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) · Min 2 Max 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 15 Max 15

ISA-07 · I05 · Interchange ID Qualifier · Required · Identifier (ID) · Min 2 Max 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 15 Max 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 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

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)

• 2B: Third-Party Administrator
• 36: Employer
• 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 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)

• 24: Employer's Identification Number
• 46: Electronic Transmitter Identification Number (ETIN)
• FI: Federal Taxpayer's Identification Number
• NI: National Association of Insurance Commissioners (NAIC) Identification
• PI: Payor Identification
• XV: Centers for Medicare and Medicaid Services PlanID
• XX: Centers for Medicare and Medicaid Services National Provider Identifier

NM1-09 · 67 · Information Source Primary Identifier · Required · String (AN) · Min 2 Max 80

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*842610001~
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*842610001~
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*842610001~
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~