375976250~
IEA*1*500292536~