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My Edition [X12 HIPAA] 834 Benefit Enrollment and Maintenance (X220A1)
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  • EDI Inspector
Bezrukava

X12 834 My Edition [X12 HIPAA] 834 Benefit Enrollment and Maintenance (X220A1)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Benefit Enrollment and Maintenance Transaction Set (834) for use within the context of an Electronic Data Interchange (EDI) environment.
This transaction set can be used to establish communication between the sponsor of the insurance product and the payer. Such transaction(s) may or may not take place through a third party administrator (TPA).

For the purpose of this standard, the sponsor is the party or entity that ultimately pays for the coverage, benefit or product. A sponsor can be an employer, union, government agency, association, or insurance agency.

The payer refers to an entity that pays claims, administers the insurance product or benefit, or both. A payer can be an insurance company, health maintenance organization (HMO), preferred provider organization (PPO), government agency (Medicare, Medicaid, Champus, etc.), or an entity that may be contracted by one of these former groups.

For the purpose of the 834 transaction set, a third party administrator (TPA) can be contracted by a sponsor to handle data gathering from those covered by the sponsor if the sponsor does not elect to perform this function itself.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
ST
0100
Transaction Set Header
Max use 1
Required
BGN
0200
Beginning Segment
Max use 1
Required
REF
0300
Transaction Set Policy Number
Max use 1
Optional
DTP
0400
File Effective Date
Max use 1
Optional
QTY
0600
Transaction Set Control Totals
Max use 3
Optional
Sponsor Name Loop
TPA/Broker Name Loop
detail
Member Level Detail Loop
INS
0100
Member Level Detail
Max use 1
Required
REF
0200
Member Policy Number
Max use 1
Optional
REF
0200
Member Supplemental Identifier
Max use 13
Optional
REF
0200
Subscriber Identifier
Max use 1
Required
DTP
0250
Member Level Dates
Max use 24
Optional
LS
6880
Loop Header
Max use 1
Optional
LE
6885
Loop Trailer
Max use 1
Optional
SE
6900
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

To start and identify an interchange of zero or more functional groups and interchange-related control segments

Example
ISA-01
I01
Authorization Information Qualifier
Required
Identifier (ID)

Code identifying the type of information in the Authorization Information

00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

ISA-03
I03
Security Information Qualifier
Required
Identifier (ID)

Code identifying the type of information in the Security Information

00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

ISA-05
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

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

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

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

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

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

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

ISA-09
I08
Interchange Date
Required
Date (DT)
YYMMDD format

Date of the interchange

ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format

Time of the interchange

ISA-11
I65
Repetition Separator
Required
String (AN)
Min 1Max 1

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

^
Repetition Separator
ISA-12
I11
Interchange Control Version Number
Required
Identifier (ID)

Code specifying the version number of the interchange control segments

00501
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA-13
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

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

Code indicating sender's request for an interchange acknowledgment

0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

>
Component Element Separator
GS

Functional Group Header

RequiredMax use 1

To indicate the beginning of a functional group and to provide control information

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

Code identifying a group of application related transaction sets

BE
Benefit Enrollment and Maintenance (834)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

Code identifying party sending transmission; codes agreed to by trading partners

GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15

Code identifying party receiving transmission; codes agreed to by trading partners

GS-04
373
Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

GS-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

GS-06
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

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

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

T
Transportation Data Coordinating Committee (TDCC)
X
Accredited Standards Committee X12
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)

Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

005010X220A1

Heading

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

To indicate the start of a transaction set and to assign a control number

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

Code uniquely identifying a Transaction Set

  • The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
834
Benefit Enrollment and Maintenance
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • The Transaction Set Control Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.
ST-03
1705
Implementation Convention Reference
Required
String (AN)

Reference assigned to identify Implementation Convention

  • The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
Usage notes
  • This element must be populated with the guide identifier named in Section 1.2.
  • This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
005010X220A1
BGN
0200
Heading > BGN

Beginning Segment

RequiredMax use 1

To indicate the beginning of a transaction set

Example
BGN-01
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

00
Original

If the original transaction has already been processed, an incoming transaction using this code may be rejected by the receiver. The rejection will be identified to the sender by telephone or other direct contact.

The "00" indicates the first time the transaction is sent.

15
Re-Submission

Send the "15" when the original transmission was incorrect, has yet to be processed by the receiver, and a new corrected transmission is being sent. This transmission can then be pended by the receiver's translator for further review.

22
Information Copy

Send the "22" when the original transmission was lost or not processed, and the sender is passing another transmission that is the same as the original.

BGN-02
127
Transaction Set Reference Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • BGN02 is the transaction set reference number.
Usage notes
  • This element is the transaction set reference number assigned by the sender's application. It uniquely identifies this occurrence of the transaction for future reference.
BGN-03
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

  • BGN03 is the transaction set date.
Usage notes
  • This element identifies the date that the submitter created the file.
BGN-04
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

  • BGN04 is the transaction set time.
Usage notes
  • This element is used as a time stamp to uniquely identify the transmission.
BGN-05
623
Time Zone Code
Optional
Identifier (ID)

Code identifying the time. In accordance with International Standards Organization standard 8601, time can be specified by a + or - and an indication in hours in relation to Universal Time Coordinate (UTC) time; since + is a restricted character, + and - are substituted by P and M in the codes that follow

  • BGN05 is the transaction set time qualifier.
01
Equivalent to ISO P01
02
Equivalent to ISO P02
03
Equivalent to ISO P03
04
Equivalent to ISO P04
05
Equivalent to ISO P05
06
Equivalent to ISO P06
07
Equivalent to ISO P07
08
Equivalent to ISO P08
09
Equivalent to ISO P09
10
Equivalent to ISO P10
11
Equivalent to ISO P11
12
Equivalent to ISO P12
13
Equivalent to ISO M12
14
Equivalent to ISO M11
15
Equivalent to ISO M10
16
Equivalent to ISO M09
17
Equivalent to ISO M08
18
Equivalent to ISO M07
19
Equivalent to ISO M06
20
Equivalent to ISO M05
21
Equivalent to ISO M04
22
Equivalent to ISO M03
23
Equivalent to ISO M02
24
Equivalent to ISO M01
AD
Alaska Daylight Time
AS
Alaska Standard Time
AT
Alaska Time
CD
Central Daylight Time
CS
Central Standard Time
CT
Central Time
ED
Eastern Daylight Time
ES
Eastern Standard Time
ET
Eastern Time
GM
Greenwich Mean Time
HD
Hawaii-Aleutian Daylight Time
HS
Hawaii-Aleutian Standard Time
HT
Hawaii-Aleutian Time
LT
Local Time
MD
Mountain Daylight Time
MS
Mountain Standard Time
MT
Mountain Time
ND
Newfoundland Daylight Time
NS
Newfoundland Standard Time
NT
Newfoundland Time
PD
Pacific Daylight Time
PS
Pacific Standard Time
PT
Pacific Time
TD
Atlantic Daylight Time
TS
Atlantic Standard Time
TT
Atlantic Time
UT
Universal Time Coordinate
BGN-06
127
Original Transaction Set Reference Number
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • BGN06 is the transaction set reference number of a previously sent transaction affected by the current transaction.
BGN-08
306
Action Code
Required
Identifier (ID)

Code indicating type of action

2
Change (Update)

Used to identify a transaction of additions, terminations and changes to the current enrollment.

4
Verify

Used to identify a full enrollment transaction to verify that the sponsor's and payer's systems are synchronized.

RX
Replace

Used to identify a full enrollment transmission to be used to identify additions, terminations and changes that need to be applied to the payer's enrollment system.

REF
0300
Heading > REF

Transaction Set Policy Number

OptionalMax use 1

To specify identifying information

Usage notes
  • The definition of the Master Policy Number is determined by the issuer of the policy, the Payer/Plan Administrator. The Master Policy Number may be used to meet various business needs such as indicating the line of business under which the policy is defined.
  • Required when the insurance contract or trading partner agreement identifies a Master Policy Number for use with electronic enrollment. If not required may be provided at the sender's discretion if a unique ID Number for a group applies to the entire transaction set.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

38
Master Policy Number
REF-02
127
Master Policy Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

DTP
0400
Heading > DTP

File Effective Date

OptionalMax use >1

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when specified in the contract. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

007
Effective
090
Report Start
091
Report End
303
Maintenance Effective
382
Enrollment
388
Payment Commencement
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Date Time Period
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

QTY
0600
Heading > QTY

Transaction Set Control Totals

OptionalMax use 3

To specify quantity information

Usage notes
  • Required when the contract or trading partner agreement specifies that this information be included in the transaction set. If not required by this implementation guide, do not send.
Example
QTY-01
673
Quantity Qualifier
Required
Identifier (ID)

Code specifying the type of quantity

DT
Dependent Total
ET
Employee Total
TO
Total
QTY-02
380
Record Totals
Required
Decimal number (R)
Min 1Max 15

Numeric value of quantity

1000A Sponsor Name Loop
RequiredMax 1
Variants (all may be used)
Payer LoopTPA/Broker Name Loop
N1
0700
Heading > Sponsor Name Loop > N1

Sponsor Name

RequiredMax use 1

To identify a party by type of organization, name, and code

Usage notes
  • This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.
Example
N1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

P5
Plan Sponsor
N1-02
93
Plan Sponsor Name
Optional
String (AN)
Min 1Max 60

Free-form name

N1-03
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

24
Employer's Identification Number

The identifier is the Employer Identification Number (EIN) issued by the IRS. The EIN has been adopted as the HIPAA Standard Unique Employer Identifier.

94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
N1-04
67
Sponsor Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

  • This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
1000A Sponsor Name Loop end
1000B Payer Loop
RequiredMax 1
Variants (all may be used)
Sponsor Name LoopTPA/Broker Name Loop
N1
0700
Heading > Payer Loop > N1

Payer

RequiredMax use 1

To identify a party by type of organization, name, and code

Usage notes
  • This loop identifies the payer. See section 1.5 for the definition of payer.
Example
N1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

IN
Insurer
N1-02
93
Insurer Name
Optional
String (AN)
Min 1Max 60

Free-form name

N1-03
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

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

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

N1-04
67
Insurer Identification Code
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

  • This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
1000B Payer Loop end
1000C TPA/Broker Name Loop
OptionalMax 2
Variants (all may be used)
Sponsor Name LoopPayer Loop
N1
0700
Heading > TPA/Broker Name Loop > N1

TPA/Broker Name

RequiredMax use 1

To identify a party by type of organization, name, and code

Usage notes
  • Required when a TPA or a Broker is involved in this enrollment. See section 1.5 for definitions. If not required by this implementation guide, do not send.
Example
N1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

BO
Broker or Sales Office
TV
Third Party Administrator (TPA)
N1-02
93
TPA or Broker Name
Required
String (AN)
Min 1Max 60

Free-form name

N1-03
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

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

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

N1-04
67
TPA or Broker Identification Code
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

  • This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.
1100C TPA/Broker Account Information Loop
OptionalMax 1
ACT
1200
Heading > TPA/Broker Name Loop > TPA/Broker Account Information Loop > ACT

TPA/Broker Account Information

RequiredMax use 1

To specify account information

Usage notes
  • Required when the account number of the TPA or Broker is different than the account number for the sponsor. If not required by this implementation guide, do not send.
Example
ACT-01
508
TPA or Broker Account Number
Required
String (AN)
Min 1Max 35

Account number assigned

ACT-06
508
TPA or Broker Account Number
Optional
String (AN)
Min 1Max 35

Account number assigned

  • ACT06 is an account associated with the account in ACT01.
1100C TPA/Broker Account Information Loop end
1000C TPA/Broker Name Loop end
Heading end

Detail

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

Member Level Detail

RequiredMax use 1

To provide benefit information on insured entities

Usage notes
  • Subscriber information must preceed dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission.
Example
If either Date Time Period Format Qualifier (INS-11) or Member Individual Death Date (INS-12) is present, then the other is required
INS-01
1073
Member Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
N
Dependent
Y
Primary
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

Usage notes
  • The value 18 must be used for the subscriber.;
  • For dependents, this value identifies their relationship to the subscriber. For example, a daughter would be value 19.
01
Spouse
18
Self
19
Child
INS-03
875
Maintenance Type Code
Required
Identifier (ID)

Code identifying the specific type of item maintenance

001
Change

Use this code to indicate a change to an existing subscriber/dependent record.

021
Addition

Use this code to add a subscriber or dependent.

024
Cancellation or Termination

Use this code for cancellation, termination, or deletion of a subscriber or dependent.

025
Reinstatement

Use this code for reinstatement of a cancelled subscriber/dependent record.

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

Code identifying the reason for the maintenance change

01
Divorce
02
Birth
03
Death
04
Retirement
05
Adoption
06
Strike
07
Termination of Benefits
08
Termination of Employment
09
Consolidation Omnibus Budget Reconciliation Act (COBRA)
10
Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
11
Surviving Spouse
14
Voluntary Withdrawal
15
Primary Care Provider (PCP) Change
16
Quit
17
Fired
18
Suspended
20
Active
21
Disability
22
Plan Change

Use this code when a member changes from one Plan to a different Plan. This is not intended to identify changes to a Plan.

25
Change in Identifying Data Elements

Use this code when a change has been made to the primary elements that identify a member. Such primary elements include the following: first name, last name, Social Security Number, date of birth, and employee identification number.

26
Declined Coverage

Use this code when a member declined a previously active coverage.

27
Pre-Enrollment

Use this code to enroll newborns prior to receiving the newborn's application.

28
Initial Enrollment

Use this code the first time the member selected coverage with the Plan Sponsor.

29
Benefit Selection

Use this code when a member changes benefits within a Plan.

31
Legal Separation
32
Marriage
33
Personnel Data

Use this code for any data change that is not included in any of the other allowed codes. An example would be change in Coordination of Benefits information.

37
Leave of Absence with Benefits
38
Leave of Absence without Benefits
39
Lay Off with Benefits
40
Lay Off without Benefits
41
Re-enrollment
43
Change of Location

Use this code to indicate a change of address.

59
Non Payment
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
AJ
Appointment Times not Met in a Timely Manner
AL
Algorithm Assigned Benefit Selection
EC
Member Benefit Selection

Use this code for initial and subsequent enrollment when an insurance carrier needs to recognize that a member made an explicit plan choice.

XN
Notification Only

Use this code in complete enrollment transmissions. This is used when INS03 is equal to 030 (Audit/Compare).

XT
Transfer

Use this code when a member has an organizational change (i.e. a location change within the organization) with no change in benefits or plan.

INS-05
1216
Benefit Status Code
Optional
Identifier (ID)

The type of coverage under which benefits are paid

A
Active
C
Consolidated Omnibus Budget Reconciliation Act (COBRA)
S
Surviving Insured
T
Tax Equity and Fiscal Responsibility Act (TEFRA)
INS-06
C052
Medicare Status Code
OptionalMax use 1
To provide Medicare coverage and associated reason for Medicare eligibility
Usage notes

Required if a member is being enrolled or disenrolled in Medicare, is currently in Medicare or has terminated or changed their Medicare enrollment. If not required by this implementation guide, do not send.

C052-01
1218
Medicare Plan Code
Required
Identifier (ID)

Code identifying the Medicare Plan

A
Medicare Part A
B
Medicare Part B
C
Medicare Part A and B
D
Medicare
E
No Medicare
C052-02
1701
Medicare Eligibility Reason Code
Optional
Identifier (ID)

Code specifying reason for eligibility

0
Age
1
Disability
2
End Stage Renal Disease (ESRD)
INS-07
1219
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code
Optional
Identifier (ID)

A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary

1
Termination of Employment
2
Reduction of work hours
3
Medicare
4
Death
5
Divorce
6
Separation
7
Ineligible Child
8
Bankruptcy of Retiree's Former Employer (26 U.S.C. 4980B(f)(3)(F))
9
Layoff
10
Leave of Absence
ZZ
Mutually Defined
INS-08
584
Employment Status Code
Optional
Identifier (ID)

Code showing the general employment status of an employee/claimant

Usage notes
  • If this insurance enrollment is through a non-employment based program such as Medicare or Medicaid then this data element will contain the status of the subscriber in that program, rather than their employment status. Codes for non-employment based programs will be limited to "AC", Active and "TE", Terminated.
AC
Active
AO
Active Military - Overseas
AU
Active Military - USA
FT
Full-time

Full time active employee

L1
Leave of Absence
PT
Part-time

Part time Active Employee

RT
Retired
TE
Terminated
INS-09
1220
Student Status Code
Optional
Identifier (ID)

Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured

F
Full-time
N
Not a Student
P
Part-time
INS-10
1073
Handicap Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value indicates an individual is not handicapped.
N
No
Y
Yes
INS-11
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
INS-12
1251
Member Individual Death Date
Optional
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • INS12 is the date of death.
INS-13
1165
Confidentiality Code
Optional
Identifier (ID)

Code indicating the access to insured information

R
Restricted Access
U
Unrestricted Access
INS-17
1470
Birth Sequence Number
Optional
Numeric (N0)
Min 1Max 9

A generic number

  • INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
REF
0200
Detail > Member Level Detail Loop > REF

Member Policy Number

OptionalMax use 1

To specify identifying information

Usage notes
  • The policy number passed in this segment is an attribute of the contract relationship between the plan sponsor (sender) and the payer (receiver) and not an attribute of an individual's participation in any coverage passed in an HD loop.
  • Required when the policy or group number applies to all coverage data (all 2300 loops for this member). If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1L
Group or Policy Number

The submitter sends the payer's pre-assigned Group or Policy Number.

REF-02
127
Member Group or Policy Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
0200
Detail > Member Level Detail Loop > REF

Member Supplemental Identifier

OptionalMax use 13

To specify identifying information

Usage notes
  • Required when sending additional identifying information on the member. If not required by this implementation guide, do not send.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

3H
Case Number
4A
Personal Identification Number (PIN)

Use this code to transmit a password that is associated with the member's record.

6O
Cross Reference Number

Used when further identification of a member is required for reporting, indexing, or other purpose as mutually agreed upon between the sender and receiver of the transaction set.

17
Client Reporting Category

Used when further identification of a member is required under the insurance contract between the sponsor and the payer and allowed by federal and state regulations.

23
Client Number

To be used to pass a payer specific identifier for a member. Not to be used after the HIPAA standard National Identifier for Individuals is implemented.

ABB
Personal ID Number
D3
National Council for Prescription Drug Programs Pharmacy Number
DX
Department/Agency Number

Use when members in a coverage group are set up as different departments or divisions under the terms of the insurance policy.

F6
Health Insurance Claim (HIC) Number

Use when reporting Medicare eligibility for a member until the National Identifier is mandated for use.

P5
Position Code

Use this code to transmit the title of the member's employment position.

Q4
Prior Identifier Number

Use to pass the Identifier Number under which the member had previous coverage with the payer. This could be the result of a change in employment or coverage that resulted in a new ID number being assigned but left the member covered by the same payer.

QQ
Unit Number

Use when members in a coverage group are set up as different units under the terms of the insurance policy. Units may exist within another grouping such as division or department.

ZZ
Mutually Defined
REF-02
127
Member Supplemental Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
0200
Detail > Member Level Detail Loop > REF

Subscriber Identifier

RequiredMax use 1

To specify identifying information

Usage notes
  • This segment must contain a unique SUBSCRIBER identification number (SSN or other). This occurrence is identified by the 0F qualifier (REF01). This identifier is used for linking the subscriber with dependents as required under many policies.
  • The developers recommend using the identifier developed under the HIPAA legislation, when that becomes available.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

0F
Subscriber Number

The assignment of the Subscriber Number is designated within the Insurance Contract.

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

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

DTP
0250
Detail > Member Level Detail Loop > DTP

Member Level Dates

OptionalMax use 24

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when enrolling a member or when the sponsor is informed of a change to any applicable date listed in DTP01. Only those dates that apply to the particular insurance contract need to be sent. If not required by this implementation guide, do not send.
  • While many of the dates listed for DTP01 are related to termination, the only code that is used to actually terminate a Member is 357 (Eligibility End). Similarly, the Eligibility Begin Date (code 356) is the date the individual is eligible for coverage, not the date coverage is effective.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

050
Received

Used to identify the date an enrollment application is received.

286
Retirement
296
Initial Disability Period Return To Work
297
Initial Disability Period Last Day Worked
300
Enrollment Signature Date
301
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event
303
Maintenance Effective

This code is used to send the effective date of a change to an existing member's information, excluding changes made in Loop 2300.

336
Employment Begin
337
Employment End
338
Medicare Begin
339
Medicare End
340
Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
341
Consolidated Omnibus Budget Reconciliation Act (COBRA) End
350
Education Begin

This is the start date for the student at the current educational institution.

351
Education End

This is the expected graduation date the student at the current educational institution.

356
Eligibility Begin

The date when a member could elect to enroll or begin benefits in any health care plan through the employer. This is not the actual begin date of coverage, which is conveyed in the DTP segment at position 2700.

357
Eligibility End

The eligibility end date represents the last date of coverage for which claims will be paid for the individual being terminated. For example, if a date of 02/28/2001 is passed then claims for this individual will be paid through 11:59 p.m. on 02/28/2001.

383
Adjusted Hire
385
Credited Service Begin

The start date from which an employee's length of service, as defined in the plan document, will be calculated.

386
Credited Service End

The end date to be used in the calculation of an employee's length of service, as defined in the plan document.

393
Plan Participation Suspension
394
Rehire
473
Medicaid Begin
474
Medicaid End
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Status Information Effective Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

NM1
0300
Detail > Member Level Detail Loop > Member Name Loop > NM1

Member Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Example
If either Identification Code Qualifier (NM1-08) or Member Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

Usage notes
  • This code identifies if this is a correction to a previous enrollment or if it is a new, or update, enrollment transaction.
74
Corrected Insured

Use this code if this transmission is correcting the identifier information on a member already enrolled. Usage of this code requires the sending of an NM1 with code '70' in loop 2100B.

IL
Insured or Subscriber

Use this code for enrolling a new member or updating a member with no change in identifying information. The identifying information for a member is specified under the insurance contract between the sponsor and payer.

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

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Member Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Member First Name
Required
String (AN)
Min 1Max 35

Individual first name

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

Individual middle name or initial

NM1-06
1038
Member Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

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

Suffix to individual name

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

Code designating the system/method of code structure used for Identification Code (67)

34
Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.

ZZ
Mutually Defined

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

NM1-09
67
Member Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
0400
Detail > Member Level Detail Loop > Member Name Loop > PER

Member Communications Numbers

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
  • Required when enrolling subscribers, dependents with different contact information, or when changing a member's contact information and the information is provided to the sponsor for the member. If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

IP
Insured Party
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

N3
0500
Detail > Member Level Detail Loop > Member Name Loop > N3

Member Residence Street Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.
Example
N3-01
166
Member Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

N4
0600
Detail > Member Level Detail Loop > Member Name Loop > N4

Member City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.
Example
Only one of Member State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Location Identifier (N4-06) is present, then Location Qualifier (N4-05) is required
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Member City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Member State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Member Postal Zone or Zip Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-05
309
Location Qualifier
Optional
Identifier (ID)

Code identifying type of location

60
Area
CY
County/Parish
N4-06
310
Location Identifier
Optional
String (AN)
Min 1Max 30

Code which identifies a specific location

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

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
DMG
0800
Detail > Member Level Detail Loop > Member Name Loop > DMG

Member Demographics

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when enrolling a new member, changing a member's demographic information, or terminating a member. If not required by this implementation guide, do not send.
Example
If either Code List Qualifier Code (DMG-10) or Race or Ethnicity Collection Code (DMG-11) is present, then the other is required
If Race or Ethnicity Collection Code (DMG-11) is present, then Composite Race or Ethnicity Information (DMG-05) is required
DMG-01
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Member Birth Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • DMG02 is the date of birth.
DMG-03
1068
Gender Code
Required
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown

This code is to be used only when the gender is unknown or when it can not be sent due to reporting restrictions.

DMG-04
1067
Marital Status Code
Optional
Identifier (ID)

Code defining the marital status of a person

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

This code should be used if the previous status is unknown.

W
Widowed
X
Legally Separated
DMG-05
C056
Composite Race or Ethnicity Information
OptionalMax use 10
To send general and detailed information on race or ethnicity
Usage notes

Required when such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide, do not send.

If either Code List Qualifier Code (C056-02) or Race or Ethnicity Code (C056-03) is present, then the other is required
C056-01
1109
Race or Ethnicity Code
Optional
Identifier (ID)

Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes

7
Not Provided
8
Not Applicable
A
Asian or Pacific Islander
B
Black
C
Caucasian
D
Subcontinent Asian American
E
Other Race or Ethnicity
F
Asian Pacific American
G
Native American
H
Hispanic
I
American Indian or Alaskan Native
J
Native Hawaiian
N
Black (Non-Hispanic)
O
White (Non-Hispanic)
P
Pacific Islander
Z
Mutually Defined
C056-02
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C056-02 and C056-03 are used to specify detailed information about race or ethnicity.
RET
Classification of Race or Ethnicity
C056-03
1271
Race or Ethnicity Code
Optional
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

Usage notes
  • CODE SOURCE 859: Classification of Race or Ethnicity
DMG-06
1066
Citizenship Status Code
Optional
Identifier (ID)

Code indicating citizenship status

1
U.S. Citizen
2
Non-Resident Alien
3
Resident Alien
4
Illegal Alien
5
Alien
6
U.S. Citizen - Non-Resident
7
U.S. Citizen - Resident
DMG-10
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

REC
Race or Ethnicity Collection Code
DMG-11
1271
Race or Ethnicity Collection Code
Optional
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
EC
1000
Detail > Member Level Detail Loop > Member Name Loop > EC

Employment Class

OptionalMax use >1

To provide class of employment information

Usage notes
  • Required when sending additional employment class information on the member. If not required by this implementation guide, do not send.
Example
EC-01
1176
Employment Class Code
Required
Identifier (ID)

Code indicating category of employee

01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
EC-02
1176
Employment Class Code
Optional
Identifier (ID)

Code indicating category of employee

01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
EC-03
1176
Employment Class Code
Optional
Identifier (ID)

Code indicating category of employee

01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
ICM
1100
Detail > Member Level Detail Loop > Member Name Loop > ICM

Member Income

OptionalMax use 1

To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions

Usage notes
  • Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
Example
ICM-01
594
Frequency Code
Required
Identifier (ID)

Code indicating frequency or type of activities or actions being reported

  • ICM01 is the frequency at which an individual's wages are paid.
1
Weekly
2
Biweekly
3
Semimonthly
4
Monthly
6
Daily
7
Annual
8
Two Calendar Months
9
Lump-Sum Separation Allowance
B
Year-to-Date
C
Single
H
Hourly
Q
Quarterly
S
Semiannual
U
Unknown
ICM-02
782
Wage Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

  • ICM02 is the yearly wages amount.
ICM-03
380
Work Hours Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • ICM03 is the weekly hours.
ICM-04
310
Location Identification Code
Optional
String (AN)
Min 1Max 30

Code which identifies a specific location

  • ICM04 is the employer location qualifier such as a department number.
ICM-05
1214
Salary Grade Code
Optional
String (AN)
Min 1Max 5

The salary grade code assigned by the employer

AMT
1200
Detail > Member Level Detail Loop > Member Name Loop > AMT

Member Policy Amounts

OptionalMax use 7

To indicate the total monetary amount

Usage notes
  • Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

B9
Co-insurance - Actual

This will contain any co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract.

C1
Co-Payment Amount
D2
Deductible Amount
EBA
Expected Expenditure Amount
FK
Other Unlisted Amount
P3
Premium Amount
R
Spend Down
AMT-02
782
Contract Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

HLH
1300
Detail > Member Level Detail Loop > Member Name Loop > HLH

Member Health Information

OptionalMax use 1

To provide health information

Usage notes
  • Required on initial enrollment of a member when appropriate medical information about the member is available. If not required by this implementation guide, do not send.
Example
HLH-01
1212
Health Related Code
Required
Identifier (ID)

Code indicating a specific health situation

N
None
S
Substance Abuse
T
Tobacco Use
U
Unknown
X
Tobacco Use and Substance Abuse
HLH-02
65
Member Height
Optional
Decimal number (R)
Min 1Max 8

Vertical dimension of an object measured when the object is in the upright position

Usage notes
  • The height must be reported in inches.
HLH-03
81
Member Weight
Optional
Decimal number (R)
Min 1Max 10

Numeric value of weight

  • HLH03 is the current weight in pounds.
LUI
1500
Detail > Member Level Detail Loop > Member Name Loop > LUI

Member Language

OptionalMax use >1

To specify language, type of usage, and proficiency or fluency

Usage notes
  • Required if the sponsor knows that the member's primary language is not English, and such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide do not send.
  • Any need to send/collect this information will need to be contained in the trading partner agreement.
Example
If either Identification Code Qualifier (LUI-01) or Language Code (LUI-02) is present, then the other is required
If Language Use Indicator (LUI-04) is present, then at least one of Language Code (LUI-02) or Language Description (LUI-03) is required
LUI-01
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

LD
NISO Z39.53 Language Codes
LE
ISO 639 Language Codes
LUI-02
67
Language Code
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

  • LUI02 is the language code.
LUI-03
352
Language Description
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • LUI03 is the name of the language.
LUI-04
1303
Language Use Indicator
Optional
Identifier (ID)

Code indicating the use of a language

5
Language Reading
6
Language Writing
7
Language Speaking
8
Native Language
2100A Member Name Loop end
NM1
0300
Detail > Member Level Detail Loop > Incorrect Member Name Loop > NM1

Incorrect Member Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required if a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70. If not required by this implementation guide, do not send.
  • If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70.
Example
If either Identification Code Qualifier (NM1-08) or Prior Incorrect Insured Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

Usage notes
  • This code identifies that the information that follows is previously reported enrollment information that is being corrected.
70
Prior Incorrect Insured
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Prior Incorrect Member Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Prior Incorrect Member First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Prior Incorrect Member Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-06
1038
Prior Incorrect Member Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

NM1-07
1039
Prior Incorrect Member Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

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

Code designating the system/method of code structure used for Identification Code (67)

34
Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.

ZZ
Mutually Defined

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

NM1-09
67
Prior Incorrect Insured Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • NM109 is the identifier that was previously sent in error. This allows matching with data on receiver's system.
DMG
0800
Detail > Member Level Detail Loop > Incorrect Member Name Loop > DMG

Incorrect Member Demographics

OptionalMax use 1

To supply demographic information

Usage notes
  • Required when there is a change to the previously supplied demographic information. If not required by this implementation guide, do not send.
Example
If either Date Time Period Format Qualifier (DMG-01) or Prior Incorrect Insured Birth Date (DMG-02) is present, then the other is required
If either Code List Qualifier Code (DMG-10) or Race or Ethnicity Collection Code (DMG-11) is present, then the other is required
If Race or Ethnicity Collection Code (DMG-11) is present, then Composite Race or Ethnicity Information (DMG-05) is required
DMG-01
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Prior Incorrect Insured Birth Date
Optional
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • DMG02 is the date of birth.
DMG-03
1068
Prior Incorrect Insured Gender Code
Optional
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
DMG-04
1067
Marital Status Code
Optional
Identifier (ID)

Code defining the marital status of a person

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

This code should be used if the previous status is unknown.

W
Widowed
X
Legally Separated
DMG-05
C056
Composite Race or Ethnicity Information
OptionalMax use 10
To send general and detailed information on race or ethnicity
Usage notes

Required when the members Race or Ethnicity is being corrected. If not required this implementation guide, do not send.

If either Code List Qualifier Code (C056-02) or Race or Ethnicity Code (C056-03) is present, then the other is required
C056-01
1109
Race or Ethnicity Code
Optional
Identifier (ID)

Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes

7
Not Provided
8
Not Applicable
A
Asian or Pacific Islander
B
Black
C
Caucasian
D
Subcontinent Asian American
E
Other Race or Ethnicity
F
Asian Pacific American
G
Native American
H
Hispanic
I
American Indian or Alaskan Native
J
Native Hawaiian
N
Black (Non-Hispanic)
O
White (Non-Hispanic)
P
Pacific Islander
Z
Mutually Defined
C056-02
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

  • C056-02 and C056-03 are used to specify detailed information about race or ethnicity.
RET
Classification of Race or Ethnicity
C056-03
1271
Race or Ethnicity Code
Optional
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

DMG-06
1066
Citizenship Status Code
Optional
Identifier (ID)

Code indicating citizenship status

1
U.S. Citizen
2
Non-Resident Alien
3
Resident Alien
4
Illegal Alien
5
Alien
6
U.S. Citizen - Non-Resident
7
U.S. Citizen - Resident
DMG-10
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

REC
Race or Ethnicity Collection Code
DMG-11
1271
Race or Ethnicity Collection Code
Optional
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

  • DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
2100B Incorrect Member Name Loop end
NM1
0300
Detail > Member Level Detail Loop > Member Mailing Address Loop > NM1

Member Mailing Address

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the member mailing address is different from the residence address sent in loop 2100A or when the dependent's address is different from the subscriber. If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

31
Postal Mailing Address
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
N3
0500
Detail > Member Level Detail Loop > Member Mailing Address Loop > N3

Member Mail Street Address

RequiredMax use 1

To specify the location of the named party

Example
N3-01
166
Member Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

N4
0600
Detail > Member Level Detail Loop > Member Mailing Address Loop > N4

Member Mail City, State, ZIP Code

RequiredMax use 1

To specify the geographic place of the named party

Example
Only one of Member Mail State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Member Mail City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Member Mail State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Member Mail Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2100C Member Mailing Address Loop end
NM1
0300
Detail > Member Level Detail Loop > Member Employer Loop > NM1

Member Employer

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the member is employed by someone other than the sponsor and the insurance contract requires the payer to be notified of such employment. If not required by this implementation guide, do not send.
  • This segment is not used to collect Coordination of Benefits (COB) information. COB information must be passed in the 2320 loop.
Example
If either Identification Code Qualifier (NM1-08) or Member Employer Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

36
Employer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Member Employer Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Member Employer First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Member Employer Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-06
1038
Member Employer Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

NM1-07
1039
Member Employer Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

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

Code designating the system/method of code structure used for Identification Code (67)

24
Employer's Identification Number

This is the "HIPAA Employer Identifier".

34
Social Security Number
NM1-09
67
Member Employer Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
0400
Detail > Member Level Detail Loop > Member Employer Loop > PER

Member Employer Communications Numbers

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
  • Required when the Member Employers contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

EP
Employer Contact
PER-02
93
Member Employer Communications Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

N3
0500
Detail > Member Level Detail Loop > Member Employer Loop > N3

Member Employer Street Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
Example
N3-01
166
Member Employer Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Member Employer Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0600
Detail > Member Level Detail Loop > Member Employer Loop > N4

Member Employer City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
Example
Only one of Member Employer State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Member Employer City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Member Employer State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Member Employer Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2100D Member Employer Loop end
NM1
0300
Detail > Member Level Detail Loop > Member School Loop > NM1

Member School

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the member is enrolled in school and the payer is required to be notified under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

M8
Educational Institution
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
School Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

PER
0400
Detail > Member Level Detail Loop > Member School Loop > PER

Member School Commmunications Numbers

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
  • Required when the Member School contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

SK
School Clerk
PER-02
93
Member School Communications Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

N3
0500
Detail > Member Level Detail Loop > Member School Loop > N3

Member School Street Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
Example
N3-01
166
School Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

N4
0600
Detail > Member Level Detail Loop > Member School Loop > N4

Member School City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
Example
Only one of Member School State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Member School City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Member School State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Member School Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2100E Member School Loop end
NM1
0300
Detail > Member Level Detail Loop > Custodial Parent Loop > NM1

Custodial Parent

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when the custodial parent of a minor dependent is someone other than the subscriber. If not required by this implementation guide, do not send.
  • Any other situation, (examples: Guardianship, Legal Indemnity, Power of Attorney, and/or Separation Agreements) would be handled under the Responsible Party NM1 segment.
Example
If either Identification Code Qualifier (NM1-08) or Custodial Parent Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

S3
Custodial Parent
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Custodial Parent Last Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Custodial Parent First Name
Required
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Custodial Parent Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-06
1038
Custodial Parent Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

NM1-07
1039
Custodial Parent Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

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

Code designating the system/method of code structure used for Identification Code (67)

34
Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.

ZZ
Mutually Defined

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

NM1-09
67
Custodial Parent Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
0400
Detail > Member Level Detail Loop > Custodial Parent Loop > PER

Custodial Parent Communications Numbers

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
  • Required when the Custodial Parent contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

PQ
Parent or Guardian
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

N3
0500
Detail > Member Level Detail Loop > Custodial Parent Loop > N3

Custodial Parent Street Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.
Example
N3-01
166
Custodial Parent Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Custodial Parent Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0600
Detail > Member Level Detail Loop > Custodial Parent Loop > N4

Custodial Parent City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send.
Example
Only one of Custodial Parent State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Custodial Parent City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Custodial Parent State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Custodial Parent Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2100F Custodial Parent Loop end
NM1
0300
Detail > Member Level Detail Loop > Responsible Person Loop > NM1

Responsible Person

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required to identify the person(s), other than the subscriber, who are responsible for the member. If not required by this implementation guide, do not send.
Example
If either Identification Code Qualifier (NM1-08) or Responsible Party Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

6Y
Case Manager
9K
Key Person
E1
Person or Other Entity Legally Responsible for a Child

Used to identify a legal indemnity situation.

This code is used when a Qualified Medical Child Support Order (QMSCO) is present.

EI
Executor of Estate

This is used when the subscriber is deceased and the executor/responsible party is other than a surviving spouse.

EXS
Ex-spouse

This is used to identify a separated spouse under a separation agreement, or that the member is the divorced spouse and self responsible. This is NOT USED to identify the custodial parent for dependent children after a divorce.

GB
Other Insured
GD
Guardian
J6
Power of Attorney
LR
Legal Representative
QD
Responsible Party
S1
Parent
TZ
Significant Other
X4
Spouse
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Responsible Party Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Responsible Party First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Responsible Party Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-06
1038
Responsible Party Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

NM1-07
1039
Responsible Party Suffix Name
Optional
String (AN)
Min 1Max 10

Suffix to individual name

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

Code designating the system/method of code structure used for Identification Code (67)

34
Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.

ZZ
Mutually Defined

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

NM1-09
67
Responsible Party Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
0400
Detail > Member Level Detail Loop > Responsible Person Loop > PER

Responsible Person Communications Numbers

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
  • Required when the Responsible Person contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

RP
Responsible Person
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

N3
0500
Detail > Member Level Detail Loop > Responsible Person Loop > N3

Responsible Person Street Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.
Example
N3-01
166
Responsible Party Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Responsible Party Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0600
Detail > Member Level Detail Loop > Responsible Person Loop > N4

Responsible Person City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send.
Example
Only one of Responsible Person State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Responsible Person City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Responsible Person State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Responsible Person Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2100G Responsible Person Loop end
NM1
0300
Detail > Member Level Detail Loop > Drop Off Location Loop > NM1

Drop Off Location

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when member has requested shipments to be sent to an address other then their residence or mailing. If not required by this implementation guide, do not send.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

45
Drop-off Location
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Name Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

NM1-06
1038
Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

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

Suffix to individual name

N3
0500
Detail > Member Level Detail Loop > Drop Off Location Loop > N3

Drop Off Location Street Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.
Example
N3-01
166
Drop Off Location Address Line
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Drop Off Location Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0600
Detail > Member Level Detail Loop > Drop Off Location Loop > N4

Drop Off Location City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.
Example
Only one of Drop Off Location State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Drop Off Location City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Drop Off Location State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Drop Off Location Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
2100H Drop Off Location Loop end
2200 Disability Information Loop
OptionalMax >1
DSB
2000
Detail > Member Level Detail Loop > Disability Information Loop > DSB

Disability Information

RequiredMax use 1

To supply disability information

Usage notes
  • Required when enrolling a disabled member or when disability information about an existing member is added or changed. If not required by this implementation guide, do not send.
Example
If either Product or Service ID Qualifier (DSB-07) or Diagnosis Code (DSB-08) is present, then the other is required
DSB-01
1146
Disability Type Code
Required
Identifier (ID)

Code identifying the disability status of the individual

1
Short Term Disability
2
Long Term Disability
3
Permanent or Total Disability
4
No Disability
DSB-07
235
Product or Service ID Qualifier
Optional
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

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

To be used for the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) - Diagnosis.

CODE SOURCE: 897 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

DSB-08
1137
Diagnosis Code
Optional
String (AN)
Min 1Max 15

Code value for describing a medical condition or procedure

  • DSB08 is the functional status code for the disability.
DTP
2100
Detail > Member Level Detail Loop > Disability Information Loop > DTP

Disability Eligibility Dates

OptionalMax use 2

To specify any or all of a date, a time, or a time period

Usage notes
  • This segment is used to send the first and last date of disability.
  • Required when enrolling a disabled member or when disability dates change for an existing member, and the disability dates are known by the sponsor. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

360
Initial Disability Period Start
361
Initial Disability Period End
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Disability Eligibility Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

2200 Disability Information Loop end
2300 Health Coverage Loop
OptionalMax 99
HD
2600
Detail > Member Level Detail Loop > Health Coverage Loop > HD

Health Coverage

RequiredMax use 1

To provide information on health coverage

Usage notes
  • Required when enrolling a new member or when adding, updating, removing coverage or auditing an existing member. If not required by this implementation guide, do not send.
  • Refer to section 1.4.4 "Termination" for additional information relative to removing a member's coverage.
Example
HD-01
875
Maintenance Type Code
Required
Identifier (ID)

Code identifying the specific type of item maintenance

Usage notes
  • Required to identify the specific type of item maintenance.
001
Change
002
Delete

Use this code for deleting an incorrect coverage record.

021
Addition
024
Cancellation or Termination

Use this code for cancelling/terminating a coverage.

025
Reinstatement
026
Correction

This code is used to correct an incorrect record.

030
Audit or Compare
032
Employee Information Not Applicable

Certain situations, such as military duty and CHAMPUS/TRICARE, classify the subscriber as ineligible for coverage or benefits. However, dependents of the subscribers are still eligible for coverage or benefits under the subscriber. Subscriber identifying elements are needed to accurately identify dependents.

HD-03
1205
Insurance Line Code
Required
Identifier (ID)

Code identifying a group of insurance products

AG
Preventative Care/Wellness
AH
24 Hour Care
AJ
Medicare Risk
AK
Mental Health
DCP
Dental Capitation

This identifies a dental managed care organization (DMO).

DEN
Dental
EPO
Exclusive Provider Organization
FAC
Facility
HE
Hearing
HLT
Health

Includes both hospital and professional coverage.

HMO
Health Maintenance Organization
LTC
Long-Term Care
LTD
Long-Term Disability
MM
Major Medical
MOD
Mail Order Drug
PDG
Prescription Drug
POS
Point of Service
PPO
Preferred Provider Organization
PRA
Practitioners
STD
Short-Term Disability
UR
Utilization Review
VIS
Vision
HD-04
1204
Plan Coverage Description
Optional
String (AN)
Min 1Max 50

A description or number that identifies the plan or coverage

HD-05
1207
Coverage Level Code
Optional
Identifier (ID)

Code indicating the level of coverage being provided for this insured

Usage notes
  • See section 1.4.6, Coverage Levels and Dependents, for additional information.
CHD
Children Only
DEP
Dependents Only
E1D
Employee and One Dependent

For this code, the dependent is a non-spouse dependent. This code is not used for identification of Employee and Spouse. See code ESP.

E2D
Employee and Two Dependents
E3D
Employee and Three Dependents
E5D
Employee and One or More Dependents
E6D
Employee and Two or More Dependents
E7D
Employee and Three or More Dependents
E8D
Employee and Four or More Dependents
E9D
Employee and Five or More Dependents
ECH
Employee and Children
EMP
Employee Only
ESP
Employee and Spouse
FAM
Family
IND
Individual
SPC
Spouse and Children
SPO
Spouse Only
TWO
Two Party
HD-09
1073
Late Enrollment Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • HD09 is a late enrollee indicator. A "Y" value indicates the insured is a late enrollee, which can result in a reduction of benefits; an "N" value indicates the insured is a regular enrollee.
N
No
Y
Yes
DTP
2700
Detail > Member Level Detail Loop > Health Coverage Loop > DTP

Health Coverage Dates

RequiredMax use 6

To specify any or all of a date, a time, or a time period

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

Code specifying type of date or time, or both date and time

300
Enrollment Signature Date
303
Maintenance Effective

This is the effective date of a change where a member's coverage is not being added or removed.

343
Premium Paid to Date End
348
Benefit Begin

This is the effective date of coverage. This code must always be sent when adding or reinstating coverage.

349
Benefit End

The termination date represents the last date of coverage in which claims will be paid for the individual being terminated. For example, if a date of 02/28/2001 is passed then claims for this individual will be paid through 11:59 p.m. on 2/28/01.

543
Last Premium Paid Date
695
Previous Period

This value is only to be used when reporting Previous Coverage Months.

DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Coverage Period
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

AMT
2800
Detail > Member Level Detail Loop > Health Coverage Loop > AMT

Health Coverage Policy

OptionalMax use 9

To indicate the total monetary amount

Usage notes
  • Required when such transmission is required under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.
Example
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

B9
Co-insurance - Actual

This will contain any co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract.

C1
Co-Payment Amount
D2
Deductible Amount
EBA
Expected Expenditure Amount
FK
Other Unlisted Amount
P3
Premium Amount
R
Spend Down
AMT-02
782
Contract Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

REF
2900
Detail > Member Level Detail Loop > Health Coverage Loop > REF

Health Coverage Policy Number

OptionalMax use 14

To specify identifying information

Usage notes
  • Required when such transmission is required under the Trading Partner Agreement between the sponsor and the payer. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
REFPrior Coverage Months
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

1L
Group or Policy Number

Required when a group number that applies to this individual's participation in the coverage passed in this HD loop is required by the terms of the contract between the sponsor (sender) and payer (receiver); if not required may be sent at the sender's discretion.

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

Use this code for the Payment Plan Type Code (Annual or Quarterly) until a standard code is assigned.

REF-02
127
Member Group or Policy Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF
2900
Detail > Member Level Detail Loop > Health Coverage Loop > REF

Prior Coverage Months

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the portability provisions of the Health Insurance Portability and Accountability Act require reporting of the number of months of prior health coverage that meet the certification requirements of the Act.
Example
Variants (all may be used)
REFHealth Coverage Policy Number
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

QQ
Unit Number

This code is used in this implementation guide to indicate that the value in REF02 is the response required under the portability provisions of HIPAA.

REF-02
127
Prior Coverage Month Count
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Indicator identifying the number of prior months insurance coverage that may apply under the portability provisions of the Health Insurance Portability and Accountability Act.
  • This field will contain the number of months of prior health insurance coverage that meets the portability requirements of the HIPAA certification requirements. To be sent on new enrollments when available.
IDC
3000
Detail > Member Level Detail Loop > Health Coverage Loop > IDC

Identification Card

OptionalMax use 3

To provide notification to produce replacement identification card(s)

Usage notes
  • Required when requesting the production of an identification card as the result of an enrollment add, change, or statement. If not required by this implementation guide, do not send.
  • An enrollment statement refers to a situation where no change is being made to the enrollment except to request a replacement ID card.
Example
IDC-01
1204
Plan Coverage Description
Required
String (AN)
Min 1Max 50

A description or number that identifies the plan or coverage

Usage notes
  • If no additional information is needed, this element will be sent as a single zero.
IDC-02
1215
Identification Card Type Code
Required
Identifier (ID)

Code identifying the type of identification card

Usage notes
  • This code is used to identify that the card issued will be specific to the coverage identified in the related HD segment.
D
Dental Insurance
H
Health Insurance
P
Prescription Drug Service Drug Insurance
IDC-03
380
Identification Card Count
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

  • IDC03 is the number of cards being requested.
Usage notes
  • Only non-negative integer values are to be sent.
IDC-04
306
Action Code
Optional
Identifier (ID)

Code indicating type of action

  • IDC04 is the reason for the card being requested, i.e., add or a change.
1
Add
2
Change (Update)
RX
Replace

Use when requesting replacement cards with no change to data.

2310 Provider Information Loop
OptionalMax 30
LX
3100
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > LX

Provider Information

RequiredMax use 1

To reference a line number in a transaction set

Usage notes
  • Required to provide information about the primary care or capitated physicians and pharmacies chosen by the enrollee in a managed care plan when that selection is made through the sponsor. If not required by this implementation guide, do not send.
  • Use one iteration of the loop to identify each applicable health care service provider.
  • The primary care provider effective date is defaulted to the effective date of the product identified in the DTP segment of the 2300 loop. When an enrollee switches from one primary care provider to another through the sponsor, the new provider must be listed with the effective date of change.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

Usage notes
  • This is a sequential number representing the number of loops for this insured person. Begin with 1 for each insured person.
NM1
3200
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > NM1

Provider Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • The National Provider ID must be passed in NM109. Until that ID is available, the Federal Taxpayer's Identification Number or another identification number that is necessary to identify the entity must be sent if available. If the identification number is not available then the Provider's Name must be passed using elements NM103 through NM107 as outlined in segment note 2.
Example
If either Identification Code Qualifier (NM1-08) or Provider Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

1X
Laboratory
3D
Obstetrics and Gynecology Facility
80
Hospital
FA
Facility
OD
Doctor of Optometry
P3
Primary Care Provider
QA
Pharmacy
QN
Dentist
Y2
Managed Care Organization
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Provider Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Individual first name

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

Individual middle name or initial

NM1-06
1038
Provider Name Prefix
Optional
String (AN)
Min 1Max 10

Prefix to individual name

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

Suffix to individual name

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

Code designating the system/method of code structure used for Identification Code (67)

34
Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.

FI
Federal Taxpayer's Identification Number
SV
Service Provider Number

This is a number assigned by the payer used to identify a provider.

XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Provider Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

NM1-10
706
Entity Relationship Code
Required
Identifier (ID)

Code describing entity relationship

  • NM110 and NM111 further define the type of entity in NM101.
Usage notes
  • This element indicates whether or not the member is an existing patient of the provider.
25
Established Patient
26
Not Established Patient
72
Unknown
N3
3500
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > N3

Provider Address

OptionalMax use 2

To specify the location of the named party

Usage notes
  • Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.
Example
N3-01
166
Provider Address Line
Required
String (AN)
Min 1Max 55

Address information

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

Address information

N4
3600
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > N4

Provider City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.
Example
Only one of Provider State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Provider City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Provider State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Provider Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
PER
3700
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > PER

Provider Communications Numbers

OptionalMax use 2

To identify a person or office to whom administrative communications should be directed

Usage notes
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).
  • Required when the Provider contact information is provided to the sponsor. If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-05) or Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

IC
Information Contact
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-06
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

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

Code identifying the type of communication number

AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
PER-08
364
Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

PLA
3950
Detail > Member Level Detail Loop > Health Coverage Loop > Provider Information Loop > PLA

Provider Change Reason

OptionalMax use 1

To indicate action to be taken for the location specified and to qualify the location specified

Usage notes
  • Required to report the reason and the effective date that a member changes providers as described by the NM1 segment in Loop 2310. If not required by this implementation guide, do not send.
Example
PLA-01
306
Action Code
Required
Identifier (ID)

Code indicating type of action

2
Change (Update)
PLA-02
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

1P
Provider
PLA-03
373
Provider Effective Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

  • PLA03 is the effective date for the action identified in PLA01.
Usage notes
  • This is the effective date of the change of PCP.
PLA-05
1203
Maintenance Reason Code
Required
Identifier (ID)

Code identifying the reason for the maintenance change

Usage notes
  • If none of the specific Maintenance Reasons apply, send 'AI', No Reason Given.
14
Voluntary Withdrawal
22
Plan Change
46
Current Customer Information File in Error
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
AJ
Appointment Times not Met in a Timely Manner
2310 Provider Information Loop end
2320 Coordination of Benefits Loop
OptionalMax 5
COB
4000
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > COB

Coordination of Benefits

RequiredMax use 1

To supply information on coordination of benefits

Usage notes
  • Required whenever an individual has another insurance plan with benefits similar to those covered by the insurance product specified in the HD segment for this occurrence of Loop ID-2300. If not required by this implementation guide, do not send.
Example
COB-01
1138
Payer Responsibility Sequence Number Code
Required
Identifier (ID)

Code identifying the insurance carrier's level of responsibility for a payment of a claim

P
Primary
S
Secondary
T
Tertiary
U
Unknown
COB-02
127
Member Group or Policy Number
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • COB02 is the policy number.
COB-03
1143
Coordination of Benefits Code
Required
Identifier (ID)

Code identifying whether there is a coordination of benefits

1
Coordination of Benefits
5
Unknown
6
No Coordination of Benefits

This code is sent when it has been determined that there is no COB.

COB-04
1365
Service Type Code
Optional
Identifier (ID)
Max use 9

Code identifying the classification of service

1
Medical Care
35
Dental Care
48
Hospital - Inpatient
50
Hospital - Outpatient
54
Long Term Care
89
Free Standing Prescription Drug
90
Mail Order Prescription Drug
A4
Psychiatric
AG
Skilled Nursing Care
AL
Vision (Optometry)
BB
Partial Hospitalization (Psychiatric)
REF
4050
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > REF

Additional Coordination of Benefits Identifiers

OptionalMax use 4

To specify identifying information

Usage notes
  • Required if additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.
  • Use the Social Security Number until the National ID Number for individuals is available.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

6P
Group Number
60
Account Suffix Code
SY
Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.

ZZ
Mutually Defined

Mutually Defined, will be used in this REF01 for National Individual Identifier until a standard code is defined.

REF-02
127
Member Group or Policy Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

DTP
4070
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > DTP

Coordination of Benefits Eligibility Dates

OptionalMax use 2

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the submitter needs to send effective dates for coordination of benefits. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

344
Coordination of Benefits Begin
345
Coordination of Benefits End
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Coordination of Benefits Date
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

2330 Coordination of Benefits Related Entity Loop
OptionalMax 3
NM1
4100
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > NM1

Coordination of Benefits Related Entity

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required to send the name of the insurance company when provided to the sponsor. If not required by this implementation guide, do not send.
Example
If either Identification Code Qualifier (NM1-08) or Coordination of Benefits Insurer Identification Code (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

36
Employer
GW
Group
IN
Insurer
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
2
Non-Person Entity
NM1-03
1035
Coordination of Benefits Insurer Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

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

Code designating the system/method of code structure used for Identification Code (67)

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

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

NM1-09
67
Coordination of Benefits Insurer Identification Code
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

N3
4300
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > N3

Coordination of Benefits Related Entity Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
Example
N3-01
166
Address Information
Required
String (AN)
Min 1Max 55

Address information

N3-02
166
Address Information
Optional
String (AN)
Min 1Max 55

Address information

N4
4400
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > N4

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

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
Example
Only one of Coordination of Benefits Other Insurance Company State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Coordination of Benefits Other Insurance Company City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Coordination of Benefits Other Insurance Company State Code
Optional
Identifier (ID)
Min 2Max 2

Code (Standard State/Province) as defined by appropriate government agency

  • N402 is required only if city name (N401) is in the U.S. or Canada.
N4-03
116
Coordination of Benefits Other Insurance Company Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

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

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
PER
4500
Detail > Member Level Detail Loop > Health Coverage Loop > Coordination of Benefits Loop > Coordination of Benefits Related Entity Loop > PER

Administrative Communications Contact

OptionalMax use 1

To identify a person or office to whom administrative communications should be directed

Usage notes
  • Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.
Example
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

CN
General Contact
PER-03
365
Communication Number Qualifier
Required
Identifier (ID)

Code identifying the type of communication number

TE
Telephone
PER-04
364
Communication Number
Required
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

2330 Coordination of Benefits Related Entity Loop end
2320 Coordination of Benefits Loop end
2300 Health Coverage Loop end
LS
6880
Detail > Member Level Detail Loop > LS

Loop Header

OptionalMax use 1

To indicate that the next segment begins a loop

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

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

2700 Member Reporting Categories Loop
OptionalMax >1
LX
6881
Detail > Member Level Detail Loop > Member Reporting Categories Loop > LX

Member Reporting Categories

RequiredMax use 1

To reference a line number in a transaction set

Usage notes
  • Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send.
Example
LX-01
554
Assigned Number
Required
Numeric (N0)
Min 1Max 6

Number assigned for differentiation within a transaction set

Usage notes
  • Use this sequential non-negative integer for LX loops for this member's additional reporting categories.
2750 Reporting Category Loop
OptionalMax 1
N1
6882
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > N1

Reporting Category

RequiredMax use 1

To identify a party by type of organization, name, and code

Usage notes
  • Required to specify the name of the reporting category of the member's participating entity.
Example
N1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

75
Participant
N1-02
93
Member Reporting Category Name
Required
String (AN)
Min 1Max 60

Free-form name

REF
6883
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > REF

Reporting Category Reference

OptionalMax use 1

To specify identifying information

Usage notes
  • Required to specify the reference identifier associated with the reporting category of the member's participating entity.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

00
Contracting District Number
3L
Branch Identifier
6M
Application Number
9V
Payment Category
9X
Account Category
17
Client Reporting Category
18
Plan Number
19
Division Identifier
26
Union Number
GE
Geographic Number
LU
Location Number
PID
Program Identification Number
XX1
Special Program Code
XX2
Service Area Code
YY
Geographic Key
ZZ
Mutually Defined
REF-02
127
Member Reporting Category Reference ID
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

DTP
6884
Detail > Member Level Detail Loop > Member Reporting Categories Loop > Reporting Category Loop > DTP

Reporting Category Date

OptionalMax use 1

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when called for in the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
  • Use this segment to associate a date or date range with a reporting category.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

007
Effective
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

Code indicating the date format, time format, or date and time format

  • DTP02 is the date or time or period format that will appear in DTP03.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

A range of dates expressed in the format CCYYMMDD-CCYYMMDD where CCYY is the numerical expression of the century CC and year YY. MM is the numerical expression of the month within the year, and DD is the numerical expression of the day within the year; the first occurrence of CCYYMMDD is the beginning date and the second occurrence is the ending date.

DTP-03
1251
Member Reporting Category Effective Date(s)
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

2750 Reporting Category Loop end
2700 Member Reporting Categories Loop end
LE
6885
Detail > Member Level Detail Loop > LE

Loop Trailer

OptionalMax use 1

To indicate that the loop immediately preceding this segment is complete

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

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

2000 Member Level Detail Loop end
SE
6900
Detail > SE

Transaction Set Trailer

RequiredMax use 1

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

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

Total number of segments included in a transaction set including ST and SE segments

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

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. For example, start with the number 0001 and increment from there. This number must be unique within a specific group and interchange, but the number can repeat in other groups and interchanges.
Detail end
GE

Functional Group Trailer

RequiredMax use 1

To indicate the end of a functional group and to provide control information

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

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

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

Assigned number originated and maintained by the sender

IEA

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

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

A count of the number of functional groups included in an interchange

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

A control number assigned by the interchange sender

EDI Samples

834 Inbound Envelope

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**HP*7172343334*WP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
COB*P*890111*5~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**VIS~
DTP*348*D8*19960601~
SE*21*12345~
GE*1*000000103~
IEA*1*000000103~

834 Outbound Envelope

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**HP*7172343334*WP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
COB*P*890111*5~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**VIS~
DTP*348*D8*19960601~
SE*21*12345~
GE*1*000000103~
IEA*1*000000103~

Example 1: Enroll an Employee in Multiple Health Care Insurance Products

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*356*D8*19960523~
NM1*IL*1*DOE*JOHN*P***34*123456789~
PER*IP**HP*7172343334*WP*7172341240~
N3*100 MARKET ST*APT 3G~
N4*CAMP HILL*PA*17011**CY*CUMBERLAND~
DMG*D8*19400816*M~
HD*021**HLT~
DTP*348*D8*19960601~
COB*P*890111*5~
HD*021**DEN~
DTP*348*D8*19960601~
HD*021**VIS~
DTP*348*D8*19960601~
SE*21*12345~
GE*1*000000103~
IEA*1*000000103~

Example 10: Reinstate member eligibility (INS)

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*025**A***FT~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****ZZ*202443307~
SE*10*12345~
GE*1*000000103~
IEA*1*000000103~

Example 2: Add a Dependent (Full-time Student) to an Existing Enrollment

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*N*19*021*28*A****F~
REF*0F*123456789~
REF*1L*123456001~
DTP*351*D8*19980515~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19770816*M~
NM1*M8*2*PENN STATE UNIVERSITY~
HD*021**HLT~
DTP*348*D8*19960601~
SE*15*12345~
GE*1*000000103~
IEA*1*000000103~

Example 3: Enroll an Employee in a Managed Care Product

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*021*20*A***FT~
REF*0F*202443307~
REF*1L*123456001~
DTP*356*D8*19960112~
NM1*IL*1*SMITH*WILLIAM****34*202443307~
PER*IP**HP*7172343334*WP*7172341240~
N3*1715 SOUTHWIND AVENUE~
N4*ANYTOWN*PA*171110000~
DMG*D8*19700614*M~
HD*021**HMO~
DTP*348*D8*19960601~
LX*01~
NM1*P3*1*BROWN*BERNARD**DR**SV*143766*25~
SE*18*12345~
GE*1*000000103~
IEA*1*000000103~

Example 4: Add Subscriber Coverage

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*001*22*A***FT~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****ZZ*2024433307~
HD*021**DEN~
DTP*348*D8*20020701~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~

Example 5: Change subscriber information

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5*GENERIC INC*FI*000111000~
N1*IN*ABC INSURANCE*FI*654456654~
INS*Y*18*001*25*A***FT~
REF*0F*123456789~
REF*1L*123456001~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19500415*M~
NM1*70*1*DOE*JAMES*E~
DMG*D8*19500416*M~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~

Example 6: Cancel a dependent

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*N*19*024*07*A~
REF*0F*123456789~
REF*1L*123456001~
DTP*357*D8*19960801~
NM1*IL*1*DOE*JAMES*E***34*103229876~
DMG*D8*19770816*M~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~

Example 7: Terminate Eligibility for a Subscriber

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*024*08*A***TE~
REF*0F*123456789~
REF*1L*123456001~
DTP*357*D8*19961001~
NM1*IL*1*DOE*JOHN*E***34*103229876~
SE*10*12345~
GE*1*000000103~
IEA*1*000000103~

Example 8: Reinstate an Employee

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*19980520*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*025*20*A***FT~
REF*0F*123456789~
REF*1L*123456001~
DTP*303*D8*19961001~
NM1*IL*1*DOE*JOHN*E***34*103229876~
SE*11*12345~
GE*1*000000103~
IEA*1*000000103~

Example 9: Reinstate the Employee at the Coverage (HD) Level

ISA*00* *00* *ZZ*SENDERNAME *ZZ*RECEIVERNAME *041227*1324*^*00501*000000103*0*P*>~
GS*BE*SENDERNAME*RECEIVERNAME*20041227*1324*000000103*X*005010X220A1~
ST*834*12345*005010X220A1~
BGN*00*12456*20020601*1200****2~
REF*38*ABCD012354~
N1*P5**FI*999888777~
N1*IN**FI*654456654~
INS*Y*18*025**A***FT~
REF*0F*202443307~
REF*1L*123456001~
NM1*IL*1*SMITH*WILLIAM****ZZ*202443307~
HD*025**DEN~
DTP*348*D8*20020701~
SE*12*12345~
GE*1*000000103~
IEA*1*000000103~

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