OTI Other insurance

To provide payer, insured, and payment information when benefits are being coordinated between third party benefit carriers.

Position

Element

Name

Type

Requirement

Min

Max

Repeat

010 E206 Object identification Composite (composite) Mandatory 5

010 · 7402 · Object identifier · String (AN) · Mandatory · 1 · 35 · -

Code specifying the unique identity of an object.

020 · 7405 · Object identification code qualifier · String (AN) · Conditional · 1 · 3 · -

Code qualifying the identification of an object.

030 · 4405 · Status description code · String (AN) · Conditional · 1 · 3 · -

Code specifying a status.

1 For transport status, use UN/ECE Recommendation 24.

020 · 9645 · Payer responsibility level code · String (AN) · Mandatory · 1 · 3 · 1

Code specifying the level of responsibility of a payer.

030 E507 Date/time/period Composite (composite) Conditional 2

010 · 2005 · Date or time or period function code qualifier · String (AN) · Mandatory · 1 · 3 · -

Code qualifying the function of a date, time or period.

020 · 2380 · Date or time or period text · String (AN) · Conditional · 1 · 35 · -

The value of a date, a date and time, a time or of a period in a specified representation.

030 · 2379 · Date or time or period format code · String (AN) · Conditional · 1 · 3 · -

Code specifying the representation of a date, time or period.

040 · 5267 · Service type code · String (AN) · Conditional · 1 · 3 · 10

Code specifying the type of service.

050 · 5004 · Monetary amount · Numeric (N) · Conditional · 1 · 35 · 4

To specify a monetary amount.

060 E030 Adjustment information Composite (composite) Conditional 15

010 · 9619 · Adjustment category code · String (AN) · Mandatory · 1 · 3 · -

Code specifying the general category of adjustment.

020 · 4465 · Adjustment reason description code · String (AN) · Mandatory · 1 · 3 · -

Code specifying the adjustment reason.

030 · 5004 · Monetary amount · Numeric (N) · Conditional · 1 · 35 · -

To specify a monetary amount.

070 · 4497 · Insurance cover type code · String (AN) · Conditional · 1 · 3 · 1

Code specifying the meaning of the insurance cover.

080 · 9143 · Relationship description code · String (AN) · Conditional · 1 · 3 · 1

Code specifying a relationship.

090 · 9607 · Yes or no indicator code · String (AN) · Conditional · 1 · 3 · 1

Code specifying either a yes or no.