Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
Payer Responsibility Sequence Number Code
Identifier (ID)
Optional
1
1
1
Code identifying the insurance carrier's level of responsibility for a payment
of a claim
02
Reference Identification
String (AN)
Optional
1
80
1
Reference information as defined for a particular Transaction Set or as
specified by the Reference Identification Qualifier
COB02 is the policy number.
03
Coordination of Benefits Code
Identifier (ID)
Optional
1
1
1
Code identifying whether there is a coordination of benefits
04
Service Type Code
Identifier (ID)
Optional
1
2
9
Code identifying the classification of service