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EDI platform
Eligibility Check Raw X12
curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3/raw-x12 \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--data '{
"x12": "<string>"
}'{
"meta": {
"senderId": "<string>",
"submitterId": "<string>",
"billerId": "<string>",
"applicationMode": "<string>",
"traceId": "<string>",
"outboundTraceId": "<string>"
},
"controlNumber": "<string>",
"reassociationKey": "<string>",
"tradingPartnerServiceId": "<string>",
"provider": {
"providerName": "<string>",
"providerFirstName": "<string>",
"providerOrgName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"entityIdentifier": "<string>",
"entityType": "<string>",
"npi": "<string>",
"providerCode": "<string>",
"referenceIdentification": "<string>",
"employersId": "<string>",
"ssn": "<string>",
"federalTaxpayersIdNumber": "<string>",
"payorIdentification": "<string>",
"pharmacyProcessorNumber": "<string>",
"serviceProviderNumber": "<string>",
"servicesPlanID": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
},
"subscriber": {
"healthCareDiagnosisCodes": [
{
"diagnosisTypeCode": "<string>",
"diagnosisCode": "<string>"
}
],
"memberId": "<string>",
"firstName": "<string>",
"lastName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"gender": "M",
"entityIdentifier": "<string>",
"entityType": "<string>",
"uniqueHealthIdentifier": "<string>",
"dateOfBirth": "<string>",
"informationStatusCode": "<string>",
"employmentStatusCode": "<string>",
"governmentServiceAffiliationCode": "<string>",
"description": "<string>",
"militaryServiceRankCode": "<string>",
"dateTimePeriodFormatQualifier": "<string>",
"dateTimePeriod": "<string>",
"endDateTimePeriod": "<string>",
"startDateTimePeriod": "<string>",
"ssn": "<string>",
"groupNumber": "<string>",
"planNumber": "<string>",
"planNetworkIdNumber": "<string>",
"relationToSubscriber": "<string>",
"relationToSubscriberCode": "<string>",
"insuredIndicator": "<string>",
"maintenanceTypeCode": "<string>",
"maintenanceReasonCode": "<string>",
"birthSequenceNumber": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"responseProvider": {
"providerName": "<string>",
"providerFirstName": "<string>",
"providerOrgName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"entityIdentifier": "<string>",
"entityType": "<string>",
"npi": "<string>",
"providerCode": "<string>",
"referenceIdentification": "<string>",
"employersId": "<string>",
"ssn": "<string>",
"federalTaxpayersIdNumber": "<string>",
"payorIdentification": "<string>",
"pharmacyProcessorNumber": "<string>",
"serviceProviderNumber": "<string>",
"servicesPlanID": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
},
"subscriberTraceNumbers": [
{
"traceTypeCode": "<string>",
"traceType": "<string>",
"referenceIdentification": "<string>",
"originatingCompanyIdentifier": "<string>",
"secondaryReferenceIdentification": "<string>"
}
],
"dependents": [
{
"healthCareDiagnosisCodes": [
{
"diagnosisTypeCode": "<string>",
"diagnosisCode": "<string>"
}
],
"memberId": "<string>",
"firstName": "<string>",
"lastName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"gender": "M",
"entityIdentifier": "<string>",
"entityType": "<string>",
"uniqueHealthIdentifier": "<string>",
"dateOfBirth": "<string>",
"informationStatusCode": "<string>",
"employmentStatusCode": "<string>",
"governmentServiceAffiliationCode": "<string>",
"description": "<string>",
"militaryServiceRankCode": "<string>",
"dateTimePeriodFormatQualifier": "<string>",
"dateTimePeriod": "<string>",
"endDateTimePeriod": "<string>",
"startDateTimePeriod": "<string>",
"ssn": "<string>",
"groupNumber": "<string>",
"planNumber": "<string>",
"planNetworkIdNumber": "<string>",
"relationToSubscriber": "<string>",
"relationToSubscriberCode": "<string>",
"insuredIndicator": "<string>",
"maintenanceTypeCode": "<string>",
"maintenanceReasonCode": "<string>",
"birthSequenceNumber": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"responseProvider": {
"providerName": "<string>",
"providerFirstName": "<string>",
"providerOrgName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"entityIdentifier": "<string>",
"entityType": "<string>",
"npi": "<string>",
"providerCode": "<string>",
"referenceIdentification": "<string>",
"employersId": "<string>",
"ssn": "<string>",
"federalTaxpayersIdNumber": "<string>",
"payorIdentification": "<string>",
"pharmacyProcessorNumber": "<string>",
"serviceProviderNumber": "<string>",
"servicesPlanID": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
}
],
"payer": {
"entityIdentifier": "<string>",
"entityType": "<string>",
"firstName": "<string>",
"lastName": "<string>",
"name": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"employersId": "<string>",
"federalTaxpayersIdNumber": "<string>",
"naic": "<string>",
"npi": "<string>",
"centersForMedicareAndMedicaidPlanId": "<string>",
"payorIdentification": "<string>",
"contactInformation": {
"name": "<string>",
"contacts": [
{
"communicationMode": "<string>",
"communicationNumber": "<string>"
}
]
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
],
"etin": "<string>"
},
"planInformation": {
"stateLicenseNumber": "<string>",
"medicareProviderNumber": "<string>",
"medicaidProviderNumber": "<string>",
"facilityIdNumber": "<string>",
"personalIdentificationNumber": "<string>",
"planNumber": "<string>",
"planDescription": "<string>",
"policyNumber": "<string>",
"memberId": "<string>",
"caseNumber": "<string>",
"familyUnitNumber": "<string>",
"groupNumber": "<string>",
"groupDescription": "<string>",
"referralNumber": "<string>",
"alternativeListId": "<string>",
"classOfContractCode": "<string>",
"coverageListId": "<string>",
"contractNumber": "<string>",
"medicalRecordIdentificationNumber": "<string>",
"electronicDevicePin": "<string>",
"submitterIdentificationNumber": "<string>",
"patientAccountNumber": "<string>",
"hicNumber": "<string>",
"drugFormularyNumber": "<string>",
"priorAuthorizationNumber": "<string>",
"idCardSerialNumber": "<string>",
"idCardNumber": "<string>",
"centersForMedicareAndMedicaidServicesNPI": "<string>",
"issueNumber": "<string>",
"insurancePolicyNumber": "<string>",
"userIdentification": "<string>",
"medicalAssistanceCategory": "<string>",
"eligibilityCategory": "<string>",
"planNetworkIdNumber": "<string>",
"planNetworkIdDescription": "<string>",
"facilityNetworkIdentificationNumber": "<string>",
"medicaidRecipientIdNumber": "<string>",
"priorIdNumber": "<string>",
"socialSecurityNumber": "<string>",
"federalTaxpayersIdentificationNumber": "<string>",
"agencyClaimNumber": "<string>"
},
"planDateInformation": {
"discharge": "<string>",
"issue": "<string>",
"effectiveDateOfChange": "<string>",
"periodStart": "<string>",
"periodEnd": "<string>",
"completion": "<string>",
"coordinationOfBenefits": "<string>",
"plan": "<string>",
"benefit": "<string>",
"primaryCareProvider": "<string>",
"latestVisitOrConsultation": "<string>",
"eligibility": "<string>",
"added": "<string>",
"cobraBegin": "<string>",
"cobraEnd": "<string>",
"premiumPaidToDateBegin": "<string>",
"premiumPaidToDateEnd": "<string>",
"planBegin": "<string>",
"planEnd": "<string>",
"benefitBegin": "<string>",
"benefitEnd": "<string>",
"eligibilityBegin": "<string>",
"eligibilityEnd": "<string>",
"enrollment": "<string>",
"admission": "<string>",
"dateOfDeath": "<string>",
"certification": "<string>",
"service": "<string>",
"policyEffective": "<string>",
"policyExpiration": "<string>",
"dateOfLastUpdate": "<string>",
"status": "<string>"
},
"planStatus": [
{
"statusCode": "<string>",
"status": "<string>",
"planDetails": "<string>",
"serviceTypeCodes": [
"<string>"
]
}
],
"benefitsInformation": [
{
"code": "<string>",
"name": "<string>",
"coverageLevelCode": "<string>",
"coverageLevel": "<string>",
"serviceTypeCodes": [
"<string>"
],
"serviceTypes": [
"<string>"
],
"insuranceTypeCode": "<string>",
"insuranceType": "<string>",
"planCoverage": "<string>",
"timeQualifierCode": "<string>",
"timeQualifier": "<string>",
"benefitAmount": "<string>",
"benefitPercent": "<string>",
"quantityQualifierCode": "<string>",
"quantityQualifier": "<string>",
"benefitQuantity": "<string>",
"authOrCertIndicator": "<string>",
"inPlanNetworkIndicatorCode": "<string>",
"inPlanNetworkIndicator": "<string>",
"headerLoopIdentifierCode": "<string>",
"trailerLoopIdentifierCode": "<string>",
"compositeMedicalProcedureIdentifier": {
"productOrServiceIdQualifierCode": "<string>",
"productOrServiceIdQualifier": "<string>",
"procedureCode": "<string>",
"procedureModifiers": [
"<string>"
],
"productOrServiceID": "<string>",
"diagnosisCodePointer": [
"<string>"
]
},
"benefitsAdditionalInformation": {
"stateLicenseNumber": "<string>",
"medicareProviderNumber": "<string>",
"medicaidProviderNumber": "<string>",
"facilityIdNumber": "<string>",
"personalIdentificationNumber": "<string>",
"planNumber": "<string>",
"policyNumber": "<string>",
"memberId": "<string>",
"caseNumber": "<string>",
"familyUnitNumber": "<string>",
"groupNumber": "<string>",
"referralNumber": "<string>",
"alternativeListId": "<string>",
"classOfContractCode": "<string>",
"coverageListId": "<string>",
"contractNumber": "<string>",
"medicalRecordIdentificationNumber": "<string>",
"electronicDevicePin": "<string>",
"submitterIdentificationNumber": "<string>",
"patientAccountNumber": "<string>",
"hicNumber": "<string>",
"drugFormularyNumber": "<string>",
"priorAuthorizationNumber": "<string>",
"idCardSerialNumber": "<string>",
"idCardNumber": "<string>",
"centersForMedicareAndMedicaidServicesNPI": "<string>",
"issueNumber": "<string>",
"insurancePolicyNumber": "<string>",
"userIdentification": "<string>",
"medicalAssistanceCategory": "<string>",
"eligibilityCategory": "<string>",
"planNetworkIdNumber": "<string>",
"facilityNetworkIdentificationNumber": "<string>",
"medicaidRecepientIdNumber": "<string>",
"priorIdNumber": "<string>",
"socialSecurityNumber": "<string>",
"federalTaxpayersIdentificationNumber": "<string>",
"agencyClaimNumber": "<string>"
},
"benefitsDateInformation": {
"discharge": "<string>",
"discharges": [
{
"date": "<string>",
"startDate": "<string>",
"endDate": "<string>"
}
],
"issue": "<string>",
"effectiveDateOfChange": "<string>",
"periodStart": "<string>",
"periodEnd": "<string>",
"completion": "<string>",
"coordinationOfBenefits": "<string>",
"plan": "<string>",
"benefit": "<string>",
"primaryCareProvider": "<string>",
"latestVisitOrConsultation": "<string>",
"eligibility": "<string>",
"added": "<string>",
"cobraBegin": "<string>",
"cobraEnd": "<string>",
"premiumPaidtoDateBegin": "<string>",
"premiumPaidToDateEnd": "<string>",
"planBegin": "<string>",
"planEnd": "<string>",
"benefitBegin": "<string>",
"benefitEnd": "<string>",
"eligibilityBegin": "<string>",
"eligibilityEnd": "<string>",
"enrollment": "<string>",
"admission": "<string>",
"admissions": [
{
"date": "<string>",
"startDate": "<string>",
"endDate": "<string>"
}
],
"dateOfDeath": "<string>",
"certification": "<string>",
"service": "<string>",
"policyEffective": "<string>",
"policyExpiration": "<string>",
"dateOfLastUpdate": "<string>",
"status": "<string>"
},
"benefitsRelatedEntity": {
"entityIdentifier": "<string>",
"entityType": "<string>",
"entityName": "<string>",
"entityFirstname": "<string>",
"entityMiddlename": "<string>",
"entitySuffix": "<string>",
"entityIdentification": "<string>",
"entityIdentificationValue": "<string>",
"entityRelationship": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"contactInformation": {
"name": "<string>",
"contacts": [
{
"communicationMode": "<string>",
"communicationNumber": "<string>"
}
]
},
"providerInformation": {
"providerCode": "<string>",
"referenceIdentification": "<string>"
}
},
"benefitsRelatedEntities": [
{
"entityIdentifier": "<string>",
"entityType": "<string>",
"entityName": "<string>",
"entityFirstname": "<string>",
"entityMiddlename": "<string>",
"entitySuffix": "<string>",
"entityIdentification": "<string>",
"entityIdentificationValue": "<string>",
"entityRelationship": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"contactInformation": {
"name": "<string>",
"contacts": [
{
"communicationMode": "<string>",
"communicationNumber": "<string>"
}
]
},
"providerInformation": {
"providerCode": "<string>",
"referenceIdentification": "<string>"
}
}
],
"benefitsServiceDelivery": [
{
"quantityQualifierCode": "<string>",
"quantityQualifier": "<string>",
"quantity": "<string>",
"unitForMeasurementCode": "<string>",
"sampleSelectionModulus": "<string>",
"timePeriodQualifierCode": "<string>",
"timePeriodQualifier": "<string>",
"numOfPeriods": "<string>",
"deliveryOrCalendarPatternCode": "<string>",
"deliveryPatternTimeCode": "<string>",
"unitForMeasurementQualifierCode": "<string>",
"unitForMeasurementQualifier": "<string>",
"deliveryOrCalendarPatternQualifierCode": "<string>",
"deliveryOrCalendarPatternQualifier": "<string>",
"deliveryPatternTimeQualifierCode": "<string>",
"deliveryPatternTimeQualifier": "<string>"
}
],
"additionalInformation": [
{
"description": "<string>"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "<string>",
"industryCode": "<string>",
"codeCategory": "<string>",
"injuredBodyPartName": "<string>"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "<string>",
"industryCode": "<string>",
"codeCategory": "<string>",
"injuredBodyPartName": "<string>"
}
]
}
],
"errors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
],
"status": "<string>",
"transactionSetAcknowledgement": "<string>",
"implementationTransactionSetSyntaxError": "<string>",
"x12": "<string>"
}A direct replacement for Change Healthcare’s Check Eligibility x12 API.
Authorizations
API key authentication via the 'Authorization' header
Body
Response
Meta data about the response
Sender id assigned to this request
Submitter id assigned to this request
Billing id assigned to this request
Used by Optum to identify where this request can be found for support
Unique Id assigned to each request by Optum
BHT03 Value for submitterTransactionIdentifier
Segment: ISA, Element: ISA13, Notes: Interchange Control Number original request
Segment: ISA, Element: ISA13, Notes: Interchange Control Number
This is the payorId or Identification Code that was sent in the 270
Provider
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Name Last
Loop: 2100B, Segment: NM1, Element: NM104, Notes: Name First
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Organization Name
Loop: 2100B, Segment: NM1, Element: NM105, Notes: Name Middle
Loop: 2100B, Segment: NM1, Element: NM107, Notes: suffix
Loop: 2100B, Segment: NM1, Element: NM101, Notes: Entity Identifier Code
Loop: 2100B, Segment: NM1, Element: NM102, Notes: Entity Type Qualifier
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier
Loop: 2100B, 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Provider Code
Loop: 2100C, 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: PRV02=PXC Reference Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=24 Employer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=34 Social Security Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=FI Federal Taxpayer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PI Payor Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PP Pharmacy Processor Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=SV Service Provider Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
ResponseMember
Loop: 2100C and 2100D, Segment: HI, Element: HI01-1, HI02-1, HI03-1, HI04-1, HI05-1, HI06-1, HI01-7, HI08-1
Loop: 2100C and 2100D, Segment: HI, Element: HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI01-2, HI08-2
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM109, Notes: NM108=MI Member Identification Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM104, Notes: First Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM103, Notes: Last Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1 Element: NM105, Notes: Middle Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM107, Notes: suffix
Loop: 2000C, 2000D, 2100C, 2100D, Segment: DMG, Element: DMG03, Notes: gender
M, F, U Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM101, Notes: entityIdentifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM102, Notes: entityType
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM109, Notes: NM108=II uniqueHealthIdentifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: DMG, Element: DMG02, Notes: Date of Birth
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI01, Notes: Information Status Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI02, Notes: Employment Status Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI03, Notes: Government Service Affiliation Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI04, Notes: Description
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI05, Notes: Military Service Rank Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI06, Notes: Date Time Period Format Qualifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI07, Notes: MPI06=D8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI08, Notes: MPI06=RD8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI08, Notes: MPI06=RD8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=SY Social Security Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=6P Group Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=18 Plan Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=N6 Plan Network Identification Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS02, Notes: Individual Relationship Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS02, Notes: Individual Relationship Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS01, Notes: Insured Indicator
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS03, Notes: Maintenance Type Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS04, Notes: Maintenance Reason Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS17, Notes: Birth Sequence Number Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
Provider
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Name Last
Loop: 2100B, Segment: NM1, Element: NM104, Notes: Name First
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Organization Name
Loop: 2100B, Segment: NM1, Element: NM105, Notes: Name Middle
Loop: 2100B, Segment: NM1, Element: NM107, Notes: suffix
Loop: 2100B, Segment: NM1, Element: NM101, Notes: Entity Identifier Code
Loop: 2100B, Segment: NM1, Element: NM102, Notes: Entity Type Qualifier
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier
Loop: 2100B, 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Provider Code
Loop: 2100C, 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: PRV02=PXC Reference Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=24 Employer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=34 Social Security Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=FI Federal Taxpayer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PI Payor Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PP Pharmacy Processor Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=SV Service Provider Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
Loop: 2100C and 2100D, Segment: TRN, Notes: Subscriber Trace Numbers
Loop: 2100C and 2100D, Segment: TRN, Element: TRN01, Notes: Trace Type Code
Loop: 2100C and 2100D, Segment: TRN, Element: TRN01, Notes: Trace Type
Loop: 2100C and 2100D, Segment: TRN, Element: TRN02, Notes: Reference Identification
Loop: 2100C and 2100D, Segment: TRN, Element: TRN03, Notes: Originating Company Identifier
Loop: 2100C and 2100D, Segment: TRN, Element: TRN04, Notes: Originating Company Identifier
Loop: 2100D, Notes: Dependent Details
Loop: 2100C and 2100D, Segment: HI, Element: HI01-1, HI02-1, HI03-1, HI04-1, HI05-1, HI06-1, HI01-7, HI08-1
Loop: 2100C and 2100D, Segment: HI, Element: HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI01-2, HI08-2
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM109, Notes: NM108=MI Member Identification Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM104, Notes: First Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM103, Notes: Last Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1 Element: NM105, Notes: Middle Name
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM107, Notes: suffix
Loop: 2000C, 2000D, 2100C, 2100D, Segment: DMG, Element: DMG03, Notes: gender
M, F, U Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM101, Notes: entityIdentifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM102, Notes: entityType
Loop: 2000C, 2000D, 2100C, 2100D, Segment: NM1, Element: NM109, Notes: NM108=II uniqueHealthIdentifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: DMG, Element: DMG02, Notes: Date of Birth
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI01, Notes: Information Status Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI02, Notes: Employment Status Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI03, Notes: Government Service Affiliation Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI04, Notes: Description
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI05, Notes: Military Service Rank Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI06, Notes: Date Time Period Format Qualifier
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI07, Notes: MPI06=D8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI08, Notes: MPI06=RD8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: MPI, Element: MPI08, Notes: MPI06=RD8 Date Time Period
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=SY Social Security Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=6P Group Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=18 Plan Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: REF, Element: REF02, Notes: REF01=N6 Plan Network Identification Number
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS02, Notes: Individual Relationship Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS02, Notes: Individual Relationship Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS01, Notes: Insured Indicator
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS03, Notes: Maintenance Type Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS04, Notes: Maintenance Reason Code
Loop: 2000C, 2000D, 2100C, 2100D, Segment: INS, Element: INS17, Notes: Birth Sequence Number Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
Provider
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Name Last
Loop: 2100B, Segment: NM1, Element: NM104, Notes: Name First
Loop: 2100B, Segment: NM1, Element: NM103, Notes: Organization Name
Loop: 2100B, Segment: NM1, Element: NM105, Notes: Name Middle
Loop: 2100B, Segment: NM1, Element: NM107, Notes: suffix
Loop: 2100B, Segment: NM1, Element: NM101, Notes: Entity Identifier Code
Loop: 2100B, Segment: NM1, Element: NM102, Notes: Entity Type Qualifier
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier
Loop: 2100B, 2100C and 2100D, Segment: PRV, Element: PRV01, Notes: Provider Code
Loop: 2100C, 2100C and 2100D, Segment: PRV, Element: PRV03, Notes: PRV02=PXC Reference Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=24 Employer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=34 Social Security Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=FI Federal Taxpayer's Identification Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PI Payor Identification
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=PP Pharmacy Processor Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=SV Service Provider Number
Loop: 2100B, Segment: NM1, Element: NM109, Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
Payer
Loop: 2100A, Segments: NM1, Element: NM101 Notes: Entity Identifier Code
Loop: 2100A, Segments: NM1, Element: NM102 Notes: Entity Type Qualifier
Loop: 2100A, Segments: NM1, Element: NM104 Notes: Name First
Loop: 2100A, Segments: NM1, Element: NM103 Notes: Name Last
Loop: 2100A, Segments: NM1, Element: NM103 Notes: Organization Name
Loop: 2100A, Segments: NM1, Element: NM105 Notes: Name Middle
Loop: 2100A, Segments: NM1, Element: NM107 Notes: Name Suffix
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=24 Employer's Identification Number
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=FI Federal Taxpayer's Identification Number
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=NI National Association of Insurance Commissioners (NAIC) Identification
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=XX Centers for Medicare and Medicaid Services National Provider Identifier
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=XV Centers for Medicare and Medicaid Services PlanID
Loop: 2100A, Segments: NM1, Element: NM109 Notes: NM108=PI Payor Identification
ContactInformation
Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER02, Notes: Name
Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER03-8, Notes: Communication
Loop: 2100A, Segments: PER, Element: PER03-8, Notes: Communication Number Qualifier
Loop: 2100A, Segments: PER, Element: PER03-8, Notes: Communication Number
PlanInformation
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=0B State License Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1C Medicare Provider Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1D Medicaid Provider Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=1J Facility ID Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=4A Personal Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=18 Plan Number
Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=18 Plan Description
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=1L Group or Policy Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=1W Member Identification Number
Loop: 2100C; Segments: REF; Element: REF02; Notes: REF01=3H Case Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=49 Family Unit Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=6P Group Number
Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=6P Group Description
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=9F Referral Number
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=ALS Alternative List ID
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=CE Class of Contract Code
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=CLI Coverage List ID
Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=CT Contract Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=EA Medical Record Identification Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=EL Electronic device pin number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=EO Submitter Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=EJ Patient Account Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=F6 Health Insurance Claim Number
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=FO Drug Formulary Number
Loop: 2110C, 2110D; Segments: REF; Element: REF02; Notes: REF01=G1 Prior Authorization Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=GH Identification Card Serial Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=HJ Identity Card Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=HPI Centers for Medicare and Medicaid Services NPI
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=IF Issue Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=IG Insurance Policy Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=JD User Identification
Loop: 2110C; Segments: REF; Element: REF02; Notes: REF01=M7 Medical Assistance Category
Loop: 2100D; Segments: REF; Element: REF02; Notes: REF01=MRC Eligibility Category
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=N6 Plan Network Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF03; Notes: REF01=N6 Plan Network Identification Description
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=N7 Facility Network Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=NQ Medicaid Recipient Identification Number
Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=Q4 Prior Identifier Number
Loop: 2100B, 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=SY Social Security Number
Loop: 2100B; Segments: REF; Element: REF02; Notes: REF01=TJ Federal Taxpayer's Identification Number
Loop: 2100C, 2100D; Segments: REF; Element: REF02; Notes: REF01=Y4 Agency Claim Number
PlanDateInformation
Loop: 2100C and 2100D or 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=096 Discharge
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=102 issue
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=152 effectiveDateOfChange
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=193 periodStart
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=194 periodEnd
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=198 completion
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=290 coordinationOfBenefits
Loop: 2100C and 2100D or 2110C and 2110D, Segments: DTP, Element: DTP03, Notes: DTP01=291 plan
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=292 benefit
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=295 primaryCareProvider
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=304 latestVisitOrConsultation
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=307 eligibility
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=318 added
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=340 cobraBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=341 cobraEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=342 premiumPaidToDateBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=343 premiumPaidToDateEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=346 planBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=347 planEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=348 benefitBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=349 benefitEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=356 eligibilityBegin
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=357 eligibilityEnd
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=382 enrollment
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=435 admission
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=442 dateOfDeath
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=458 certification
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=472 service
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=539 policyEffective
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=540 policyExpiration
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=636 dateOfLastUpdate
Loop: 2100C and 2100D, Segments: DTP, Element: DTP03, Notes: DTP01=771 status
Loop: 2110C and 2110D, Segments: EB, Notes: Subscriber/Dependent Eligibility Benefit Information - Deprecated please use benefitsInformation
Loop: 2110C and 2110D, Segments: EB, Element: EB01, Notes: Eligibility or Benefit Information Code
Loop: 2110C and 2110D, Segments: EB, Element: EB01, Notes: Eligibility or Benefit Information Code Description
Loop: 2110C and 2110D, Segments: EB, Element: EB05, Notes: Plan Coverage Description
Loop: 2110C and 2110D, Segments: NM1, PER, PRV, N3, N4, EB, H SD, MSG, LS, LE, REF, DTP, Notes: Subscriber/Dependent Eligibility Benefit Information
Loop: 2110C and 2110D, Segments: EB, Element: EB01, Notes: Eligibility or Benefit Information Code
Loop: 2110C and 2110D, Segments: EB, Element: EB01, Notes: Eligibility or Benefit Information Code
Loop: 2110C and 2110D, Segments: EB, Element: EB02, Notes: Coverage Level Code
Loop: 2110C and 2110D, Segments: EB, Element: EB02, Notes: Coverage Level
Loop: 2110C and 2110D, Segments: EB, Element: EB03, Notes: Service Type Codes
Loop: 2110C and 2110D, Segments: EB, Element: EB03, Notes: Service Types
Loop: 2110C and 2110D, Segments: EB, Element: EB04, Notes: Insurance Type Code
Loop: 2110C and 2110D, Segments: EB, Element: EB04, Notes: Insurance Type
Loop: 2110C and 2110D, Segments: EB, Element: EB05, Notes: Plan Coverage Description
Loop: 2110C and 2110D, Segments: EB, Element: EB06, Notes: Time Period Qualifier Code
Loop: 2110C and 2110D, Segments: EB, Element: EB06, Notes: Time Period Qualifier
Loop: 2110C and 2110D, Segments: EB, Element: EB07, Notes: Monetary Amount
Loop: 2110C and 2110D, Segments: EB, Element: EB08, Notes: Percentage as Decimal
Loop: 2110C and 2110D, Segments: EB, Element: EB09, Notes: Quantity Qualifier Code
Loop: 2110C and 2110D, Segments: EB, Element: EB09, Notes: Quantity Qualifier
Loop: 2110C and 2110D, Segments: EB, Element: EB10, Notes: Quantity
Loop: 2110C and 2110D, Segments: EB, Element: EB11, Notes: Yes/No Condition or Response Code
Loop: 2110C and 2110D, Segments: EB, Element: EB12, Notes: Yes/No Condition or Response Code
Loop: 2110C and 2110D, Segments: EB, Element: EB12, Notes: Yes/No Condition or Response
Loop: 2110C and 2110D, Segments: LS, Element: LS01, Notes: Loop Identifier Code
Loop: 2110C and 2110D, Segments: LE, Element: LE01, Notes: Loop Identifier Code
CompositeMedicalProcedureIdentifier
Loop: 2110C and 2110D, Segments: EB, Element: EB13-1, Notes: Product or Service ID Qualifier Code
Loop: 2110C and 2110D, Segments: EB, Element: EB13-1, Notes: Product or Service ID Qualifier
Loop: 2110C and 2110D, Segments: EB, Element: EB13-2, Notes: Procedure Code
Loop: 2110C and 2110D, Segments: EB, Element: EB13-3-6, Notes: ProcedureModifier
Loop: 2110C and 2110D, Segments: EB, Element: EB13-8, Notes: Product or Service ID
Loop: 2110C and 2110D, Segments: EB, Element: EB14-1-4, Notes: DiagnosisCodePointer
BenefitsAdditionalInformation
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=0B stateLicenseNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1D medicareProviderNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1C medicaidProviderNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1J facilityIdNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=4A personalIdentificationNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=18 planNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1L policyNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=1W memberId
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=3H caseNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=46 familyUnitNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=6P groupNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=9F referralNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=ALS alternativeListId
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=CEE classOfContractCode
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=CLI coverageListId
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=CT contractNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=EA medicalRecordIdentificationNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=EL electronicDevicePin
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=EO submitterIdentificationNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=EJ patientAccountNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=F6 hicNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=FO drugFormularyNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=G1 priorAuthorizationNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=GH idCardSerialNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=HJ idCardNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=HPI centersForMedicareAndMedicaidServicesNPI
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=IF issueNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=IG insurancePolicyNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=JD userIdentification
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=M7 medicalAssistanceCategory
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=MRC medicalAssistanceCategory
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=N6 planNetworkIdNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=N7 facilityNetworkIdentificationNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=NQ medicaidRecipientIdNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=Q4 priorIdNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=SY socialSecurityNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=TJ federalTaxpayersIdentificationNumber
Loop: 2110C and 2110D, Segments: REF, Element: REF02, Notes: REF01=Y4 agencyClaimNumber
BenefitsDateInformation
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=096 Discharge
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=096 Discharge
DTP03 where DTP02=D8, single date
DTP03 where DTP02=RD8 left side of date range
DTP03 where DTP02=RD8 right side of date range
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=102 issue
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=152 effectiveDateOfChange
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=193 periodStart
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=193 periodEnd
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=198 completion
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=290 coordinationOfBenefits
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=291 plan
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=292 benefit
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=295 primaryCareProvider
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=304 latestVisitOrConsultation
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=307 eligibility
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=318 added
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=340 cobraBegin
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=341 cobraEnd
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=342 premiumPaidToDateBegin
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=343 premiumPaidToDateEnd
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=346 planBegin
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=347 planEnd
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=348 benefitBegin
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=349 benefitEnd
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=356 eligibilityBegin
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=357 eligibilityEnd
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=382 enrollment
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=435 admission
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=435 admission
DTP03 where DTP02=D8, single date
DTP03 where DTP02=RD8 left side of date range
DTP03 where DTP02=RD8 right side of date range
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=442 dateOfDeath
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=458 certification
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=472 service
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=539 policyEffective
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=540 policyExpiration
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=636 dateOfLastUpdate
Loop: 2110C and 2110D, Segments: DTP, Element: DTP03 Notes: DTP01=771 status
BenefitsRelatedEntity
Loop: 2120C and 2120D, Segments: NM1, Element: NM101, Notes: Entity Identifier Code
Loop: 2120C and 2120D, Segments: NM1, Element: NM102, Notes: Entity Type Qualifier
Loop: 2120C and 2120D, Segments: NM1, Element: NM103, Notes: Benefit Related Entity Last or Organization Name
Loop: 2120C and 2120D, Segments: NM1, Element: NM104, Notes: Name First
Loop: 2120C and 2120D, Segments: NM1, Element: NM105, Notes: Name Middle
Loop: 2120C and 2120D, Segments: NM1, Element: NM107, Notes: Name Suffix
Loop: 2120C and 2120D, Segments: NM1, Element: NM108, Notes: Identification Code Qualifier
Loop: 2120C and 2120D, Segments: NM1, Element: NM109, Notes: Benefit Related Entity Identifier
Loop: 2120C and 2120D, Segments: NM1, Element: NM110, Notes: Entity Relationship Code
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
ContactInformation
Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER02, Notes: Name
Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER03-8, Notes: Communication
Loop: 2100A, Segments: PER, Element: PER03-8, Notes: Communication Number Qualifier
Loop: 2100A, Segments: PER, Element: PER03-8, Notes: Communication Number
ProviderInformation
Loop: 2120C and 2120D, Segments: PRV, Element: PRV01, Notes: providerCode
Loop: 2120C and 2120D, Segments: PRV, Element: PRV03, Notes: Benefit Related Entity Provider Taxonomy Code
Loop: 2120C and 2120D, Segments: NM1, N3, N4, PER, PRV, Notes: All occurrence of SUBSCRIBER/DEPENDENT BENEFIT RELATED ENTITY
Loop: 2120C and 2120D, Segments: NM1, Element: NM101, Notes: Entity Identifier Code
Loop: 2120C and 2120D, Segments: NM1, Element: NM102, Notes: Entity Type Qualifier
Loop: 2120C and 2120D, Segments: NM1, Element: NM103, Notes: Benefit Related Entity Last or Organization Name
Loop: 2120C and 2120D, Segments: NM1, Element: NM104, Notes: Name First
Loop: 2120C and 2120D, Segments: NM1, Element: NM105, Notes: Name Middle
Loop: 2120C and 2120D, Segments: NM1, Element: NM107, Notes: Name Suffix
Loop: 2120C and 2120D, Segments: NM1, Element: NM108, Notes: Identification Code Qualifier
Loop: 2120C and 2120D, Segments: NM1, Element: NM109, Notes: Benefit Related Entity Identifier
Loop: 2120C and 2120D, Segments: NM1, Element: NM110, Notes: Entity Relationship Code
Address: N3 and N4
Segment: N3, Element: N301, Notes: Required, Address Information
Segment: N3, Element: N302, Notes: Address Information
Segment: N4, Element: N401, Notes: Required, city
Segment: N4, Element: N402, Notes: state example: TN, WA
Segment: N4, Element: N403
Segment: N4, Element: N404
Segment: N4, Element: N406
Segment: N4, Element: N407, Notes: Country SubDivision Code
ContactInformation
Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER02, Notes: Name
Loop: 2100A, 2120C and 2120D, Segments: PER, Element: PER03-8, Notes: Communication
Loop: 2100A, Segments: PER, Element: PER03-8, Notes: Communication Number Qualifier
Loop: 2100A, Segments: PER, Element: PER03-8, Notes: Communication Number
ProviderInformation
Loop: 2120C and 2120D, Segments: PRV, Element: PRV01, Notes: providerCode
Loop: 2120C and 2120D, Segments: PRV, Element: PRV03, Notes: Benefit Related Entity Provider Taxonomy Code
Loop: 2110C and 2110D, Segment: HSD, Element: HSD01
Loop: 2110C and 2110D, Segment: HSD, Element: HSD01, Notes: Description of the quantityQualifier Code
Loop: 2110C and 2110D, Segment: HSD, Element: HSD02
Loop: 2110C and 2110D, Segment: HSD, Element: HSD03, Notes: Description of the qualifier Code
Loop: 2110C and 2110D, Segment: HSD, Element: HSD04
Loop: 2110C and 2110D, Segment: HSD, Element: HSD05
Loop: 2110C and 2110D, Segment: HSD, Element: HSD05, Notes: Description of the timePeriodQualifier Code
Loop: 2110C and 2110D, Segment: HSD, Element: HSD06
Loop: 2110C and 2110D, Segment: HSD, Element: HSD07, Notes: Description of the deliveryOrCalendarPatternQualifier Code
Loop: 2110C and 2110D, Segment: HSD, Element: HSD08
Loop: 2110C and 2110D, Segment: HSD, Element: HSD03
Loop: 2110C and 2110D, Segment: HSD, Element: HSD03, Notes: Description of the unitForMeasurementQualifier Code
Loop: 2110C and 2110D, Segment: HSD, Element: HSD07
Loop: 2110C and 2110D, Segment: HSD, Element: HSD07, Notes: Description of the deliveryOrCalendarPatternQualifier Code
Loop: 2110C and 2110D, Segment: HSD, Element: HSD08
Loop: 2110C and 2110D, Segment: HSD, Element: HSD08, Notes: Description of the deliveryPatternTimeQualifier Code
Loop: 2110C and 2110D, Segment: MSG, Element: MSG01, Notes: Message Text Description
EligibilityAdditionalInformation
Loop: 2110C and 2110D, Segment: III, Element: III01
Loop: 2110C and 2110D, Segment: III, Element: III02
Loop: 2110C and 2110D, Segment: III, Element: III03
Loop: 2110C and 2110D, Segment: III, Element: III04
Loop: 2115C and 2115D, Segments: III Notes: all occurrences
Loop: 2110C and 2110D, Segment: III, Element: III01
Loop: 2110C and 2110D, Segment: III, Element: III02
Loop: 2110C and 2110D, Segment: III, Element: III03
Loop: 2110C and 2110D, Segment: III, Element: III04
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curl --request POST \
--url https://healthcare.us.stedi.com/2024-04-01/change/medicalnetwork/eligibility/v3/raw-x12 \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--data '{
"x12": "<string>"
}'{
"meta": {
"senderId": "<string>",
"submitterId": "<string>",
"billerId": "<string>",
"applicationMode": "<string>",
"traceId": "<string>",
"outboundTraceId": "<string>"
},
"controlNumber": "<string>",
"reassociationKey": "<string>",
"tradingPartnerServiceId": "<string>",
"provider": {
"providerName": "<string>",
"providerFirstName": "<string>",
"providerOrgName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"entityIdentifier": "<string>",
"entityType": "<string>",
"npi": "<string>",
"providerCode": "<string>",
"referenceIdentification": "<string>",
"employersId": "<string>",
"ssn": "<string>",
"federalTaxpayersIdNumber": "<string>",
"payorIdentification": "<string>",
"pharmacyProcessorNumber": "<string>",
"serviceProviderNumber": "<string>",
"servicesPlanID": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
},
"subscriber": {
"healthCareDiagnosisCodes": [
{
"diagnosisTypeCode": "<string>",
"diagnosisCode": "<string>"
}
],
"memberId": "<string>",
"firstName": "<string>",
"lastName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"gender": "M",
"entityIdentifier": "<string>",
"entityType": "<string>",
"uniqueHealthIdentifier": "<string>",
"dateOfBirth": "<string>",
"informationStatusCode": "<string>",
"employmentStatusCode": "<string>",
"governmentServiceAffiliationCode": "<string>",
"description": "<string>",
"militaryServiceRankCode": "<string>",
"dateTimePeriodFormatQualifier": "<string>",
"dateTimePeriod": "<string>",
"endDateTimePeriod": "<string>",
"startDateTimePeriod": "<string>",
"ssn": "<string>",
"groupNumber": "<string>",
"planNumber": "<string>",
"planNetworkIdNumber": "<string>",
"relationToSubscriber": "<string>",
"relationToSubscriberCode": "<string>",
"insuredIndicator": "<string>",
"maintenanceTypeCode": "<string>",
"maintenanceReasonCode": "<string>",
"birthSequenceNumber": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"responseProvider": {
"providerName": "<string>",
"providerFirstName": "<string>",
"providerOrgName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"entityIdentifier": "<string>",
"entityType": "<string>",
"npi": "<string>",
"providerCode": "<string>",
"referenceIdentification": "<string>",
"employersId": "<string>",
"ssn": "<string>",
"federalTaxpayersIdNumber": "<string>",
"payorIdentification": "<string>",
"pharmacyProcessorNumber": "<string>",
"serviceProviderNumber": "<string>",
"servicesPlanID": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
},
"subscriberTraceNumbers": [
{
"traceTypeCode": "<string>",
"traceType": "<string>",
"referenceIdentification": "<string>",
"originatingCompanyIdentifier": "<string>",
"secondaryReferenceIdentification": "<string>"
}
],
"dependents": [
{
"healthCareDiagnosisCodes": [
{
"diagnosisTypeCode": "<string>",
"diagnosisCode": "<string>"
}
],
"memberId": "<string>",
"firstName": "<string>",
"lastName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"gender": "M",
"entityIdentifier": "<string>",
"entityType": "<string>",
"uniqueHealthIdentifier": "<string>",
"dateOfBirth": "<string>",
"informationStatusCode": "<string>",
"employmentStatusCode": "<string>",
"governmentServiceAffiliationCode": "<string>",
"description": "<string>",
"militaryServiceRankCode": "<string>",
"dateTimePeriodFormatQualifier": "<string>",
"dateTimePeriod": "<string>",
"endDateTimePeriod": "<string>",
"startDateTimePeriod": "<string>",
"ssn": "<string>",
"groupNumber": "<string>",
"planNumber": "<string>",
"planNetworkIdNumber": "<string>",
"relationToSubscriber": "<string>",
"relationToSubscriberCode": "<string>",
"insuredIndicator": "<string>",
"maintenanceTypeCode": "<string>",
"maintenanceReasonCode": "<string>",
"birthSequenceNumber": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"responseProvider": {
"providerName": "<string>",
"providerFirstName": "<string>",
"providerOrgName": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"entityIdentifier": "<string>",
"entityType": "<string>",
"npi": "<string>",
"providerCode": "<string>",
"referenceIdentification": "<string>",
"employersId": "<string>",
"ssn": "<string>",
"federalTaxpayersIdNumber": "<string>",
"payorIdentification": "<string>",
"pharmacyProcessorNumber": "<string>",
"serviceProviderNumber": "<string>",
"servicesPlanID": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
]
}
],
"payer": {
"entityIdentifier": "<string>",
"entityType": "<string>",
"firstName": "<string>",
"lastName": "<string>",
"name": "<string>",
"middleName": "<string>",
"suffix": "<string>",
"employersId": "<string>",
"federalTaxpayersIdNumber": "<string>",
"naic": "<string>",
"npi": "<string>",
"centersForMedicareAndMedicaidPlanId": "<string>",
"payorIdentification": "<string>",
"contactInformation": {
"name": "<string>",
"contacts": [
{
"communicationMode": "<string>",
"communicationNumber": "<string>"
}
]
},
"aaaErrors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
],
"etin": "<string>"
},
"planInformation": {
"stateLicenseNumber": "<string>",
"medicareProviderNumber": "<string>",
"medicaidProviderNumber": "<string>",
"facilityIdNumber": "<string>",
"personalIdentificationNumber": "<string>",
"planNumber": "<string>",
"planDescription": "<string>",
"policyNumber": "<string>",
"memberId": "<string>",
"caseNumber": "<string>",
"familyUnitNumber": "<string>",
"groupNumber": "<string>",
"groupDescription": "<string>",
"referralNumber": "<string>",
"alternativeListId": "<string>",
"classOfContractCode": "<string>",
"coverageListId": "<string>",
"contractNumber": "<string>",
"medicalRecordIdentificationNumber": "<string>",
"electronicDevicePin": "<string>",
"submitterIdentificationNumber": "<string>",
"patientAccountNumber": "<string>",
"hicNumber": "<string>",
"drugFormularyNumber": "<string>",
"priorAuthorizationNumber": "<string>",
"idCardSerialNumber": "<string>",
"idCardNumber": "<string>",
"centersForMedicareAndMedicaidServicesNPI": "<string>",
"issueNumber": "<string>",
"insurancePolicyNumber": "<string>",
"userIdentification": "<string>",
"medicalAssistanceCategory": "<string>",
"eligibilityCategory": "<string>",
"planNetworkIdNumber": "<string>",
"planNetworkIdDescription": "<string>",
"facilityNetworkIdentificationNumber": "<string>",
"medicaidRecipientIdNumber": "<string>",
"priorIdNumber": "<string>",
"socialSecurityNumber": "<string>",
"federalTaxpayersIdentificationNumber": "<string>",
"agencyClaimNumber": "<string>"
},
"planDateInformation": {
"discharge": "<string>",
"issue": "<string>",
"effectiveDateOfChange": "<string>",
"periodStart": "<string>",
"periodEnd": "<string>",
"completion": "<string>",
"coordinationOfBenefits": "<string>",
"plan": "<string>",
"benefit": "<string>",
"primaryCareProvider": "<string>",
"latestVisitOrConsultation": "<string>",
"eligibility": "<string>",
"added": "<string>",
"cobraBegin": "<string>",
"cobraEnd": "<string>",
"premiumPaidToDateBegin": "<string>",
"premiumPaidToDateEnd": "<string>",
"planBegin": "<string>",
"planEnd": "<string>",
"benefitBegin": "<string>",
"benefitEnd": "<string>",
"eligibilityBegin": "<string>",
"eligibilityEnd": "<string>",
"enrollment": "<string>",
"admission": "<string>",
"dateOfDeath": "<string>",
"certification": "<string>",
"service": "<string>",
"policyEffective": "<string>",
"policyExpiration": "<string>",
"dateOfLastUpdate": "<string>",
"status": "<string>"
},
"planStatus": [
{
"statusCode": "<string>",
"status": "<string>",
"planDetails": "<string>",
"serviceTypeCodes": [
"<string>"
]
}
],
"benefitsInformation": [
{
"code": "<string>",
"name": "<string>",
"coverageLevelCode": "<string>",
"coverageLevel": "<string>",
"serviceTypeCodes": [
"<string>"
],
"serviceTypes": [
"<string>"
],
"insuranceTypeCode": "<string>",
"insuranceType": "<string>",
"planCoverage": "<string>",
"timeQualifierCode": "<string>",
"timeQualifier": "<string>",
"benefitAmount": "<string>",
"benefitPercent": "<string>",
"quantityQualifierCode": "<string>",
"quantityQualifier": "<string>",
"benefitQuantity": "<string>",
"authOrCertIndicator": "<string>",
"inPlanNetworkIndicatorCode": "<string>",
"inPlanNetworkIndicator": "<string>",
"headerLoopIdentifierCode": "<string>",
"trailerLoopIdentifierCode": "<string>",
"compositeMedicalProcedureIdentifier": {
"productOrServiceIdQualifierCode": "<string>",
"productOrServiceIdQualifier": "<string>",
"procedureCode": "<string>",
"procedureModifiers": [
"<string>"
],
"productOrServiceID": "<string>",
"diagnosisCodePointer": [
"<string>"
]
},
"benefitsAdditionalInformation": {
"stateLicenseNumber": "<string>",
"medicareProviderNumber": "<string>",
"medicaidProviderNumber": "<string>",
"facilityIdNumber": "<string>",
"personalIdentificationNumber": "<string>",
"planNumber": "<string>",
"policyNumber": "<string>",
"memberId": "<string>",
"caseNumber": "<string>",
"familyUnitNumber": "<string>",
"groupNumber": "<string>",
"referralNumber": "<string>",
"alternativeListId": "<string>",
"classOfContractCode": "<string>",
"coverageListId": "<string>",
"contractNumber": "<string>",
"medicalRecordIdentificationNumber": "<string>",
"electronicDevicePin": "<string>",
"submitterIdentificationNumber": "<string>",
"patientAccountNumber": "<string>",
"hicNumber": "<string>",
"drugFormularyNumber": "<string>",
"priorAuthorizationNumber": "<string>",
"idCardSerialNumber": "<string>",
"idCardNumber": "<string>",
"centersForMedicareAndMedicaidServicesNPI": "<string>",
"issueNumber": "<string>",
"insurancePolicyNumber": "<string>",
"userIdentification": "<string>",
"medicalAssistanceCategory": "<string>",
"eligibilityCategory": "<string>",
"planNetworkIdNumber": "<string>",
"facilityNetworkIdentificationNumber": "<string>",
"medicaidRecepientIdNumber": "<string>",
"priorIdNumber": "<string>",
"socialSecurityNumber": "<string>",
"federalTaxpayersIdentificationNumber": "<string>",
"agencyClaimNumber": "<string>"
},
"benefitsDateInformation": {
"discharge": "<string>",
"discharges": [
{
"date": "<string>",
"startDate": "<string>",
"endDate": "<string>"
}
],
"issue": "<string>",
"effectiveDateOfChange": "<string>",
"periodStart": "<string>",
"periodEnd": "<string>",
"completion": "<string>",
"coordinationOfBenefits": "<string>",
"plan": "<string>",
"benefit": "<string>",
"primaryCareProvider": "<string>",
"latestVisitOrConsultation": "<string>",
"eligibility": "<string>",
"added": "<string>",
"cobraBegin": "<string>",
"cobraEnd": "<string>",
"premiumPaidtoDateBegin": "<string>",
"premiumPaidToDateEnd": "<string>",
"planBegin": "<string>",
"planEnd": "<string>",
"benefitBegin": "<string>",
"benefitEnd": "<string>",
"eligibilityBegin": "<string>",
"eligibilityEnd": "<string>",
"enrollment": "<string>",
"admission": "<string>",
"admissions": [
{
"date": "<string>",
"startDate": "<string>",
"endDate": "<string>"
}
],
"dateOfDeath": "<string>",
"certification": "<string>",
"service": "<string>",
"policyEffective": "<string>",
"policyExpiration": "<string>",
"dateOfLastUpdate": "<string>",
"status": "<string>"
},
"benefitsRelatedEntity": {
"entityIdentifier": "<string>",
"entityType": "<string>",
"entityName": "<string>",
"entityFirstname": "<string>",
"entityMiddlename": "<string>",
"entitySuffix": "<string>",
"entityIdentification": "<string>",
"entityIdentificationValue": "<string>",
"entityRelationship": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"contactInformation": {
"name": "<string>",
"contacts": [
{
"communicationMode": "<string>",
"communicationNumber": "<string>"
}
]
},
"providerInformation": {
"providerCode": "<string>",
"referenceIdentification": "<string>"
}
},
"benefitsRelatedEntities": [
{
"entityIdentifier": "<string>",
"entityType": "<string>",
"entityName": "<string>",
"entityFirstname": "<string>",
"entityMiddlename": "<string>",
"entitySuffix": "<string>",
"entityIdentification": "<string>",
"entityIdentificationValue": "<string>",
"entityRelationship": "<string>",
"address": {
"address1": "<string>",
"address2": "<string>",
"city": "<string>",
"state": "<string>",
"postalCode": "<string>",
"countryCode": "<string>",
"locationIdentifier": "<string>",
"countrySubDivisionCode": "<string>"
},
"contactInformation": {
"name": "<string>",
"contacts": [
{
"communicationMode": "<string>",
"communicationNumber": "<string>"
}
]
},
"providerInformation": {
"providerCode": "<string>",
"referenceIdentification": "<string>"
}
}
],
"benefitsServiceDelivery": [
{
"quantityQualifierCode": "<string>",
"quantityQualifier": "<string>",
"quantity": "<string>",
"unitForMeasurementCode": "<string>",
"sampleSelectionModulus": "<string>",
"timePeriodQualifierCode": "<string>",
"timePeriodQualifier": "<string>",
"numOfPeriods": "<string>",
"deliveryOrCalendarPatternCode": "<string>",
"deliveryPatternTimeCode": "<string>",
"unitForMeasurementQualifierCode": "<string>",
"unitForMeasurementQualifier": "<string>",
"deliveryOrCalendarPatternQualifierCode": "<string>",
"deliveryOrCalendarPatternQualifier": "<string>",
"deliveryPatternTimeQualifierCode": "<string>",
"deliveryPatternTimeQualifier": "<string>"
}
],
"additionalInformation": [
{
"description": "<string>"
}
],
"eligibilityAdditionalInformation": {
"codeListQualifierCode": "<string>",
"industryCode": "<string>",
"codeCategory": "<string>",
"injuredBodyPartName": "<string>"
},
"eligibilityAdditionalInformationList": [
{
"codeListQualifierCode": "<string>",
"industryCode": "<string>",
"codeCategory": "<string>",
"injuredBodyPartName": "<string>"
}
]
}
],
"errors": [
{
"field": "<string>",
"code": "<string>",
"description": "<string>",
"followupAction": "<string>",
"location": "<string>",
"possibleResolutions": "<string>"
}
],
"status": "<string>",
"transactionSetAcknowledgement": "<string>",
"implementationTransactionSetSyntaxError": "<string>",
"x12": "<string>"
}