X12 834 Benefit Enrollment and Maintenance (X220A1)

Transaction Set Policy Number

Functional Group Header

Transaction Set Header

Transaction Set Control Totals

TPA/Broker Account Information Loop

ACT

1200

TPA/Broker Account Information

Member Supplemental Identifier

detail

Member Level Detail Loop

Subscriber Identifier

Member Communications Numbers

Member Residence Street Address

Member City, State, ZIP Code

Member Policy Amounts

Member Health Information

Incorrect Member Name Loop

NM1

0300

Incorrect Member Name

Incorrect Member Demographics

Member Mailing Address Loop

NM1

0300

Member Mailing Address

Member Mail Street Address

Member Mail City, State, ZIP Code

Member Employer Communications Numbers

Member Employer Street Address

Member Employer City, State, ZIP Code

Member School Commmunications Numbers

Member School Street Address

Member School City, State, ZIP Code

Custodial Parent Communications Numbers

Custodial Parent Loop

Custodial Parent Street Address

Custodial Parent City, State, ZIP Code

Responsible Person Communications Numbers

Responsible Person Loop

Responsible Person Street Address

Responsible Person City, State, ZIP Code

Drop Off Location Street Address

Drop Off Location Loop

Drop Off Location City, State, ZIP Code

Disability Information Loop

DSB

2000

Disability Information

Disability Eligibility Dates

Health Coverage Dates

Health Coverage Policy

Health Coverage Policy Number

Prior Coverage Months

Provider Information Loop

Provider City, State, ZIP Code

Provider Communications Numbers

Provider Change Reason

Coordination of Benefits Loop

COB

4000

Coordination of Benefits

Additional Coordination of Benefits Identifiers

Coordination of Benefits Eligibility Dates

Max use 2

Coordination of Benefits Related Entity Loop

NM1

4100

Coordination of Benefits Related Entity

Coordination of Benefits Related Entity Address

4300

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

4400

Administrative Communications Contact

Member Reporting Categories Loop

6881

Member Reporting Categories

Reporting Category Reference

Reporting Category Loop

Reporting Category Date

Transaction Set Trailer

Functional Group Trailer

Interchange Control Trailer

IEA

ISA

Interchange Control Header

RequiredMax use 1

—

Example

ISA-01

I01

Authorization Information Qualifier

Required

Identifier (ID)

—

00: No Authorization Information Present (No Meaningful Information in I02)

ISA-02

I02

Authorization Information

Required

String (AN)

Min 10Max 10

—

ISA-03

I03

Security Information Qualifier

Required

Identifier (ID)

—

00: No Security Information Present (No Meaningful Information in I04)

ISA-04

I04

Security Information

Required

String (AN)

Min 10Max 10

—

ISA-05

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 2

—

Codes

01: Duns (Dun & Bradstreet)
02: SCAC (Standard Carrier Alpha Code)
03: FMC (Federal Maritime Commission)
04: IATA (International Air Transport Association)
07: Global Location Number (GLN)
08: UCC EDI Communications ID (Comm ID)
09: X.121 (CCITT)
10: Department of Defense (DoD) Activity Address Code
11: DEA (Drug Enforcement Administration)
12: Phone (Telephone Companies)
13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
14: Duns Plus Suffix
15: Petroleum Accountants Society of Canada Company Code
16: Duns Number With 4-Character Suffix
17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
18: Association of American Railroads (AAR) Standard Distribution Code
19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
20: Health Industry Number (HIN)
21: Integrated Postsecondary Education Data System, or (IPEDS)
22: Federal Interagency Commission on Education, or FICE
23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
26: Statistics of Canada List of Postsecondary Institutions
27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
30: U.S. Federal Tax Identification Number
31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
32: U.S. Federal Employer Identification Number (FEIN)
33: National Association of Insurance Commissioners Company Code (NAIC)
34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
35: Statistics Canada Canadian College Student Information System Institution Codes
36: Statistics Canada University Student Information System Institution Codes
37: Society of Property Information Compilers and Analysts
38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
NR: National Retail Merchants Association (NRMA) - Assigned
SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
SN: Standard Address Number
ZZ: Mutually Defined

ISA-06

I06

Interchange Sender ID

Required

String (AN)

Min 15Max 15

—

ISA-07

I05

Interchange ID Qualifier

Required

Identifier (ID)

Min 2Max 2

—

Codes

01: Duns (Dun & Bradstreet)
02: SCAC (Standard Carrier Alpha Code)
03: FMC (Federal Maritime Commission)
04: IATA (International Air Transport Association)
07: Global Location Number (GLN)
08: UCC EDI Communications ID (Comm ID)
09: X.121 (CCITT)
10: Department of Defense (DoD) Activity Address Code
11: DEA (Drug Enforcement Administration)
12: Phone (Telephone Companies)
13: UCS Code (The UCS Code is a Code Used for UCS Transmissions; it includes the Area Code and Telephone Number of a Modem; it Does Not Include Punctuation, Blanks or Access Code)
14: Duns Plus Suffix
15: Petroleum Accountants Society of Canada Company Code
16: Duns Number With 4-Character Suffix
17: American Bankers Association (ABA) Transit Routing Number (Including Check Digit, 9 Digit)
18: Association of American Railroads (AAR) Standard Distribution Code
19: EDI Council of Australia (EDICA) Communications ID Number (COMM ID)
20: Health Industry Number (HIN)
21: Integrated Postsecondary Education Data System, or (IPEDS)
22: Federal Interagency Commission on Education, or FICE
23: National Center for Education Statistics Common Core of Data 12-Digit Number for Pre-K-Grade 12 Institutes, or NCES
24: The College Board's Admission Testing Program 4-Digit Code of Postsecondary Institutes, or ATP
25: ACT, Inc. 4-Digit Code of Postsecondary Institutions.
26: Statistics of Canada List of Postsecondary Institutions
27: Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)
28: Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)
29: Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)
30: U.S. Federal Tax Identification Number
31: Jurisdiction Identification Number Plus 4 as assigned by the International Association of Industrial Accident Boards and Commissions (IAIABC)
32: U.S. Federal Employer Identification Number (FEIN)
33: National Association of Insurance Commissioners Company Code (NAIC)
34: Medicaid Provider and Supplier Identification Number as assigned by individual State Medicaid Agencies in conjunction with Health Care Financing Administration (HCFA)
35: Statistics Canada Canadian College Student Information System Institution Codes
36: Statistics Canada University Student Information System Institution Codes
37: Society of Property Information Compilers and Analysts
38: The College Board and ACT, Inc. 6-Digit Code List of Secondary Institutions
AM: Association Mexicana del Codigo de Producto (AMECOP) Communication ID
NR: National Retail Merchants Association (NRMA) - Assigned
SA: User Identification Number as assigned by the Safety and Fitness Electronic Records (SAFER) System
SN: Standard Address Number
ZZ: Mutually Defined

ISA-08

I07

Interchange Receiver ID

Required

String (AN)

Min 15Max 15

—

ISA-09

I08

Interchange Date

Required

Date (DT)

YYMMDD format

—

ISA-10

I09

Interchange Time

Required

Time (TM)

HHMM format

—

ISA-11

I65

Repetition Separator

Required

String (AN)

Min 1Max 1

—

^: Repetition Separator

ISA-12

I11

Interchange Control Version Number

Required

Identifier (ID)

—

00501: Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

ISA-13

I12

Interchange Control Number

Required

Numeric (N0)

Min 9Max 9

—

ISA-14

I13

Acknowledgment Requested

Required

Identifier (ID)

Min 1Max 1

—

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

ISA-15

I14

Interchange Usage Indicator

Required

Identifier (ID)

Min 1Max 1

—

I: Information
P: Production Data
T: Test Data

ISA-16

I15

Component Element Separator

Required

String (AN)

Min 1Max 1

—

>: Component Element Separator

Functional Group Header

RequiredMax use 1

—

Example

GS-01

479

Functional Identifier Code

Required

Identifier (ID)

—

BE: Benefit Enrollment and Maintenance (834)

GS-02

142

Application Sender's Code

Required

String (AN)

Min 2Max 15

—

GS-03

124

Application Receiver's Code

Required

String (AN)

Min 2Max 15

—

GS-04

373

Date

Required

Date (DT)

CCYYMMDD format

—

GS-05

337

Time

Required

Time (TM)

HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

—

GS-06

Group Control Number

Required

Numeric (N0)

Min 1Max 9

—

GS-07

455

Responsible Agency Code

Required

Identifier (ID)

Min 1Max 2

—

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

GS-08

480

Version / Release / Industry Identifier Code

Required

String (AN)

—

005010X220A1

Heading

0100

Heading > ST

Transaction Set Header

RequiredMax use 1

—

Example

ST-01

143

Transaction Set Identifier Code

Required

Identifier (ID)

—

834: Benefit Enrollment and Maintenance

ST-02

329

Transaction Set Control Number

Required

Numeric (N)

Min 4Max 9

—

Usage notes

—

ST-03

1705

Implementation Convention Reference

Required

String (AN)

—

Usage notes

—

005010X220A1

BGN

0200

Heading > BGN

Beginning Segment

RequiredMax use 1

—

Example

BGN-01

353

Transaction Set Purpose Code

Required

Identifier (ID)

—

00: Original
—
15: Re-Submission
—
22: Information Copy
—

BGN-02

127

Transaction Set Reference Number

Required

String (AN)

Min 1Max 50

—

Usage notes

—

BGN-03

373

Transaction Set Creation Date

Required

Date (DT)

CCYYMMDD format

—

Usage notes

—

BGN-04

337

Transaction Set Creation Time

Required

Time (TM)

HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

—

Usage notes

—

BGN-05

623

Time Zone Code

Optional

Identifier (ID)

—

01: Equivalent to ISO P01
02: Equivalent to ISO P02
03: Equivalent to ISO P03
04: Equivalent to ISO P04
05: Equivalent to ISO P05
06: Equivalent to ISO P06
07: Equivalent to ISO P07
08: Equivalent to ISO P08
09: Equivalent to ISO P09
10: Equivalent to ISO P10
11: Equivalent to ISO P11
12: Equivalent to ISO P12
13: Equivalent to ISO M12
14: Equivalent to ISO M11
15: Equivalent to ISO M10
16: Equivalent to ISO M09
17: Equivalent to ISO M08
18: Equivalent to ISO M07
19: Equivalent to ISO M06
20: Equivalent to ISO M05
21: Equivalent to ISO M04
22: Equivalent to ISO M03
23: Equivalent to ISO M02
24: Equivalent to ISO M01
AD: Alaska Daylight Time
AS: Alaska Standard Time
AT: Alaska Time
CD: Central Daylight Time
CS: Central Standard Time
CT: Central Time
ED: Eastern Daylight Time
ES: Eastern Standard Time
ET: Eastern Time
GM: Greenwich Mean Time
HD: Hawaii-Aleutian Daylight Time
HS: Hawaii-Aleutian Standard Time
HT: Hawaii-Aleutian Time
LT: Local Time
MD: Mountain Daylight Time
MS: Mountain Standard Time
MT: Mountain Time
ND: Newfoundland Daylight Time
NS: Newfoundland Standard Time
NT: Newfoundland Time
PD: Pacific Daylight Time
PS: Pacific Standard Time
PT: Pacific Time
TD: Atlantic Daylight Time
TS: Atlantic Standard Time
TT: Atlantic Time
UT: Universal Time Coordinate

BGN-06

127

Original Transaction Set Reference Number

Optional

String (AN)

Min 1Max 50

—

BGN-08

306

Action Code

Required

Identifier (ID)

—

2: Change (Update)
—
4: Verify
—
RX: Replace
—

REF

0300

Heading > REF

Transaction Set Policy Number

OptionalMax use 1

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

38: Master Policy Number

127

Master Policy Number

Required

String (AN)

Min 1Max 50

—

DTP

0400

Heading > DTP

File Effective Date

OptionalMax use >1

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

007: Effective
090: Report Start
091: Report End
303: Maintenance Effective
382: Enrollment
388: Payment Commencement

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

Payer Loop TPA/Broker Name Loop

1251

Date Time Period

Required

String (AN)

Min 1Max 35

—

QTY

0600

Heading > QTY

Transaction Set Control Totals

OptionalMax use 3

—

Usage notes

—

Example

QTY-01

673

Quantity Qualifier

Required

Identifier (ID)

—

DT: Dependent Total
ET: Employee Total
TO: Total

QTY-02

380

Record Totals

Required

Decimal number (R)

Min 1Max 15

—

1000A Sponsor Name Loop

RequiredMax 1

Variants (all may be used)

0700

Heading > Sponsor Name Loop > N1

Sponsor Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

P5: Plan Sponsor

Sponsor Name Loop TPA/Broker Name Loop

Plan Sponsor Name

Optional

String (AN)

Min 1Max 60

—

N1-03

Identification Code Qualifier

Required

Identifier (ID)

—

24: Employer's Identification Number
—
94: Code assigned by the organization that is the ultimate destination of the transaction set
FI: Federal Taxpayer's Identification Number

N1-04

Sponsor Identifier

Required

String (AN)

Min 2Max 80

—

1000A Sponsor Name Loop end

1000B Payer Loop

RequiredMax 1

Variants (all may be used)

0700

Heading > Payer Loop > N1

Payer

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

IN: Insurer

Sponsor Name Loop Payer Loop

Insurer Name

Optional

String (AN)

Min 1Max 60

—

N1-03

Identification Code Qualifier

Required

Identifier (ID)

—

94: Code assigned by the organization that is the ultimate destination of the transaction set
FI: Federal Taxpayer's Identification Number
XV: Centers for Medicare and Medicaid Services PlanID
—

N1-04

Insurer Identification Code

Required

String (AN)

Min 2Max 80

—

1000B Payer Loop end

1000C TPA/Broker Name Loop

OptionalMax 2

Variants (all may be used)

0700

Heading > TPA/Broker Name Loop > N1

TPA/Broker Name

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

BO: Broker or Sales Office
TV: Third Party Administrator (TPA)

REFMember Policy Number REFMember Supplemental Identifier

TPA or Broker Name

Required

String (AN)

Min 1Max 60

—

N1-03

Identification Code Qualifier

Required

Identifier (ID)

—

94: Code assigned by the organization that is the ultimate destination of the transaction set
FI: Federal Taxpayer's Identification Number
XV: Centers for Medicare and Medicaid Services PlanID
—

N1-04

TPA or Broker Identification Code

Required

String (AN)

Min 2Max 80

—

1100C TPA/Broker Account Information Loop

OptionalMax 1

ACT

1200

Heading > TPA/Broker Name Loop > TPA/Broker Account Information Loop > ACT

TPA/Broker Account Information

RequiredMax use 1

—

Usage notes

—

Example

ACT-01

508

TPA or Broker Account Number

Required

String (AN)

Min 1Max 35

—

ACT-06

508

TPA or Broker Account Number

Optional

String (AN)

Min 1Max 35

—

1100C TPA/Broker Account Information Loop end

1000C TPA/Broker Name Loop end

Heading end

Detail

2000 Member Level Detail Loop

RequiredMax >1

INS

0100

Detail > Member Level Detail Loop > INS

Member Level Detail

RequiredMax use 1

—

Usage notes

—

Example

If either Date Time Period Format Qualifier (INS-11) or Member Individual Death Date (INS-12) is present, then the other is required

INS-01

1073

Member Indicator

Required

Identifier (ID)

—

N: No
Y: Yes

INS-02

1069

Individual Relationship Code

Required

Identifier (ID)

—

Usage notes

—

01: Spouse
03: Father or Mother
04: Grandfather or Grandmother
05: Grandson or Granddaughter
06: Uncle or Aunt
07: Nephew or Niece
08: Cousin
09: Adopted Child
10: Foster Child
11: Son-in-law or Daughter-in-law
12: Brother-in-law or Sister-in-law
13: Mother-in-law or Father-in-law
14: Brother or Sister
15: Ward
16: Stepparent
17: Stepson or Stepdaughter
18: Self
19: Child
23: Sponsored Dependent
—
24: Dependent of a Minor Dependent
25: Ex-spouse
26: Guardian
31: Court Appointed Guardian
38: Collateral Dependent
—
53: Life Partner
—
60: Annuitant
D2: Trustee
G8: Other Relationship
G9: Other Relative

INS-03

875

Maintenance Type Code

Required

Identifier (ID)

—

001: Change
—
021: Addition
—
024: Cancellation or Termination
—
025: Reinstatement
—
030: Audit or Compare
—

INS-04

1203

Maintenance Reason Code

Optional

Identifier (ID)

—

01: Divorce
02: Birth
03: Death
04: Retirement
05: Adoption
06: Strike
07: Termination of Benefits
08: Termination of Employment
09: Consolidation Omnibus Budget Reconciliation Act (COBRA)
10: Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
11: Surviving Spouse
14: Voluntary Withdrawal
15: Primary Care Provider (PCP) Change
16: Quit
17: Fired
18: Suspended
20: Active
21: Disability
22: Plan Change
—
25: Change in Identifying Data Elements
—
26: Declined Coverage
—
27: Pre-Enrollment
—
28: Initial Enrollment
—
29: Benefit Selection
—
31: Legal Separation
32: Marriage
33: Personnel Data
—
37: Leave of Absence with Benefits
38: Leave of Absence without Benefits
39: Lay Off with Benefits
40: Lay Off without Benefits
41: Re-enrollment
43: Change of Location
—
59: Non Payment
AA: Dissatisfaction with Office Staff
AB: Dissatisfaction with Medical Care/Services Rendered
AC: Inconvenient Office Location
AD: Dissatisfaction with Office Hours
AE: Unable to Schedule Appointments in a Timely Manner
AF: Dissatisfaction with Physician's Referral Policy
AG: Less Respect and Attention Time Given than to Other Patients
AH: Patient Moved to a New Location
AI: No Reason Given
AJ: Appointment Times not Met in a Timely Manner
AL: Algorithm Assigned Benefit Selection
EC: Member Benefit Selection
—
XN: Notification Only
—
XT: Transfer
—

INS-05

1216

Benefit Status Code

Required

Identifier (ID)

—

A: Active
C: Consolidated Omnibus Budget Reconciliation Act (COBRA)
S: Surviving Insured
T: Tax Equity and Fiscal Responsibility Act (TEFRA)

INS-06

C052

Medicare Status Code

OptionalMax use 1

To provide Medicare coverage and associated reason for Medicare eligibility

Usage notes

—

C052-01

1218

Medicare Plan Code

Required

Identifier (ID)

—

A: Medicare Part A
B: Medicare Part B
C: Medicare Part A and B
D: Medicare
E: No Medicare

C052-02

1701

Medicare Eligibility Reason Code

Optional

Identifier (ID)

—

0: Age
1: Disability
2: End Stage Renal Disease (ESRD)

INS-07

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code

Optional

Identifier (ID)

—

1: Termination of Employment
2: Reduction of work hours
3: Medicare
4: Death
5: Divorce
6: Separation
7: Ineligible Child
8: Bankruptcy of Retiree's Former Employer (26 U.S.C. 4980B(f)(3)(F))
9: Layoff
10: Leave of Absence
ZZ: Mutually Defined

INS-08

584

Employment Status Code

Optional

Identifier (ID)

—

Usage notes

—

AC: Active
AO: Active Military - Overseas
AU: Active Military - USA
FT: Full-time
—
L1: Leave of Absence
PT: Part-time
—
RT: Retired
TE: Terminated

INS-09

1220

Student Status Code

Optional

Identifier (ID)

—

F: Full-time
N: Not a Student
P: Part-time

INS-10

1073

Handicap Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

INS-11

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

INS-12

1251

Member Individual Death Date

Optional

String (AN)

Min 1Max 35

—

INS-13

1165

Confidentiality Code

Optional

Identifier (ID)

—

R: Restricted Access
U: Unrestricted Access

INS-17

1470

Birth Sequence Number

Optional

Numeric (N0)

Min 1Max 9

—

REF

0200

Detail > Member Level Detail Loop > REF

Subscriber Identifier

RequiredMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

0F: Subscriber Number
—

REFSubscriber Identifier REFMember Supplemental Identifier

127

Subscriber Identifier

Required

String (AN)

Min 1Max 50

—

REF

0200

Detail > Member Level Detail Loop > REF

Member Policy Number

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

1L: Group or Policy Number
—

REFSubscriber Identifier REFMember Policy Number

127

Member Group or Policy Number

Required

String (AN)

Min 1Max 50

—

REF

0200

Detail > Member Level Detail Loop > REF

Member Supplemental Identifier

OptionalMax use 13

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

3H: Case Number
4A: Personal Identification Number (PIN)
—
6O: Cross Reference Number
—
17: Client Reporting Category
—
23: Client Number
—
ABB: Personal ID Number
D3: National Council for Prescription Drug Programs Pharmacy Number
DX: Department/Agency Number
—
F6: Health Insurance Claim (HIC) Number
—
P5: Position Code
—
Q4: Prior Identifier Number
—
QQ: Unit Number
—
ZZ: Mutually Defined

127

Member Supplemental Identifier

Required

String (AN)

Min 1Max 50

—

DTP

0250

Detail > Member Level Detail Loop > DTP

Member Level Dates

OptionalMax use 24

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

050: Received
—
286: Retirement
296: Initial Disability Period Return To Work
297: Initial Disability Period Last Day Worked
300: Enrollment Signature Date
301: Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event
303: Maintenance Effective
—
336: Employment Begin
337: Employment End
338: Medicare Begin
339: Medicare End
340: Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
341: Consolidated Omnibus Budget Reconciliation Act (COBRA) End
350: Education Begin
—
351: Education End
—
356: Eligibility Begin
—
357: Eligibility End
—
383: Adjusted Hire
385: Credited Service Begin
—
386: Credited Service End
—
393: Plan Participation Suspension
394: Rehire
473: Medicaid Begin
474: Medicaid End

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

Incorrect Member Name Loop Member Mailing Address Loop Member Employer Loop Member School Loop Custodial Parent Loop Responsible Person Loop Drop Off Location Loop

1251

Status Information Effective Date

Required

String (AN)

Min 1Max 35

—

2100A Member Name Loop

RequiredMax 1

Variants (all may be used)

NM1

0300

Detail > Member Level Detail Loop > Member Name Loop > NM1

Member Name

RequiredMax use 1

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

Usage notes

—

74: Corrected Insured
—
IL: Insured or Subscriber
—

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Member Last Name

Required

String (AN)

Min 1Max 60

—

1036

Member First Name

Optional

String (AN)

Min 1Max 35

—

1037

Member Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Member Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Member Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

34: Social Security Number
—
ZZ: Mutually Defined
—

Member Identifier

Optional

String (AN)

Min 2Max 80

—

PER

0400

Detail > Member Level Detail Loop > Member Name Loop > PER

Member Communications Numbers

OptionalMax use 1

—

Usage notes

—

Example

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

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

366

Contact Function Code

Required

Identifier (ID)

—

IP: Insured Party

365

Communication Number Qualifier

Required

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Required

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

0500

Detail > Member Level Detail Loop > Member Name Loop > N3

Member Residence Street Address

OptionalMax use 1

—

Usage notes

—

Example

166

Member Address Line

Required

String (AN)

Min 1Max 55

—

166

Member Address Line

Optional

String (AN)

Min 1Max 55

—

0600

Detail > Member Level Detail Loop > Member Name Loop > N4

Member City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

If Location Identifier (N4-06) is present, then Location Qualifier (N4-05) is required

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

Member City Name

Required

String (AN)

Min 2Max 30

—

156

Member State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Member Postal Zone or Zip Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

N4-05

309

Location Qualifier

Optional

Identifier (ID)

—

60: Area
CY: County/Parish

N4-06

310

Location Identifier

Optional

String (AN)

Min 1Max 30

—

Member Name Loop Member Mailing Address Loop Member Employer Loop Member School Loop Custodial Parent Loop Responsible Person Loop Drop Off Location Loop

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

DMG

0800

Detail > Member Level Detail Loop > Member Name Loop > DMG

Member Demographics

OptionalMax use 1

—

Usage notes

—

Example

If either Code List Qualifier Code (DMG-10) or Race or Ethnicity Collection Code (DMG-11) is present, then the other is required

If Race or Ethnicity Collection Code (DMG-11) is present, then Composite Race or Ethnicity Information (DMG-05) is required

DMG-01

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DMG-02

1251

Member Birth Date

Required

String (AN)

Min 1Max 35

—

DMG-03

1068

Gender Code

Required

Identifier (ID)

—

F: Female
M: Male
U: Unknown
—

DMG-04

1067

Marital Status Code

Optional

Identifier (ID)

—

B: Registered Domestic Partner
D: Divorced
I: Single
M: Married
R: Unreported
S: Separated
U: Unmarried (Single or Divorced or Widowed)
—
W: Widowed
X: Legally Separated

DMG-05

C056

Composite Race or Ethnicity Information

OptionalMax use 10

To send general and detailed information on race or ethnicity

Usage notes

—

If either Code List Qualifier Code (C056-02) or Race or Ethnicity Code (C056-03) is present, then the other is required

C056-01

1109

Race or Ethnicity Code

Optional

Identifier (ID)

—

7: Not Provided
8: Not Applicable
A: Asian or Pacific Islander
B: Black
C: Caucasian
D: Subcontinent Asian American
E: Other Race or Ethnicity
F: Asian Pacific American
G: Native American
H: Hispanic
I: American Indian or Alaskan Native
J: Native Hawaiian
N: Black (Non-Hispanic)
O: White (Non-Hispanic)
P: Pacific Islander
Z: Mutually Defined

C056-02

1270

Code List Qualifier Code

Optional

Identifier (ID)

—

RET: Classification of Race or Ethnicity

C056-03

1271

Race or Ethnicity Code

Optional

String (AN)

Min 1Max 30

—

Usage notes

—

DMG-06

1066

Citizenship Status Code

Optional

Identifier (ID)

—

1: U.S. Citizen
2: Non-Resident Alien
3: Resident Alien
4: Illegal Alien
5: Alien
6: U.S. Citizen - Non-Resident
7: U.S. Citizen - Resident

DMG-10

1270

Code List Qualifier Code

Optional

Identifier (ID)

—

REC: Race or Ethnicity Collection Code

DMG-11

1271

Race or Ethnicity Collection Code

Optional

String (AN)

Min 1Max 30

—

1000

Detail > Member Level Detail Loop > Member Name Loop > EC

Employment Class

OptionalMax use >1

—

Usage notes

—

Example

EC-01

1176

Employment Class Code

Required

Identifier (ID)

—

01: Union
02: Non-Union
03: Executive
04: Non-Executive
05: Management
06: Non-Management
07: Hourly
08: Salaried
09: Administrative
10: Non-Administrative
11: Exempt
12: Non-Exempt
17: Highly Compensated
18: Key-Employee
19: Bargaining
20: Non-Bargaining
21: Owner
22: President
23: Vice President

EC-02

1176

Employment Class Code

Optional

Identifier (ID)

—

01: Union
02: Non-Union
03: Executive
04: Non-Executive
05: Management
06: Non-Management
07: Hourly
08: Salaried
09: Administrative
10: Non-Administrative
11: Exempt
12: Non-Exempt
17: Highly Compensated
18: Key-Employee
19: Bargaining
20: Non-Bargaining
21: Owner
22: President
23: Vice President

EC-03

1176

Employment Class Code

Optional

Identifier (ID)

—

01: Union
02: Non-Union
03: Executive
04: Non-Executive
05: Management
06: Non-Management
07: Hourly
08: Salaried
09: Administrative
10: Non-Administrative
11: Exempt
12: Non-Exempt
17: Highly Compensated
18: Key-Employee
19: Bargaining
20: Non-Bargaining
21: Owner
22: President
23: Vice President

ICM

1100

Detail > Member Level Detail Loop > Member Name Loop > ICM

Member Income

OptionalMax use 1

—

Usage notes

—

Example

ICM-01

594

Frequency Code

Required

Identifier (ID)

—

1: Weekly
2: Biweekly
3: Semimonthly
4: Monthly
6: Daily
7: Annual
8: Two Calendar Months
9: Lump-Sum Separation Allowance
B: Year-to-Date
C: Single
H: Hourly
Q: Quarterly
S: Semiannual
U: Unknown

ICM-02

782

Wage Amount

Required

Decimal number (R)

Min 1Max 15

—

ICM-03

380

Work Hours Count

Optional

Decimal number (R)

Min 1Max 15

—

ICM-04

310

Location Identification Code

Optional

String (AN)

Min 1Max 30

—

ICM-05

1214

Salary Grade Code

Optional

String (AN)

Min 1Max 5

—

AMT

1200

Detail > Member Level Detail Loop > Member Name Loop > AMT

Member Policy Amounts

OptionalMax use 7

—

Usage notes

—

Example

AMT-01

522

Amount Qualifier Code

Required

Identifier (ID)

—

B9: Co-insurance - Actual
—
C1: Co-Payment Amount
D2: Deductible Amount
EBA: Expected Expenditure Amount
FK: Other Unlisted Amount
P3: Premium Amount
R: Spend Down

AMT-02

782

Contract Amount

Required

Decimal number (R)

Min 1Max 15

—

HLH

1300

Detail > Member Level Detail Loop > Member Name Loop > HLH

Member Health Information

OptionalMax use 1

—

Usage notes

—

Example

HLH-01

1212

Health Related Code

Required

Identifier (ID)

—

N: None
S: Substance Abuse
T: Tobacco Use
U: Unknown
X: Tobacco Use and Substance Abuse

HLH-02

Member Height

Optional

Decimal number (R)

Min 1Max 8

—

Usage notes

—

HLH-03

Member Weight

Optional

Decimal number (R)

Min 1Max 10

—

LUI

1500

Detail > Member Level Detail Loop > Member Name Loop > LUI

Member Language

OptionalMax use >1

—

Usage notes

—

Example

If either Identification Code Qualifier (LUI-01) or Language Code (LUI-02) is present, then the other is required

If Language Use Indicator (LUI-04) is present, then at least one of Language Code (LUI-02) or Language Description (LUI-03) is required

LUI-01

Identification Code Qualifier

Optional

Identifier (ID)

—

LD: NISO Z39.53 Language Codes
LE: ISO 639 Language Codes

LUI-02

Language Code

Optional

String (AN)

Min 2Max 80

—

LUI-03

352

Language Description

Optional

String (AN)

Min 1Max 80

—

LUI-04

1303

Language Use Indicator

Optional

Identifier (ID)

—

5: Language Reading
6: Language Writing
7: Language Speaking
8: Native Language

2100A Member Name Loop end

2100B Incorrect Member Name Loop

OptionalMax 1

Variants (all may be used)

NM1

0300

Detail > Member Level Detail Loop > Incorrect Member Name Loop > NM1

Incorrect Member Name

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

Usage notes

—

70: Prior Incorrect Insured

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Prior Incorrect Member Last Name

Required

String (AN)

Min 1Max 60

—

1036

Prior Incorrect Member First Name

Optional

String (AN)

Min 1Max 35

—

1037

Prior Incorrect Member Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Prior Incorrect Member Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Prior Incorrect Member Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

34: Social Security Number
—
ZZ: Mutually Defined
—

Member Name Loop Incorrect Member Name Loop Member Employer Loop Member School Loop Custodial Parent Loop Responsible Person Loop Drop Off Location Loop

Prior Incorrect Insured Identifier

Optional

String (AN)

Min 2Max 80

—

Usage notes

—

DMG

0800

Detail > Member Level Detail Loop > Incorrect Member Name Loop > DMG

Incorrect Member Demographics

OptionalMax use 1

—

Usage notes

—

Example

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

If either Code List Qualifier Code (DMG-10) or Race or Ethnicity Collection Code (DMG-11) is present, then the other is required

If Race or Ethnicity Collection Code (DMG-11) is present, then Composite Race or Ethnicity Information (DMG-05) is required

DMG-01

1250

Date Time Period Format Qualifier

Optional

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

DMG-02

1251

Prior Incorrect Insured Birth Date

Optional

String (AN)

Min 1Max 35

—

DMG-03

1068

Prior Incorrect Insured Gender Code

Optional

Identifier (ID)

—

F: Female
M: Male
U: Unknown

DMG-04

1067

Marital Status Code

Optional

Identifier (ID)

—

B: Registered Domestic Partner
D: Divorced
I: Single
M: Married
R: Unreported
S: Separated
U: Unmarried (Single or Divorced or Widowed)
—
W: Widowed
X: Legally Separated

DMG-05

C056

Composite Race or Ethnicity Information

OptionalMax use 10

To send general and detailed information on race or ethnicity

Usage notes

—

If either Code List Qualifier Code (C056-02) or Race or Ethnicity Code (C056-03) is present, then the other is required

C056-01

1109

Race or Ethnicity Code

Optional

Identifier (ID)

—

7: Not Provided
8: Not Applicable
A: Asian or Pacific Islander
B: Black
C: Caucasian
D: Subcontinent Asian American
E: Other Race or Ethnicity
F: Asian Pacific American
G: Native American
H: Hispanic
I: American Indian or Alaskan Native
J: Native Hawaiian
N: Black (Non-Hispanic)
O: White (Non-Hispanic)
P: Pacific Islander
Z: Mutually Defined

C056-02

1270

Code List Qualifier Code

Optional

Identifier (ID)

—

RET: Classification of Race or Ethnicity

C056-03

1271

Race or Ethnicity Code

Optional

String (AN)

Min 1Max 30

—

DMG-06

1066

Citizenship Status Code

Optional

Identifier (ID)

—

1: U.S. Citizen
2: Non-Resident Alien
3: Resident Alien
4: Illegal Alien
5: Alien
6: U.S. Citizen - Non-Resident
7: U.S. Citizen - Resident

DMG-10

1270

Code List Qualifier Code

Optional

Identifier (ID)

—

REC: Race or Ethnicity Collection Code

DMG-11

1271

Race or Ethnicity Collection Code

Optional

String (AN)

Min 1Max 30

—

2100B Incorrect Member Name Loop end

2100C Member Mailing Address Loop

OptionalMax 1

Variants (all may be used)

NM1

0300

Detail > Member Level Detail Loop > Member Mailing Address Loop > NM1

Member Mailing Address

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

31: Postal Mailing Address

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

0500

Detail > Member Level Detail Loop > Member Mailing Address Loop > N3

Member Mail Street Address

RequiredMax use 1

—

Example

166

Member Address Line

Required

String (AN)

Min 1Max 55

—

166

Member Address Line

Optional

String (AN)

Min 1Max 55

—

0600

Detail > Member Level Detail Loop > Member Mailing Address Loop > N4

Member Mail City, State, ZIP Code

RequiredMax use 1

—

Example

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

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

Member Mail City Name

Required

String (AN)

Min 2Max 30

—

156

Member Mail State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Member Mail Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

Member Name Loop Incorrect Member Name Loop Member Mailing Address Loop Member School Loop Custodial Parent Loop Responsible Person Loop Drop Off Location Loop

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

2100C Member Mailing Address Loop end

2100D Member Employer Loop

OptionalMax 3

Variants (all may be used)

NM1

0300

Detail > Member Level Detail Loop > Member Employer Loop > NM1

Member Employer

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

36: Employer

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Member Employer Name

Optional

String (AN)

Min 1Max 60

—

1036

Member Employer First Name

Optional

String (AN)

Min 1Max 35

—

1037

Member Employer Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Member Employer Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Member Employer Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

24: Employer's Identification Number
—
34: Social Security Number

Member Employer Identifier

Optional

String (AN)

Min 2Max 80

—

PER

0400

Detail > Member Level Detail Loop > Member Employer Loop > PER

Member Employer Communications Numbers

OptionalMax use 1

—

Usage notes

—

Example

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

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

366

Contact Function Code

Required

Identifier (ID)

—

EP: Employer Contact

PER-02

Member Employer Communications Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Required

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

364

Communication Number

Required

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

0500

Detail > Member Level Detail Loop > Member Employer Loop > N3

Member Employer Street Address

OptionalMax use 1

—

Usage notes

—

Example

166

Member Employer Address Line

Required

String (AN)

Min 1Max 55

—

166

Member Employer Address Line

Optional

String (AN)

Min 1Max 55

—

0600

Detail > Member Level Detail Loop > Member Employer Loop > N4

Member Employer City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Member Employer City Name

Required

String (AN)

Min 2Max 30

—

156

Member Employer State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Member Employer Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

Member Name Loop Incorrect Member Name Loop Member Mailing Address Loop Member Employer Loop Custodial Parent Loop Responsible Person Loop Drop Off Location Loop

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

2100D Member Employer Loop end

2100E Member School Loop

OptionalMax 3

Variants (all may be used)

NM1

0300

Detail > Member Level Detail Loop > Member School Loop > NM1

Member School

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

M8: Educational Institution

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

School Name

Required

String (AN)

Min 1Max 60

—

PER

0400

Detail > Member Level Detail Loop > Member School Loop > PER

Member School Commmunications Numbers

OptionalMax use 1

—

Usage notes

—

Example

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

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

366

Contact Function Code

Required

Identifier (ID)

—

SK: School Clerk

PER-02

Member School Communications Contact Name

Optional

String (AN)

Min 1Max 60

—

365

Communication Number Qualifier

Required

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

364

Communication Number

Required

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
TE: Telephone

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

0500

Detail > Member Level Detail Loop > Member School Loop > N3

Member School Street Address

OptionalMax use 1

—

Usage notes

—

Example

166

School Address Line

Required

String (AN)

Min 1Max 55

—

166

School Address Line

Optional

String (AN)

Min 1Max 55

—

0600

Detail > Member Level Detail Loop > Member School Loop > N4

Member School City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Member School City Name

Required

String (AN)

Min 2Max 30

—

156

Member School State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Member School Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

Member Name Loop Incorrect Member Name Loop Member Mailing Address Loop Member Employer Loop Member School Loop Responsible Person Loop Drop Off Location Loop

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

2100E Member School Loop end

2100F Custodial Parent Loop

OptionalMax 1

Variants (all may be used)

NM1

0300

Detail > Member Level Detail Loop > Custodial Parent Loop > NM1

Custodial Parent

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

S3: Custodial Parent

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Custodial Parent Last Name

Required

String (AN)

Min 1Max 60

—

1036

Custodial Parent First Name

Required

String (AN)

Min 1Max 35

—

1037

Custodial Parent Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Custodial Parent Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Custodial Parent Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

34: Social Security Number
—
ZZ: Mutually Defined
—

Custodial Parent Identifier

Optional

String (AN)

Min 2Max 80

—

PER

0400

Detail > Member Level Detail Loop > Custodial Parent Loop > PER

Custodial Parent Communications Numbers

OptionalMax use 1

—

Usage notes

—

Example

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

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

366

Contact Function Code

Required

Identifier (ID)

—

PQ: Parent or Guardian

365

Communication Number Qualifier

Required

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Required

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

0500

Detail > Member Level Detail Loop > Custodial Parent Loop > N3

Custodial Parent Street Address

OptionalMax use 1

—

Usage notes

—

Example

166

Custodial Parent Address Line

Required

String (AN)

Min 1Max 55

—

166

Custodial Parent Address Line

Optional

String (AN)

Min 1Max 55

—

0600

Detail > Member Level Detail Loop > Custodial Parent Loop > N4

Custodial Parent City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Custodial Parent City Name

Required

String (AN)

Min 2Max 30

—

156

Custodial Parent State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Custodial Parent Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

Member Name Loop Incorrect Member Name Loop Member Mailing Address Loop Member Employer Loop Member School Loop Custodial Parent Loop Drop Off Location Loop

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

2100F Custodial Parent Loop end

2100G Responsible Person Loop

OptionalMax 13

Variants (all may be used)

NM1

0300

Detail > Member Level Detail Loop > Responsible Person Loop > NM1

Responsible Person

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

6Y: Case Manager
9K: Key Person
E1: Person or Other Entity Legally Responsible for a Child
—
EI: Executor of Estate
—
EXS: Ex-spouse
—
GB: Other Insured
GD: Guardian
J6: Power of Attorney
LR: Legal Representative
QD: Responsible Party
S1: Parent
TZ: Significant Other
X4: Spouse

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Responsible Party Last or Organization Name

Required

String (AN)

Min 1Max 60

—

1036

Responsible Party First Name

Optional

String (AN)

Min 1Max 35

—

1037

Responsible Party Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Responsible Party Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Responsible Party Suffix Name

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

34: Social Security Number
—
ZZ: Mutually Defined
—

Responsible Party Identifier

Optional

String (AN)

Min 2Max 80

—

PER

0400

Detail > Member Level Detail Loop > Responsible Person Loop > PER

Responsible Person Communications Numbers

OptionalMax use 1

—

Usage notes

—

Example

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

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

366

Contact Function Code

Required

Identifier (ID)

—

RP: Responsible Person

365

Communication Number Qualifier

Required

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Required

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

0500

Detail > Member Level Detail Loop > Responsible Person Loop > N3

Responsible Person Street Address

OptionalMax use 1

—

Usage notes

—

Example

166

Responsible Party Address Line

Required

String (AN)

Min 1Max 55

—

166

Responsible Party Address Line

Optional

String (AN)

Min 1Max 55

—

0600

Detail > Member Level Detail Loop > Responsible Person Loop > N4

Responsible Person City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Responsible Person City Name

Required

String (AN)

Min 2Max 30

—

156

Responsible Person State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Responsible Person Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

Member Name Loop Incorrect Member Name Loop Member Mailing Address Loop Member Employer Loop Member School Loop Custodial Parent Loop Responsible Person Loop

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

2100G Responsible Person Loop end

2100H Drop Off Location Loop

OptionalMax 1

Variants (all may be used)

NM1

0300

Detail > Member Level Detail Loop > Drop Off Location Loop > NM1

Drop Off Location

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

45: Drop-off Location

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person

1035

Name Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Name First

Optional

String (AN)

Min 1Max 35

—

1037

Name Middle

Optional

String (AN)

Min 1Max 25

—

1038

Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Name Suffix

Optional

String (AN)

Min 1Max 10

—

0500

Detail > Member Level Detail Loop > Drop Off Location Loop > N3

Drop Off Location Street Address

OptionalMax use 1

—

Usage notes

—

Example

166

Drop Off Location Address Line

Required

String (AN)

Min 1Max 55

—

166

Drop Off Location Address Line

Optional

String (AN)

Min 1Max 55

—

0600

Detail > Member Level Detail Loop > Drop Off Location Loop > N4

Drop Off Location City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Drop Off Location City Name

Required

String (AN)

Min 2Max 30

—

156

Drop Off Location State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Drop Off Location Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

2100H Drop Off Location Loop end

2200 Disability Information Loop

OptionalMax >1

DSB

2000

Detail > Member Level Detail Loop > Disability Information Loop > DSB

Disability Information

RequiredMax use 1

—

Usage notes

—

Example

If either Product or Service ID Qualifier (DSB-07) or Diagnosis Code (DSB-08) is present, then the other is required

DSB-01

1146

Disability Type Code

Required

Identifier (ID)

—

1: Short Term Disability
2: Long Term Disability
3: Permanent or Total Disability
4: No Disability

DSB-07

235

Product or Service ID Qualifier

Optional

Identifier (ID)

—

DX: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis
ZZ: Mutually Defined
—

DSB-08

1137

Diagnosis Code

Optional

String (AN)

Min 1Max 15

—

DTP

2100

Detail > Member Level Detail Loop > Disability Information Loop > DTP

Disability Eligibility Dates

OptionalMax use 2

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

360: Initial Disability Period Start
361: Initial Disability Period End

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Disability Eligibility Date

Required

String (AN)

Min 1Max 35

—

2200 Disability Information Loop end

2300 Health Coverage Loop

OptionalMax 99

2600

Detail > Member Level Detail Loop > Health Coverage Loop > HD

Health Coverage

RequiredMax use 1

—

Usage notes

—

Example

HD-01

875

Maintenance Type Code

Required

Identifier (ID)

—

Usage notes

—

001: Change
002: Delete
—
021: Addition
024: Cancellation or Termination
—
025: Reinstatement
026: Correction
—
030: Audit or Compare
032: Employee Information Not Applicable
—

HD-03

1205

Insurance Line Code

Required

Identifier (ID)

—

AG: Preventative Care/Wellness
AH: 24 Hour Care
AJ: Medicare Risk
AK: Mental Health
DCP: Dental Capitation
—
DEN: Dental
EPO: Exclusive Provider Organization
FAC: Facility
HE: Hearing
HLT: Health
—
HMO: Health Maintenance Organization
LTC: Long-Term Care
LTD: Long-Term Disability
MM: Major Medical
MOD: Mail Order Drug
PDG: Prescription Drug
POS: Point of Service
PPO: Preferred Provider Organization
PRA: Practitioners
STD: Short-Term Disability
UR: Utilization Review
VIS: Vision

HD-04

1204

Plan Coverage Description

Optional

String (AN)

Min 1Max 50

—

HD-05

1207

Coverage Level Code

Optional

Identifier (ID)

—

Usage notes

—

CHD: Children Only
DEP: Dependents Only
E1D: Employee and One Dependent
—
E2D: Employee and Two Dependents
E3D: Employee and Three Dependents
E5D: Employee and One or More Dependents
E6D: Employee and Two or More Dependents
E7D: Employee and Three or More Dependents
E8D: Employee and Four or More Dependents
E9D: Employee and Five or More Dependents
ECH: Employee and Children
EMP: Employee Only
ESP: Employee and Spouse
FAM: Family
IND: Individual
SPC: Spouse and Children
SPO: Spouse Only
TWO: Two Party

HD-09

1073

Late Enrollment Indicator

Optional

Identifier (ID)

—

N: No
Y: Yes

DTP

2700

Detail > Member Level Detail Loop > Health Coverage Loop > DTP

Health Coverage Dates

RequiredMax use 6

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

300: Enrollment Signature Date
303: Maintenance Effective
—
343: Premium Paid to Date End
348: Benefit Begin
—
349: Benefit End
—
543: Last Premium Paid Date
695: Previous Period
—

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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

1251

Coverage Period

Required

String (AN)

Min 1Max 35

—

AMT

2800

Detail > Member Level Detail Loop > Health Coverage Loop > AMT

Health Coverage Policy

OptionalMax use 9

—

Usage notes

—

Example

AMT-01

522

Amount Qualifier Code

Required

Identifier (ID)

—

B9: Co-insurance - Actual
—
C1: Co-Payment Amount
D2: Deductible Amount
EBA: Expected Expenditure Amount
FK: Other Unlisted Amount
P3: Premium Amount
R: Spend Down

AMT-02

782

Contract Amount

Required

Decimal number (R)

Min 1Max 15

—

REF

2900

Detail > Member Level Detail Loop > Health Coverage Loop > REF

Health Coverage Policy Number

OptionalMax use 14

—

Usage notes

—

Example

Variants (all may be used)

REFPrior Coverage Months

128

Reference Identification Qualifier

Required

Identifier (ID)

—

1L: Group or Policy Number
—
9V: Payment Category
17: Client Reporting Category
CE: Class of Contract Code
E8: Service Contract (Coverage) Number
M7: Medical Assistance Category
PID: Program Identification Number
RB: Rate code number
X9: Internal Control Number
XM: Issuer Number
XX1: Special Program Code
XX2: Service Area Code
ZX: County Code
ZZ: Mutually Defined
—

REFHealth Coverage Policy Number

127

Member Group or Policy Number

Required

String (AN)

Min 1Max 50

—

REF

2900

Detail > Member Level Detail Loop > Health Coverage Loop > REF

Prior Coverage Months

OptionalMax use 1

—

Usage notes

—

Example

Variants (all may be used)

128

Reference Identification Qualifier

Required

Identifier (ID)

—

QQ: Unit Number
—

127

Prior Coverage Month Count

Required

String (AN)

Min 1Max 50

—

Usage notes

—

IDC

3000

Detail > Member Level Detail Loop > Health Coverage Loop > IDC

Identification Card

OptionalMax use 3

—

Usage notes

—

Example

IDC-01

1204

Plan Coverage Description

Required

String (AN)

Min 1Max 50

—

Usage notes

—

IDC-02

1215

Identification Card Type Code

Required

Identifier (ID)

—

Usage notes

—

D: Dental Insurance
H: Health Insurance
P: Prescription Drug Service Drug Insurance

IDC-03

380

Identification Card Count

Optional

Decimal number (R)

Min 1Max 15

—

Usage notes

—

IDC-04

306

Action Code

Optional

Identifier (ID)

—

1: Add
2: Change (Update)
RX: Replace
—

2310 Provider Information Loop

OptionalMax 30

3100

Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > LX

Provider Information

RequiredMax use 1

—

Usage notes

—

Example

LX-01

554

Assigned Number

Required

Numeric (N0)

Min 1Max 6

—

Usage notes

—

NM1

3200

Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > NM1

Provider Name

RequiredMax use 1

—

Usage notes

—

Example

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

Entity Identifier Code

Required

Identifier (ID)

—

1X: Laboratory
3D: Obstetrics and Gynecology Facility
80: Hospital
FA: Facility
OD: Doctor of Optometry
P3: Primary Care Provider
QA: Pharmacy
QN: Dentist
Y2: Managed Care Organization

1065

Entity Type Qualifier

Required

Identifier (ID)

—

1: Person
2: Non-Person Entity

1035

Provider Last or Organization Name

Optional

String (AN)

Min 1Max 60

—

1036

Provider First Name

Optional

String (AN)

Min 1Max 35

—

1037

Provider Middle Name

Optional

String (AN)

Min 1Max 25

—

1038

Provider Name Prefix

Optional

String (AN)

Min 1Max 10

—

1039

Provider Name Suffix

Optional

String (AN)

Min 1Max 10

—

Identification Code Qualifier

Optional

Identifier (ID)

—

34: Social Security Number
—
FI: Federal Taxpayer's Identification Number
SV: Service Provider Number
—
XX: Centers for Medicare and Medicaid Services National Provider Identifier

Provider Identifier

Optional

String (AN)

Min 2Max 80

—

NM1-10

706

Entity Relationship Code

Required

Identifier (ID)

—

Usage notes

—

25: Established Patient
26: Not Established Patient
72: Unknown

3500

Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > N3

Provider Address

OptionalMax use 2

—

Usage notes

—

Example

166

Provider Address Line

Required

String (AN)

Min 1Max 55

—

166

Provider Address Line

Optional

String (AN)

Min 1Max 55

—

3600

Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > N4

Provider City, State, ZIP Code

OptionalMax use 1

—

Usage notes

—

Example

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

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

Provider City Name

Required

String (AN)

Min 2Max 30

—

156

Provider State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Provider Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

3700

Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > PER

Provider Communications Numbers

OptionalMax use 2

—

Usage notes

—

Example

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

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

366

Contact Function Code

Required

Identifier (ID)

—

IC: Information Contact

365

Communication Number Qualifier

Required

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Required

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

365

Communication Number Qualifier

Optional

Identifier (ID)

—

AP: Alternate Telephone
BN: Beeper Number
CP: Cellular Phone
EM: Electronic Mail
EX: Telephone Extension
FX: Facsimile
HP: Home Phone Number
TE: Telephone
WP: Work Phone Number

364

Communication Number

Optional

String (AN)

Min 1Max 256

—

PLA

3950

Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > PLA

Provider Change Reason

OptionalMax use 1

—

Usage notes

—

Example

PLA-01

306

Action Code

Required

Identifier (ID)

—

2: Change (Update)

PLA-02

Entity Identifier Code

Required

Identifier (ID)

—

1P: Provider

PLA-03

373

Provider Effective Date

Required

Date (DT)

CCYYMMDD format

—

Usage notes

—

PLA-05

1203

Maintenance Reason Code

Required

Identifier (ID)

—

Usage notes

—

14: Voluntary Withdrawal
22: Plan Change
46: Current Customer Information File in Error
AA: Dissatisfaction with Office Staff
AB: Dissatisfaction with Medical Care/Services Rendered
AC: Inconvenient Office Location
AD: Dissatisfaction with Office Hours
AE: Unable to Schedule Appointments in a Timely Manner
AF: Dissatisfaction with Physician's Referral Policy
AG: Less Respect and Attention Time Given than to Other Patients
AH: Patient Moved to a New Location
AI: No Reason Given
AJ: Appointment Times not Met in a Timely Manner

2310 Provider Information Loop end

2320 Coordination of Benefits Loop

OptionalMax 5

COB

4000

Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > COB

Coordination of Benefits

RequiredMax use 1

—

Usage notes

—

Example

COB-01

1138

Payer Responsibility Sequence Number Code

Required

Identifier (ID)

—

P: Primary
S: Secondary
T: Tertiary
U: Unknown

COB-02

127

Member Group or Policy Number

Optional

String (AN)

Min 1Max 50

—

COB-03

1143

Coordination of Benefits Code

Required

Identifier (ID)

—

1: Coordination of Benefits
5: Unknown
6: No Coordination of Benefits
—

COB-04

1365

Service Type Code

Optional

Identifier (ID)

Max use 9

—

1: Medical Care
35: Dental Care
48: Hospital - Inpatient
50: Hospital - Outpatient
54: Long Term Care
89: Free Standing Prescription Drug
90: Mail Order Prescription Drug
A4: Psychiatric
AG: Skilled Nursing Care
AL: Vision (Optometry)
BB: Partial Hospitalization (Psychiatric)

REF

4050

Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > REF

Additional Coordination of Benefits Identifiers

OptionalMax use 4

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

6P: Group Number
60: Account Suffix Code
SY: Social Security Number
—
ZZ: Mutually Defined
—

127

Member Group or Policy Number

Required

String (AN)

Min 1Max 50

—

DTP

4070

Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > DTP

Coordination of Benefits Eligibility Dates

OptionalMax use 2

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

344: Coordination of Benefits Begin
345: Coordination of Benefits End

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

D8: Date Expressed in Format CCYYMMDD

1251

Coordination of Benefits Date

Required

String (AN)

Min 1Max 35

—

2330 Coordination of Benefits Related Entity Loop

OptionalMax 3

NM1

4100

Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > NM1

Coordination of Benefits Related Entity

RequiredMax use 1

—

Usage notes

—

Example

If either Identification Code Qualifier (NM1-08) or Coordination of Benefits Insurer Identification Code (NM1-09) is present, then the other is required

Entity Identifier Code

Required

Identifier (ID)

—

36: Employer
GW: Group
IN: Insurer

1065

Entity Type Qualifier

Required

Identifier (ID)

—

2: Non-Person Entity

1035

Coordination of Benefits Insurer Name

Optional

String (AN)

Min 1Max 60

—

Identification Code Qualifier

Optional

Identifier (ID)

—

FI: Federal Taxpayer's Identification Number
NI: National Association of Insurance Commissioners (NAIC) Identification
XV: Centers for Medicare and Medicaid Services PlanID
—

Coordination of Benefits Insurer Identification Code

Optional

String (AN)

Min 2Max 80

—

4300

Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > N3

Coordination of Benefits Related Entity Address

OptionalMax use 1

—

Usage notes

—

Example

166

Address Information

Required

String (AN)

Min 1Max 55

—

166

Address Information

Optional

String (AN)

Min 1Max 55

—

4400

Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > N4

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

OptionalMax use 1

—

Usage notes

—

Example

Only one of Coordination of Benefits Other Insurance Company State Code (N4-02) or Country Subdivision Code (N4-07) may be present

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

Coordination of Benefits Other Insurance Company City Name

Required

String (AN)

Min 2Max 30

—

156

Coordination of Benefits Other Insurance Company State Code

Optional

Identifier (ID)

Min 2Max 2

—

116

Coordination of Benefits Other Insurance Company Postal Zone or ZIP Code

Optional

Identifier (ID)

Min 3Max 15

—

Country Code

Optional

Identifier (ID)

Min 2Max 3

—

Usage notes

—

1715

Country Subdivision Code

Optional

Identifier (ID)

Min 1Max 3

—

Usage notes

—

PER

4500

Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > PER

Administrative Communications Contact

OptionalMax use 1

—

Usage notes

—

Example

366

Contact Function Code

Required

Identifier (ID)

—

CN: General Contact

365

Communication Number Qualifier

Required

Identifier (ID)

—

TE: Telephone

364

Communication Number

Required

String (AN)

Min 1Max 256

—

2330 Coordination of Benefits Related Entity Loop end

2320 Coordination of Benefits Loop end

2300 Health Coverage Loop end

6880

Detail > Member Level Detail Loop > LS

Loop Header

OptionalMax use 1

—

Example

LS-01

447

Loop Identifier Code

Required

String (AN)

Min 1Max 6

—

2700 Member Reporting Categories Loop

OptionalMax >1

6881

Detail > Member Level Detail Loop > Member Reporting Categories Loop > LX

Member Reporting Categories

RequiredMax use 1

—

Usage notes

—

Example

LX-01

554

Assigned Number

Required

Numeric (N0)

Min 1Max 6

—

Usage notes

—

2750 Reporting Category Loop

OptionalMax 1

6882

Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > N1

Reporting Category

RequiredMax use 1

—

Usage notes

—

Example

Entity Identifier Code

Required

Identifier (ID)

—

75: Participant

Member Reporting Category Name

Required

String (AN)

Min 1Max 60

—

REF

6883

Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > REF

Reporting Category Reference

OptionalMax use 1

—

Usage notes

—

Example

128

Reference Identification Qualifier

Required

Identifier (ID)

—

00: Contracting District Number
3L: Branch Identifier
6M: Application Number
9V: Payment Category
9X: Account Category
17: Client Reporting Category
18: Plan Number
19: Division Identifier
26: Union Number
GE: Geographic Number
LU: Location Number
PID: Program Identification Number
XX1: Special Program Code
XX2: Service Area Code
YY: Geographic Key
ZZ: Mutually Defined

127

Member Reporting Category Reference ID

Required

String (AN)

Min 1Max 50

—

DTP

6884

Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > DTP

Reporting Category Date

OptionalMax use 1

—

Usage notes

—

Example

374

Date Time Qualifier

Required

Identifier (ID)

—

007: Effective

1250

Date Time Period Format Qualifier

Required

Identifier (ID)

—

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