Health Care Claim Status Request

Health Care Information Status Notification

Health Care Claim

Used when sending to Data Reporting Entity, e.g. All Payer Claim Database - 
APCD entity

Dependent between the ages of 0 and 19; age qualifications may vary depending 
on policy

Dependents between the ages of 19 and 25 not attending school; age 
qualifications may vary depending on policy

A child not legally of age who has been granted adult status

An adult who is given legal responsibility for a child by the court

Dependent between the ages of 19 and 25 attending school; age qualifications 
may vary depending on policy

The residence or legal custody of the student is with both parents

A person who has been judged by a court of competent jurisdiction to be allowed 
to act in his or her own interest; no adult is legally responsible for this 
minor; this may be declared as a result of marriage

Relative related by blood or marriage who resides in the home and is dependent 
on the insured for a major portion of their support

Individual receiving medical service in order to donate organs for a transplant

Deceased individual donating body to be used for research or transplants

Child Where Insured Has No Financial Responsibility

Child is covered by the insured but the insured is not the legal guardian

The state affiliated insurance organization providing coverage and or benefits 
to the claimant

SBR02 specifies the relationship to the person insured.

Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group 
Health Plan

Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated 
Coordination Period with an Employer's Group Health Plan

Medicare Secondary, No-fault Insurance including Auto is Primary

Medicare Secondary Public Health Service (PHS)or Other Federal Agency

Medicare Secondary Veteran's Administration

Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health 
Plan (LGHP)

Medicare Secondary, Other Liability Insurance is Primary

Provides periodic payments to replace income when an insured person is unable 
to work as a result of illness, injury or disease

Consolidated Omnibus Budget Reconciliation Act (COBRA)

Gives subscriber a choice of providers from an approved/contracted payer list; 
there are fixed dollar co-payments for most covered services in return for 
using plan providers

Two or more people who are part of complete unit who enter into an insurance 
contract with an insurance company

Health Maintenance Organization (HMO) - Medicare Risk

An individual eligible for Medicare for whom Medicaid pays only Medicare 
premiums

Gives a subscriber the choice to select any provider.  Payment is fixed 
percentage of the cost for covered care after satisfying an annual deductible

Coverage designed to help pay for some or all long term care costs, reducing 
the risk that a policy-holder would need to deplete all of his or her assets to 
pay for long term care

Program of health care services made available to medically indigent and other 
needy persons, regardless of age, under terms of a 1965 amendment to the U.S. 
Social Security Act

Health insurance policy intended to cover the non-covered portion of expenses 
eligible for Medicare Part A reimbursement which must be paid by a Medicare 
beneficiary for health care services and/or supplies received

Health insurance policy intended to cover the non-covered portion of expenses 
eligible for Medicare Part B reimbursement which must be paid by a Medicare 
beneficiary for health care services and/or supplies received

Medicare has the primary responsibility to pay for health care services and/or 
supplies received by a covered beneficiary (a person entitled to Medicare 
benefits)

Coverage for a Medicare eligible individual for whom Medicaid pays only for 
Medicare premiums, co-insurance, and deductibles

An insurance policy intended to cover non-covered charges of another insurance 
policy

Tax Equity Fiscal Responsibility Act (TEFRA)

Coverage provides medical treatment, rehabilitation, lost wages and related 
expenses arising from a job related injury or disease

A Workers Compensation Policy written for a specific job site, which will 
include or cover more than one insured

Medicare Advantage Point of Service (POS) Plan that excludes Part D coverage

Medicare Advantage Preferred Provider Organization (PPO) Plan that excludes 
Part D Coverage

Medicare Advantage Private Fee for Service

Medicare Advantage Health Maintenance Organization (HMO) Plan that includes 
Part D Coverage

Medicare Advantage Health Maintenance Organization (HMO) Risk Plan that 
includes Part D Coverage

Medicare Advantage Indemnity Plan that includes Part D Coverage

Medicare Advantage Preferred Provider Organization (PPO) Plan that includes 
Part D Coverage

Medicare Advantage Indemnity Plan that excludes Part D coverage

Medicare Advantage Point of Service (POS) Plan that includes Part D Coverage

Medicare Advantage Health Maintenance Organization (HMO) Risk Plan that 
excludes Part D coverage

Medicare Advantage Health Maintenance Organization (HMO) Plan that excludes 
Part D coverage

A method of integrating benefits payable under more than one group health 
insurance plan so that the insured's benefits from all sources do not exceed 
100 percent of the allowable medical expenses

Coordination of Benefits applies to Spouse Only

Coordination of Benefits applies to Spouse and Dependents

Coordination of Benefits applies to Dependents Only

Coordination of Benefits Applies to Subscriber Only

Coordination of Benefits Applies to Whole Family

SBR07 is destination payer code. A "Y" value indicates the payer is the 
destination payer; an "N" value indicates the payer is not the destination 
payer.

Non-applicable Employment Status Category

Disqualified: Medical or Physical Condition

Furloughed: Job Abolished, Force Reduction

Leave of Absence: Family Medical Leave Act (FMLA)

Leave of Absence for Non-Military Government Request Other Than Jury Duty

Leave of Absence: Without Permission, Unauthorized

Health Maintenance Organization (HMO) Medicare Risk

Mortgagee obtains property through foreclosure or by deed-in-lieu after default

Mortgagee assigns mortgage in default to mortgage insurer

Certain insured mortgages not in default assigned to mortgage insurer after 20 
years

Mortgagee acquires property after default and sells; loss on sale is shared by 
mortgage insurer and mortgagee

Amendment to application made when additional amounts are owed or due

Property Nonconveyance (Claim without Conveyance of Title)

Property is not conveyed by the mortgagee, but may be sold to a third party at 
the foreclosure sale

Property sold by mortgagor to avoid foreclosure; mortgagee can file a claim for 
the difference between net sale proceeds and indebtedness

First claim filed by the insured for mortgage insurance benefits

Workers' Compensation First Report of Injury

Workers' Compensation Subsequent Report of Injury

Workers' Compensation Combined First and Subsequent Report

SBR Subscriber Information

To record information specific to the primary insured and the insurance carrier for that insured