Sequence
Element
Name
Type
Requirement
Min
Max
Repeat
01
Plan Coverage Description
String (AN)
Mandatory
1
50
1
A description or number that identifies the plan or coverage
02
Identification Card Type Code
Identifier (ID)
Mandatory
1
1
1
Code identifying the type of identification card
03
Quantity
Decimal number (R)
Optional
1
15
1
Numeric value of quantity
IDC03 is the number of cards being requested.
04
Action Code
Identifier (ID)
Optional
1
2
1
Code indicating type of action
IDC04 is the reason for the card being requested, i.e., add or a change.