Eligibility A 1 To 5010
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ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010
ISA01 ISA02
INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information
ISA01 ISA02
INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information
ID 2-2 AN 10-10
R R
00, 03
ID 2-2 AN 10-10
R R
00, 03
ISA03 ISA04
Security Information Qualifier Security Information
ID 2-2 AN 10-10
R R
00, 01
ISA03 ISA04
Security Information Qualifier Security Information
ID 2-2 AN 10-10
R R
00, 01
ISA05 ISA06
Interchange ID Qualifier Interchange Sender ID
ID 2-2 AN 15-15
R R
ISA05 ISA06
Interchange ID Qualifier Interchange Sender ID
ID 2-2 AN 15-15
R R
ISA07 ISA08 ISA09 ISA10
ID 2-2 AN 15-15 DT 6-6 TM 4-4
R R R R
ID
1-1
ISA12
Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number
YYMMDD HHMM
ISA07 ISA08 ISA09 ISA10
Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time
ID 2-2 AN 15-15 DT 6-6 TM 4-4
R R R R
R
U
ISA11
5-5
R
00401
ISA12
Repetition Seperator Interchange Control Version Number
ID
ISA13
Interchange Control Number
N0
9-9
R
ISA13
ISA14
Acknowledgement Requested
ID
1-1
R
0, 1
ISA15
ID
1-1
R
P, T
ISA16
Usage Indicator Component Element Separator
1-1
R
GS GS01 GS02
FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender's Code
ID AN
1 2-2 2-15
R R R
AN DT TM N0 ID
2-15 8-8 4-8 1-9 1-2
R R R R R
AN
1-12
R
ISA
ISA11
GS03 GS04 GS05 GS06 GS07 GS08
Application Receiver's Code Date Time Group Control Number Responsible Agency Code Version/ Release/ Industry Identifier Code
1
R
ISA
01, 14, 20, 27, 28, 29, 30, 33, ZZ
01, 14, 20, 27, 28, 29, 30, 33, ZZ
HB, HS
R
01, 14, 20, 27, 28, 29, 30, 33, ZZ
01, 14, 20, 27, 28, 29, 30, 33, ZZ YYMMDD HHMM Code Change Name Change
1-1
R
ID
5-5
R
Interchange Control Number
N0
9-9
R
ISA14
Acknowledgement Requested
ID
1-1
R
0, 1
ISA15
ID
1-1
R
P, T
ISA16
Interchange Usage Indicator Component Element Separator
1-1
R
GS GS01 GS02
FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender's Code
ID AN
1 2-2 2-15
R R R
AN DT TM N0 ID
2-15 8-8 4-8 1-9 1-2
R R R R R
AN
1-12
R
X
GS03 GS04 GS05 GS06 GS07
004010X092
GS08
CCYYMMDD HHMM
1
Application Receiver's Code Date Time Group Control Number Responsible Agency Code Version/Release/ Industry Identifier Code
Page 1 of 20
00501
Code Change
Code Change
CCYYMMDD HHMM X 005010X279
Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 ST ST01 ST02
BHT
TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number
1
R
ID
3-3
R
AN
4-9
R
BEGINNING OF HIERARCHICAL TRANSACTION
1
R
ST03
BHT
BEGINNING OF HIERARCHICAL TRANSACTION
ST 270
ST01 ST02
ID
4-4
R
0022
BHT01
BHT02 BHT03
ID AN
2-2 1-30
R S
01,13, 36
BHT02 BHT03
BHT04 BHT05 BHT06
Date Time Transaction Type Code
DT TM ID
8-8 4-8 2-2
R R S
CCYYMMDD
BHT04 BHT05 BHT06
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
N/U R R
1
R
HL02 HL03 HL04
INFORMATION SOURCE LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
NM1
INFORMATION SOURCE NAME
HL HL01
NM101 NM102
Entity Identifier Code Entity Type Qualifier
ID ID
2-3 1-1
R R
NM103 NM104 NM105 NM106 NM107
Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
S S S N/U S
NM108 NM109 NM110 NM111
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference
Hierarchical Structure Code Transaction Set Purpose Code Reference Identification
BHT01
ID
RT, RU
2000A
>1
2100A
1 2B, 36, GP, P5, PR 1, 2
24, 46, FI, NI, PI, XV, XX
R
ID
3-3
R
AN
4-9
R
AN
1-35
R
1
R
ID
4-4
R
0022
ID AN
2-2 1-50
R S
01,13
DT TM ID
8-8 4-8 2-2
R R S
CCYYMMDD
Name Change
RT
Code deleted
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
N/U R R
1
R
HL02 HL03 HL04
INFORMATION SOURCE LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
NM1
INFORMATION SOURCE NAME
NM101 NM102
Entity Identifier Code Entity Type Qualifier
ID ID
2-3 1-1
R R
NM103 NM104 NM105 NM106 NM107
Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
R S S N/U S
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
AN
1-60
N/U
HL HL01
20 1
Hierarchical Structure Code Transaction Set Purpose Code Reference Identification Transaction Set Creation Date Time Transaction Type Code
1
NM108 NM109 NM110 NM111 NM112
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
Page 2 of 20
270
005010X279
2000A
New Element
Code deleted Increase from 30 - 50
>1
20 1
2100A
1 2B, 36, GP, P5, PR 1, 2 Increase from 35 - 60 Usage change to Required Increase from 25 - 35
24, 46, FI, NI, PI, XV, XX
New Element
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
HL02 HL03 HL04
INFORMATION RECEIVER LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
NM1
INFORMATION RECEIVER NAME
HL HL01
AN
1 1/12
R R
AN ID ID
1/12 1/2 1/1
R R R
1
R
NM101 NM102
Entity Identifier Code Entity Type Qualifier
ID ID
2/3 1/1
R R
NM103 NM104 NM105 NM106 NM107
Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1/35 1/25 1/25 1-10 1-10
S S S N/U S
NM108 NM109 NM110 NM111
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
REF
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
INFORMATION RECEIVER ADDRESS Address Information Address Information
N4 N401 N402
9
S
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
2000B
>1
Values
270 5010 2000B
>1
1 1P, 2B, 36, 80, FA, GP, P5, PR 1, 2
24, 34, FI, PI, PP, SV, XV, XX
2100B 0B, 1C, 1D, 1J, 4A, CT, EL, EO, HPI, JD, N5, N7, Q4, SY, TJ
ID AN AN
2-3 1-30 1-80
R R S N/U
S R S
2100B
AN AN
1 1-55 1-55
INFORMATION RECEIVER CITY/ STATE/ ZIPCODE City Name
S R
2100B
AN
1 2-30
State or Province Code
ID
2-2
R
NM1
INFORMATION RECEIVER NAME
NM101 NM102
Entity Identifier Code Entity Type Qualifier
ID ID
2-3 1-1
R R
NM103 NM104 NM105 NM106 NM107
Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
R S S N/U S
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
AN
1-60
N/U
9
S
HL HL01
21 1
2100B
HL02 HL03 HL04
INFORMATION RECEIVER LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
NM112
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
REF
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
NM108 NM109 NM110 NM111
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
R R R
1
R
21 1
2100B
1P, 2B, 36, 80, FA, GP, P5, PR 1, 2 Increase from 35 - 60 Usage change to Required Increase from 25 - 35
24, 34, FI, PI, PP, SV, XV, XX
New Element
2100B 0B, 1C, 1D, 1J, 4A, CT, EL, EO, HPI, JD, N5, N7, Q4, SY, TJ
ID AN AN
2-3 1-50 1-80
R R S N/U
INFORMATION RECEIVER ADDRESS Address Information Address Information
1 1-55 1-55
S R S
2100B
AN AN
N4 N401
INFORMATION RECEIVER CITY/STATE/ ZIP CODE City Name
1 2-30
S R
2100B
AN
N402
State or Province Code
ID
2-2
S
Page 3 of 20
1
Increase from 30 - 50
Usage change to Required
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 N403 N404 N405 N406
Postal Code Country Code Location Qualifier Location Qualifier
PER07 PER08 PER09
INFORMATION RECEIVER CONTACT INFORMATION Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference
PRV
INFORMATION RECEIVER PROVIDER INFORMATION
PER PER01 PER02 PER03 PER04 PER05 PER06
PRV01
Provider Code
PRV02
Reference Identification Qualifier
ID ID ID AN
3 2-2 1-60
S R S
ID AN
2-2 1-80
S S
ID AN
2-2 1-80
S S
ID AN AN
2-2 1-80 1-20
S S N/U
1
S
ID
ID
AN ID
PRV05 PRV06
Provider Organization Code
ID
HL HL01
SUBSCRIBER LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
HL02 HL03 HL04
1-3
2-3
N403 N404 N405 N406 N407
Postal Code Country Code Location Qualifier Location Qualifier Country Subdivision Code
Usage Reg.
Loop
Loop Repeat
Values
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
Usage change to Required
S S N/U N/U S
New Element
Segment Deleted
2100B IC
ED, EM, FX, TE ED, EM, EX, FX, TE AAABBBCCCC ED, EM, EX, FX, TE AAABBBCCCC
2100B
PRV AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
ZZ
R
INFORMATION RECEIVER PROVIDER INFORMATION
PRV01
Provider Code
PRV02
Reference Identification Qualifier
R N/U
PRV03 PRV04
N/U
PRV05
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
3-3
N/U
PRV06
Provider Organization Code
AN
1 1-12
R R
HL HL01
AN ID ID
1-12 1-2 1-1
R R R
SUBSCRIBER LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
1-30 2-2
Min. Max.
270 5010
R S N/U N/U
ID AN
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
PRV03 PRV04
3-15 2-3 1-2 1-30
ID
2000C
>1
22 0, 1
HL02 HL03 HL04
Page 4 of 20
1
ID
ID
1-3
2-3
1-50 2-2
S
2100B AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
PXC
S
AN ID
ID
3-3
N/U
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
R R R
Code Change Usage change to Situational Increase from 30 - 50 Usage change to Situational
S N/U N/U
2000C
>1
22 0, 1
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
TRN TRN01 TRN02
SUBSCRIBER TRACE NUMBER Trace Type Code Reference Identification
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
TRN TRN01 TRN02
SUBSCRIBER TRACE NUMBER Trace Type Code Reference Identifier
270 4010A1
TRN03 TRN04
2 1-2 1-30
S R R
Originating Company Identifier AN 10-10 Reference Identification AN 1-30
R S
ID AN
ID ID
1 2-3 1-1
R R R
NM103 NM104 NM105 NM106 NM107
SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
S S S N/U S
NM108 NM109 NM110 NM111
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
S S N/U N/U
NM1 NM101 NM102
REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
SUBSCRIBER ADDRESS Address Information Address Information
N4
SUBSCRIBER CITY/ STATE/ ZIPE CODE
N401 N402 N403 N404 N405 N406
City Name State or Province Name Postal Code Country Code Location Qualifier Location Qualifier
9
S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 2000C 1
TRN03 TRN04 2100C
1 IL 1
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
MI, ZZ
2100C 18, 1L, 1W, 3H, 49, 6P, A6, CT, EA, EJ
ID AN AN
2-3 1-30 1-80
R R N/U N/U
1 1-55 1-55
S R S
2100C
AN AN
1
S
2100C
2-30 2-2 3-15 2-3 1-2 1-30
S S S S N/U N/U
AN ID ID ID ID AN
ID
2 1-2 1-50
S R R
Originating Company Identifier AN 10-10 Reference Identification AN 1-50
R S
SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
NM112
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
NM108 NM109 NM110 NM111
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
SUBSCRIBER ADDRESS Address Information Address Information
N4
SUBSCRIBER CITY/STATE/ZIP CODE
N401 N402 N403 N404 N405 N406 N407
City Name State or Province Name Postal Code Country Code Location Qualifier Location Qualifier Country Subdivision Code
Page 5 of 20
ID AN
ID ID
1 2-3 1-1
R R R
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
S S S N/U S
ID AN ID ID
1-2 2-80 2-2 2-3
S S N/U N/U
AN
1-60
N/U
9
S
2000C 1 Increase from 30 - 50
Increase from 30 - 50 2100C
IL 1 Increase from 35 - 60 Increase from 25 - 35
II, MI
Code Change
New Element
2100C 18, 1L, 1W, 3H, 6P, CT, EA, EJ, F6, GH, HJ, IG, N6, NQ, SY, Y4
ID AN AN
2-3 1-50 1-80
R R N/U N/U
1 1-55 1-55
S R S
2100C
AN AN
1
S
2100C
2-30 2-2 3-15 2-3 1-2 1-30 1-3
R S S S N/U N/U S
AN ID ID ID ID AN ID
1
Code Change Increase from 30 - 50
Usage change to Required
New Element
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 PRV
PRV01 PRV02
PROVIDER INFORMATION
Provider Code Reference Identification Qualifier
1
ID
1-3
R
ID
2-3
R
AN ID
PRV05
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
ID
PRV03 PRV04
DMG01 DMG02 DMG03 DMG04
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Date Time Period Gender Code Marital Status Code
DMG05 DMG06 DMG07 DMG08 DMG09
Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity
DMG
INS01
SUBSCRIBER RELATIONSHIP Yes/No Condition or Response Code
INS02 INS03 INS04 INS05 INS06
Individual Relationsgip Code Maintenance Type Code Maintenance Reason Code Benefit Status Code Medicare Plan Code
INS07 INS08 INS09
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying Employment Status Code Student Status Code
INS
S
1-30 2-2
3-3
2100C
PRV AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU 9K, D3, EI, HPI, SY, TJ, ZZ
PRV01 PRV02
2-3 1-35 1-1 1-1
S S S N/U
ID ID ID ID R
1-1 1-2 2-3 1-2 1-15
N/U N/U N/U N/U N/U
F, M
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 DMG10 DMG11
S
ID
1-1
R
Y
INS01
MULTIPLE BIRTH SEQUENCE NUMBER Yes/No Condition or Response Code
ID ID ID ID ID
2-2 3-3 2-3 1-1 1-1
R N/U N/U N/U N/U
18
INS02 INS03 INS04 INS05 INS06
Individual Relationsgip Code Maintenance Type Code Maintenance Reason Code Benefit Status Code MEDICARE STATUS CODE
INS07 INS08 INS09
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying Employment Status Code Student Status Code
1-2 2-2 1-1
N/U N/U N/U
2100C
ID
2-3
S
ID
DMG D8
R
Provider Organization Code SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Date Time Period Gender Code Marital Status Code Composite Race or Ethnicity Information Citizenship Status Code Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code
INS
Page 6 of 20
S
1-3
PRV06
1
ID ID ID
Usage Reg.
ID
PRV05
N/U
ID AN ID ID
Provider Code Reference Identification Qualifier
1
AN ID
N/U
2100C
PROVIDER INFORMATION
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
PRV03 PRV04
S
Min. Max.
Loop
Loop Repeat
Values
270 5010
R N/U
1
ID
1-50 2-2
2100C AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SK, SU Code deleted 9K, D3, EI, HPI, Usage change to PXC, SY, TJ Situational Increase from 30 - 50 Usage change to Situational
S N/U N/U
3-3
N/U
1
S
ID AN ID ID
2-3 1-35 1-1 1-1
S S S N/U
ID ID ID R ID AN
1-2 2-3 1-2 1-15 1-3 1-30
N/U N/U N/U N/U N/U N/U N/U
1
S
ID
1-1
R
Y
ID ID ID ID
2-2 3-3 2-3 1-1
R N/U N/U N/U N/U
18
ID ID ID
1-2 2-2 1-1
N/U N/U N/U
2100C D8 F, M
New Element New Element
Name Change
2100C
Name Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 INS10 INS11 INS12 INS13 INS14 INS15 INS16 INS17
Yes/No Condition or Response Code Date Time Period Format Qualifier Date Time Period Confidentiality Code City Name State or Province Code Country Code Number
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010
ID
1-1
N/U
INS10
ID AN ID AN ID ID N0
2-3 1-35 1-1 2-30 2-2 2-3 1-9
N/U N/U N/U N/U N/U N/U R
INS11 INS12 INS13 INS14 INS15 INS16 INS17
HI HI01 HI01 - 1 HI01 - 2 HI01 - 3 HI01 - 4 HI01 - 5 HI01 - 6 HI01 - 7 HI01 - 8 HI01 - 9 HI02 HI02 - 1 HI02 - 2 HI02 - 3 HI02 - 4 HI02 - 5 HI02 - 6 HI02 - 7 HI02 - 8 HI02 - 9 HI03 HI03 - 1 HI03 - 2 HI03 - 3 HI03 - 4 HI03 - 5 HI03 - 6 HI03 - 7 HI03 - 8
Yes/No Condition or Response Code Date Time Period Format Qualifier Date Time Period Confidentiality Code City Name State or Province Code Country Code Number SUBSCRIBER HEALTH CARE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code
Page 7 of 20
ID
1-1
N/U
ID AN ID AN ID ID N0
2-3 1-35 1-1 2-30 2-2 2-3 1-9
N/U N/U N/U N/U N/U N/U R
1
S
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
New Segment
2100C
ABK, BK
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 HI03 - 9 HI04 HI04 - 1 HI04 - 2 HI04 - 3 HI04 - 4 HI04 - 5 HI04 - 6 HI04 - 7 HI04 - 8 HI04 - 9 HI05 HI05 - 1 HI05 - 2 HI05 - 3 HI05 - 4 HI05 - 5 HI05 - 6 HI05 - 7 HI05 - 8 HI05 - 9 HI06 HI06 - 1 HI06 - 2 HI06 - 3 HI06 - 4 HI06 - 5 HI06 - 6 HI06 - 7 HI06 - 8 HI06 - 9 HI07 HI07 - 1 HI07 - 2 HI07 - 3 HI07 - 4 HI07 - 5 HI07 - 6
Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity
Page 8 of 20
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R
2-3 1-35 1-18 1-15
N/U N/U N/U N/U
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
HI12
Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION
DTP
SUBSCRIBER DATE
102, 307, 435, 472
DTP01 DTP02
Date Time Qualifier Date Time Period Format Qualifier
HI07 - 9 HI08 HI08 - 1 HI08 - 2 HI08 - 3 HI08 - 4 HI08 - 5 HI08 - 6 HI08 - 7 HI08 - 8 HI08 - 9 HI09 HI10 HI11
DTP01
Date/Time Qualifier Date Time Period Format Qualifier
DTP02
DTP03
Date Time Period
EQ
SUBSCRIBER ELIGIBILITY/BENEFIT INQUIRY INFORMATION
2
S
ID
3-3
R
ID
2-3
R
D8, RD8
R
CCYYMMDD, CCYYMMDDCCYYMMDD
AN
1-35
1
S
Loop
Loop Repeat
Values
270 5010 HI07 - 7 HI07 - 8
SUBSCRIBER DATE
Usage Reg.
ID
270 4010A1
DTP
Min. Max.
Description
2100C
2110C
99
DTP03
Date Time Period
EQ
SUBSCIBER ELIGIBILITY/BENEFIT INQUIRY INFORMATION
Page 9 of 20
ABF, BF
N/U N/U N/U N/U 2
S
ID
3-3
R
ID
2-3
R
D8, RD8
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
1
S
AN
2100C 102, 291
2110C
99
Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
EQ01 EQ02
Service Type Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
EQ02 - 1 Product/Service ID Qualifier Product/Service ID EQ02 - 2 Procedure Modifier EQ02 - 3 Procedure Modifier EQ02 - 4 Procedure Modifier EQ02 - 5 Procedure Modifier EQ02 - 6 Description EQ02 - 7
EQ03
Coverage Level Code
ID
1-2
S
ID
2-2 1-48 2-2 2-2 2-2 2-2 1-80
3-3
R R S S S S N/U
S
Min. Max.
Usage Reg.
270 5010
1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12,13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI , AJ, AK, AL, AM, AN ,AO, AQ, AR, BA,BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS
S ID AN AN AN AN AN AN
ID
Service Type Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
ID
EQ02 - 1 Product/Service ID Qualifier Product/Service ID EQ02 - 2 Procedure Modifier EQ02 - 3 Procedure Modifier EQ02 - 4 Procedure Modifier EQ02 - 5 Procedure Modifier EQ02 - 6 Description EQ02 - 7 Product/Service ID EQ02 - 8
ID AN AN AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2 1-80 1-48
R R S S S S N/U N/U
ID
3-3
S
EQ01 EQ02
AD, CJ, HC, ID, IV, N4, ZZ
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO
EQ03
Coverage Level Code
Page 10 of 20
1-2
S
Loop
Loop Repeat
Values
1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12,13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI , AJ, AK, AL, AM, AN ,AO, AQ, AR, B1, B2, B3, BA,BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, Code Change
S AD, CJ, HC, ID, IV, N4, ZZ
New Element
FAM
Code Deleted
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
EQ04
Insurance Type Code
ID
1-3
SUBSCRIBER SPEND DOWN AMOUNT Amount Qualifier Code
S
AMT02 AMT03
Monetary Amount Credit/Debit Flag Code
III III01
SUBSCRIBER ELIGIBILITY/ BENEFIT ADDITIONAL INQUIRY INFORMATION Code List Qualifier Code
III06
Industry Code Code Category Free-Form Message Text Quantity COMPOSITE UNIT OF MEASURE
III07
Surface/Layer/Position Code
III02 III03 III04 III05
ID
1 1-3
S R
R ID
1-18 1-1
N/U N/U
ID
10 1-3
AN 1-30 ID 2-2 AN 1-264 R 1-15
ID
2-2
S R
Usage Reg.
Loop
Loop Repeat
Values
2110C R
2110C BF, BK, ZZ
If Ill01 = BK or BF: use diagnosis code from code source 131; If III01 = ZZ: 11, 12, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 50, 51, 52, 53, 54, 55, 56, 60, 61, 62, 65, 71, 72, 81, 99
Usage change to Not Used Code Deleted
Insurance Type Code COMPOSITE DIAGNOSIS CODE POINTER Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer
ID
1-3
N/U
N0 N0 N0 N0
1-2 1-2 1-2 1-2
S R S S S
AMT AMT01
SUBSCRIBER SPEND DOWN AMOUNT Amount Qualifier Code
ID
1 1-3
S R
AMT02 AMT03
Monetary Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT AMT01 AMT02 AMT03
SUBSCRIBER SPEND DOWN TOTAL BILLED AMOUNT Amount Qualifier Code Monetary Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2110C
ID R ID
III III01
SUBSCRIBER ELIGIBILITY/BENEFIT ADDITIONAL INQUIRY INFORMATION Code List Qualifier Code
10 1-3
S R
2110C
ID
EQ04
N/U
III06
Industry Code Code Category Free-Form Message Text Quantity COMPOSITE UNIT OF MEASURE
N/U
III07
Surface/Layer/Position Code
R N/U N/U N/U
Min. Max.
270 5010 AP, C1, CO, GP, HM, HN, IP, MA, MB, MC, PR, PS, SP, WC
EQ05 EQ05 - 1 EQ05 - 2 EQ05 - 3 EQ05 - 4
AMT AMT01
ID
III02 III03 III04 III05
Page 11 of 20
AN 1-30 ID 2-2 AN 1-264 R 1-15
R N/U N/U N/U N/U
ID
2-2
N/U
New Element New Element New Element New Element New Element
2110C R Usage change to Required
New Segment PB
ZZ
Code Deleted
01, 03, 04, 05, 06, 07, 08, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, 56, 57, 60, 61, 62, 65, 71, 72, 81, 99 Code Deleted
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010
III08
Surface/Layer/Position Code
ID
2-2
N/U
III08
Surface/Layer/Position Code
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
1
S
1
S
2-3 1-30 1-80
R R N/U N/U
2-3 1-50 1-80
R R N/U N/U
1 3-3
S R
1 3-3
S R
2-3
R
2-3
R
D8, RD8 CCYYMMDD, CCYYMMDDCCYYMMDD
REF REF01 REF02 REF03 REF04
DTP DTP01 DTP02
SUBSRIBER ADDITIONAL INFORMATION Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
SUBSCRIBER ELIGIBILITY/BENEFIT DATE Date/Time Qualifier ID Date Time Period Format Qualifier ID
DTP03
Date Time Period
HL HL01 HL02 HL03 HL04
DEPENDENT LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
TRN TRN01 TRN02
DEPENDENT TRACE NUMBER Trace Type Code Reference Identification
TRN03 TRN04
ID AN AN
AN
1-35
R
AN
1 1-12
S R
AN ID ID
1-12 1-2 1-1
R R R
ID AN
2 1-2 1-30
S R R
Originating Company Identifier AN 10-10 Reference Identification AN 1-30
R S
ID ID
1 2-3 1-1
R R R
NM103 NM104 NM105 NM106 NM107
DEPENDENT NAME Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
S S S N/U S
NM108
Identification Code Qualifier
ID
1-2
N/U
NM1 NM101 NM102
2110C
REF 9F,G1
2110C
REF01 REF02 REF03 REF04
307, 435, 472
DTP DTP01
D8, RD8
DTP02
DTP03 2000D
>1
2000D 1
1 03 1
Date Time Period Format Qualifier
AN
1-35
R
AN
1 1-12
S R
AN ID ID
1-12 1-2 1-1
R R R
ID AN
2 1-2 1-50
S R R
Originating Company Identifier AN 10-10 Reference Identification AN 1-50
R S
HL02 HL03 HL04
TRN TRN01 TRN02
DEPENDENT TRACE NUMBER Trace Type Code Reference Identification
TRN03 TRN04 2100D
SUBSCRIBER ELIGIBILITY/BENEFIT DATE Date Time Qualifier ID Date Time Period Format Qualifier ID
DEPENDENT LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
HL HL01
23 0
SUBSCRIBER ADDITIONAL INFORMATION Reference Identification Qualifier ID Reference Identification AN Description AN REFERENCE IDENTIFIER
ID ID
1 2-3 1-1
R R R
NM103 NM104 NM105 NM106 NM107
DEPENDENT NAME Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
S S S N/U S
NM108
Identification Code Qualifier
ID
1-2
N/U
NM1 NM101 NM102
Page 12 of 20
2110C 9F, G1 Increase from 30 - 50
2110C 291
2000D
Code Change
Code Added
>1
23 0
2000D 1 Increase from 30 - 50
Increase from 30 - 50 2100D
1 03 1 Increase from 35 - 60 Increase from 25 - 35
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
NM109 NM110 NM111
Identification Code Entity Relationship Code Entity Identifier Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
REF
DEPENDENT ADDITIONAL IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
DEPENDENT ADDRESS Address Information Address Information
N4
DEPENDENT CITY/STATE/ZIP CODE
N401 N402 N403 N404 N405 N406
City Name State or Provine Code Postal Code Country Code Location Qualifier Location Qualifier
PRV
9
AN ID ID
2-80 2-2 2-3
N/U N/U N/U
NM112
Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
Provider Code
PRV02
Reference Identification Qualifier
REF
DEPENDENT ADDITIONAL IDENTIFICATION
9
S
NM109 NM110 NM111
2100D 18, 1L, 1W, 49, 6P, A6, CT, EA, EJ, F6, CJ, HC, ID, IV, N4, ZZ
2-3 1-30 1-80
R R N/U N/U
1 1-55 1-55
S R S
2100D
AN AN
1
S
2100D
2-30 2-2 3-15 2-3 1-2 1-30
S S S S N/U N/U
AN ID ID ID ID AN
1
ID
ID
AN ID
PRV05
Reference Identification State or Province Code PROVIDER SPECIALITY INFORMATION
PRV06
Provider Organization Code
ID
PRV03 PRV04
S
1-3
2-3
1-30 2-2
3-3
S
Loop
Loop Repeat
Values
270 5010
N/U N/U N/U
ID AN AN
PROVIDER INFORMATION
PRV01
2-80 2-2 2-3
Usage Reg.
ID
270 4010A1 AN ID ID
Min. Max.
Description
2100D
R
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
9K, D3, EI, HPI, SY, TJ, ZZ
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
DEPENDENT ADDRESS Address Information Address Information
N4
DEPENDENT CITY/STATE/ZIP CODE
N401 N402 N403 N404 N405 N406 N407
City Name State or Provine Code Postal Code Country Code Location Qualifier Location Qualifier Country Subdivision Code
PRV
PROVIDER INFORMATION
PRV01
Provider Code
PRV02
Reference Identification Qualifier
R R N/U N/U
1 1-55 1-55
S R S
2100D
AN AN
1
S
2100D
2-30 2-2 3-15 2-3 1-2 1-30 1-3
R S S S N/U N/U S
1
S
AN ID ID ID ID AN ID
ID
ID
PRV05 PRV06
Provider Organization Code
ID
N/U N/U
Page 13 of 20
18, 1L, 6P, CT, EA, EJ, F6, GH, HJ, IF, IG, MRC, N6, SY, Y4 Code Change Increase from 30 - 50
2-3 1-50 1-80
AN ID
PRV03 PRV04
2100D
ID AN AN
Reference Identification State or Province Code PROVIDER SPECIALITY INFORMATION
R N/U
New Element
1-3
2-3
1-50 2-2
R
S
S N/U N/U
3-3
N/U
Usage change to Required
New Element
2100D AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, Code Deleted PE, R, RF, SK, SU Usage change to Required 9K, D3, EI, HPI, PXC, SY, TJ
Code Change Usage change to Situational Increase from 30 - 50 Usage change to Situational
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
DMG01 DMG02 DMG03 DMG04
DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Date Time Period Gender Code Marital Status Code
DMG05 DMG06 DMG07 DMG08 DMG09
Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity
DMG
INS01
DEPENDENT RELATIONSHIP Yes/No Condition or Response Code
INS02 INS03 INS04 INS05 INS06
Individual Relationship Code Maintenance Type Code Maintenance Reason Code Benefit Status Code Medicare Plan Code
INS
INS07 INS08 INS09 INS10 INS11 INS12 INS13 INS14 INS15 INS16 INS17
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying Employment Status Code Student Status Code Yes/No Condition or Response Code Date Time Period Format Qualifier Date Time Period Confidentiality Code City Name State or Province Code Country Code Number
1
S
ID AN ID ID
2-3 1-35 1-1 1-1
S S S N/U
ID ID ID ID R
1-1 1-2 2-3 1-2 1-15
N/U N/U N/U N/U N/U
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 2100D
DMG D8 CCYYMMDD F, M
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 DMG10 DMG11
DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Date Time Period Gender Code Marital Status Code Composite Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code
1
S
ID
1-1
R
N
INS01
DEPENDENT RELATIONSHIP Yes/No Condition or Response Code
ID ID ID ID ID
2-2 3-3 2-3 1-1 1-1
R N/U N/U N/U N/U
01, 19, 34
INS02 INS03 INS04 INS05 INS06
Individual Relationship Code Maintenance Type Code Maintenance Reason Code Benefit Status Code MEDICARE STATUS CODE
2100D
INS
ID ID ID
1-2 2-2 1-1
N/U N/U N/U
INS07 INS08 INS09
ID
1-1
N/U
INS10
ID AN ID AN ID ID N0
2-3 1-35 1-1 2-30 2-2 2-3 1-9
N/U N/U N/U N/U N/U N/U S
INS11 INS12 INS13 INS14 INS15 INS16 INS17
HI HI01 HI01 - 1 HI01 - 2
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying Employment Status Code Student Status Code Yes/No Condition or Response Code Date Time Period Format Qualifier Date Time Period Confidentiality Code City Name State or Province Code Country Code Number DEPENDENT HEALTH CARE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code
Page 14 of 20
1
S
ID AN ID ID
2-3 1-35 1-1 1-1
S S S N/U
ID ID ID R ID AN
1-2 2-3 1-2 1-15 1-3 1-30
N/U N/U N/U N/U N/U N/U N/U
1
S
ID
1-1
R
N
ID ID ID ID
2-2 3-3 2-3 1-1 1-1
R N/U N/U N/U N/U
01, 19, 34
ID ID ID
1-2 2-2 1-1
N/U N/U N/U
ID
1-1
N/U
ID AN ID AN ID ID N0
2-3 1-35 1-1 2-30 2-2 2-3 1-9
N/U N/U N/U N/U N/U N/U S
1
S
1-3 1-30
R R R
ID AN
2100D D8 CCYYMMDD F, M
New Element New Element
2100D
New Segment
2100D
ABK, BK
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 HI01 - 3 HI01 - 4 HI01 - 5 HI01 - 6 HI01 - 7 HI01 - 8 HI01 - 9 HI02 HI02 - 1 HI02 - 2 HI02 - 3 HI02 - 4 HI02 - 5 HI02 - 6 HI02 - 7 HI02 - 8 HI02 - 9 HI03 HI03 - 1 HI03 - 2 HI03 - 3 HI03 - 4 HI03 - 5 HI03 - 6 HI03 - 7 HI03 - 8 HI03 - 9 HI04 HI04 - 1 HI04 - 2 HI04 - 3 HI04 - 4 HI04 - 5 HI04 - 6 HI04 - 7 HI04 - 8 HI04 - 9 HI05
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
Page 15 of 20
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U S
ABF, BF
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
270 4010A1
Loop
Loop Repeat
Values
270 5010 HI05 - 1 HI05 - 2 HI05 - 3 HI05 - 4 HI05 - 5 HI05 - 6 HI05 - 7 HI05 - 8 HI05 - 9 HI06 HI06 - 1 HI06 - 2 HI06 - 3 HI06 - 4 HI06 - 5 HI06 - 6 HI06 - 7 HI06 - 8 HI06 - 9 HI07 HI07 - 1 HI07 - 2 HI07 - 3 HI07 - 4 HI07 - 5 HI07 - 6 HI07 - 7 HI07 - 8 HI07 - 9 HI08 HI08 - 1 HI08 - 2 HI08 - 3 HI08 - 4 HI08 - 5 HI08 - 6 HI08 - 7 HI08 - 8 HI08 - 9
Page 16 of 20
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
HI10 HI11 HI12
DTP02
DEPENDENT DATE Date/Time Qualifier Date Time Period Format Qualifier
DTP03
Date Time Period
EQ
DEPENDENT ELIGIBILITY/ BENEFIT INQUIRY INFORMATION
ID
2 3-3
S R
ID
2-3
AN
1-35
1
102,307,435,472
DTP DTP01
R
D8, RD8
DTP02
R
CCYYMMDD, CCYYMMDDCCYYMMDD
R
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 HI09
DTP DTP01
ID
2100D
2110D
99
HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION DEPENDENT DATE Date Time Qualifier Date Time Period Format Qualifier
DTP03
Date Time Period
EQ
DEPENDENT ELIGIBILITY/BENEFIT INQUIRY
Page 17 of 20
N/U N/U N/U N/U
ID
2 3-3
S R
ID
2-3
R
D8, RD8
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
1
R
AN
2100D 102, 291
2110D
99
Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
EQ01 EQ02
Service Type Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
EQ02 - 1 Product/Service ID Qualifier Product/Service ID EQ02 - 2 Procdeure Modifier EQ02 - 3 Procdeure Modifier EQ02 - 4 Procdeure Modifier EQ02 - 5 Procdeure Modifier EQ02 - 6 Description EQ02 - 7
EQ03
Coverage Level Code
ID
1-2
S
ID
2-2 1-48 2-2 2-2 2-2 2-2 1-80
3-3
R R S S S S N/U
S
Min. Max.
Usage Reg.
270 5010
1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI , AJ, AK, AL, AM, AN ,AO, AQ, AR, BA,BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS
S ID AN AN AN AN AN AN
ID
Service Type Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
ID
EQ02 - 1 Product/Service ID Qualifier Product/Service ID EQ02 - 2 Procdeure Modifier EQ02 - 3 Procdeure Modifier EQ02 - 4 Procdeure Modifier EQ02 - 5 Procdeure Modifier EQ02 - 6 Description EQ02 - 7 Product/Service ID EQ02 - 8
ID AN AN AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2 1-80 1-48
R R S S S S N/U N/U
ID
3-3
N/U
EQ01 EQ02
AD, CJ, HC, ID, IV, N4, ZZ
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO
EQ03
Coverage Level Code
Page 18 of 20
1-2
S
Loop
Loop Repeat
Values
1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12,13, 14, 15, 16, 17, 18, 19, 20, 21,22,23,24,25,26, 27,28,30,32,33,34, 35,36,37,38,39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI , AJ, AK, AL, AM, AN ,AO, AQ, AR, B1, B2, B3, BA,BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN ,CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, Code Added
S AD, CJ, HC, ID, IV, N4, ZZ
New Element Code Deleted Usage Change to Not Used
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 EQ04
Insurance Type Code
ID
1-3
III III01
ID
III06
Industry Code Code Category Free-Form Message Text Quantity COMPOSITE UNIT OF MEASURE
III07
Surface/Layer/Position Code
ID
III08
Surface/Layer/Position Code
III09
Surface/Layer/Position Code
III02 III03 III04 III05
REF01 REF02 REF03 REF04
DEPENDENT ADDITIONAL INFORMATION Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
DTP DTP01
DEPENDENT ELIGIBILITY/ BENEFIT DATE Date/Time Qualifier
REF
10 1-3
S
S R
Min. Max.
Usage Reg.
EQ04
2110D BF, BK, ZZ
If Ill01 = BK or BF, use diagnosis code from code source 131; If III01 = ZZ: 11, 12, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 50, 51, 52, 53, 54, 55, 56, 60, 61, 62, 65, 71, 72, 81, 99
III III01
Insurance Type Code COMPOSITE DIAGNOSIS CODE POINTER Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer
ID
1-3
N/U
N0 N0 N0 N0
1-2 1-2 1-2 1-2
S R S S S
DEPENDENT ELIGIBILITY/BENEFIT ADDITIONAL INQUIRY Code List Qualifier Code
ID
10 1-3
S R
N/U
III06
Industry Code Code Category Free-Form Message Text Quantity COMPOSITE UNIT OF MEASURE
2-2
N/U
III07
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III08
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
1
S
1
S
ID AN AN
2-3 1-30 1-80
R R N/U N/U
ID AN AN
2-3 1-50 1-80
R R N/U N/U
ID
1 3-3
S R
ID
1 3-3
S R
AN 1-30 ID 2-2 AN 1-264 R 1-15
Loop
Loop Repeat
Values
270 5010 AP, C1, CO, GP, HM, IP, OT, PR, PS, SP, WC
EQ05 EQ05 - 1 EQ05 - 2 EQ05 - 3 EQ05 - 4 DEPENDENT ELIGIBILITY/ BENEFIT ADDITIONAL INQUIRY INFORMATION Code List Qualifier Code
ID
R N/U N/U N/U
2110D
III02 III03 III04 III05
REF01 REF02 REF03 REF04
DEPENDENT ADDITIONAL INFORMATION Reference Identification Qualifier Reference Identification Description REFRENCE IDENTIFIER
DTP DTP01
DEPENDENT ELIGIBILITY/ BENEFIT DATE Date Time Qualifier
REF 9F,G1
2110D 307,435,472
Page 19 of 20
AN 1-30 ID 2-2 AN 1-264 R 1-15
Code Deleted Usage Change to Not Used New Element New Element New Element New Element New Element
2110D ZZ
Code Deleted
01, 03, 04, 05, 06, 07, 08, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, 56,57, 60, 61, 62, 65, 71, 72, 81, 99 Code Deleted
R N/U N/U N/U N/U
2110D 9F, G1 Increase from 30 - 50
2110D 291
Code Deleted
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
DTP02
Date Time Period Format Qualifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
2-3
R
AN
1-35
R
1
R
N0
1-10
R
AN
4-9
R
1
R
1-6 1-9
R R
1
R
270 4010A1
DTP03
SE SE01 SE02
GE GE01 GE02
Date Time Period TRANSACTION SET TRAILER Number of Included Segments Transaction Set Control Number FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included Group Control Number
R
D8, RD8
DTP02
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
DTP03
Date Time Period
1
R
SE
N0
1-10
R
SE01
AN
4-9
R
SE02
AN
2-3
GE N0 N0
1-6 1-9
R R
1
R
IEA
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
IEA
Loop
Loop Repeat
Values
270 5010 Date Time Period Format Qualifier
ID
ID
Min. Max.
Usage Reg.
Element Identifier
Must=GS06
GE01 GE02
TRANSACTION SET TRAILER Number of Included Segments Transaction Set Control Number FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included Group Control Number
N0 N0
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
Page 20 of 20
D8, RD8
Code Added
Must=GS06
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
ISA01
INTERCHANGE CONTROL HEADER Authorization Information Qualifier
ISA02
Authorization Information
ISA03
Security Information Qualifier
ISA04
Security Information
ISA05
ISA
ID
1
R
2/2
R
AN 10/10
R
ID
R
2/2
AN 10/10
R
Interchange ID Qualifier
ID
R
ISA06
Interchange Sender ID
AN 15/15
R
ISA07
Interchange ID Qualifier
ID
R
ISA08
Interchange Receiver ID
AN 15/15
R
ISA09
Interchange Date
DT
6/6
ISA10
TM
ISA12
Interchange Time Interchange Control Standards ID Interchange Control Version Number
ISA13
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010
ISA01
INTERCHANGE CONTROL HEADER Authorization Information Qualifier
ISA02
Authorization Information
ISA03
Security Information Qualifier
ISA04
Security Information
ISA05
ISA 00, 03
00, 01
ID
1
R
2-2
R
AN 10-10
R
ID
R
2-2
00, 03
00, 01
AN 10-10
R
Interchange ID Qualifier
ID
R
ISA06
Interchange Sender ID
AN 15-15
R
01, 14, 20, 27, 28, 29, 30, 33, ZZ
ISA07
Interchange ID Qualifier
ID
R
ISA08
Interchange Receiver ID
AN 15-15
R
R
YYMMDD
ISA09
Interchange Date
DT
6-6
R
YYMMDD
4/4
R
HHMM
ISA10
Interchange Time
TM
4-4
R
HHMM
ID
1/1
R
U
ISA11
1-1
R
ID
5/5
R
00401
ISA12
Repetition Seperator Interchange Control Version Number
ID
5-5
R
Interchange Control Number
N0
9/9
R
ISA13
Interchange Control Number
N0
9-9
R
ISA14
Acknowledgement Requested
ID
1/1
R
0, 1
ISA14
Acknowledgement Requested
ID
1-1
R
0, 1
ISA15
ID
1/1
R
P, T
ISA15
1-1
R
P, T
1/1
R
ISA16
Interchange Usage Indicator Component Element Separator
ID
ISA16
Usage Indicator Component Element Separator
1-1
R
GS
FUNCTIONAL GROUP HEADER
1
R
GS
FUNCTIONAL GROUP HEADER
1
R
GS01
Functional Identifier Code
ID
2/2
R
GS01
Functional Identifier Code
ID
2-2
R
GS02
Application Sender's Code
AN
2/15
R
GS02
Application Sender's Code
AN
2-15
R
ISA11
2/2
2/2
01, 14, 20, 27, 28, 29, 30, 33, ZZ
HB, HS
2-2
2-2
01, 14, 20, 27, 28, 29, 30, 33, ZZ
01, 14, 20, 27, 28, 29, 30, 33, ZZ
Code Change Name Change 00501
Code Deleted
GS03
Application Receiver's Code
AN
2/15
R
GS03
Application Receiver's Code
AN
2-15
R
GS04
Date
DT
8/8
R
CCYYMMDD
GS04
Date
DT
8-8
R
CCYYMMDD
GS05
Time
TM
4/8
R
HHMM
GS05
Time
TM
4-8
R
HHMM
GS06
Group Control Number
N0
1/9
R
GS06
Group Control Number
N0
1-9
R
GS07
Responsible Agency Code Version/ Release/ Industry Identifier Code
ID
1/2
R
X
GS07
ID
1-2
R
X
AN
1/12
R
004010X092
GS08
Responsible Agency Code Version/Release/ Industry Identifier Code
AN
1-12
R
005010X279
GS08
Page 1 of 32
Code Change
Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 ST ST01 ST02
BHT
TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number
R
ID
3-3
R
AN
4-9
R
BEGINNING OF HIERARCHICAL TRANSACTION
ST03
BHT
BEGINNING OF HIERARCHICAL TRANSACTION
ST 271
ST01 ST02
1
R R
0022
BHT01
ID
2-2
R
11
AN
1-30
S
DT
8-8
R
Time
TM
4-8
R
Transaction Type Code
ID
2-2
N/U
1
R
1-12 1-12
R N/U
BHT02 BHT03
Reference Identification
BHT04
Date
BHT05 BHT06
HL
INFORMATION SOURCE LEVEL
HL01 HL02
Hierarchical ID Number Number
ID
AN AN
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010 TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference
4-4
Hierarchical Structure Code Transaction Set Purpose Code
BHT01
1
ID
CCYYMMDD
2000A
>1
1
R
ID
3-3
R
AN
4-9
R
AN
1-35
R
1
R
ID
4-4
R
0022 06, 11
BHT02
Hierarchical Structure Code Transaction Set Purpose Code
ID
2-2
R
BHT03
Reference Identification
AN
1-50
S
BHT04
Date
DT
8-8
R
BHT05
Time
TM
4-8
R
BHT06
Transaction Type Code
ID
2-2
N/U
HL
INFORMATION SOURCE LEVEL
1
R
HL01 HL02
Hierarchical ID Number Number
AN AN
1-12 1-12
R N/U
271
005010X279
Increase from 30 - 50
2000A
>1
HL03
Hierarchical Level Code
ID
1-2
R
20
HL03
Hierarchical Level Code
ID
1-2
R
20
Hierarchical Child Code
ID
1-1
R
0, 1
HL04
Hierarchical Child Code
ID
1-1
R
0, 1
AAA
9
S
AAA
S
ID
1-1
R
AAA01
REQUEST VALIDATION Yes/No Condition or Response Code
9
AAA01
REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA02
Agency Qualifier Code
ID
2-2
N/U
N, Y
Code Added
CCYYMMDD
HL04
2000A
New Element
2000A N, Y
AAA03
Reject Reason Code
ID
2-2
R
04, 41, 42, 79
AAA03
Reject Reason Code
ID
2-2
R
04, 41, 42, 79
AAA04
Follow-up Action Code
ID
1-1
R
C, N, P, R, S, Y
AAA04
Follow-up Action Code
ID
1-1
R
C, N, P, R, S, Y
NM1
INFORMATION SOURCE NAME
1
R
NM1
INFORMATION SOURCE NAME
1
R
NM101
Entity Identifier Code
ID
2-3
R
2B, 36, GP, P5, PR
NM102
Entity Type Qualifier
ID
1-1
R
1, 2
NM103
Name Last or Organization Name
AN
1-60
R
Increase from 35 - 60 Usage change to Required Incrase from 25 - 35
2100A
1
NM101
Entity Identifier Code
ID
2-3
R
2B, 36, GP, P5, PR
NM102
Entity Type Qualifier
ID
1-1
R
1, 2
NM103
Name Last or Organization Name
AN
1-35
S
NM104
Name First
AN
1-25
S
NM104
Name First
AN
1-35
S
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
Page 2 of 32
2100A
1
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 Identification Code Qualifier
ID
1-2
NM109
Identification Code
AN
2-80
R
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code
ID
2-3
N/U
NM108
REF01 REF02
Reference Identification
AN
1-80
REF
R
REF03
Description
REF04
REFERENCE INDENTIFIER
PER
INFORMATION SOURCE CONTACT INFORMATION
PER01
Contact Function Code
PER02
9
S
ID
2-3
R
AN
1-30
R
ID
1-2
NM109
Identification Code
AN
2-80
R
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code Name Last or Organization Name
ID
2-3
N/U
AN
1-60
N/U
2100A
PER
PAYER CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
Communication Number Communication Number Qualifier
AN 1-256
AN 1-256
PER07
Communication Number Communication Number Qualifier
PER08
Communication Number
AN 1-256
PER09
Contact Inquiry Reference
AAA AAA01
REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
HL
INFORMATION RECEIVER LEVEL
1
S
AN
1-12
R
AN
1-12
R
AN
1-60
S
ID
2-2
S
ED, EM, FX, TE
PER03
Communication Number Communication Number Qualifier
AN
1-80
S
PER04
ID
2-2
S
AAABBBCCCC ED, EM, EX, FX, TE
AN
1-80
S
ID
2-2
S
AAABBBCCCC ED, EM, EX, FX, TE
PER06
PER07
Communication Number Communication Number Qualifier
PER08
Communication Number
AN
1-80
S
AAABBBCCCC
PER09
Contact Inquiry Reference
AN
1-20
N/U
AAA
9
S
AAA01
REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
HL
INFORMATION RECEIVER LEVEL
1
S
AN
1-12
R
HL01
AN
1-12
R
HL02
HL02
New Element
S
Name Communication Number Qualifier
Hierarchical ID Number Hierarchical Parent ID Number
24, 46, FI, NI, PI, XV, XX
R
N/U
R
HL01
Values
18, 55
2-2
PER05
Loop Repeat
Segment Deleted
ID
PER06
Loop
2100A
S
PER04
Usage Reg.
Identification Code Qualifier
NM108
3
PER03
Min. Max.
271 5010 24, 46, FI, NI, PI, XV, XX
NM112 INFORMATION SOURCE ADDITIONAL IDENTIFICATION Reference Identification Qualifier
ID
IC
2100A N, Y 04, 41, 42, 79, 80, T4 C, N, P, R, S, W, X, Y
2000B
>1
PER05
Hierarchical ID Number Hierarchical Parent ID Number
Page 3 of 32
ID
ID AN
2-2
2-2
2100A IC ED, EM, TE, FX, UR Code Added AAABBBCCCC Increase from 80 - 256 ED, EM, TE, FX, EX, UR Code Added
S S
S
AAABBBCCCC Increase from 80 - 256 ED, EM, TE, FX, EX, UR Code Added
S
AAABBBCCCC
S
1-20
N/U
9
S
2100A N, Y 04, 41, 42, 79, 80, T4 C, N, P, R, S, W, X, Y
2000B
>1
Increase from 80 - 256
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
HL03
Hierarchical Level Code
ID
1-2
HL04
Hierarchical Child Code
ID
NM1
INFORMATION RECEIVER NAME
ID
Min. Max.
Usage Reg.
5010 Values
Element Identifier
Description
ID
R
21
HL03
Hierarchical Level Code
ID
1-2
R
21
1-1
R
0,1
HL04
Hierarchical Child Code
ID
1-1
R
0, 1
1
R
NM1
INFORMATION RECEIVER NAME
1
R
NM101
Entity Identifier Code
ID
2-3
R
1P, 2B, 36, 80, FA, GP, P5, PR
NM102
ID
1-1
R
1, 2
AN
1-60
S
Increase from 35 - 60
AN
1-35
S
Increase from 25 - 35
Loop
Loop Repeat
271 4010A1
Min. Max.
Usage Reg.
2100B
1
NM101
Entity Identifier Code
ID
2-3
R
NM102
ID
1-1
R
1, 2
NM103
Entity Type Qualifier Name Last or Organization Name
AN
1-35
S
NM103
Entity Type Qualifier Name Last or Organization Name
NM104
Name First
AN
1-25
S
NM104
Name First
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
R
24, 34, FI, PI, PP, SV, XV, XX
Identification Code Qualifier
ID
1-2
NM109
Identification Code
AN
2-80
R
NM109
Identification Code
AN
2-80
R
NM110
Entity Relationship Code
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
REF
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
9
S
REF
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
9
R
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
0B, 1C, 1D, 1J, 4A, CT, EL, EO, HPI
Reference Identification Qualifier
ID
2-3
R
R
REF02
Reference Identification
AN
1-50
R
S
REF03
Description
AN
1-80
S
N/U
REF04
REFERENCE IDENTIFIER
AAA01
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
9
2100B
REF01
INFORMATION RECEIVER REQUEST VALIDATION Yes/ No Condition or Response Code
AAA
S
Loop Repeat
Values
271 5010
1P, 2B, 36, 80, FA, GP, P5, PR
NM108
Loop
2100B
1
24, 34, FI, PI, PP, SV, XV, XX
New Element
2100B 0B, 1C, 1D, 1J, 4A, CT, EL, EO, HPI, JD, N5, N7, Q4, SY, TJ Code Added Increase from 30 - 50
N/U
AAA01
INFORMATION RECEIVER VALIDATION REQUEST Yes/ No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
46, 47, 48, 50, 51, 79, 97, T4
AAA03
Reject Reason Code
ID
2-2
R
46, 47, 48, 50, 51, 79, 97, T4
C, N, R, S, W, X, Y
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
2100B
AAA N, Y
Page 4 of 32
9
S
2100B N, Y
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
PRV
INFORMATION RECEIVER PROVIDER INFORMATION
271 4010A1
Values
PXC
ID
2-2
N/U
PRV05 PRV06
Provider Organization Code
ID
3-3
S R
HL02
AN
1-12
R
HL03
Hierarchical Level Code
ID
1-2
R
22
HL04
Hierarchical Child Code
ID
1-1
R
0, 1
TRN
SUBSCRIBER TRACE NUMBER
3
S
TRN01
Trace Type Code
ID
1-2
R
TRN02
Reference Identification
AN
1-30
R
Originating Company Identifier AN 10-10
R
TRN03
S
TRN04
Reference Identification
1, 2
S S
State or Province Code PROVIDER SPECIALITY INFORMATION
1
2000C
2-3
PRV04
ID
New Element
2100B
1-50
ID
1-12
1-30
Loop Repeat
R
AN
AN
AN
Loop
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
Reference Identification
SUBSCRIBER LEVEL
>1
S
PRV02
Hierarchical Number HierarchicalID Parent ID Number
2000C
1
PRV03
HL
Reference Identification
Usage Reg.
Provider Code Reference Identification Qualifier
HL01
TRN03
Min. Max.
271 5010
PRV01
TRN04
ID
1-3
N/U N/U
HL
SUBSCRIBER LEVEL
1
S
HL01
AN
1-12
R
HL02
Hierarchical Number HierarchicalID Parent ID Number
AN
1-12
R
HL03
Hierarchical Level Code
ID
1-2
R
22
HL04
Hierarchical Child Code
ID
1-1
R
0, 1
TRN
SUBSCRIBER TRACE NUMBER
3
S
TRN01
Trace Type Code
ID
1-2
R
TRN02
Reference Identification
AN
1-50
R
Originating Company Identifier AN 10-10
R
AN
1-50
S
2000C
>1
2000C 1, 2 Increase form 30 - 50
Increase form 30 - 50
NM1
SUBSCRIBER NAME
1
R
NM1
SUBSCRIBER NAME
1
R
NM101
Entity Identifier Code
ID
2-3
R
IL
NM101
Entity Identifier Code
ID
2-3
R
IL
NM102
Entity Type Qualifier
ID
1-1
R
1
NM102
Entity Type Qualifier
ID
1-1
R
1
NM103
Name Last or Organization Name
AN
1-35
S
NM103
Name Last or Organization Name
AN
1-60
S
Increase from 35 - 60
NM104
Name First
AN
1-25
S
NM104
Name First
AN
1-35
S
Increase from 25 - 35
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
S
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
S
NM108
Identification Code Qualifier
ID
1-2
S
NM109
Identification Code
AN
2-80
S
NM109
Identification Code
AN
2-80
S
NM110
Entity Relationship Code
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code
ID
2-3
N/U
NM111
Entity Identifier Code Name Last or Organization Name
ID
2-3
N/U
AN
1-60
N/U
2100C
1
MI, ZZ
NM112
Page 5 of 32
2100C
1
II, MI
Code Change
New Element
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
2100C
REF 18, 1L, 1W, 3H, 49, 6P, A6, EA, EJ, F6, GH, HJ, IF, IG, ML, N6, NQ, Q4, SY
SUBSCRIBER ADDITIONAL IDENTIFICATION
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
R
REF02
Reference Identification
AN
1-50
R
S
REF03
Description
AN
1-80
S
N/U
REF04
REFERENCE IDENTIFIER
SUBSCRIBER ADDRESS
1
S
N3
SUBSCRIBER ADDRESS
1
S
Address Information
AN
1-55
R
N301
Address Information
AN
1-55
R
N302
Address Information
AN
1-55
S
N302
Address Information
AN
1-55
S
N4
SUBSCRIBER CITY/ STATE/ ZIP CODE
1
S
N4
SUBSCRIBER CITY/STATE/ZIP CODE
1
S
N401
City Name
2-30
S
N401
City Name
AN
2-30
R
2100C
2100C
N402
State or Province Code
ID
2-2
S
N402
State or Province Code
ID
2-2
S
N403
Postal Code
ID
3-15
S
N403
Postal Code
ID
3-15
S
N404
Country Code
ID
2-3
S
N404
Country Code
ID
2-3
S
N405
Location Qualifier
ID
1-2
S
N405
Location Qualifier
ID
1-2
N/U
N406
Location Qualifier
AN
1-30
S
N406
Location Qualifier
AN
1-30
N/U
N407
Country Subdivision Code
ID
1-3
S
CY, FI
PER
SUBSCRIBER CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
HP, TE, WP
Communication Number Communication Number Qualifier
AN
1-80
S
AAABBBCCCC
ID
2-2
S
EX, HP, TE, WP
AN
1-80
S
AAABBBCCCC
PER07
Communication Number Communication Number Qualifier
ID
2-2
S
EX, HP, TE, WP
PER08
Communication Number
AN
1-80
S
PER09
Contact Inquiry Reference
AN
1-20
N/U
AAA
SUBSCRIBER REQUEST VALIDATION
9
S
PER04 PER05 PER06
Values
2100C 18, 1L, 1W, 3H, 49, 6P, CT, EA, EJ, F6, GH, HJ, IF, IG, N6, NQ, Q4, SY, Y4
Increase from 30 - 50
2100C
2100C
CY, FI
Usage change to Not Used Usage change to Not Used New Element
Segment Deleted
2100C IC
2100C
Code Change
N/U
N3
PER03
Loop Repeat
271 5010
N301
AN
Loop
AAA
SUBSCRIBER REQUEST VALIDATION
Page 6 of 32
9
S
2100C
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
AAA01
Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
AAA01
Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
271 4010A1 N, Y
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
DMG01
ID
2-3
S
DMG02
Date Time Period
AN
1-35
S
1
S
DMG03
Gender Code
ID
1-1
S
DMG04
Marital Status Code
ID
1-1
N/U
Usage Reg.
Loop
Loop Repeat
Values
2100C D8 F, M, U
N, Y
AAA03
Reject Reason Code
ID
2-2
R
15, 35, 42, 43, 45, 47, 48, 49, 51, 52, 56, 57, 58, 60, 61, 62, 63, 71, 72, 73, 74, 75, 76, 77, 78 Code Deleted
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
PRV
PROVIDER INFORMATION
1
S
R
2-3
S
PXC
1-50
S
PRV02
ID
PRV03
Reference Identification
AN
PRV04
ID
2-2
N/U
PRV05
State or Province Code PROVIDER SPECIALITY INFORMATION
PRV06
Provider Organization Code
ID
DMG DMG01
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier
DMG02
Date Time Period
DMG03
Gender Code
ID
1-1
S
DMG04
ID
1-1
N/U
ID
New Element
2100C AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SK, SU
Provider Code Reference Identification Qualifier
PRV01
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier
Min. Max.
271 5010
15, 42, 43, 45, 47, 48, 49, 51, 52, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 71, 72, 73, 74, 75, 76, 77, 78
DMG
ID
1-3
N/U 3-3
N/U
1
S
ID
2-3
S
AN
1-35
S
2100C D8 F, M, U
DMG05
Race or Ethnicity Code
ID
1-1
N/U
DMG05
Marital Status CodeOR COMPOSITE RACE ETHNICITY INFORMATION
ID
1-1
N/U
DMG06
Citizenship Status Code
ID
1-2
N/U
DMG06
Citizenship Status Code
ID
1-2
N/U
DMG07
Country Code
ID
2-3
N/U
DMG07
Country Code
ID
2-3
N/U
DMG08
Basis of Verification Code
ID
1-2
N/U
DMG08
Basis of Verification Code
ID
1-2
N/U
DMG09
Quantity
R
1-15
N/U
DMG09
Quantity
R
1-15
N/U
DMG10
Code List Qalifier Code
ID
1-3
N/U
New Element
DMG11
Industry Code
AN
1-30
N/U
New Element
INS
SUBSCRIBER RELATIONSHIP
1
S
INS
SUBSCRIBER REALTIONSHIP
1
S
2100C
Page 7 of 32
2100C
ELIGIBILITY STATUS
4010A1 Description
INS01
Yes/ No Condition or Response Code
ID
1-1
R
INS02
Individual Relationship Code
ID
2-2
R
INS03
Maintenance Type Code
ID
3-3
S
001
INS03
Maintenance Type Code
INS04
Maintenance Reason Code
ID
2-3
S
25
INS04
Maintenance Reason Code
INS05
Benefit Status Code
ID
1-1
N/U
INS05
Benefit Status Code
INS06
Medicare Plan Code
ID
1-1
N/U
INS06
MEDICARE STATUS CODE
INS07
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying
ID
1-2
N/U
INS07
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying
ID
1-2
N/U
INS08
Employment Status Code
ID
2-2
N/U
INS08
Employment Status Code
ID
2-2
N/U
INS09
ID
1-1
S
F, N, P
INS09
1-1
S
F, N, P
ID
1-1
S
N, Y
INS10
ID
1-1
S
N, Y
ID
2-3
N/U
INS11
Student Status Code Yes/ No Condition or Response Code Date Time Period Format Qualifier
ID
INS11
Student Status Code Yes/ No Condition or Response Code Date Time Period Format Qualifier
ID
2-3
N/U
INS12
Date Time Period
AN
1-35
N/U
INS12
Date Time Period
AN
1-35
N/U
INS13
Confidentiality Code
ID
1-1
N/U
INS13
Confidentiality Code
ID
1-1
N/U
ID
Min. Max.
Usage Reg.
5010
Element Identifier
Loop
Loop Repeat
Element Identifier
Description
Y
INS01
Yes/ No Condition or Response Code
ID
1-1
R
Y
18
INS02
Individual Relationship Code
ID
2-2
R
18
ID
3-3
S
001
ID
2-3
S
25
ID
1-1
N/U
ID
1-1
N/U
Values
271 4010A1
INS10
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010
INS14
City Name
AN
2-30
N/U
INS14
City Name
AN
2-30
N/U
INS15
State or Province Code
ID
2-2
N/U
INS15
State or Province Code
ID
2-2
N/U
INS16
Country Code
ID
2-3
N/U
INS16
Country Code
ID
2-3
N/U
INS17
Number
N0
1-9
S
INS17
Number
N0
1-9
S
1
S
HI HI01
SUBSCRIBER HEALTH CARE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION
R
HI01 - 1
Code List Qualifier Code
ID
1-3
R
HI01 - 2
AN
1-30
R
HI01 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI01 - 4
Date Time Period
AN
1-35
N/U
HI01 - 5
Monetary Amount
R
1-18
N/U N/U
HI01 - 6
Quantity
R
1-15
HI01 - 7
Version Identifier
AN
1-30
N/U
HI01 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI02 - 1
Code List Qualifier Code
ID
1-3
R
HI02 - 2
AN
1-30
R
HI02 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI02 - 4
Date Time Period
AN
1-35
N/U
HI02 - 5
Monetary Amount
R
1-18
N/U
HI01 - 9 HI02
Page 8 of 32
New Element
2100C
ABK, BK
S ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
HI02 - 6
Quantity
R
1-15
HI02 - 7
Version Identifier
AN
1-30
N/U
HI02 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI03 - 1
Code List Qualifier Code
ID
1-3
R
HI03 - 2
AN
1-30
R
HI03 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI03 - 4
Date Time Period
AN
1-35
N/U
HI03 - 5
Monetary Amount
R
1-18
N/U N/U
271 4010A1
Loop
Loop Repeat
Values
271 5010
HI02 - 9 HI03
N/U
S
HI03 - 6
Quantity
R
1-15
HI03 - 7
Version Identifier
AN
1-30
N/U
HI03 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI04 - 1
Code List Qualifier Code
ID
1-3
R
HI04 - 2
Industry Code
AN
1-30
R
HI04 - 3
Date Time Period Format Qualifier
ID
2-3
N/U
HI04 - 4
Date Time Period
AN
1-35
N/U
HI04 - 5
Monetary Amount
R
1-18
N/U N/U
HI03 - 9 HI04
S
HI04 - 6
Quantity
R
1-15
HI04 - 7
Version Identifier
AN
1-30
N/U
HI04 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI05 - 1
Code List Qualifier Code
ID
1-3
R
HI05 - 2
AN
1-30
R
HI05 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI05 - 4
Date Time Period
AN
1-35
N/U
HI05 - 5
Monetary Amount
R
1-18
N/U N/U
HI04 - 9 HI05
Quantity
R
1-15
HI05 - 7
Version Identifier
AN
1-30
N/U
HI05 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI06
Page 9 of 32
ABF, BF
S
HI05 - 6
HI05 - 9
ABF, BF
S
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
HI06 - 1
Code List Qualifier Code
ID
1-3
R
HI06 - 2
AN
1-30
R
HI06 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI06 - 4
Date Time Period
AN
1-35
N/U
HI06 - 5
Monetary Amount
R
1-18
N/U N/U
271 4010A1
Loop
Loop Repeat
Values
271 5010
HI06 - 6
Quantity
R
1-15
HI06 - 7
Version Identifier
AN
1-30
N/U
HI06 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI07 - 1
Code List Qualifier Code
ID
1-3
R
HI07 - 2
AN
1-30
R
HI07 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI07 - 4
Date Time Period
AN
1-35
N/U
HI07 - 5
Monetary Amount
R
1-18
N/U N/U
HI06 - 9 HI07
S
HI07 - 6
Quantity
R
1-15
HI07 - 7
Version Identifier
AN
1-30
N/U
HI07 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI08 - 1
Code List Qualifier Code
ID
1-3
R
HI08 - 2
AN
1-30
R
HI08 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI08 - 4
Date Time Period
AN
1-35
N/U
HI08 - 5
Monetary Amount
R
1-18
N/U N/U
HI07 - 9 HI08
Quantity
R
1-15
HI08 - 7
Version Identifier
AN
1-30
N/U
HI08 - 8
Industry Code
AN
1-30
N/U
ID
1-1
N/U
HI09 HI10 HI11 HI12
Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION
Page 10 of 32
ABF, BF
S
HI08 - 6
HI08 - 9
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 DTP
DTP01 DTP02
DTP03
SUBSCRIBER DATE
Date/Time Qualifier Date Time Period Format Qualifier
Date Time Period
9
S
2100C
DTP
ID
3-3
R
ID
2-3
R
D8, RD8
1-35
R
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010
102, 152, 291, 307, 318, 340, 341, 342, 343, 346, 347, 356, 357, 382, 435, 442, 458, 472, 539, 540, 636, 771
AN
ID
CCYYMMDDCCYYMMDD
DTP01 DTP02
SUBSCRIBER DATE
Date Time Qualifier Date Time Period Format Qualifier
DTP03
Date Time Period
MPI
SUBSCRIBER MILITARY PERSONNEL INFORMATION
MPI01
Information Status Code
MPI02
MPI03
Employment Status Code
9
Description
R
ID
2-3
R
D8, RD8
R
CCYYMMDD, CCYYMMDDCCYYMMDD
AN
1-35
1
S
ID
1-1
R
A, C, L, O, P, S, T
R
AE, AO, AS, AT, AU, CC, DD, HD, IR, LX, PE, RE, RM, RR, RU
1-1
R
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, Q, R, S, U, W
1-80
S
ID
AN
MPI06
ID
MPI07
Date Time Period
AN
Page 11 of 32
096, 102, 152, 291, 307, 318, 340, 341, 342, 343, 346, 347, 356, 357, 382, 435, 442, 458, 472, 539, 540, 636, 771
3-3
Military Service Rank Code Date Time Period Format Qualifier
MPI05
2100C
ID
Government Service Affiliation Code ID
MPI04
S
ID
2-2
Code Added
New Element
2100C
S
A1, A2, A3, B1, B2, C1, C2, C3, C4, C5, C6, C7, C8, C9, E1, F1, F2, F3, F4, G1, G4, L1, L2, L3, L4, L5, L6, M1, M2, M3, M4, M5, M6, P1, P2, P3, P4, P5, R1, S1, S2, S3, S4, S5, S6, S7, S8, S9, SA, SB, SC, T1, V1, W1
2-3
S
D8, RD8
1-35
S
2-2
Code Added
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 EB
EB01
EB02
EB03
SUBSCRIBER ELIGIBILITY/ BENEFIT INFORMATION
Eligibility or Benefit Information
Coverage Level Code
Service Type Code
1
ID
ID
ID
1-2
3-3
1-2
S
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
2110C
>1
Values
271 5010 2110C
>1
EB
SUBSCRIBER ELIGIBILITY/ BENEFIT INFORMATION
1
S
R
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S, T, U, V, W, X, Y
S
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO
EB02
Coverage Level Code
ID
3-3
S
S
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 44, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 99, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL BM, BN, BP, BQ, BR, BS
EB03
Service Type Code
ID
1-2
S
EB01
Eligibility or Benefit Information
Page 12 of 32
ID
1-2
R
1, 2, 3, 4, 5, 6, 7, 8, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S, T, U, V, W, X, Y CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 44, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 99, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GY, IC, MH, Code Added
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
EB04
Insurance Type Code
ID
1-3
S
EB05
Plan Coverage Description
AN
1-50
S
ID
Min. Max.
Usage Reg.
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36
EB04
Insurance Type Code
ID
1-3
S
EB05
Plan Coverage Description
AN
1-50
S
Time Period Qualifier
ID
1-2
S
EB06
Time Period Qualifier
ID
1-2
S
EB07
Monetary Amount
R
1-18
S
EB07
Monetary Amount
R
1-18
S
EB08
Percent
R
1-10
S
EB08
Percentage as Decimal
R
1-10
S
Quantity Qualifier
ID
2-2
S
EB10
Quantity
R
1-15
S
EB11
Yes/No Condition or Response Code
EB12
Yes/No Condition or ResponseMEDICAL Code COMPOSITE
EB13
PROCEDURE IDENTIFIER
EB13 - 1 Product/Service ID Qualifier Product/Service ID EB13 - 2
ID ID
1-1 1-1
S S
99, CA, CE, DB, DY, HS, LA, LE, MN, P6, QA, S7, S8, VS, YY
N,U,Y N,U,Y
S ID AN
2-2 1-48
R R
Loop Repeat
Values
271 5010
EB06
EB09
Loop
AD, CJ, HC, ID, IV, N4, ZZ
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, IP, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36
8H, 99, CA, CE, DB, DY, HS, LA, LE, M2, MN, P6, QA, S7, S8, VS, YY Code Added
Quantity Qualifier
ID
2-2
S
EB10
Quantity
R
1-15
S
EB11
Yes/No Condition or Response Code
ID
1-1
S
N,U,Y
EB12
Yes/No Condition or ResponseMEDICAL Code COMPOSITE
ID
1-1
S
N,U,W,Y
EB13
PROCEDURE IDENTIFIER
EB09
EB13 - 1 Product/Service ID Qualifier Product/Service ID EB13 - 2
Code Added
S ID AN
2-2 1-48
R R
EB13 - 3
Procedure Modifier
AN
2-2
S
EB13 - 3
Procedure Modifier
AN
2-2
S
EB13 - 4
Procedure Modifier
AN
2-2
S
EB13 - 4
Procedure Modifier
AN
2-2
S
AD, CJ, HC, ID, IV, N4, ZZ
EB13 - 5
Procedure Modifier
AN
2-2
S
EB13 - 5
Procedure Modifier
AN
2-2
S
EB13 - 6
Procedure Modifier
AN
2-2
S
EB13 - 6
Procedure Modifier
AN
2-2
S
EB13 - 7
Description
AN
1-80
N/U
EB13 - 7
Description
AN
1-80
N/U
EB13 - 8
Product/Service ID COMPOSITE DIAGNOSIS CODE POINTER
AN
1-48
S S
New Element
Diagnosis Code Pointer
N0
1-2
R
New Element
EB14 EB14 - 1
New Element
EB14 - 2
Diagnosis Code Pointer
N0
1-2
S
New Element
EB14 - 3
Diagnosis Code Pointer
N0
1-2
S
New Element
Page 13 of 32
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
Diagnosis Code Pointer
N0
271 4010A1 HEALTH CARE SERVICES DELIVERY
9
S
HSD01
Quantity Qualifier
ID
2-2
S
HSD02
R
1-15
S
HSD03
Quantity Unit or Basis for Measurement Code
ID
2-2
S
HSD04
Sample Selection Modulus
R
1-6
S
HSD05
Time Period Qualifier
ID
1-2
S
HSD06
Number of Periods
N0
1-3
S
HSD08
Ship/Delivery or Calendar Pattern Code Ship/Delivery Pattern Time Code
REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
HSD07
ID
1-2
S
ID
1-1
S
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
DTP
SUBSCRIBER ELIGIBILITY/BENEFIT DATE
20
Usage Reg.
2110C DY, FL, HS, MN, VS DA, MO, VS, WK, YR 6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, ,H, J, K, L ,M N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y A, B, C, D, E, F, G, Y
2110C 18, 1L, 1W, 49, 6P, 9F, A6, F6, G1, IG, N6, NQ
1-2
S
9
S
HSD
HEALTH CARE SERVICES DELIVERY
HSD01
Quantity Qualifier
ID
2-2
S
HSD02
R
1-15
S
HSD03
Quantity Unit or Basis for Measurement Code
ID
2-2
S
HSD04
Sample Selection Modulus
R
1-6
S
HSD05
Time Period Qualifier
ID
1-2
S
HSD06
Number of Periods
N0
1-3
S
HSD08
Ship/Delivery or Calendar Pattern Code Ship/Delivery Pattern Time Code
REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
HSD07
ID
1-2
S
ID
1-1
S
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
R
REF02
Reference Identification
AN
1-50
R
S
REF03
Description
AN
1-80
N/U
REF04
REFERENCE IDENTIFIER
DTP
SUBSCRIBER ELIGIBILITY/ BENEFIT DATE
S
Loop
Loop Repeat
Values
271 5010 EB14 - 4
HSD
Min. Max.
2110C
Page 14 of 32
New Element
2110C DY, FL, HS, MN, VS DA, MO, VS, WK, YR 6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, ,H, J, K, L ,M N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y A, B, C, D, E, F, G, Y
2110C 18, 1L, 1W, 49, 6P, 9F, ALS, CLI, F6, FO, G1, IG, M7, N6, NQ Code Change Increase from 30 - 50
S N/U
20
S
2110C
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
DTP01 DTP02
DTP03
Date/Time Qualifier Date Time Period Format Qualifier
Date Time Period
ID
3-3
R
ID
2-3
R
D8, RD8
1-35
R
9
S
AAA01
SUBSCRIBER REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA
CCYYMMDDCCYYMMDD
2110C N, Y
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action code
ID
1-1
R
C, N, R, W, X, Y
MSG
MESSAGE TEXT Free-Form Message Text
10 AN 1-264
S
DTP01 DTP02
2110C
R
Date Time Qualifier Date Time Period Format Qualifier
Date Time Period
DTP03
Usage Reg.
2-3
R
R8, RD8
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
9
S
AN
AAA01
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action code
ID
1-1
R
MSG
MESSAGE TEXT
MSG01
Free-Form Message Text
10 AN 1-264
S
ID
2-2
N/U
MSG02
Printer Carriage Control Code
ID
2-2
N/U
N0
1-9
N/U
MSG03
Number
N0
1-9
N/U
III
SUBSCRIBER ELIGIBILITY/ BENEFIT ADDITIONAL INFORMATION
III
SUBSCRIBER ELIGIBILITY/BENEFIT ADDITIONAL INFORMATION
1
S
III01
Code List Quantifier Code
III01
Code List Quantifier Code
1-3
S
1-3
R
10
BF, BK, ZZ
Page 15 of 32
ID
Code Added
Code Added
2110C N, Y
15, 33, 52, 53, 54, 55, 56, 57, 60, 61, 62, 63, 69, 70, 98, AA, AE, AF, AG, AO, CI, E8, IA, MA Code Added C, N, R, W, X, Y 2110C
R
Number
2115C
096, 193, 194, 198, 290, 291, 292, 295, 304, 307, 318, 346, 348, 349, 356, 357, 435, 472, 636, 771
ID
Printer Carriage Control Code
ID
Values
R
MSG02
S
Loop Repeat
3-3
MSG03
1
Loop
ID
SUBSCRIBER REQUEST VALIDATION Yes/No Condition or Response Code
AAA
15, 52, 53, 55, 56, 57, 60, 61, 62, 63, 69, 70
MSG01
Min. Max.
271 5010 193, 194, 198, 290, 292, 295, 304, 307, 318, 348, 349, 356, 357, 435, 472, 636
AN
ID
2115C
10
GR, NI, ZZ
Code Change Usage change to Situational
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
III02
Industry Code
III03
Code Category
III04
Free-Form Message Text
III05
R
III06
Quantity COMPOSITE UNIT OF MEASURE
III07
Surface/Layer/Position Code
ID
III08
Surface/Layer/Position Code
III09
Surface/Layer/Position Code
LS
LOOP HEADER
LS01
Loop Identifier Code
NM1
SUBSCRIBER BENEFIT RELATED ENTITY NAME
AN
ID
1-30
2-2
ID
Min. Max.
Usage Reg.
If III01=ZZ: 11, 12, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 50, 51, 52, 53, 54, 55, 56, 60, 61, 62, 65, 71, 72, 81, 99
R
N/U
III02
Industry Code
III03
Code Category
AN
ID
1-30
2-2
III04
Free-Form Message Text
III05
R
N/U
III06
Quantity COMPOSITE UNIT OF MEASURE
2-2
N/U
III07
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III08
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
1
S
1
S
AN
1-6
R
AN
1-4
R
1
S
1
S
2110C 2120
2120C
1
LS
LOOP HEADER
LS01
Loop Identifier Code
NM1
SUBSCRIBER BENEFIT RELATED ENTITY NAME
AN 1-264 1-15
S
N/U
Entity Identifier Code
ID
2-3
R
NM102
ID
1-1
R
1, 2
NM103
Entity Type Qualifier Name Last or Organization Name
AN
1-35
S
NM103
Entity Type Qualifier Name Last or Organization Name
NM104
Name First
AN
1-25
S
NM104
Name First
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
Identification Code Qualifier
ID
1-2
S
Code Added Usage change to Situational Usage change to Situational
N/U
NM101
24, 34, 46, FA, FI, MI, NI, PI, PP, SV, XV, XX, ZZ
44
S
13, 1P, 2B, 36, 73, FA, GP, IL, LR, P3, P4, P5, PR, PRP, SEP, TTP, VN, X3
NM108
Values
If III01=ZZ: 01, 03, 04, 05, 06, 07, 08, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, Code Added 56, 57, 60, 61, 62, Usage change to 65, 71, 72, 81, 99 Situational
S
N/U
1-15
Loop Repeat
271 5010
N/U
AN 1-264
Loop
2110C 2120
2120C
Decrease from 6 - 4
23 13, 1I, 1P, 2B, 36, 73, FA, GP, GW, I3, IL, LR, OC, P3, P4, P5, PR, PRP, SEP, TTP, VN, VY, X3 Code Added
NM101
Entity Identifier Code
ID
2-3
R
NM102
ID
1-1
R
AN
1-60
S
Increase from 35 - 60
AN
1-35
S
Increase from 25 - 35
NM108
Identification Code Qualifier
Page 16 of 32
ID
1-2
S
1, 2
24, 34, 46, FA, FI, II, MI, NI, PI, PP, SV, XV, XX Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
NM109
Identification Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
NM109
Identification Code
AN
271 4010A1 AN
2-80
Min. Max.
Usage Reg.
2-80
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
S
NM111
Entity Identifier Code
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3
SUBSCRIBER RELATED ENTITY ADDRESS
1
S
N3
SUBSCRIBER BENEFIT RELATED ENTITY ADDRESS
1
S
N301
Address Information
AN
1-55
R
N301
Address Information
AN
1-55
R
N302
Address Information
AN
1-55
S
N302
Address Information
AN
1-55
S
N4
SUBSCRIBER BENEFIT RELATED CITY/STATE/ZIP CODE
N4
SUBSCRIBER BENEFIT RELATED ENTITY CITY/STATE/ZIP CODE
1
S
2120C
2110C
N401
City Name
AN
2-30
S
N401
City Name
AN
2-30
R
N402
State or Province Code
ID
2-2
S
N402
State or Province Code
ID
2-2
S
N403
Postal Code
ID
3-15
S
N403
Postal Code
ID
3-15
S
N404
Country Code
ID
2-3
S
N404
Country Code
ID
2-3
S
N405
Location Qualifier
ID
1-2
S
N406
Location Qualifier
AN
1-30
S
PER
SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
Communication Number Communication Number Qualifier
AN
1-80
S
ID
2-2
S
AN
1-80
S
PER07
Communication Number Communication Number Qualifier
ID
2-2
PER08
Communication Number
AN
1-80
PER09
Contact Inquiry Reference
AN
1-20
N/U
PRV
SUBSCRIBER BENEFIT RELATED PROVIDER INFORMATION
PER03 PER04 PER05 PER06
1
RJ
2120C IC ED, EM, FX, TE, WP
N405
Location Qualifier
ID
1-2
S
N406
Location Qualifier
AN
1-30
S
N407
Country Subdivision Code
ID
1-3
S
New Element
2120C
2120C Usage change to Required
RJ Code Added
PER
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
Communication Number Communication Number Qualifier
AN 1-256
S
ID
S
AN 1-256
S
ID
S
AAABBBCCCC Increase from 80 - 256 ED, EM, FX, TE, UR, WP Code Added
AN 1-256
S
AAABBBCCCC
PER03 PER04
PER06
S
AAABBBCCCC ED, EM, FX, TE, WP
PER07
Communication Number Communication Number Qualifier
S
AAABBBCCCC
PER08
Communication Number
PER09
Contact Inquiry Reference
PRV
SUBSCRIBER BENEFIT RELATED PROVIDER INFORMATION
2120C
Usage change to 01, 02, 27, 41, 48, Situational 65, 72 Code Added
SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION
AAABBBCCCC ED, EM, FX, TE, WP
S
Values
S
Entity Relationship Code
S
Loop Repeat
271 5010
S
NM110
1
Loop
PER05
Page 17 of 32
AN
2-2
2-2 1-20
N/U
1
S
2120C IC ED, EM, FX, TE, UR, WP Code Added AAABBBCCCC Increase from 80 - 256 ED, EM, FX, TE, UR, WP Code Added
2120C
Increase from 80 - 256
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
PRV01
Provider Code
PRV02
Reference Identification Qualifier
ID
ID
1-3
2-3
ID
Min. Max.
Usage Reg.
R
R
9K, D3, EI, HPI, SY, TJ, ZZ
PRV01
Provider Code
PRV02
Reference Identification Qualifier
ID
ID
1-3
2-3
AN
1-30
R
PRV03
Reference Identification
AN
1-50
S
ID
2-2
N/U
PRV04
2-2
N/U
N/U
PRV05
State or Province Code PROVIDER SPECIALTY INFORMATION
ID
PRV05
State or Province Code PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
ID
3-3
N/U
PRV06
Provider Organization Code
ID
3-3
1
S
1
S
AN
1-6
R
AN
1-4
R
1
S
HL
DEPENDENT LEVEL
1
S
AN
1-12
R
HL01
AN
1-12
R
AN
1-12
R
HL02
Hierarchical ID Number Hierarchical Parent ID Number
AN
1-12
R
LOOP TRAILER
HL
DEPENDENT LEVEL
HL01 HL02
Hierarchical ID Number Hierarchical Parent ID Number
2110C 2120 2000D
>1
LE
LOOP TRAILER
LE01
Loop Identifier Code
PXC
S
Reference Identification
Loop Identifier Code
Values
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
PRV03
LE
Loop Repeat
271 5010 AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
PRV04
LE01
Loop
Increase from 30 - 50 Usage change to Situational
N/U N/U
2120C Decrease from 6 - 4 2000D
>1
HL03
Hierarchical Level Code
ID
1-2
R
23
HL03
Hierarchical Level Code
ID
1-2
R
23
HL04
Hierarchical Child Code
ID
1-1
R
0
HL04
Hierarchical Child Code
ID
1-1
R
0
TRN
DEPENDENT TRACE NUMBER
3
S
TRN
DEPENDENT TRACE NUMBER
3
S
TRN01
Trace Type Code
ID
1-2
R
TRN01
Trace Type Code
ID
1-2
R
TRN02
Reference Identification
AN
1-30
R
TRN02
Reference Identification
AN
1-50
R
Originating Company Identifier AN 10-10
R
TRN03
Originating Company Identifier AN 10-10
R
S
TRN04
Reference Identification
TRN03 TRN04
Reference Identification
AN
1-30
2000D 1, 2
Code Change Usage change to Situational
AN
1-50
2000D 1, 2 Increase from 30 - 50
Increase from 30 - 50
S
NM1
DEPENDENT NAME
1
R
NM1
DEPENDENT NAME
1
R
NM101
Entity Identifier Code
ID
2-3
R
03
NM101
Entity Identifier Code
ID
2-3
R
03
NM102
ID
1-1
R
1
NM102
1-1
R
1
AN
1-35
S
NM103
Entity Type Qualifier Name Last or Organization Name
ID
NM103
Entity Type Qualifier Name Last or Organization Name
AN
1-60
S
Increase from 35 - 60
NM104
Name First
AN
1-25
S
NM104
Name First
AN
1-35
S
Increase from 25 - 35
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
2100D
1
Page 18 of 32
2100D
1
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
S
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
N/U
Code Deleted Usage change to Not Used Usage change to Not Used
271 4010A1
Min. Max.
Usage Reg.
MI, ZZ
NM109
Identification Code
AN
2-80
S
NM109
Identification Code
AN
2-80
N/U
Entity Relationship Code
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
REF
DEPENDENT ADDITIONAL IDENTIFICATION
9
S
DEPENDENT ADDITIONAL IDENTIFICATION
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
2100D 18, 1L, 1W, 49, 6P, A6, CT, EA, EJ, F6, CJ, HC, ID, IV, N4, ZZ
REF01
Reference Identification Qualifier
ID
2-3
R
R
REF02
Reference Identification
AN
1-50
R
S
REF03
Description
AN
1-80
S
N/U
REF04
REFERENCE IDENTIFIER
N3
DEPENDENT ADDRESS
1
S
N3
DEPENDENT ADDRESS
1
S
Address Information
AN
1-55
R
N301
Address Information
AN
1-55
R
N302
Address Information
AN
1-55
S
N302
Address Information
AN
1-55
S
N4
DEPENDENT CITY/STATE/ZIP CODE
1
S
N4
DEPENDENT CITY/STATE/ZIP CODE
1
S
2100D
2100D
N401
City Name
AN
2-30
S
N401
City Name
AN
2-30
R
N402
State or Province Code
ID
2-2
S
N402
State or Province Code
ID
2-2
S
N403
Postal Code
ID
3-15
S
N403
Postal Code
ID
3-15
S
N404
Country Code
ID
2-3
S
N404
Country Code
ID
2-3
S
N405
Location Qualifier
ID
1-2
N/U
N405
Location Qualifier
ID
1-2
N/U
N406
Location Qualifier
AN
1-30
N/U
N406
Location Qualifier
AN
1-30
N/U
N407
Country Subdivision Code
ID
1-3
PER
DEPENDENT CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
HP, TE, WP
AN
1-80
S
AAABBBCCCC
PER05
Communication Number Communication Number Qualifier
ID
2-2
S
EX, HP, TE, WP
PER06
Communication Number
AN
1-80
S
AAABBBCCCC
PER04
Values
New Element
2100D 18, 1L, 49, 6P, CT, EA, EJ, F6, GH, HJ, IF, IG, MRC, N6, NQ, Q4, SY, Y4 Code Change Increase from 30 - 50
N/U
N301
PER03
Loop Repeat
271 5010
NM110
REF
Loop
2100D
2100D Usage change to Required
New Element
Segment Deleted
2100D IC
Page 19 of 32
ELIGIBILITY STATUS
4010A1 Description
PER07
Communication Number Qualifier
ID
2-2
S
HP, TE, WP
PER08
Communication Number
AN
1-80
S
AAABBBCCCC
PER09
Contact Inquiry Reference
AN
1-20
N/U
9
S
ID
Min. Max.
Usage Reg.
5010
Element Identifier
Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
AAA01
DEPENDENT REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA
2100D N, Y
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
AAA01
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
DMG01
ID
2-3
S
DMG02
Date Time Period
AN
1-35
S
DMG03 DMG04
Gender Code Marital Status Code
ID ID
1-1 1-1
S N/U
S
Loop
Loop Repeat
Values
2100D D8 F, M, U
9
S
2100D N, Y
AAA03
Reject Reason Code
ID
2-2
R
15, 35, 42, 43, 45, 47, 48, 49, 51, 52, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 71, 77 Code Added
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
PRV
PROVIDER INFORMATION
1
S
R
2-3
S
PXC
1-50
S
PRV02
ID
PRV03
Reference Identification
AN
PRV04
ID
2-2
N/U
PRV05
State or Province Code PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
ID
3-3
N/U
DMG
1
S
DMG01
DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier
ID
2-3
S
DMG02
Date Time Period
AN
1-35
S
DMG03 DMG04
ID ID
1-1 1-1
S N/U
ID
1-3
N/U
DMG05
Race or Ethnicity Code
ID
1-1
N/U
DMG05
Gender Code Marital Status Code COMPOSITE RACE OR ETHNICITY INFORMATION
DMG06
Citizenship Status Code
ID
1-2
N/U
DMG06
Citizenship Status Code
ID
1-2
N/U
DMG07
Country Code
ID
2-3
N/U
DMG07
Country Code
ID
2-3
N/U
DMG08
Basis of Verification Code
ID
1-2
N/U
DMG08
Basis of Verification Code
ID
1-2
N/U
DMG09
Quantity
R
1-15
N/U
DMG09
Quantity
R
1-15
N/U
Page 20 of 32
New Segment
2100D AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, SK, SU
Provider Code Reference Identification Qualifier
PRV01
1
Usage Reg.
DEPENDENT REQUEST VALIDATION Yes/No Condition or Response Code
AAA
AAA03
DMG
Min. Max.
271 5010
15, 42, 43, 45, 47, 48, 49, 51, 52, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 71
DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier
ID
N/U
2100D D8 F, M, U
Name Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
DMG10
Code List Qalifier Code
ID
1-3
N/U
New Element
DMG11
Industry Code
AN
1-30
N/U
New Element
1
S
271 4010A1
INS01
DEPENDENT RELATIONSHIP Yes/No Condition or Response Code
INS02 INS03
INS
Usage Reg.
Loop
Loop Repeat
Values
271 5010
INS01
DEPENDENT RELATIONSHIP Yes/No Condition or Response Code
ID
1-1
R
01, 19, 21, 34
INS02
Individual Relationship Code
ID
2-2
R
001
INS03
Maintenance Type Code
ID
3-3
S
001
25
INS04
Maintenance Reason Code
ID
2-3
S
25
N/U
INS05
Benefit Status Code
ID
1-1
N/U
N/U
INS06
MEDICARE STATUS CODE
N/U
INS07
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying
ID
1-2
N/U
N/U
INS08
Employment Status Code
ID
2-2
N/U
F, N, P
INS09
Student Status Code
ID
1-1
N/U
Usage change to Not Used Code Deleted
N, Y
INS10
ID
1-1
N/U
Usage change to Not Used Code Deleted
N/U
1
S
ID
1-1
R
N
Individual Relationship Code
ID
2-2
R
Maintenance Type Code
ID
3-3
S
INS04
Maintenance Reason Code
ID
2-3
S
INS05
Benefit Status Code
ID
1-1
INS06
Medicare Plan Code
ID
1-1
INS07
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying
ID
1-2
INS08
Employment Status Code
ID
2-2
INS09
Student Status Code
ID
1-1
S
2100D
INS
ID
1-1
S
INS11
Yes/No Condition or Response Code Date Time Period Format Qualifier
ID
2-3
N/U
INS12
Date Time Period
AN
1-35
N/U
INS13
Confidentiality Code
ID
1-1
N/U
INS14
City Name
AN
2-30
N/U
INS15
State or Province Code
ID
2-2
N/U
INS16
Country Code
ID
2-3
N/U
INS16
INS17
Number
N0
1-9
S
INS17
INS10
Min. Max.
INS11
ID
2-3
INS12
Date Time Period
AN
1-35
N/U
INS13
Confidentiality Code
ID
1-1
N/U
INS14
City Name
AN
2-30
N/U
INS15
State or Province Code
ID
2-2
N/U
Country Code
ID
2-3
N/U
Number
N0
1-9
S
1
S
HI01
DEPENDENT HEALTH CARE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION Code List Qualifier Code
ID
1-3
R
HI01 - 2
AN
1-30
R
HI01 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI01 - 4
Date Time Period
AN
1-35
N/U
HI01 - 5
Monetary Amount
R
1-18
N/U N/U
HI01 - 6
Quantity
R
1-15
HI01 - 7
Version Identifier
AN
1-30
N/U
HI01 - 8
Industry Code Yes/No Condition or Response Code
AN
1-30
N/U
ID
1-1
N/U
Page 21 of 32
New Segment
2100D
R
HI01 - 1
HI01 - 9
N 01, 19, 20, 21, 39, 40, 53, G8 Code Change
N/U
Yes/No Condition or Response Code Date Time Period Format Qualifier
HI
2100D
ABK, BK
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
HI02
HEALTH CARE CODE INFORMATION
271 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010 S
HI02 - 1
Code List Qualifier Code
ID
1-3
R
HI02 - 2
AN
1-30
R
HI02 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI02 - 4
Date Time Period
AN
1-35
N/U
HI02 - 5
Monetary Amount
R
1-18
N/U N/U
HI02 - 6
Quantity
R
1-15
HI02 - 7
Version Identifier
AN
1-30
N/U
HI02 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI03 - 1
Code List Qualifier Code
ID
1-3
R
HI03 - 2
AN
1-30
R
HI03 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI03 - 4
Date Time Period
AN
1-35
N/U
HI03 - 5
Monetary Amount
R
1-18
N/U N/U
HI02 - 9 HI03
S
HI03 - 6
Quantity
R
1-15
HI03 - 7
Version Identifier
AN
1-30
N/U
HI03 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI04 - 1
Code List Qualifier Code
ID
1-3
R
HI04 - 2
AN
1-30
R
HI04 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI04 - 4
Date Time Period
AN
1-35
N/U
HI04 - 5
Monetary Amount
R
1-18
N/U
HI03 - 9 HI04
Quantity
R
1-15
N/U
HI04 - 7
Version Identifier
AN
1-30
N/U
HI04 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI05 - 1
Code List Qualifier Code
ID
1-3
R
HI05 - 2
Industry Code
AN
1-30
R
HI05
Page 22 of 32
ABF, BF
S
HI04 - 6
HI04 - 9
ABF, BF
ABF, BF
S ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010 HI05 - 3
Date Time Period Format Qualifier
ID
2-3
HI05 - 4
Date Time Period
AN
1-35
N/U
HI05 - 5
Monetary Amount
R
1-18
N/U N/U
N/U
HI05 - 6
Quantity
R
1-15
HI05 - 7
Version Identifier
AN
1-30
N/U
HI05 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI06 - 1
Code List Qualifier Code
ID
1-3
R
HI06 - 2
AN
1-30
R
HI06 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI06 - 4
Date Time Period
AN
1-35
N/U
HI06 - 5
Monetary Amount
R
1-18
N/U N/U
HI05 - 9 HI06
S
HI06 - 6
Quantity
R
1-15
HI06 - 7
Version Identifier
AN
1-30
N/U
HI06 - 8
Industry Code Yes/No Condition or Response Code
AN
1-30
N/U
ID
1-1
N/U
HI06 - 9 HI07
HEALTH CARE CODE INFORMATION
S
HI07 - 1
Code List Qualifier Code
ID
1-3
R
HI07 - 2
AN
1-30
R
HI07 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI07 - 4
Date Time Period
AN
1-35
N/U
HI07 - 5
Monetary Amount
R
1-18
N/U
HI07 - 6
Quantity
R
1-15
N/U
HI07 - 7
Version Identifier
AN
1-30
N/U
HI07 - 8
Industry Code Yes/No Condition or Response Code
AN
1-30
N/U
ID
1-1
N/U
HI07 - 9 HI08
HEALTH CARE CODE INFORMATION
ABF, BF
S
HI08 - 1
Code List Qualifier Code
ID
1-3
R
HI08 - 2
AN
1-30
R
HI08 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI08 - 4
Date Time Period
AN
1-35
N/U
HI08 - 5
Monetary Amount
R
1-18
N/U
Page 23 of 32
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 Quantity
R
1-15
N/U
HI08 - 7
Version Identifier
AN
1-30
N/U
HI08 - 8
Industry Code Yes/No Condition or Response Code
AN
1-30
N/U
ID
1-1
N/U
S
2100D
DTP01
Date/Time Qualifier
ID
3-3
R
102, 152, 291, 307, 318, 340, 341, 342, 343, 346, 347, 382, 435, 442, 458, 472, 539, 540, 636
DTP02
Date Time Period Format Qualifier
ID
2-3
R
D8, RD8
DTP03
Date Time Period
AN
1-35
R
HEALTH CARE CODE INFORMATION
Loop
Loop Repeat
Values
N/U
HI11
HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE
N/U
HI12
INFORMATION
N/U
DTP
DEPENDENT DATE
HI10
9
Usage Reg.
HI08 - 6
HI09
DEPENDENT DATE
Min. Max.
271 5010
HI08 - 9
DTP
ID
N/U
9
S
2100D 096, 102, 152, 291, 307, 318, 340, 341, 342, 343, 346, 347, 356 357, 382, 435, 442, 458, 472, 539, 540, 636, 771 Code Added
DTP01
Date Time Qualifier
ID
3-3
R
DTP02
Date Time Period Format Qualifier
ID
2-3
R
D8, RD8
R
CCYYMMDD, CCYYMMDDCCYYMMDD
DTP03
Date Time Period
MPI
DEPENDENT MILITARY PERSONNEL INFORMATION
MPI01
Information Status Code
MPI02
MPI03
Employment Status Code
AN
1-35
1
S
ID
1-1
R
A, C, L, O, P, S, T
R
AE, AO, AS, AT, AU, CC, DD, HD, IR, LX, PE, RE, RM, RR, RU
R
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, Q, R, S, U, W
ID
Government Service Affiliation Code ID
Page 24 of 32
2-2
1-1
Code Deleted
New Segment
2100D
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
MPI04
Description
AN
1-80
S
MPI05
Military Service Rank Code
ID
2-2
S
A1, A2, A3, B1, B2, C1, C2, C3,
MPI06
Date Time Period Format Qualifier
ID
2-3
S
D8, RD8
MPI07
Date Time Period
AN
1-35
S
EB
DEPENDENT ELIGIBILITY/BENEFIT INFORMATION
1
2110D
271 4010A1
EB
EB01
EB02
DEPENDENT ELIGIBILITY/BENEFIT INFORMATION
Eligibility/ Benefit Information
Coverage Level Code
1
ID
ID
1-2
3-3
S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010
2110D
>1
R
1, 2, 3, 4, 5, 6, 7, 8, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S,T, U, V, W, X, Y
S
CHD, DEP, ECH, ESP, FAM, IND, SPC, SPO
EB01
EB02
Eligibility or Benefit Information Code
Coverage Level Code
Page 25 of 32
ID
ID
1-2
3-3
>1
R
1, 2, 3, 4, 5, 6, 7, 8, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S, T, U, V, W, X, Y
S
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO Code Added
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
EB03
Service Type Code
ID
1-2
S
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, IP, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU
Insurance Type Code
ID
1-3
S
EB05
Plan Coverage Description
AN
1-50
S
Min. Max.
Usage Reg.
271 5010
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS
EB04
ID
EB03
Service Type Code
ID
1-2
Loop Repeat
Values
S
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 44, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 99, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GY, IC, MH,
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, IP, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU
EB04
Insuarance Type Code
ID
1-3
S
EB05
Plan Coverage Description
AN
1-50
S
Page 26 of 32
Loop
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
ID
Min. Max.
Usage Reg.
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36
Time Period Qualifier
ID
2-2
S
EB06
Time Period Qualifier
ID
1-2
S
EB07
Monetary Amount
R
1-18
S
EB07
Monetary Amount
R
1-18
S
EB08
Percent
R
1-10
S
EB08
Percentage as Decimal
R
1-10
S
99, CA, CE, DB, DY, HS, LA, LE, MN, P6, S7, S8, VS, YY
EB09
Quantity Qualifier
ID
2-2
S
EB10
Quantity Yes/No Condition or Response Code Yes/No Condition or Response Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
R
1-15
S
ID
1-1
S
N, U, Y
EB11
ID
1-1
S
N, U, Y
EB12
EB12 EB13
EB13 - 1 Product/Service ID Qualifier EB13 - 2
Product/Service ID
S ID
2-2
R
AN
1-48
R
Loop Repeat
Values
271 5010
EB06
EB11
Loop
8H, 99, CA, CE, D3, DB, DY, HS, LA, LE, M2, MN, P6, QA, S7, S8, VS, YY Code Added
EB09
Quantity Qualifier
ID
2-2
S
EB10
Quantity Yes/No Condition or Response Code Yes/No Condition or Response Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
R
1-15
S
ID
1-1
S
N,U,Y
ID
1-1
S
N,U,W,Y
Code Added
AD, CJ, HC, ID, IV, N4, ZZ
Code Change
EB13 AD, CJ, HC, ID, ND, ZZ
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36
EB13 - 1 Product/Service ID Qualifier EB13 - 2
Product/Service ID
S ID
2-2
R
AN
1-48
R
EB13 - 3
Procedure Modifier
AN
2-2
S
EB13 - 3
Procedure Modifier
AN
2-2
S
EB13 - 4
Procedure Modifier
AN
2-2
S
EB13 - 4
Procedure Modifier
AN
2-2
S
EB13 - 5
Procedure Modifier
AN
2-2
S
EB13 - 5
Procedure Modifier
AN
2-2
S
EB13 - 6
Procedure Modifier
AN
2-2
S
EB13 - 6
Procedure Modifier
AN
2-2
S
EB13 - 7
Description
AN
1-80
N/U
EB13 - 7
Description
AN
1-80
N/U
EB13 - 8
Product/Service ID COMPOSITE DIAGNOSIS CODE POINTER
AN
1-48
S S
New Element
Diagnosis Code Pointer
N0
1-2
R
New Element
EB14 EB14 - 1
HSD
HEALTH CARE SERVICES DELIVERY
9
S
HSD01
Quantity Qualifier
ID
2-2
S
HSD02
R
1-15
S
HSD03
Quantity Unit or Basis for Measurement Code
ID
2-2
S
HSD04
Sample Selection Modulus
R
1-6
S
HSD05
Time Period Qualifier
ID
1-2
S
2110D DY, FL, HS, MN, VS DA, MO, VS, WK, YR 6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35
New Element
EB14 - 2
Diagnosis Code Pointer
N0
1-2
S
New Element
EB14 - 3
Diagnosis Code Pointer
N0
1-2
S
New Element
EB14 - 4
Diagnosis Code Pointer
N0
1-2
S
New Element
9
2110C
HSD
HEALTH CARE SERVICES DELIVERY
HSD01
Quantity Qualifier
ID
2-2
S
HSD02
R
1-15
S
HSD03
Quantity Unit or Basis for Measurement Code
ID
2-2
S
HSD04
Sample Selection Modulus
R
1-6
S
HSD05
Time Period Qualifier
Page 27 of 32
ID
1-2
S
DY, FL, HS, MN, VS DA, MO, VS, WK, YR 6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
HSD06
Number of Periods
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
HSD06
Number of Periods
N0
271 4010A1
HSD08
Ship/Delivery or Calendar Pattern Code Ship/Delivery Pattern Time Code
REF
DEPENDENT ADDITIONAL IDENTIFICATION
HSD07
N0
1-3
1-2
S
ID
1-1
S
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
DTP
DEPENDENT ELIGIBILITY/BENEFIT DATE
DTP01
Date/Time Qualifier
DTP02
Date Time Period Format Qualifier
DTP03
Date Time Period
20
ID ID
AN
3-3 2-3
S
ID
1-1
S
9
S
ID
2-3
R
AN
1-50
R
S
REF03
Description
AN
1-80
S
N/U
REF04
REFERENCE IDENTIFIER
DTP
DEPENDENT ELIGIBILITY/BENEFIT DATE
2110D 193, 194, 198, 290, 292, 295, 304, 307, 318, 348, 349, 356, 357, 435, 472, 636, 771
R
D8, RD8
R
1-35
R
9
S
ID
1-1
R
ID
2-2
N/U
2-2
DEPENDENT ADDITIONAL IDENTIFICATION
1-2
Reference Identification
Agency Qualifier Code
ID
18, 1L, 1W, 49, 6P, 9F, A6, F6, G1, IG, N6, NQ
REF
ID
REF02
S
R
Loop
Loop Repeat
Values
S
R
AAA01
Reject Reason Code
2110D
HSD08
Ship/Delivery or Calendar Pattern Code Ship/Delivery Pattern Time Code
HSD07
1-3
Reference Identification Qualifier
AAA02
AAA03
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y A, B, C, D, E, F, G, Y
REF01
DEPENDENT REQUEST VALIDATION Yes/No Condition or Response Code
AAA
Usage Reg.
271 5010
S
ID
Min. Max.
15, 52, 53, 54, 55, 56, 57, 60, 61, 62, 63, 69, 70
18, 1L, 1W, 49, 6P, 9F, ALS, CLI, F6, FO, G1, IG, N6, NQ Code Change Increase from 30 - 50
N/U
20
S
2110D 096, 193, 194, 198, 290, 291, 292, 295, 304, 307, 318, 346, 348, 349, 356, 357, 435, 472, 636, 771
Date Time Qualifier
ID
3-3
R
DTP02
Date Time Period Format Qualifier
ID
2-3
R
D8, RD8
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
9
S
Date Time Period
AN
AAA01
DEPENDENT REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA N, Y
2110D
DTP01
DTP03
2110D
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y A, B, C, D, E, F, G, Y
AAA03
Reject Reason Code
Page 28 of 32
ID
2-2
R
Code Added
Code Added
2110D N, Y
15, 33, 52, 53, 54, 55, 56, 57, 60, 61, 62, 63, 69, 70, 98, AA, AE, AF, AG, AO, CI, E8, IA, MA Code Added
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
AAA04
Follow-up Action Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
C, N, R, W, X, Y
AAA04
Follow-up Action Code
ID
271 4010A1 MSG
MESSAGE TEXT
MSG01
Free-Form Message Text
ID
1-1 10
AN 1-264
Usage Reg.
2110D
R
MSG
MESSAGE TEXT
MSG01
Free-Form Message Text
1-1 10
AN 1-264
S
Printer Carriage Control Code
ID
2-2
N/U
MSG02
Printer Carriage Control Code
ID
2-2
N/U
Number
N0
1-9
N/U
MSG03
Number
N0
1-9
N/U
III
DEPENDENT ELIGIBILITY/BENEFIT ADDITIONAL INFORMATION
III
DEPENDENT ELIGIBILITY/BENEFIT ADDITIONAL INFORMATION
1
S
III01
Code List Qualifier Code
III01
Code List Qualifier Code
ID
1-3
2115D
10
BF, BK, ZZ
R
III02
Industry Code
AN
1-30
R
III03
Code Category
ID
2-2
III04
Free-Form Message Text
III05
R
III06
Quantity COMPOSITE UNIT OF MEASURE
III07
Surface/Layer/Position Code
ID
III08
Surface/Layer/Position Code
III09
Surface/Layer/Position Code
LS
DEPENDENT ELIGIBILITY/ BENEFIT INFORMATION
LS01
Loop Identifier Code
NM1
DEPENDENT BENEFIT RELATED ENTITY NAME
If III01=ZZ: 11, 12, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 50, 51, 52, 53, 54, 55, 56, 60, 61, 62, 65, 71, 72, 81, 99
ID
1-3
Industry Code
AN
1-30
S
N/U
III03
Code Category
ID
2-2
S
N/U
III04
Free-Form Message Text
N/U
III05
R
N/U
III06
Quantity COMPOSITE UNIT OF MEASURE
2-2
N/U
III07
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III08
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
1
S
1
S
AN
1-6
R
AN
1-4
R
1
S
1
S
1-15
2110D 2120
2120D
1
LS
LOOP HEADER
LS01
Loop Identifier Code
NM1
DEPENDENT BENEFIT RELATED ENTITY NAME
Page 29 of 32
AN 1-264 1-15
C, N, R, W, X, Y 2110D
2115D
10
GR, NI, ZZ
S
III02
AN 1-264
Values
R
MSG02
S
Loop Repeat
R
MSG03
1
Loop
271 5010
R S
Min. Max.
Code Change Usage change to Situational
If III01=ZZ: 01, 03, 04, 05, 06, 07, 08, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, Code Change 56, 57, 60, 61, 62, Usage change to 65, 71, 72, 81, 99 Situational
44
Code Added Usage change to Situational
N/U N/U N/U
2115D 2120
2120D
23
Decrease from 6 - 4
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
ID
Min. Max.
Usage Reg.
271 5010
NM101
Entity Identifier Code
ID
2-3
R
13, 1P, 2B, 36, 73, FA, GP, IL, LR, P3, P4, P5, PR, PRP, SEP, TTP, VN, X3
NM102
ID
1-1
R
1, 2
NM103
Entity Type Qualifier Name Last or Organization Name
AN
1-35
S
NM103
Entity Type Qualifier Name Last or Organization Name
NM104
Name First
AN
1-25
S
NM104
Name First
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
S
NM109
Identification Code
AN
2-80
S
24, 34, 46, FA, FI, MI, NI, PI, PP, SV, XV, XX, ZZ
ID
2-3
R
ID
1-1
R
AN
1-60
S
Increase from 35 - 60
AN
1-35
S
Increase from 25 - 35
NM108
Identification Code Qualifier
ID
1-2
S
NM109
Identification Code
AN
2-80
S
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
S
Entity Identifier Code
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3
DEPENDENT BENEFIT RELATED ENTITY ADDRESS
1
S
N3
DEPENDENT BENEFIT RELATED ENTITY ADDRESS
1
S
N301
Address Information
AN
1-55
R
N301
Address Information
AN
1-55
R
N302
Address Information
AN
1-55
S
N302
Address Information
AN
1-55
S
N4
DEPENDENT BENEFIT RELATED ENTITY CITY/STATE/ZIP CODE
N4
DEPENDENT BENEFIT RELATED ENTITY CITY/STATE/ZIP CODE
1
S
2120D
N401
City Name
AN
2-30
S
N401
City Name
AN
2-30
R
N402
State or Province Code
ID
2-2
S
N402
State or Province Code
ID
2-2
S
N403
Postal Code
ID
3-15
S
N403
Postal Code
ID
3-15
S
N404
Country Code
ID
2-3
S
N404
Country Code
ID
2-3
S
N405
Location Qualifier
ID
1-2
S
N406
Location Qualifier
AN
1-30
S
PER
DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name
AN
1-60
S
RJ
2120D IC
13, 1I, 1P, 2B, 36, 73, FA, GP, GW, I3, IL, LR, OC, P3, P4, PR, PRP, SEP, TTP, VN, VY, X3 Code Change
Entity Identifier Code
Entity Relationship Code
S
Values
NM102
NM110
2120D
Loop Repeat
NM101
NM111
1
Loop
N405
Location Qualifier
ID
1-2
S
N406
Location Qualifier
AN
1-30
S
N407
Country Subdivision Code
ID
1-3
S
PER
DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name
AN
1-60
S
Page 30 of 32
1, 2
24, 34, 46, FA, FI, II, MI, NI, PI, PP, SV, XV, XX Code Change Usage change to 01, 02, 27, 41, 48, Situational 65, 72 Code Added
New Element
2120D
2120D Usage change to Required
RJ New Element
2120D IC
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
PER03
Communication Number Qualifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
PER03
Communication Number Qualifier
271 4010A1 ID
2-2
S
Communication Number Communication Number Qualifier
AN
1-80
S
ID
2-2
S
AN
1-80
S
PER07
Communication Number Communication Number Qualifier
ID
2-2
PER08
Communication Number
AN
1-80
PER09
Contact Inquiry
AN
1-20
N/U
PRV
DEPENDENT BENEFIT RELATED PROVIDER INFORMATION
1
S
PER04 PER05 PER06
PRV01
Provider Code
PRV02
Reference Identification Qualifier
ID
ID
1-3
2-3
AAABBBCCCC ED, EM, EX, FX, TE, WP
PER04
PER06
S
AAABBBCCCC ED, EM, EX, FX, TE, WP
S
AAABBBCCCC
2120D
R
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
9K, D3, EI, HPI, SY, TJ, ZZ
AN 1-256
PER07
Communication Number Communication Number Qualifier
PER08
Communication Number
AN 1-256
PER09
Contact Inquiry Reference
PRV
DEPENDENT BENEFIT RELATED PROVIDER INFORMATION
PER05
PRV01
Provider Code
PRV02
Reference Identification Qualifier
PRV06
Provider Organization Code
ID
3-3
1
S
AN
1-6
R
1
R
SE
N0
1-10
R
SE01
AN
4-9
R
SE02
LE
LOOP TRAILER Lopp Identifier Code
SE SE01 SE02
TRANSACTION SET TRAILER Number of Included Segments Transaction Set Control Number
N0
1-6
R
Group Control Number
N0
1-9
R
2120
ID AN
ID
ID
2-2
Values
2-2
S
S
AAABBBCCCC Increase from 80 - 256 ED, EM, EX, FX, TE, UR, WP Code Added
S
AAABBBCCCC
1-20
N/U
1
S
1-3
2-3
R
S
ID
3-3
1
S
AN
1-4
R
1
R
N0
1-10
R
AN
4-9
R
1
R
LE
LOOP TRAILER
LE01
Lopp Identifier Code
TRANSACTION SET TRAILER Number of Included Segments Transaction Set Control Number
1-50 2-2
Increase from 80 - 256
2120D AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
PXC
Code Change Usage change to Situational Increase from 30 - 50 Usage change to Situational
S N/U N/U N/U
GE01
FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included
N0
1-6
R
GE02
Group Control Number
N0
1-9
R
Page 31 of 32
AAABBBCCCC Increase from 80 - 256 ED, EM, EX, FX, TE, UR, WP Code Added
S
Provider Organization Code
GE
Must=GS06
ID
PRV06
N/U
GE01
Loop Repeat
ED, EM, FX, TE, UR, WP Code Added
S
PRV05
N/U
GE02
Loop
S
AN ID
PRV03 PRV04
FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included
GE
Usage Reg.
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
R N/U
2110D
2-2
AN 1-256
PRV05
LE01
ID
Communication Number Communication Number Qualifier
AN ID
1-30 2-2
Min. Max.
271 5010 ED, EM, FX, TE, WP
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
PRV03 PRV04
ID
2120
Decrease from 6 - 4
Code Deleted
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
IEA
ID
Min. Max.
Usage Reg.
271 5010
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
IEA02
Interchange Control Number
IEA
Page 32 of 32
1
R
N0
1-5
R
N0
9-9
R
Loop
Loop Repeat
Values
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010
ISA01 ISA02
INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information
ISA01 ISA02
INTERCHANGE CONTROL HEADER Authorization Information Qualifier Authorization Information
ID 2-2 AN 10-10
R R
00, 03
ID 2-2 AN 10-10
R R
00, 03
ISA03 ISA04
Security Information Qualifier Security Information
ID 2-2 AN 10-10
R R
00, 01
ISA03 ISA04
Security Information Qualifier Security Information
ID 2-2 AN 10-10
R R
00, 01
ISA05 ISA06
Interchange ID Qualifier Interchange Sender ID
ID 2-2 AN 15-15
R R
ISA05 ISA06
Interchange ID Qualifier Interchange Sender ID
ID 2-2 AN 15-15
R R
ISA07 ISA08 ISA09 ISA10
ID 2-2 AN 15-15 DT 6-6 TM 4-4
R R R R
ID
1-1
ISA12
Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time Interchange Control Standards ID Interchange Control Version Number
YYMMDD HHMM
ISA07 ISA08 ISA09 ISA10
Interchange ID Qualifier Interchange Receiver ID Interchange Date Interchange Time
ID 2-2 AN 15-15 DT 6-6 TM 4-4
R R R R
R
U
ISA11
5-5
R
00401
ISA12
Repetition Seperator Interchange Control Version Number
ID
ISA13
Interchange Control Number
N0
9-9
R
ISA13
ISA14
Acknowledgement Requested
ID
1-1
R
0, 1
ISA15
ID
1-1
R
P, T
ISA16
Usage Indicator Component Element Separator
1-1
R
GS GS01 GS02
FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender's Code
ID AN
1 2-2 2-15
R R R
AN DT TM N0 ID
2-15 8-8 4-8 1-9 1-2
R R R R R
AN
1-12
R
ISA
ISA11
GS03 GS04 GS05 GS06 GS07 GS08
Application Receiver's Code Date Time Group Control Number Responsible Agency Code Version/ Release/ Industry Identifier Code
1
R
ISA
01, 14, 20, 27, 28, 29, 30, 33, ZZ
01, 14, 20, 27, 28, 29, 30, 33, ZZ
HB, HS
R
01, 14, 20, 27, 28, 29, 30, 33, ZZ
01, 14, 20, 27, 28, 29, 30, 33, ZZ YYMMDD HHMM Code Change Name Change
1-1
R
ID
5-5
R
Interchange Control Number
N0
9-9
R
ISA14
Acknowledgement Requested
ID
1-1
R
0, 1
ISA15
ID
1-1
R
P, T
ISA16
Interchange Usage Indicator Component Element Separator
1-1
R
GS GS01 GS02
FUNCTIONAL GROUP HEADER Functional Identifier Code Application Sender's Code
ID AN
1 2-2 2-15
R R R
AN DT TM N0 ID
2-15 8-8 4-8 1-9 1-2
R R R R R
AN
1-12
R
X
GS03 GS04 GS05 GS06 GS07
004010X092
GS08
CCYYMMDD HHMM
1
Application Receiver's Code Date Time Group Control Number Responsible Agency Code Version/Release/ Industry Identifier Code
Page 1 of 20
00501
Code Change
Code Change
CCYYMMDD HHMM X 005010X279
Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 ST ST01 ST02
BHT
TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number
1
R
ID
3-3
R
AN
4-9
R
BEGINNING OF HIERARCHICAL TRANSACTION
1
R
ST03
BHT
BEGINNING OF HIERARCHICAL TRANSACTION
ST 270
ST01 ST02
ID
4-4
R
0022
BHT01
BHT02 BHT03
ID AN
2-2 1-30
R S
01,13, 36
BHT02 BHT03
BHT04 BHT05 BHT06
Date Time Transaction Type Code
DT TM ID
8-8 4-8 2-2
R R S
CCYYMMDD
BHT04 BHT05 BHT06
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
N/U R R
1
R
HL02 HL03 HL04
INFORMATION SOURCE LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
NM1
INFORMATION SOURCE NAME
HL HL01
NM101 NM102
Entity Identifier Code Entity Type Qualifier
ID ID
2-3 1-1
R R
NM103 NM104 NM105 NM106 NM107
Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
S S S N/U S
NM108 NM109 NM110 NM111
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference
Hierarchical Structure Code Transaction Set Purpose Code Reference Identification
BHT01
ID
RT, RU
2000A
>1
2100A
1 2B, 36, GP, P5, PR 1, 2
24, 46, FI, NI, PI, XV, XX
R
ID
3-3
R
AN
4-9
R
AN
1-35
R
1
R
ID
4-4
R
0022
ID AN
2-2 1-50
R S
01,13
DT TM ID
8-8 4-8 2-2
R R S
CCYYMMDD
Name Change
RT
Code deleted
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
N/U R R
1
R
HL02 HL03 HL04
INFORMATION SOURCE LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
NM1
INFORMATION SOURCE NAME
NM101 NM102
Entity Identifier Code Entity Type Qualifier
ID ID
2-3 1-1
R R
NM103 NM104 NM105 NM106 NM107
Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
R S S N/U S
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
AN
1-60
N/U
HL HL01
20 1
Hierarchical Structure Code Transaction Set Purpose Code Reference Identification Transaction Set Creation Date Time Transaction Type Code
1
NM108 NM109 NM110 NM111 NM112
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
Page 2 of 20
270
005010X279
2000A
New Element
Code deleted Increase from 30 - 50
>1
20 1
2100A
1 2B, 36, GP, P5, PR 1, 2 Increase from 35 - 60 Usage change to Required Increase from 25 - 35
24, 46, FI, NI, PI, XV, XX
New Element
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
HL02 HL03 HL04
INFORMATION RECEIVER LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
NM1
INFORMATION RECEIVER NAME
HL HL01
AN
1 1/12
R R
AN ID ID
1/12 1/2 1/1
R R R
1
R
NM101 NM102
Entity Identifier Code Entity Type Qualifier
ID ID
2/3 1/1
R R
NM103 NM104 NM105 NM106 NM107
Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1/35 1/25 1/25 1-10 1-10
S S S N/U S
NM108 NM109 NM110 NM111
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
REF
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
INFORMATION RECEIVER ADDRESS Address Information Address Information
N4 N401 N402
9
S
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
2000B
>1
Values
270 5010 2000B
>1
1 1P, 2B, 36, 80, FA, GP, P5, PR 1, 2
24, 34, FI, PI, PP, SV, XV, XX
2100B 0B, 1C, 1D, 1J, 4A, CT, EL, EO, HPI, JD, N5, N7, Q4, SY, TJ
ID AN AN
2-3 1-30 1-80
R R S N/U
S R S
2100B
AN AN
1 1-55 1-55
INFORMATION RECEIVER CITY/ STATE/ ZIPCODE City Name
S R
2100B
AN
1 2-30
State or Province Code
ID
2-2
R
NM1
INFORMATION RECEIVER NAME
NM101 NM102
Entity Identifier Code Entity Type Qualifier
ID ID
2-3 1-1
R R
NM103 NM104 NM105 NM106 NM107
Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
R S S N/U S
ID AN ID ID
1-2 2-80 2-2 2-3
R R N/U N/U
AN
1-60
N/U
9
S
HL HL01
21 1
2100B
HL02 HL03 HL04
INFORMATION RECEIVER LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
NM112
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
REF
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
NM108 NM109 NM110 NM111
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
R R R
1
R
21 1
2100B
1P, 2B, 36, 80, FA, GP, P5, PR 1, 2 Increase from 35 - 60 Usage change to Required Increase from 25 - 35
24, 34, FI, PI, PP, SV, XV, XX
New Element
2100B 0B, 1C, 1D, 1J, 4A, CT, EL, EO, HPI, JD, N5, N7, Q4, SY, TJ
ID AN AN
2-3 1-50 1-80
R R S N/U
INFORMATION RECEIVER ADDRESS Address Information Address Information
1 1-55 1-55
S R S
2100B
AN AN
N4 N401
INFORMATION RECEIVER CITY/STATE/ ZIP CODE City Name
1 2-30
S R
2100B
AN
N402
State or Province Code
ID
2-2
S
Page 3 of 20
1
Increase from 30 - 50
Usage change to Required
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 N403 N404 N405 N406
Postal Code Country Code Location Qualifier Location Qualifier
PER07 PER08 PER09
INFORMATION RECEIVER CONTACT INFORMATION Contact Function Code Name Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Communication Number Qualifier Communication Number Contact Inquiry Reference
PRV
INFORMATION RECEIVER PROVIDER INFORMATION
PER PER01 PER02 PER03 PER04 PER05 PER06
PRV01
Provider Code
PRV02
Reference Identification Qualifier
ID ID ID AN
3 2-2 1-60
S R S
ID AN
2-2 1-80
S S
ID AN
2-2 1-80
S S
ID AN AN
2-2 1-80 1-20
S S N/U
1
S
ID
ID
AN ID
PRV05 PRV06
Provider Organization Code
ID
HL HL01
SUBSCRIBER LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
HL02 HL03 HL04
1-3
2-3
N403 N404 N405 N406 N407
Postal Code Country Code Location Qualifier Location Qualifier Country Subdivision Code
Usage Reg.
Loop
Loop Repeat
Values
ID ID ID AN ID
3-15 2-3 1-2 1-30 1-3
Usage change to Required
S S N/U N/U S
New Element
Segment Deleted
2100B IC
ED, EM, FX, TE ED, EM, EX, FX, TE AAABBBCCCC ED, EM, EX, FX, TE AAABBBCCCC
2100B
PRV AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
ZZ
R
INFORMATION RECEIVER PROVIDER INFORMATION
PRV01
Provider Code
PRV02
Reference Identification Qualifier
R N/U
PRV03 PRV04
N/U
PRV05
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
3-3
N/U
PRV06
Provider Organization Code
AN
1 1-12
R R
HL HL01
AN ID ID
1-12 1-2 1-1
R R R
SUBSCRIBER LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
1-30 2-2
Min. Max.
270 5010
R S N/U N/U
ID AN
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
PRV03 PRV04
3-15 2-3 1-2 1-30
ID
2000C
>1
22 0, 1
HL02 HL03 HL04
Page 4 of 20
1
ID
ID
1-3
2-3
1-50 2-2
S
2100B AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
PXC
S
AN ID
ID
3-3
N/U
AN
1 1-12
R R
AN ID ID
1-12 1-2 1-1
R R R
Code Change Usage change to Situational Increase from 30 - 50 Usage change to Situational
S N/U N/U
2000C
>1
22 0, 1
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
TRN TRN01 TRN02
SUBSCRIBER TRACE NUMBER Trace Type Code Reference Identification
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
TRN TRN01 TRN02
SUBSCRIBER TRACE NUMBER Trace Type Code Reference Identifier
270 4010A1
TRN03 TRN04
2 1-2 1-30
S R R
Originating Company Identifier AN 10-10 Reference Identification AN 1-30
R S
ID AN
ID ID
1 2-3 1-1
R R R
NM103 NM104 NM105 NM106 NM107
SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
S S S N/U S
NM108 NM109 NM110 NM111
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code
ID AN ID ID
1-2 2-80 2-2 2-3
S S N/U N/U
NM1 NM101 NM102
REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
SUBSCRIBER ADDRESS Address Information Address Information
N4
SUBSCRIBER CITY/ STATE/ ZIPE CODE
N401 N402 N403 N404 N405 N406
City Name State or Province Name Postal Code Country Code Location Qualifier Location Qualifier
9
S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 2000C 1
TRN03 TRN04 2100C
1 IL 1
NM1 NM101 NM102 NM103 NM104 NM105 NM106 NM107
MI, ZZ
2100C 18, 1L, 1W, 3H, 49, 6P, A6, CT, EA, EJ
ID AN AN
2-3 1-30 1-80
R R N/U N/U
1 1-55 1-55
S R S
2100C
AN AN
1
S
2100C
2-30 2-2 3-15 2-3 1-2 1-30
S S S S N/U N/U
AN ID ID ID ID AN
ID
2 1-2 1-50
S R R
Originating Company Identifier AN 10-10 Reference Identification AN 1-50
R S
SUBSCRIBER NAME Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
NM112
Identification Code Qualifier Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
NM108 NM109 NM110 NM111
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
SUBSCRIBER ADDRESS Address Information Address Information
N4
SUBSCRIBER CITY/STATE/ZIP CODE
N401 N402 N403 N404 N405 N406 N407
City Name State or Province Name Postal Code Country Code Location Qualifier Location Qualifier Country Subdivision Code
Page 5 of 20
ID AN
ID ID
1 2-3 1-1
R R R
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
S S S N/U S
ID AN ID ID
1-2 2-80 2-2 2-3
S S N/U N/U
AN
1-60
N/U
9
S
2000C 1 Increase from 30 - 50
Increase from 30 - 50 2100C
IL 1 Increase from 35 - 60 Increase from 25 - 35
II, MI
Code Change
New Element
2100C 18, 1L, 1W, 3H, 6P, CT, EA, EJ, F6, GH, HJ, IG, N6, NQ, SY, Y4
ID AN AN
2-3 1-50 1-80
R R N/U N/U
1 1-55 1-55
S R S
2100C
AN AN
1
S
2100C
2-30 2-2 3-15 2-3 1-2 1-30 1-3
R S S S N/U N/U S
AN ID ID ID ID AN ID
1
Code Change Increase from 30 - 50
Usage change to Required
New Element
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 PRV
PRV01 PRV02
PROVIDER INFORMATION
Provider Code Reference Identification Qualifier
1
ID
1-3
R
ID
2-3
R
AN ID
PRV05
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
ID
PRV03 PRV04
DMG01 DMG02 DMG03 DMG04
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Date Time Period Gender Code Marital Status Code
DMG05 DMG06 DMG07 DMG08 DMG09
Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity
DMG
INS01
SUBSCRIBER RELATIONSHIP Yes/No Condition or Response Code
INS02 INS03 INS04 INS05 INS06
Individual Relationsgip Code Maintenance Type Code Maintenance Reason Code Benefit Status Code Medicare Plan Code
INS07 INS08 INS09
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying Employment Status Code Student Status Code
INS
S
1-30 2-2
3-3
2100C
PRV AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU 9K, D3, EI, HPI, SY, TJ, ZZ
PRV01 PRV02
2-3 1-35 1-1 1-1
S S S N/U
ID ID ID ID R
1-1 1-2 2-3 1-2 1-15
N/U N/U N/U N/U N/U
F, M
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 DMG10 DMG11
S
ID
1-1
R
Y
INS01
MULTIPLE BIRTH SEQUENCE NUMBER Yes/No Condition or Response Code
ID ID ID ID ID
2-2 3-3 2-3 1-1 1-1
R N/U N/U N/U N/U
18
INS02 INS03 INS04 INS05 INS06
Individual Relationsgip Code Maintenance Type Code Maintenance Reason Code Benefit Status Code MEDICARE STATUS CODE
INS07 INS08 INS09
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying Employment Status Code Student Status Code
1-2 2-2 1-1
N/U N/U N/U
2100C
ID
2-3
S
ID
DMG D8
R
Provider Organization Code SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Date Time Period Gender Code Marital Status Code Composite Race or Ethnicity Information Citizenship Status Code Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code
INS
Page 6 of 20
S
1-3
PRV06
1
ID ID ID
Usage Reg.
ID
PRV05
N/U
ID AN ID ID
Provider Code Reference Identification Qualifier
1
AN ID
N/U
2100C
PROVIDER INFORMATION
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
PRV03 PRV04
S
Min. Max.
Loop
Loop Repeat
Values
270 5010
R N/U
1
ID
1-50 2-2
2100C AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SK, SU Code deleted 9K, D3, EI, HPI, Usage change to PXC, SY, TJ Situational Increase from 30 - 50 Usage change to Situational
S N/U N/U
3-3
N/U
1
S
ID AN ID ID
2-3 1-35 1-1 1-1
S S S N/U
ID ID ID R ID AN
1-2 2-3 1-2 1-15 1-3 1-30
N/U N/U N/U N/U N/U N/U N/U
1
S
ID
1-1
R
Y
ID ID ID ID
2-2 3-3 2-3 1-1
R N/U N/U N/U N/U
18
ID ID ID
1-2 2-2 1-1
N/U N/U N/U
2100C D8 F, M
New Element New Element
Name Change
2100C
Name Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 INS10 INS11 INS12 INS13 INS14 INS15 INS16 INS17
Yes/No Condition or Response Code Date Time Period Format Qualifier Date Time Period Confidentiality Code City Name State or Province Code Country Code Number
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010
ID
1-1
N/U
INS10
ID AN ID AN ID ID N0
2-3 1-35 1-1 2-30 2-2 2-3 1-9
N/U N/U N/U N/U N/U N/U R
INS11 INS12 INS13 INS14 INS15 INS16 INS17
HI HI01 HI01 - 1 HI01 - 2 HI01 - 3 HI01 - 4 HI01 - 5 HI01 - 6 HI01 - 7 HI01 - 8 HI01 - 9 HI02 HI02 - 1 HI02 - 2 HI02 - 3 HI02 - 4 HI02 - 5 HI02 - 6 HI02 - 7 HI02 - 8 HI02 - 9 HI03 HI03 - 1 HI03 - 2 HI03 - 3 HI03 - 4 HI03 - 5 HI03 - 6 HI03 - 7 HI03 - 8
Yes/No Condition or Response Code Date Time Period Format Qualifier Date Time Period Confidentiality Code City Name State or Province Code Country Code Number SUBSCRIBER HEALTH CARE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code
Page 7 of 20
ID
1-1
N/U
ID AN ID AN ID ID N0
2-3 1-35 1-1 2-30 2-2 2-3 1-9
N/U N/U N/U N/U N/U N/U R
1
S
ID AN
1-3 1-30
R R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
New Segment
2100C
ABK, BK
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 HI03 - 9 HI04 HI04 - 1 HI04 - 2 HI04 - 3 HI04 - 4 HI04 - 5 HI04 - 6 HI04 - 7 HI04 - 8 HI04 - 9 HI05 HI05 - 1 HI05 - 2 HI05 - 3 HI05 - 4 HI05 - 5 HI05 - 6 HI05 - 7 HI05 - 8 HI05 - 9 HI06 HI06 - 1 HI06 - 2 HI06 - 3 HI06 - 4 HI06 - 5 HI06 - 6 HI06 - 7 HI06 - 8 HI06 - 9 HI07 HI07 - 1 HI07 - 2 HI07 - 3 HI07 - 4 HI07 - 5 HI07 - 6
Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity
Page 8 of 20
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R
2-3 1-35 1-18 1-15
N/U N/U N/U N/U
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
AN AN
1-30 1-30
N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
HI12
Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION
DTP
SUBSCRIBER DATE
102, 307, 435, 472
DTP01 DTP02
Date Time Qualifier Date Time Period Format Qualifier
HI07 - 9 HI08 HI08 - 1 HI08 - 2 HI08 - 3 HI08 - 4 HI08 - 5 HI08 - 6 HI08 - 7 HI08 - 8 HI08 - 9 HI09 HI10 HI11
DTP01
Date/Time Qualifier Date Time Period Format Qualifier
DTP02
DTP03
Date Time Period
EQ
SUBSCRIBER ELIGIBILITY/BENEFIT INQUIRY INFORMATION
2
S
ID
3-3
R
ID
2-3
R
D8, RD8
R
CCYYMMDD, CCYYMMDDCCYYMMDD
AN
1-35
1
S
Loop
Loop Repeat
Values
270 5010 HI07 - 7 HI07 - 8
SUBSCRIBER DATE
Usage Reg.
ID
270 4010A1
DTP
Min. Max.
Description
2100C
2110C
99
DTP03
Date Time Period
EQ
SUBSCIBER ELIGIBILITY/BENEFIT INQUIRY INFORMATION
Page 9 of 20
ABF, BF
N/U N/U N/U N/U 2
S
ID
3-3
R
ID
2-3
R
D8, RD8
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
1
S
AN
2100C 102, 291
2110C
99
Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
EQ01 EQ02
Service Type Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
EQ02 - 1 Product/Service ID Qualifier Product/Service ID EQ02 - 2 Procedure Modifier EQ02 - 3 Procedure Modifier EQ02 - 4 Procedure Modifier EQ02 - 5 Procedure Modifier EQ02 - 6 Description EQ02 - 7
EQ03
Coverage Level Code
ID
1-2
S
ID
2-2 1-48 2-2 2-2 2-2 2-2 1-80
3-3
R R S S S S N/U
S
Min. Max.
Usage Reg.
270 5010
1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12,13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI , AJ, AK, AL, AM, AN ,AO, AQ, AR, BA,BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS
S ID AN AN AN AN AN AN
ID
Service Type Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
ID
EQ02 - 1 Product/Service ID Qualifier Product/Service ID EQ02 - 2 Procedure Modifier EQ02 - 3 Procedure Modifier EQ02 - 4 Procedure Modifier EQ02 - 5 Procedure Modifier EQ02 - 6 Description EQ02 - 7 Product/Service ID EQ02 - 8
ID AN AN AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2 1-80 1-48
R R S S S S N/U N/U
ID
3-3
S
EQ01 EQ02
AD, CJ, HC, ID, IV, N4, ZZ
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO
EQ03
Coverage Level Code
Page 10 of 20
1-2
S
Loop
Loop Repeat
Values
1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12,13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI , AJ, AK, AL, AM, AN ,AO, AQ, AR, B1, B2, B3, BA,BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, Code Change
S AD, CJ, HC, ID, IV, N4, ZZ
New Element
FAM
Code Deleted
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
EQ04
Insurance Type Code
ID
1-3
SUBSCRIBER SPEND DOWN AMOUNT Amount Qualifier Code
S
AMT02 AMT03
Monetary Amount Credit/Debit Flag Code
III III01
SUBSCRIBER ELIGIBILITY/ BENEFIT ADDITIONAL INQUIRY INFORMATION Code List Qualifier Code
III06
Industry Code Code Category Free-Form Message Text Quantity COMPOSITE UNIT OF MEASURE
III07
Surface/Layer/Position Code
III02 III03 III04 III05
ID
1 1-3
S R
R ID
1-18 1-1
N/U N/U
ID
10 1-3
AN 1-30 ID 2-2 AN 1-264 R 1-15
ID
2-2
S R
Usage Reg.
Loop
Loop Repeat
Values
2110C R
2110C BF, BK, ZZ
If Ill01 = BK or BF: use diagnosis code from code source 131; If III01 = ZZ: 11, 12, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 50, 51, 52, 53, 54, 55, 56, 60, 61, 62, 65, 71, 72, 81, 99
Usage change to Not Used Code Deleted
Insurance Type Code COMPOSITE DIAGNOSIS CODE POINTER Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer
ID
1-3
N/U
N0 N0 N0 N0
1-2 1-2 1-2 1-2
S R S S S
AMT AMT01
SUBSCRIBER SPEND DOWN AMOUNT Amount Qualifier Code
ID
1 1-3
S R
AMT02 AMT03
Monetary Amount Credit/Debit Flag Code
R ID
1-18 1-1
R N/U
AMT AMT01 AMT02 AMT03
SUBSCRIBER SPEND DOWN TOTAL BILLED AMOUNT Amount Qualifier Code Monetary Amount Credit/Debit Flag Code
1 1-3 1-18 1-1
S R R N/U
2110C
ID R ID
III III01
SUBSCRIBER ELIGIBILITY/BENEFIT ADDITIONAL INQUIRY INFORMATION Code List Qualifier Code
10 1-3
S R
2110C
ID
EQ04
N/U
III06
Industry Code Code Category Free-Form Message Text Quantity COMPOSITE UNIT OF MEASURE
N/U
III07
Surface/Layer/Position Code
R N/U N/U N/U
Min. Max.
270 5010 AP, C1, CO, GP, HM, HN, IP, MA, MB, MC, PR, PS, SP, WC
EQ05 EQ05 - 1 EQ05 - 2 EQ05 - 3 EQ05 - 4
AMT AMT01
ID
III02 III03 III04 III05
Page 11 of 20
AN 1-30 ID 2-2 AN 1-264 R 1-15
R N/U N/U N/U N/U
ID
2-2
N/U
New Element New Element New Element New Element New Element
2110C R Usage change to Required
New Segment PB
ZZ
Code Deleted
01, 03, 04, 05, 06, 07, 08, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, 56, 57, 60, 61, 62, 65, 71, 72, 81, 99 Code Deleted
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010
III08
Surface/Layer/Position Code
ID
2-2
N/U
III08
Surface/Layer/Position Code
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
1
S
1
S
2-3 1-30 1-80
R R N/U N/U
2-3 1-50 1-80
R R N/U N/U
1 3-3
S R
1 3-3
S R
2-3
R
2-3
R
D8, RD8 CCYYMMDD, CCYYMMDDCCYYMMDD
REF REF01 REF02 REF03 REF04
DTP DTP01 DTP02
SUBSRIBER ADDITIONAL INFORMATION Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
SUBSCRIBER ELIGIBILITY/BENEFIT DATE Date/Time Qualifier ID Date Time Period Format Qualifier ID
DTP03
Date Time Period
HL HL01 HL02 HL03 HL04
DEPENDENT LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
TRN TRN01 TRN02
DEPENDENT TRACE NUMBER Trace Type Code Reference Identification
TRN03 TRN04
ID AN AN
AN
1-35
R
AN
1 1-12
S R
AN ID ID
1-12 1-2 1-1
R R R
ID AN
2 1-2 1-30
S R R
Originating Company Identifier AN 10-10 Reference Identification AN 1-30
R S
ID ID
1 2-3 1-1
R R R
NM103 NM104 NM105 NM106 NM107
DEPENDENT NAME Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-35 1-25 1-25 1-10 1-10
S S S N/U S
NM108
Identification Code Qualifier
ID
1-2
N/U
NM1 NM101 NM102
2110C
REF 9F,G1
2110C
REF01 REF02 REF03 REF04
307, 435, 472
DTP DTP01
D8, RD8
DTP02
DTP03 2000D
>1
2000D 1
1 03 1
Date Time Period Format Qualifier
AN
1-35
R
AN
1 1-12
S R
AN ID ID
1-12 1-2 1-1
R R R
ID AN
2 1-2 1-50
S R R
Originating Company Identifier AN 10-10 Reference Identification AN 1-50
R S
HL02 HL03 HL04
TRN TRN01 TRN02
DEPENDENT TRACE NUMBER Trace Type Code Reference Identification
TRN03 TRN04 2100D
SUBSCRIBER ELIGIBILITY/BENEFIT DATE Date Time Qualifier ID Date Time Period Format Qualifier ID
DEPENDENT LEVEL Hierarchical ID Number Hierarchical Parent ID Number Hierarchical Level Code Hierarchical Child Code
HL HL01
23 0
SUBSCRIBER ADDITIONAL INFORMATION Reference Identification Qualifier ID Reference Identification AN Description AN REFERENCE IDENTIFIER
ID ID
1 2-3 1-1
R R R
NM103 NM104 NM105 NM106 NM107
DEPENDENT NAME Entity Identifier Code Entity Type Qualifier Name Last or Organization Name Name First Name Middle Name Prefix Name Suffix
AN AN AN AN AN
1-60 1-35 1-25 1-10 1-10
S S S N/U S
NM108
Identification Code Qualifier
ID
1-2
N/U
NM1 NM101 NM102
Page 12 of 20
2110C 9F, G1 Increase from 30 - 50
2110C 291
2000D
Code Change
Code Added
>1
23 0
2000D 1 Increase from 30 - 50
Increase from 30 - 50 2100D
1 03 1 Increase from 35 - 60 Increase from 25 - 35
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
NM109 NM110 NM111
Identification Code Entity Relationship Code Entity Identifier Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
REF
DEPENDENT ADDITIONAL IDENTIFICATION
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
DEPENDENT ADDRESS Address Information Address Information
N4
DEPENDENT CITY/STATE/ZIP CODE
N401 N402 N403 N404 N405 N406
City Name State or Provine Code Postal Code Country Code Location Qualifier Location Qualifier
PRV
9
AN ID ID
2-80 2-2 2-3
N/U N/U N/U
NM112
Identification Code Entity Relationship Code Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
Provider Code
PRV02
Reference Identification Qualifier
REF
DEPENDENT ADDITIONAL IDENTIFICATION
9
S
NM109 NM110 NM111
2100D 18, 1L, 1W, 49, 6P, A6, CT, EA, EJ, F6, CJ, HC, ID, IV, N4, ZZ
2-3 1-30 1-80
R R N/U N/U
1 1-55 1-55
S R S
2100D
AN AN
1
S
2100D
2-30 2-2 3-15 2-3 1-2 1-30
S S S S N/U N/U
AN ID ID ID ID AN
1
ID
ID
AN ID
PRV05
Reference Identification State or Province Code PROVIDER SPECIALITY INFORMATION
PRV06
Provider Organization Code
ID
PRV03 PRV04
S
1-3
2-3
1-30 2-2
3-3
S
Loop
Loop Repeat
Values
270 5010
N/U N/U N/U
ID AN AN
PROVIDER INFORMATION
PRV01
2-80 2-2 2-3
Usage Reg.
ID
270 4010A1 AN ID ID
Min. Max.
Description
2100D
R
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
9K, D3, EI, HPI, SY, TJ, ZZ
REF01 REF02 REF03 REF04
Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
N3 N301 N302
DEPENDENT ADDRESS Address Information Address Information
N4
DEPENDENT CITY/STATE/ZIP CODE
N401 N402 N403 N404 N405 N406 N407
City Name State or Provine Code Postal Code Country Code Location Qualifier Location Qualifier Country Subdivision Code
PRV
PROVIDER INFORMATION
PRV01
Provider Code
PRV02
Reference Identification Qualifier
R R N/U N/U
1 1-55 1-55
S R S
2100D
AN AN
1
S
2100D
2-30 2-2 3-15 2-3 1-2 1-30 1-3
R S S S N/U N/U S
1
S
AN ID ID ID ID AN ID
ID
ID
PRV05 PRV06
Provider Organization Code
ID
N/U N/U
Page 13 of 20
18, 1L, 6P, CT, EA, EJ, F6, GH, HJ, IF, IG, MRC, N6, SY, Y4 Code Change Increase from 30 - 50
2-3 1-50 1-80
AN ID
PRV03 PRV04
2100D
ID AN AN
Reference Identification State or Province Code PROVIDER SPECIALITY INFORMATION
R N/U
New Element
1-3
2-3
1-50 2-2
R
S
S N/U N/U
3-3
N/U
Usage change to Required
New Element
2100D AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, Code Deleted PE, R, RF, SK, SU Usage change to Required 9K, D3, EI, HPI, PXC, SY, TJ
Code Change Usage change to Situational Increase from 30 - 50 Usage change to Situational
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
DMG01 DMG02 DMG03 DMG04
DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Date Time Period Gender Code Marital Status Code
DMG05 DMG06 DMG07 DMG08 DMG09
Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity
DMG
INS01
DEPENDENT RELATIONSHIP Yes/No Condition or Response Code
INS02 INS03 INS04 INS05 INS06
Individual Relationship Code Maintenance Type Code Maintenance Reason Code Benefit Status Code Medicare Plan Code
INS
INS07 INS08 INS09 INS10 INS11 INS12 INS13 INS14 INS15 INS16 INS17
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying Employment Status Code Student Status Code Yes/No Condition or Response Code Date Time Period Format Qualifier Date Time Period Confidentiality Code City Name State or Province Code Country Code Number
1
S
ID AN ID ID
2-3 1-35 1-1 1-1
S S S N/U
ID ID ID ID R
1-1 1-2 2-3 1-2 1-15
N/U N/U N/U N/U N/U
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 2100D
DMG D8 CCYYMMDD F, M
DMG01 DMG02 DMG03 DMG04 DMG05 DMG06 DMG07 DMG08 DMG09 DMG10 DMG11
DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier Date Time Period Gender Code Marital Status Code Composite Race or Ethnicity Code Citizenship Status Code Country Code Basis of Verification Code Quantity Code List Qualifier Code Industry Code
1
S
ID
1-1
R
N
INS01
DEPENDENT RELATIONSHIP Yes/No Condition or Response Code
ID ID ID ID ID
2-2 3-3 2-3 1-1 1-1
R N/U N/U N/U N/U
01, 19, 34
INS02 INS03 INS04 INS05 INS06
Individual Relationship Code Maintenance Type Code Maintenance Reason Code Benefit Status Code MEDICARE STATUS CODE
2100D
INS
ID ID ID
1-2 2-2 1-1
N/U N/U N/U
INS07 INS08 INS09
ID
1-1
N/U
INS10
ID AN ID AN ID ID N0
2-3 1-35 1-1 2-30 2-2 2-3 1-9
N/U N/U N/U N/U N/U N/U S
INS11 INS12 INS13 INS14 INS15 INS16 INS17
HI HI01 HI01 - 1 HI01 - 2
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying Employment Status Code Student Status Code Yes/No Condition or Response Code Date Time Period Format Qualifier Date Time Period Confidentiality Code City Name State or Province Code Country Code Number DEPENDENT HEALTH CARE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code
Page 14 of 20
1
S
ID AN ID ID
2-3 1-35 1-1 1-1
S S S N/U
ID ID ID R ID AN
1-2 2-3 1-2 1-15 1-3 1-30
N/U N/U N/U N/U N/U N/U N/U
1
S
ID
1-1
R
N
ID ID ID ID
2-2 3-3 2-3 1-1 1-1
R N/U N/U N/U N/U
01, 19, 34
ID ID ID
1-2 2-2 1-1
N/U N/U N/U
ID
1-1
N/U
ID AN ID AN ID ID N0
2-3 1-35 1-1 2-30 2-2 2-3 1-9
N/U N/U N/U N/U N/U N/U S
1
S
1-3 1-30
R R R
ID AN
2100D D8 CCYYMMDD F, M
New Element New Element
2100D
New Segment
2100D
ABK, BK
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 HI01 - 3 HI01 - 4 HI01 - 5 HI01 - 6 HI01 - 7 HI01 - 8 HI01 - 9 HI02 HI02 - 1 HI02 - 2 HI02 - 3 HI02 - 4 HI02 - 5 HI02 - 6 HI02 - 7 HI02 - 8 HI02 - 9 HI03 HI03 - 1 HI03 - 2 HI03 - 3 HI03 - 4 HI03 - 5 HI03 - 6 HI03 - 7 HI03 - 8 HI03 - 9 HI04 HI04 - 1 HI04 - 2 HI04 - 3 HI04 - 4 HI04 - 5 HI04 - 6 HI04 - 7 HI04 - 8 HI04 - 9 HI05
Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
Page 15 of 20
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U S
ABF, BF
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION Code List Qualifier Code Industry Code Date Time Period Format Qualifier Date Time Period Monetary Amount Quantity Version Identifier Industry Code Yes/No Condition or Response Code
ID AN
1-3 1-30
R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
ID AN
1-3 1-30
S R R
ID AN R R AN AN
2-3 1-35 1-18 1-15 1-30 1-30
N/U N/U N/U N/U N/U N/U
ID
1-1
N/U
270 4010A1
Loop
Loop Repeat
Values
270 5010 HI05 - 1 HI05 - 2 HI05 - 3 HI05 - 4 HI05 - 5 HI05 - 6 HI05 - 7 HI05 - 8 HI05 - 9 HI06 HI06 - 1 HI06 - 2 HI06 - 3 HI06 - 4 HI06 - 5 HI06 - 6 HI06 - 7 HI06 - 8 HI06 - 9 HI07 HI07 - 1 HI07 - 2 HI07 - 3 HI07 - 4 HI07 - 5 HI07 - 6 HI07 - 7 HI07 - 8 HI07 - 9 HI08 HI08 - 1 HI08 - 2 HI08 - 3 HI08 - 4 HI08 - 5 HI08 - 6 HI08 - 7 HI08 - 8 HI08 - 9
Page 16 of 20
ABF, BF
ABF, BF
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
HI10 HI11 HI12
DTP02
DEPENDENT DATE Date/Time Qualifier Date Time Period Format Qualifier
DTP03
Date Time Period
EQ
DEPENDENT ELIGIBILITY/ BENEFIT INQUIRY INFORMATION
ID
2 3-3
S R
ID
2-3
AN
1-35
1
102,307,435,472
DTP DTP01
R
D8, RD8
DTP02
R
CCYYMMDD, CCYYMMDDCCYYMMDD
R
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
270 5010 HI09
DTP DTP01
ID
2100D
2110D
99
HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION DEPENDENT DATE Date Time Qualifier Date Time Period Format Qualifier
DTP03
Date Time Period
EQ
DEPENDENT ELIGIBILITY/BENEFIT INQUIRY
Page 17 of 20
N/U N/U N/U N/U
ID
2 3-3
S R
ID
2-3
R
D8, RD8
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
1
R
AN
2100D 102, 291
2110D
99
Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1
EQ01 EQ02
Service Type Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
EQ02 - 1 Product/Service ID Qualifier Product/Service ID EQ02 - 2 Procdeure Modifier EQ02 - 3 Procdeure Modifier EQ02 - 4 Procdeure Modifier EQ02 - 5 Procdeure Modifier EQ02 - 6 Description EQ02 - 7
EQ03
Coverage Level Code
ID
1-2
S
ID
2-2 1-48 2-2 2-2 2-2 2-2 1-80
3-3
R R S S S S N/U
S
Min. Max.
Usage Reg.
270 5010
1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI , AJ, AK, AL, AM, AN ,AO, AQ, AR, BA,BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS
S ID AN AN AN AN AN AN
ID
Service Type Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
ID
EQ02 - 1 Product/Service ID Qualifier Product/Service ID EQ02 - 2 Procdeure Modifier EQ02 - 3 Procdeure Modifier EQ02 - 4 Procdeure Modifier EQ02 - 5 Procdeure Modifier EQ02 - 6 Description EQ02 - 7 Product/Service ID EQ02 - 8
ID AN AN AN AN AN AN AN
2-2 1-48 2-2 2-2 2-2 2-2 1-80 1-48
R R S S S S N/U N/U
ID
3-3
N/U
EQ01 EQ02
AD, CJ, HC, ID, IV, N4, ZZ
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO
EQ03
Coverage Level Code
Page 18 of 20
1-2
S
Loop
Loop Repeat
Values
1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11,12,13, 14, 15, 16, 17, 18, 19, 20, 21,22,23,24,25,26, 27,28,30,32,33,34, 35,36,37,38,39,40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI , AJ, AK, AL, AM, AN ,AO, AQ, AR, B1, B2, B3, BA,BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN ,CO, CP, CQ, DG, DM, DS, GF, GN, GY, IC, MH, Code Added
S AD, CJ, HC, ID, IV, N4, ZZ
New Element Code Deleted Usage Change to Not Used
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
270 4010A1 EQ04
Insurance Type Code
ID
1-3
III III01
ID
III06
Industry Code Code Category Free-Form Message Text Quantity COMPOSITE UNIT OF MEASURE
III07
Surface/Layer/Position Code
ID
III08
Surface/Layer/Position Code
III09
Surface/Layer/Position Code
III02 III03 III04 III05
REF01 REF02 REF03 REF04
DEPENDENT ADDITIONAL INFORMATION Reference Identification Qualifier Reference Identification Description REFERENCE IDENTIFIER
DTP DTP01
DEPENDENT ELIGIBILITY/ BENEFIT DATE Date/Time Qualifier
REF
10 1-3
S
S R
Min. Max.
Usage Reg.
EQ04
2110D BF, BK, ZZ
If Ill01 = BK or BF, use diagnosis code from code source 131; If III01 = ZZ: 11, 12, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 50, 51, 52, 53, 54, 55, 56, 60, 61, 62, 65, 71, 72, 81, 99
III III01
Insurance Type Code COMPOSITE DIAGNOSIS CODE POINTER Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer Diagnosis Code Pointer
ID
1-3
N/U
N0 N0 N0 N0
1-2 1-2 1-2 1-2
S R S S S
DEPENDENT ELIGIBILITY/BENEFIT ADDITIONAL INQUIRY Code List Qualifier Code
ID
10 1-3
S R
N/U
III06
Industry Code Code Category Free-Form Message Text Quantity COMPOSITE UNIT OF MEASURE
2-2
N/U
III07
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III08
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
1
S
1
S
ID AN AN
2-3 1-30 1-80
R R N/U N/U
ID AN AN
2-3 1-50 1-80
R R N/U N/U
ID
1 3-3
S R
ID
1 3-3
S R
AN 1-30 ID 2-2 AN 1-264 R 1-15
Loop
Loop Repeat
Values
270 5010 AP, C1, CO, GP, HM, IP, OT, PR, PS, SP, WC
EQ05 EQ05 - 1 EQ05 - 2 EQ05 - 3 EQ05 - 4 DEPENDENT ELIGIBILITY/ BENEFIT ADDITIONAL INQUIRY INFORMATION Code List Qualifier Code
ID
R N/U N/U N/U
2110D
III02 III03 III04 III05
REF01 REF02 REF03 REF04
DEPENDENT ADDITIONAL INFORMATION Reference Identification Qualifier Reference Identification Description REFRENCE IDENTIFIER
DTP DTP01
DEPENDENT ELIGIBILITY/ BENEFIT DATE Date Time Qualifier
REF 9F,G1
2110D 307,435,472
Page 19 of 20
AN 1-30 ID 2-2 AN 1-264 R 1-15
Code Deleted Usage Change to Not Used New Element New Element New Element New Element New Element
2110D ZZ
Code Deleted
01, 03, 04, 05, 06, 07, 08, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, 56,57, 60, 61, 62, 65, 71, 72, 81, 99 Code Deleted
R N/U N/U N/U N/U
2110D 9F, G1 Increase from 30 - 50
2110D 291
Code Deleted
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
DTP02
Date Time Period Format Qualifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Description
ID
2-3
R
AN
1-35
R
1
R
N0
1-10
R
AN
4-9
R
1
R
1-6 1-9
R R
1
R
270 4010A1
DTP03
SE SE01 SE02
GE GE01 GE02
Date Time Period TRANSACTION SET TRAILER Number of Included Segments Transaction Set Control Number FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included Group Control Number
R
D8, RD8
DTP02
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
DTP03
Date Time Period
1
R
SE
N0
1-10
R
SE01
AN
4-9
R
SE02
AN
2-3
GE N0 N0
1-6 1-9
R R
1
R
IEA
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
IEA
Loop
Loop Repeat
Values
270 5010 Date Time Period Format Qualifier
ID
ID
Min. Max.
Usage Reg.
Element Identifier
Must=GS06
GE01 GE02
TRANSACTION SET TRAILER Number of Included Segments Transaction Set Control Number FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included Group Control Number
N0 N0
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
Page 20 of 20
D8, RD8
Code Added
Must=GS06
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
ISA01
INTERCHANGE CONTROL HEADER Authorization Information Qualifier
ISA02
Authorization Information
ISA03
Security Information Qualifier
ISA04
Security Information
ISA05
ISA
ID
1
R
2/2
R
AN 10/10
R
ID
R
2/2
AN 10/10
R
Interchange ID Qualifier
ID
R
ISA06
Interchange Sender ID
AN 15/15
R
ISA07
Interchange ID Qualifier
ID
R
ISA08
Interchange Receiver ID
AN 15/15
R
ISA09
Interchange Date
DT
6/6
ISA10
TM
ISA12
Interchange Time Interchange Control Standards ID Interchange Control Version Number
ISA13
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010
ISA01
INTERCHANGE CONTROL HEADER Authorization Information Qualifier
ISA02
Authorization Information
ISA03
Security Information Qualifier
ISA04
Security Information
ISA05
ISA 00, 03
00, 01
ID
1
R
2-2
R
AN 10-10
R
ID
R
2-2
00, 03
00, 01
AN 10-10
R
Interchange ID Qualifier
ID
R
ISA06
Interchange Sender ID
AN 15-15
R
01, 14, 20, 27, 28, 29, 30, 33, ZZ
ISA07
Interchange ID Qualifier
ID
R
ISA08
Interchange Receiver ID
AN 15-15
R
R
YYMMDD
ISA09
Interchange Date
DT
6-6
R
YYMMDD
4/4
R
HHMM
ISA10
Interchange Time
TM
4-4
R
HHMM
ID
1/1
R
U
ISA11
1-1
R
ID
5/5
R
00401
ISA12
Repetition Seperator Interchange Control Version Number
ID
5-5
R
Interchange Control Number
N0
9/9
R
ISA13
Interchange Control Number
N0
9-9
R
ISA14
Acknowledgement Requested
ID
1/1
R
0, 1
ISA14
Acknowledgement Requested
ID
1-1
R
0, 1
ISA15
ID
1/1
R
P, T
ISA15
1-1
R
P, T
1/1
R
ISA16
Interchange Usage Indicator Component Element Separator
ID
ISA16
Usage Indicator Component Element Separator
1-1
R
GS
FUNCTIONAL GROUP HEADER
1
R
GS
FUNCTIONAL GROUP HEADER
1
R
GS01
Functional Identifier Code
ID
2/2
R
GS01
Functional Identifier Code
ID
2-2
R
GS02
Application Sender's Code
AN
2/15
R
GS02
Application Sender's Code
AN
2-15
R
ISA11
2/2
2/2
01, 14, 20, 27, 28, 29, 30, 33, ZZ
HB, HS
2-2
2-2
01, 14, 20, 27, 28, 29, 30, 33, ZZ
01, 14, 20, 27, 28, 29, 30, 33, ZZ
Code Change Name Change 00501
Code Deleted
GS03
Application Receiver's Code
AN
2/15
R
GS03
Application Receiver's Code
AN
2-15
R
GS04
Date
DT
8/8
R
CCYYMMDD
GS04
Date
DT
8-8
R
CCYYMMDD
GS05
Time
TM
4/8
R
HHMM
GS05
Time
TM
4-8
R
HHMM
GS06
Group Control Number
N0
1/9
R
GS06
Group Control Number
N0
1-9
R
GS07
Responsible Agency Code Version/ Release/ Industry Identifier Code
ID
1/2
R
X
GS07
ID
1-2
R
X
AN
1/12
R
004010X092
GS08
Responsible Agency Code Version/Release/ Industry Identifier Code
AN
1-12
R
005010X279
GS08
Page 1 of 32
Code Change
Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 ST ST01 ST02
BHT
TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number
R
ID
3-3
R
AN
4-9
R
BEGINNING OF HIERARCHICAL TRANSACTION
ST03
BHT
BEGINNING OF HIERARCHICAL TRANSACTION
ST 271
ST01 ST02
1
R R
0022
BHT01
ID
2-2
R
11
AN
1-30
S
DT
8-8
R
Time
TM
4-8
R
Transaction Type Code
ID
2-2
N/U
1
R
1-12 1-12
R N/U
BHT02 BHT03
Reference Identification
BHT04
Date
BHT05 BHT06
HL
INFORMATION SOURCE LEVEL
HL01 HL02
Hierarchical ID Number Number
ID
AN AN
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010 TRANSACTION SET HEADER Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference
4-4
Hierarchical Structure Code Transaction Set Purpose Code
BHT01
1
ID
CCYYMMDD
2000A
>1
1
R
ID
3-3
R
AN
4-9
R
AN
1-35
R
1
R
ID
4-4
R
0022 06, 11
BHT02
Hierarchical Structure Code Transaction Set Purpose Code
ID
2-2
R
BHT03
Reference Identification
AN
1-50
S
BHT04
Date
DT
8-8
R
BHT05
Time
TM
4-8
R
BHT06
Transaction Type Code
ID
2-2
N/U
HL
INFORMATION SOURCE LEVEL
1
R
HL01 HL02
Hierarchical ID Number Number
AN AN
1-12 1-12
R N/U
271
005010X279
Increase from 30 - 50
2000A
>1
HL03
Hierarchical Level Code
ID
1-2
R
20
HL03
Hierarchical Level Code
ID
1-2
R
20
Hierarchical Child Code
ID
1-1
R
0, 1
HL04
Hierarchical Child Code
ID
1-1
R
0, 1
AAA
9
S
AAA
S
ID
1-1
R
AAA01
REQUEST VALIDATION Yes/No Condition or Response Code
9
AAA01
REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA02
Agency Qualifier Code
ID
2-2
N/U
N, Y
Code Added
CCYYMMDD
HL04
2000A
New Element
2000A N, Y
AAA03
Reject Reason Code
ID
2-2
R
04, 41, 42, 79
AAA03
Reject Reason Code
ID
2-2
R
04, 41, 42, 79
AAA04
Follow-up Action Code
ID
1-1
R
C, N, P, R, S, Y
AAA04
Follow-up Action Code
ID
1-1
R
C, N, P, R, S, Y
NM1
INFORMATION SOURCE NAME
1
R
NM1
INFORMATION SOURCE NAME
1
R
NM101
Entity Identifier Code
ID
2-3
R
2B, 36, GP, P5, PR
NM102
Entity Type Qualifier
ID
1-1
R
1, 2
NM103
Name Last or Organization Name
AN
1-60
R
Increase from 35 - 60 Usage change to Required Incrase from 25 - 35
2100A
1
NM101
Entity Identifier Code
ID
2-3
R
2B, 36, GP, P5, PR
NM102
Entity Type Qualifier
ID
1-1
R
1, 2
NM103
Name Last or Organization Name
AN
1-35
S
NM104
Name First
AN
1-25
S
NM104
Name First
AN
1-35
S
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
Page 2 of 32
2100A
1
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 Identification Code Qualifier
ID
1-2
NM109
Identification Code
AN
2-80
R
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code
ID
2-3
N/U
NM108
REF01 REF02
Reference Identification
AN
1-80
REF
R
REF03
Description
REF04
REFERENCE INDENTIFIER
PER
INFORMATION SOURCE CONTACT INFORMATION
PER01
Contact Function Code
PER02
9
S
ID
2-3
R
AN
1-30
R
ID
1-2
NM109
Identification Code
AN
2-80
R
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code Name Last or Organization Name
ID
2-3
N/U
AN
1-60
N/U
2100A
PER
PAYER CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
Communication Number Communication Number Qualifier
AN 1-256
AN 1-256
PER07
Communication Number Communication Number Qualifier
PER08
Communication Number
AN 1-256
PER09
Contact Inquiry Reference
AAA AAA01
REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
HL
INFORMATION RECEIVER LEVEL
1
S
AN
1-12
R
AN
1-12
R
AN
1-60
S
ID
2-2
S
ED, EM, FX, TE
PER03
Communication Number Communication Number Qualifier
AN
1-80
S
PER04
ID
2-2
S
AAABBBCCCC ED, EM, EX, FX, TE
AN
1-80
S
ID
2-2
S
AAABBBCCCC ED, EM, EX, FX, TE
PER06
PER07
Communication Number Communication Number Qualifier
PER08
Communication Number
AN
1-80
S
AAABBBCCCC
PER09
Contact Inquiry Reference
AN
1-20
N/U
AAA
9
S
AAA01
REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
HL
INFORMATION RECEIVER LEVEL
1
S
AN
1-12
R
HL01
AN
1-12
R
HL02
HL02
New Element
S
Name Communication Number Qualifier
Hierarchical ID Number Hierarchical Parent ID Number
24, 46, FI, NI, PI, XV, XX
R
N/U
R
HL01
Values
18, 55
2-2
PER05
Loop Repeat
Segment Deleted
ID
PER06
Loop
2100A
S
PER04
Usage Reg.
Identification Code Qualifier
NM108
3
PER03
Min. Max.
271 5010 24, 46, FI, NI, PI, XV, XX
NM112 INFORMATION SOURCE ADDITIONAL IDENTIFICATION Reference Identification Qualifier
ID
IC
2100A N, Y 04, 41, 42, 79, 80, T4 C, N, P, R, S, W, X, Y
2000B
>1
PER05
Hierarchical ID Number Hierarchical Parent ID Number
Page 3 of 32
ID
ID AN
2-2
2-2
2100A IC ED, EM, TE, FX, UR Code Added AAABBBCCCC Increase from 80 - 256 ED, EM, TE, FX, EX, UR Code Added
S S
S
AAABBBCCCC Increase from 80 - 256 ED, EM, TE, FX, EX, UR Code Added
S
AAABBBCCCC
S
1-20
N/U
9
S
2100A N, Y 04, 41, 42, 79, 80, T4 C, N, P, R, S, W, X, Y
2000B
>1
Increase from 80 - 256
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
HL03
Hierarchical Level Code
ID
1-2
HL04
Hierarchical Child Code
ID
NM1
INFORMATION RECEIVER NAME
ID
Min. Max.
Usage Reg.
5010 Values
Element Identifier
Description
ID
R
21
HL03
Hierarchical Level Code
ID
1-2
R
21
1-1
R
0,1
HL04
Hierarchical Child Code
ID
1-1
R
0, 1
1
R
NM1
INFORMATION RECEIVER NAME
1
R
NM101
Entity Identifier Code
ID
2-3
R
1P, 2B, 36, 80, FA, GP, P5, PR
NM102
ID
1-1
R
1, 2
AN
1-60
S
Increase from 35 - 60
AN
1-35
S
Increase from 25 - 35
Loop
Loop Repeat
271 4010A1
Min. Max.
Usage Reg.
2100B
1
NM101
Entity Identifier Code
ID
2-3
R
NM102
ID
1-1
R
1, 2
NM103
Entity Type Qualifier Name Last or Organization Name
AN
1-35
S
NM103
Entity Type Qualifier Name Last or Organization Name
NM104
Name First
AN
1-25
S
NM104
Name First
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
R
24, 34, FI, PI, PP, SV, XV, XX
Identification Code Qualifier
ID
1-2
NM109
Identification Code
AN
2-80
R
NM109
Identification Code
AN
2-80
R
NM110
Entity Relationship Code
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
REF
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
9
S
REF
INFORMATION RECEIVER ADDITIONAL IDENTIFICATION
9
R
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
0B, 1C, 1D, 1J, 4A, CT, EL, EO, HPI
Reference Identification Qualifier
ID
2-3
R
R
REF02
Reference Identification
AN
1-50
R
S
REF03
Description
AN
1-80
S
N/U
REF04
REFERENCE IDENTIFIER
AAA01
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
9
2100B
REF01
INFORMATION RECEIVER REQUEST VALIDATION Yes/ No Condition or Response Code
AAA
S
Loop Repeat
Values
271 5010
1P, 2B, 36, 80, FA, GP, P5, PR
NM108
Loop
2100B
1
24, 34, FI, PI, PP, SV, XV, XX
New Element
2100B 0B, 1C, 1D, 1J, 4A, CT, EL, EO, HPI, JD, N5, N7, Q4, SY, TJ Code Added Increase from 30 - 50
N/U
AAA01
INFORMATION RECEIVER VALIDATION REQUEST Yes/ No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
46, 47, 48, 50, 51, 79, 97, T4
AAA03
Reject Reason Code
ID
2-2
R
46, 47, 48, 50, 51, 79, 97, T4
C, N, R, S, W, X, Y
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
2100B
AAA N, Y
Page 4 of 32
9
S
2100B N, Y
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
PRV
INFORMATION RECEIVER PROVIDER INFORMATION
271 4010A1
Values
PXC
ID
2-2
N/U
PRV05 PRV06
Provider Organization Code
ID
3-3
S R
HL02
AN
1-12
R
HL03
Hierarchical Level Code
ID
1-2
R
22
HL04
Hierarchical Child Code
ID
1-1
R
0, 1
TRN
SUBSCRIBER TRACE NUMBER
3
S
TRN01
Trace Type Code
ID
1-2
R
TRN02
Reference Identification
AN
1-30
R
Originating Company Identifier AN 10-10
R
TRN03
S
TRN04
Reference Identification
1, 2
S S
State or Province Code PROVIDER SPECIALITY INFORMATION
1
2000C
2-3
PRV04
ID
New Element
2100B
1-50
ID
1-12
1-30
Loop Repeat
R
AN
AN
AN
Loop
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
Reference Identification
SUBSCRIBER LEVEL
>1
S
PRV02
Hierarchical Number HierarchicalID Parent ID Number
2000C
1
PRV03
HL
Reference Identification
Usage Reg.
Provider Code Reference Identification Qualifier
HL01
TRN03
Min. Max.
271 5010
PRV01
TRN04
ID
1-3
N/U N/U
HL
SUBSCRIBER LEVEL
1
S
HL01
AN
1-12
R
HL02
Hierarchical Number HierarchicalID Parent ID Number
AN
1-12
R
HL03
Hierarchical Level Code
ID
1-2
R
22
HL04
Hierarchical Child Code
ID
1-1
R
0, 1
TRN
SUBSCRIBER TRACE NUMBER
3
S
TRN01
Trace Type Code
ID
1-2
R
TRN02
Reference Identification
AN
1-50
R
Originating Company Identifier AN 10-10
R
AN
1-50
S
2000C
>1
2000C 1, 2 Increase form 30 - 50
Increase form 30 - 50
NM1
SUBSCRIBER NAME
1
R
NM1
SUBSCRIBER NAME
1
R
NM101
Entity Identifier Code
ID
2-3
R
IL
NM101
Entity Identifier Code
ID
2-3
R
IL
NM102
Entity Type Qualifier
ID
1-1
R
1
NM102
Entity Type Qualifier
ID
1-1
R
1
NM103
Name Last or Organization Name
AN
1-35
S
NM103
Name Last or Organization Name
AN
1-60
S
Increase from 35 - 60
NM104
Name First
AN
1-25
S
NM104
Name First
AN
1-35
S
Increase from 25 - 35
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
S
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
S
NM108
Identification Code Qualifier
ID
1-2
S
NM109
Identification Code
AN
2-80
S
NM109
Identification Code
AN
2-80
S
NM110
Entity Relationship Code
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code
ID
2-3
N/U
NM111
Entity Identifier Code Name Last or Organization Name
ID
2-3
N/U
AN
1-60
N/U
2100C
1
MI, ZZ
NM112
Page 5 of 32
2100C
1
II, MI
Code Change
New Element
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
ID
Min. Max.
Usage Reg.
2100C
REF 18, 1L, 1W, 3H, 49, 6P, A6, EA, EJ, F6, GH, HJ, IF, IG, ML, N6, NQ, Q4, SY
SUBSCRIBER ADDITIONAL IDENTIFICATION
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
R
REF02
Reference Identification
AN
1-50
R
S
REF03
Description
AN
1-80
S
N/U
REF04
REFERENCE IDENTIFIER
SUBSCRIBER ADDRESS
1
S
N3
SUBSCRIBER ADDRESS
1
S
Address Information
AN
1-55
R
N301
Address Information
AN
1-55
R
N302
Address Information
AN
1-55
S
N302
Address Information
AN
1-55
S
N4
SUBSCRIBER CITY/ STATE/ ZIP CODE
1
S
N4
SUBSCRIBER CITY/STATE/ZIP CODE
1
S
N401
City Name
2-30
S
N401
City Name
AN
2-30
R
2100C
2100C
N402
State or Province Code
ID
2-2
S
N402
State or Province Code
ID
2-2
S
N403
Postal Code
ID
3-15
S
N403
Postal Code
ID
3-15
S
N404
Country Code
ID
2-3
S
N404
Country Code
ID
2-3
S
N405
Location Qualifier
ID
1-2
S
N405
Location Qualifier
ID
1-2
N/U
N406
Location Qualifier
AN
1-30
S
N406
Location Qualifier
AN
1-30
N/U
N407
Country Subdivision Code
ID
1-3
S
CY, FI
PER
SUBSCRIBER CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
HP, TE, WP
Communication Number Communication Number Qualifier
AN
1-80
S
AAABBBCCCC
ID
2-2
S
EX, HP, TE, WP
AN
1-80
S
AAABBBCCCC
PER07
Communication Number Communication Number Qualifier
ID
2-2
S
EX, HP, TE, WP
PER08
Communication Number
AN
1-80
S
PER09
Contact Inquiry Reference
AN
1-20
N/U
AAA
SUBSCRIBER REQUEST VALIDATION
9
S
PER04 PER05 PER06
Values
2100C 18, 1L, 1W, 3H, 49, 6P, CT, EA, EJ, F6, GH, HJ, IF, IG, N6, NQ, Q4, SY, Y4
Increase from 30 - 50
2100C
2100C
CY, FI
Usage change to Not Used Usage change to Not Used New Element
Segment Deleted
2100C IC
2100C
Code Change
N/U
N3
PER03
Loop Repeat
271 5010
N301
AN
Loop
AAA
SUBSCRIBER REQUEST VALIDATION
Page 6 of 32
9
S
2100C
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
AAA01
Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
AAA01
Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
271 4010A1 N, Y
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
DMG01
ID
2-3
S
DMG02
Date Time Period
AN
1-35
S
1
S
DMG03
Gender Code
ID
1-1
S
DMG04
Marital Status Code
ID
1-1
N/U
Usage Reg.
Loop
Loop Repeat
Values
2100C D8 F, M, U
N, Y
AAA03
Reject Reason Code
ID
2-2
R
15, 35, 42, 43, 45, 47, 48, 49, 51, 52, 56, 57, 58, 60, 61, 62, 63, 71, 72, 73, 74, 75, 76, 77, 78 Code Deleted
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
PRV
PROVIDER INFORMATION
1
S
R
2-3
S
PXC
1-50
S
PRV02
ID
PRV03
Reference Identification
AN
PRV04
ID
2-2
N/U
PRV05
State or Province Code PROVIDER SPECIALITY INFORMATION
PRV06
Provider Organization Code
ID
DMG DMG01
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier
DMG02
Date Time Period
DMG03
Gender Code
ID
1-1
S
DMG04
ID
1-1
N/U
ID
New Element
2100C AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SK, SU
Provider Code Reference Identification Qualifier
PRV01
SUBSCRIBER DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier
Min. Max.
271 5010
15, 42, 43, 45, 47, 48, 49, 51, 52, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 71, 72, 73, 74, 75, 76, 77, 78
DMG
ID
1-3
N/U 3-3
N/U
1
S
ID
2-3
S
AN
1-35
S
2100C D8 F, M, U
DMG05
Race or Ethnicity Code
ID
1-1
N/U
DMG05
Marital Status CodeOR COMPOSITE RACE ETHNICITY INFORMATION
ID
1-1
N/U
DMG06
Citizenship Status Code
ID
1-2
N/U
DMG06
Citizenship Status Code
ID
1-2
N/U
DMG07
Country Code
ID
2-3
N/U
DMG07
Country Code
ID
2-3
N/U
DMG08
Basis of Verification Code
ID
1-2
N/U
DMG08
Basis of Verification Code
ID
1-2
N/U
DMG09
Quantity
R
1-15
N/U
DMG09
Quantity
R
1-15
N/U
DMG10
Code List Qalifier Code
ID
1-3
N/U
New Element
DMG11
Industry Code
AN
1-30
N/U
New Element
INS
SUBSCRIBER RELATIONSHIP
1
S
INS
SUBSCRIBER REALTIONSHIP
1
S
2100C
Page 7 of 32
2100C
ELIGIBILITY STATUS
4010A1 Description
INS01
Yes/ No Condition or Response Code
ID
1-1
R
INS02
Individual Relationship Code
ID
2-2
R
INS03
Maintenance Type Code
ID
3-3
S
001
INS03
Maintenance Type Code
INS04
Maintenance Reason Code
ID
2-3
S
25
INS04
Maintenance Reason Code
INS05
Benefit Status Code
ID
1-1
N/U
INS05
Benefit Status Code
INS06
Medicare Plan Code
ID
1-1
N/U
INS06
MEDICARE STATUS CODE
INS07
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying
ID
1-2
N/U
INS07
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying
ID
1-2
N/U
INS08
Employment Status Code
ID
2-2
N/U
INS08
Employment Status Code
ID
2-2
N/U
INS09
ID
1-1
S
F, N, P
INS09
1-1
S
F, N, P
ID
1-1
S
N, Y
INS10
ID
1-1
S
N, Y
ID
2-3
N/U
INS11
Student Status Code Yes/ No Condition or Response Code Date Time Period Format Qualifier
ID
INS11
Student Status Code Yes/ No Condition or Response Code Date Time Period Format Qualifier
ID
2-3
N/U
INS12
Date Time Period
AN
1-35
N/U
INS12
Date Time Period
AN
1-35
N/U
INS13
Confidentiality Code
ID
1-1
N/U
INS13
Confidentiality Code
ID
1-1
N/U
ID
Min. Max.
Usage Reg.
5010
Element Identifier
Loop
Loop Repeat
Element Identifier
Description
Y
INS01
Yes/ No Condition or Response Code
ID
1-1
R
Y
18
INS02
Individual Relationship Code
ID
2-2
R
18
ID
3-3
S
001
ID
2-3
S
25
ID
1-1
N/U
ID
1-1
N/U
Values
271 4010A1
INS10
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010
INS14
City Name
AN
2-30
N/U
INS14
City Name
AN
2-30
N/U
INS15
State or Province Code
ID
2-2
N/U
INS15
State or Province Code
ID
2-2
N/U
INS16
Country Code
ID
2-3
N/U
INS16
Country Code
ID
2-3
N/U
INS17
Number
N0
1-9
S
INS17
Number
N0
1-9
S
1
S
HI HI01
SUBSCRIBER HEALTH CARE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION
R
HI01 - 1
Code List Qualifier Code
ID
1-3
R
HI01 - 2
AN
1-30
R
HI01 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI01 - 4
Date Time Period
AN
1-35
N/U
HI01 - 5
Monetary Amount
R
1-18
N/U N/U
HI01 - 6
Quantity
R
1-15
HI01 - 7
Version Identifier
AN
1-30
N/U
HI01 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI02 - 1
Code List Qualifier Code
ID
1-3
R
HI02 - 2
AN
1-30
R
HI02 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI02 - 4
Date Time Period
AN
1-35
N/U
HI02 - 5
Monetary Amount
R
1-18
N/U
HI01 - 9 HI02
Page 8 of 32
New Element
2100C
ABK, BK
S ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
HI02 - 6
Quantity
R
1-15
HI02 - 7
Version Identifier
AN
1-30
N/U
HI02 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI03 - 1
Code List Qualifier Code
ID
1-3
R
HI03 - 2
AN
1-30
R
HI03 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI03 - 4
Date Time Period
AN
1-35
N/U
HI03 - 5
Monetary Amount
R
1-18
N/U N/U
271 4010A1
Loop
Loop Repeat
Values
271 5010
HI02 - 9 HI03
N/U
S
HI03 - 6
Quantity
R
1-15
HI03 - 7
Version Identifier
AN
1-30
N/U
HI03 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI04 - 1
Code List Qualifier Code
ID
1-3
R
HI04 - 2
Industry Code
AN
1-30
R
HI04 - 3
Date Time Period Format Qualifier
ID
2-3
N/U
HI04 - 4
Date Time Period
AN
1-35
N/U
HI04 - 5
Monetary Amount
R
1-18
N/U N/U
HI03 - 9 HI04
S
HI04 - 6
Quantity
R
1-15
HI04 - 7
Version Identifier
AN
1-30
N/U
HI04 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI05 - 1
Code List Qualifier Code
ID
1-3
R
HI05 - 2
AN
1-30
R
HI05 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI05 - 4
Date Time Period
AN
1-35
N/U
HI05 - 5
Monetary Amount
R
1-18
N/U N/U
HI04 - 9 HI05
Quantity
R
1-15
HI05 - 7
Version Identifier
AN
1-30
N/U
HI05 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI06
Page 9 of 32
ABF, BF
S
HI05 - 6
HI05 - 9
ABF, BF
S
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Min. Max.
Usage Reg.
Description
ID
HI06 - 1
Code List Qualifier Code
ID
1-3
R
HI06 - 2
AN
1-30
R
HI06 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI06 - 4
Date Time Period
AN
1-35
N/U
HI06 - 5
Monetary Amount
R
1-18
N/U N/U
271 4010A1
Loop
Loop Repeat
Values
271 5010
HI06 - 6
Quantity
R
1-15
HI06 - 7
Version Identifier
AN
1-30
N/U
HI06 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI07 - 1
Code List Qualifier Code
ID
1-3
R
HI07 - 2
AN
1-30
R
HI07 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI07 - 4
Date Time Period
AN
1-35
N/U
HI07 - 5
Monetary Amount
R
1-18
N/U N/U
HI06 - 9 HI07
S
HI07 - 6
Quantity
R
1-15
HI07 - 7
Version Identifier
AN
1-30
N/U
HI07 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI08 - 1
Code List Qualifier Code
ID
1-3
R
HI08 - 2
AN
1-30
R
HI08 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI08 - 4
Date Time Period
AN
1-35
N/U
HI08 - 5
Monetary Amount
R
1-18
N/U N/U
HI07 - 9 HI08
Quantity
R
1-15
HI08 - 7
Version Identifier
AN
1-30
N/U
HI08 - 8
Industry Code
AN
1-30
N/U
ID
1-1
N/U
HI09 HI10 HI11 HI12
Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION
Page 10 of 32
ABF, BF
S
HI08 - 6
HI08 - 9
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 DTP
DTP01 DTP02
DTP03
SUBSCRIBER DATE
Date/Time Qualifier Date Time Period Format Qualifier
Date Time Period
9
S
2100C
DTP
ID
3-3
R
ID
2-3
R
D8, RD8
1-35
R
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010
102, 152, 291, 307, 318, 340, 341, 342, 343, 346, 347, 356, 357, 382, 435, 442, 458, 472, 539, 540, 636, 771
AN
ID
CCYYMMDDCCYYMMDD
DTP01 DTP02
SUBSCRIBER DATE
Date Time Qualifier Date Time Period Format Qualifier
DTP03
Date Time Period
MPI
SUBSCRIBER MILITARY PERSONNEL INFORMATION
MPI01
Information Status Code
MPI02
MPI03
Employment Status Code
9
Description
R
ID
2-3
R
D8, RD8
R
CCYYMMDD, CCYYMMDDCCYYMMDD
AN
1-35
1
S
ID
1-1
R
A, C, L, O, P, S, T
R
AE, AO, AS, AT, AU, CC, DD, HD, IR, LX, PE, RE, RM, RR, RU
1-1
R
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, Q, R, S, U, W
1-80
S
ID
AN
MPI06
ID
MPI07
Date Time Period
AN
Page 11 of 32
096, 102, 152, 291, 307, 318, 340, 341, 342, 343, 346, 347, 356, 357, 382, 435, 442, 458, 472, 539, 540, 636, 771
3-3
Military Service Rank Code Date Time Period Format Qualifier
MPI05
2100C
ID
Government Service Affiliation Code ID
MPI04
S
ID
2-2
Code Added
New Element
2100C
S
A1, A2, A3, B1, B2, C1, C2, C3, C4, C5, C6, C7, C8, C9, E1, F1, F2, F3, F4, G1, G4, L1, L2, L3, L4, L5, L6, M1, M2, M3, M4, M5, M6, P1, P2, P3, P4, P5, R1, S1, S2, S3, S4, S5, S6, S7, S8, S9, SA, SB, SC, T1, V1, W1
2-3
S
D8, RD8
1-35
S
2-2
Code Added
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 EB
EB01
EB02
EB03
SUBSCRIBER ELIGIBILITY/ BENEFIT INFORMATION
Eligibility or Benefit Information
Coverage Level Code
Service Type Code
1
ID
ID
ID
1-2
3-3
1-2
S
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
2110C
>1
Values
271 5010 2110C
>1
EB
SUBSCRIBER ELIGIBILITY/ BENEFIT INFORMATION
1
S
R
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S, T, U, V, W, X, Y
S
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO
EB02
Coverage Level Code
ID
3-3
S
S
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 44, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 99, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL BM, BN, BP, BQ, BR, BS
EB03
Service Type Code
ID
1-2
S
EB01
Eligibility or Benefit Information
Page 12 of 32
ID
1-2
R
1, 2, 3, 4, 5, 6, 7, 8, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S, T, U, V, W, X, Y CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 44, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 99, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GY, IC, MH, Code Added
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
EB04
Insurance Type Code
ID
1-3
S
EB05
Plan Coverage Description
AN
1-50
S
ID
Min. Max.
Usage Reg.
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36
EB04
Insurance Type Code
ID
1-3
S
EB05
Plan Coverage Description
AN
1-50
S
Time Period Qualifier
ID
1-2
S
EB06
Time Period Qualifier
ID
1-2
S
EB07
Monetary Amount
R
1-18
S
EB07
Monetary Amount
R
1-18
S
EB08
Percent
R
1-10
S
EB08
Percentage as Decimal
R
1-10
S
Quantity Qualifier
ID
2-2
S
EB10
Quantity
R
1-15
S
EB11
Yes/No Condition or Response Code
EB12
Yes/No Condition or ResponseMEDICAL Code COMPOSITE
EB13
PROCEDURE IDENTIFIER
EB13 - 1 Product/Service ID Qualifier Product/Service ID EB13 - 2
ID ID
1-1 1-1
S S
99, CA, CE, DB, DY, HS, LA, LE, MN, P6, QA, S7, S8, VS, YY
N,U,Y N,U,Y
S ID AN
2-2 1-48
R R
Loop Repeat
Values
271 5010
EB06
EB09
Loop
AD, CJ, HC, ID, IV, N4, ZZ
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, IP, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36
8H, 99, CA, CE, DB, DY, HS, LA, LE, M2, MN, P6, QA, S7, S8, VS, YY Code Added
Quantity Qualifier
ID
2-2
S
EB10
Quantity
R
1-15
S
EB11
Yes/No Condition or Response Code
ID
1-1
S
N,U,Y
EB12
Yes/No Condition or ResponseMEDICAL Code COMPOSITE
ID
1-1
S
N,U,W,Y
EB13
PROCEDURE IDENTIFIER
EB09
EB13 - 1 Product/Service ID Qualifier Product/Service ID EB13 - 2
Code Added
S ID AN
2-2 1-48
R R
EB13 - 3
Procedure Modifier
AN
2-2
S
EB13 - 3
Procedure Modifier
AN
2-2
S
EB13 - 4
Procedure Modifier
AN
2-2
S
EB13 - 4
Procedure Modifier
AN
2-2
S
AD, CJ, HC, ID, IV, N4, ZZ
EB13 - 5
Procedure Modifier
AN
2-2
S
EB13 - 5
Procedure Modifier
AN
2-2
S
EB13 - 6
Procedure Modifier
AN
2-2
S
EB13 - 6
Procedure Modifier
AN
2-2
S
EB13 - 7
Description
AN
1-80
N/U
EB13 - 7
Description
AN
1-80
N/U
EB13 - 8
Product/Service ID COMPOSITE DIAGNOSIS CODE POINTER
AN
1-48
S S
New Element
Diagnosis Code Pointer
N0
1-2
R
New Element
EB14 EB14 - 1
New Element
EB14 - 2
Diagnosis Code Pointer
N0
1-2
S
New Element
EB14 - 3
Diagnosis Code Pointer
N0
1-2
S
New Element
Page 13 of 32
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
Diagnosis Code Pointer
N0
271 4010A1 HEALTH CARE SERVICES DELIVERY
9
S
HSD01
Quantity Qualifier
ID
2-2
S
HSD02
R
1-15
S
HSD03
Quantity Unit or Basis for Measurement Code
ID
2-2
S
HSD04
Sample Selection Modulus
R
1-6
S
HSD05
Time Period Qualifier
ID
1-2
S
HSD06
Number of Periods
N0
1-3
S
HSD08
Ship/Delivery or Calendar Pattern Code Ship/Delivery Pattern Time Code
REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
HSD07
ID
1-2
S
ID
1-1
S
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
DTP
SUBSCRIBER ELIGIBILITY/BENEFIT DATE
20
Usage Reg.
2110C DY, FL, HS, MN, VS DA, MO, VS, WK, YR 6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, ,H, J, K, L ,M N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y A, B, C, D, E, F, G, Y
2110C 18, 1L, 1W, 49, 6P, 9F, A6, F6, G1, IG, N6, NQ
1-2
S
9
S
HSD
HEALTH CARE SERVICES DELIVERY
HSD01
Quantity Qualifier
ID
2-2
S
HSD02
R
1-15
S
HSD03
Quantity Unit or Basis for Measurement Code
ID
2-2
S
HSD04
Sample Selection Modulus
R
1-6
S
HSD05
Time Period Qualifier
ID
1-2
S
HSD06
Number of Periods
N0
1-3
S
HSD08
Ship/Delivery or Calendar Pattern Code Ship/Delivery Pattern Time Code
REF
SUBSCRIBER ADDITIONAL IDENTIFICATION
HSD07
ID
1-2
S
ID
1-1
S
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
R
REF02
Reference Identification
AN
1-50
R
S
REF03
Description
AN
1-80
N/U
REF04
REFERENCE IDENTIFIER
DTP
SUBSCRIBER ELIGIBILITY/ BENEFIT DATE
S
Loop
Loop Repeat
Values
271 5010 EB14 - 4
HSD
Min. Max.
2110C
Page 14 of 32
New Element
2110C DY, FL, HS, MN, VS DA, MO, VS, WK, YR 6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35 1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, ,H, J, K, L ,M N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y A, B, C, D, E, F, G, Y
2110C 18, 1L, 1W, 49, 6P, 9F, ALS, CLI, F6, FO, G1, IG, M7, N6, NQ Code Change Increase from 30 - 50
S N/U
20
S
2110C
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
DTP01 DTP02
DTP03
Date/Time Qualifier Date Time Period Format Qualifier
Date Time Period
ID
3-3
R
ID
2-3
R
D8, RD8
1-35
R
9
S
AAA01
SUBSCRIBER REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA
CCYYMMDDCCYYMMDD
2110C N, Y
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action code
ID
1-1
R
C, N, R, W, X, Y
MSG
MESSAGE TEXT Free-Form Message Text
10 AN 1-264
S
DTP01 DTP02
2110C
R
Date Time Qualifier Date Time Period Format Qualifier
Date Time Period
DTP03
Usage Reg.
2-3
R
R8, RD8
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
9
S
AN
AAA01
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action code
ID
1-1
R
MSG
MESSAGE TEXT
MSG01
Free-Form Message Text
10 AN 1-264
S
ID
2-2
N/U
MSG02
Printer Carriage Control Code
ID
2-2
N/U
N0
1-9
N/U
MSG03
Number
N0
1-9
N/U
III
SUBSCRIBER ELIGIBILITY/ BENEFIT ADDITIONAL INFORMATION
III
SUBSCRIBER ELIGIBILITY/BENEFIT ADDITIONAL INFORMATION
1
S
III01
Code List Quantifier Code
III01
Code List Quantifier Code
1-3
S
1-3
R
10
BF, BK, ZZ
Page 15 of 32
ID
Code Added
Code Added
2110C N, Y
15, 33, 52, 53, 54, 55, 56, 57, 60, 61, 62, 63, 69, 70, 98, AA, AE, AF, AG, AO, CI, E8, IA, MA Code Added C, N, R, W, X, Y 2110C
R
Number
2115C
096, 193, 194, 198, 290, 291, 292, 295, 304, 307, 318, 346, 348, 349, 356, 357, 435, 472, 636, 771
ID
Printer Carriage Control Code
ID
Values
R
MSG02
S
Loop Repeat
3-3
MSG03
1
Loop
ID
SUBSCRIBER REQUEST VALIDATION Yes/No Condition or Response Code
AAA
15, 52, 53, 55, 56, 57, 60, 61, 62, 63, 69, 70
MSG01
Min. Max.
271 5010 193, 194, 198, 290, 292, 295, 304, 307, 318, 348, 349, 356, 357, 435, 472, 636
AN
ID
2115C
10
GR, NI, ZZ
Code Change Usage change to Situational
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
III02
Industry Code
III03
Code Category
III04
Free-Form Message Text
III05
R
III06
Quantity COMPOSITE UNIT OF MEASURE
III07
Surface/Layer/Position Code
ID
III08
Surface/Layer/Position Code
III09
Surface/Layer/Position Code
LS
LOOP HEADER
LS01
Loop Identifier Code
NM1
SUBSCRIBER BENEFIT RELATED ENTITY NAME
AN
ID
1-30
2-2
ID
Min. Max.
Usage Reg.
If III01=ZZ: 11, 12, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 50, 51, 52, 53, 54, 55, 56, 60, 61, 62, 65, 71, 72, 81, 99
R
N/U
III02
Industry Code
III03
Code Category
AN
ID
1-30
2-2
III04
Free-Form Message Text
III05
R
N/U
III06
Quantity COMPOSITE UNIT OF MEASURE
2-2
N/U
III07
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III08
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
1
S
1
S
AN
1-6
R
AN
1-4
R
1
S
1
S
2110C 2120
2120C
1
LS
LOOP HEADER
LS01
Loop Identifier Code
NM1
SUBSCRIBER BENEFIT RELATED ENTITY NAME
AN 1-264 1-15
S
N/U
Entity Identifier Code
ID
2-3
R
NM102
ID
1-1
R
1, 2
NM103
Entity Type Qualifier Name Last or Organization Name
AN
1-35
S
NM103
Entity Type Qualifier Name Last or Organization Name
NM104
Name First
AN
1-25
S
NM104
Name First
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
Identification Code Qualifier
ID
1-2
S
Code Added Usage change to Situational Usage change to Situational
N/U
NM101
24, 34, 46, FA, FI, MI, NI, PI, PP, SV, XV, XX, ZZ
44
S
13, 1P, 2B, 36, 73, FA, GP, IL, LR, P3, P4, P5, PR, PRP, SEP, TTP, VN, X3
NM108
Values
If III01=ZZ: 01, 03, 04, 05, 06, 07, 08, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, Code Added 56, 57, 60, 61, 62, Usage change to 65, 71, 72, 81, 99 Situational
S
N/U
1-15
Loop Repeat
271 5010
N/U
AN 1-264
Loop
2110C 2120
2120C
Decrease from 6 - 4
23 13, 1I, 1P, 2B, 36, 73, FA, GP, GW, I3, IL, LR, OC, P3, P4, P5, PR, PRP, SEP, TTP, VN, VY, X3 Code Added
NM101
Entity Identifier Code
ID
2-3
R
NM102
ID
1-1
R
AN
1-60
S
Increase from 35 - 60
AN
1-35
S
Increase from 25 - 35
NM108
Identification Code Qualifier
Page 16 of 32
ID
1-2
S
1, 2
24, 34, 46, FA, FI, II, MI, NI, PI, PP, SV, XV, XX Code Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
NM109
Identification Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
NM109
Identification Code
AN
271 4010A1 AN
2-80
Min. Max.
Usage Reg.
2-80
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
S
NM111
Entity Identifier Code
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3
SUBSCRIBER RELATED ENTITY ADDRESS
1
S
N3
SUBSCRIBER BENEFIT RELATED ENTITY ADDRESS
1
S
N301
Address Information
AN
1-55
R
N301
Address Information
AN
1-55
R
N302
Address Information
AN
1-55
S
N302
Address Information
AN
1-55
S
N4
SUBSCRIBER BENEFIT RELATED CITY/STATE/ZIP CODE
N4
SUBSCRIBER BENEFIT RELATED ENTITY CITY/STATE/ZIP CODE
1
S
2120C
2110C
N401
City Name
AN
2-30
S
N401
City Name
AN
2-30
R
N402
State or Province Code
ID
2-2
S
N402
State or Province Code
ID
2-2
S
N403
Postal Code
ID
3-15
S
N403
Postal Code
ID
3-15
S
N404
Country Code
ID
2-3
S
N404
Country Code
ID
2-3
S
N405
Location Qualifier
ID
1-2
S
N406
Location Qualifier
AN
1-30
S
PER
SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
Communication Number Communication Number Qualifier
AN
1-80
S
ID
2-2
S
AN
1-80
S
PER07
Communication Number Communication Number Qualifier
ID
2-2
PER08
Communication Number
AN
1-80
PER09
Contact Inquiry Reference
AN
1-20
N/U
PRV
SUBSCRIBER BENEFIT RELATED PROVIDER INFORMATION
PER03 PER04 PER05 PER06
1
RJ
2120C IC ED, EM, FX, TE, WP
N405
Location Qualifier
ID
1-2
S
N406
Location Qualifier
AN
1-30
S
N407
Country Subdivision Code
ID
1-3
S
New Element
2120C
2120C Usage change to Required
RJ Code Added
PER
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
Communication Number Communication Number Qualifier
AN 1-256
S
ID
S
AN 1-256
S
ID
S
AAABBBCCCC Increase from 80 - 256 ED, EM, FX, TE, UR, WP Code Added
AN 1-256
S
AAABBBCCCC
PER03 PER04
PER06
S
AAABBBCCCC ED, EM, FX, TE, WP
PER07
Communication Number Communication Number Qualifier
S
AAABBBCCCC
PER08
Communication Number
PER09
Contact Inquiry Reference
PRV
SUBSCRIBER BENEFIT RELATED PROVIDER INFORMATION
2120C
Usage change to 01, 02, 27, 41, 48, Situational 65, 72 Code Added
SUBSCRIBER BENEFIT RELATED ENTITY CONTACT INFORMATION
AAABBBCCCC ED, EM, FX, TE, WP
S
Values
S
Entity Relationship Code
S
Loop Repeat
271 5010
S
NM110
1
Loop
PER05
Page 17 of 32
AN
2-2
2-2 1-20
N/U
1
S
2120C IC ED, EM, FX, TE, UR, WP Code Added AAABBBCCCC Increase from 80 - 256 ED, EM, FX, TE, UR, WP Code Added
2120C
Increase from 80 - 256
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
PRV01
Provider Code
PRV02
Reference Identification Qualifier
ID
ID
1-3
2-3
ID
Min. Max.
Usage Reg.
R
R
9K, D3, EI, HPI, SY, TJ, ZZ
PRV01
Provider Code
PRV02
Reference Identification Qualifier
ID
ID
1-3
2-3
AN
1-30
R
PRV03
Reference Identification
AN
1-50
S
ID
2-2
N/U
PRV04
2-2
N/U
N/U
PRV05
State or Province Code PROVIDER SPECIALTY INFORMATION
ID
PRV05
State or Province Code PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
ID
3-3
N/U
PRV06
Provider Organization Code
ID
3-3
1
S
1
S
AN
1-6
R
AN
1-4
R
1
S
HL
DEPENDENT LEVEL
1
S
AN
1-12
R
HL01
AN
1-12
R
AN
1-12
R
HL02
Hierarchical ID Number Hierarchical Parent ID Number
AN
1-12
R
LOOP TRAILER
HL
DEPENDENT LEVEL
HL01 HL02
Hierarchical ID Number Hierarchical Parent ID Number
2110C 2120 2000D
>1
LE
LOOP TRAILER
LE01
Loop Identifier Code
PXC
S
Reference Identification
Loop Identifier Code
Values
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
PRV03
LE
Loop Repeat
271 5010 AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
PRV04
LE01
Loop
Increase from 30 - 50 Usage change to Situational
N/U N/U
2120C Decrease from 6 - 4 2000D
>1
HL03
Hierarchical Level Code
ID
1-2
R
23
HL03
Hierarchical Level Code
ID
1-2
R
23
HL04
Hierarchical Child Code
ID
1-1
R
0
HL04
Hierarchical Child Code
ID
1-1
R
0
TRN
DEPENDENT TRACE NUMBER
3
S
TRN
DEPENDENT TRACE NUMBER
3
S
TRN01
Trace Type Code
ID
1-2
R
TRN01
Trace Type Code
ID
1-2
R
TRN02
Reference Identification
AN
1-30
R
TRN02
Reference Identification
AN
1-50
R
Originating Company Identifier AN 10-10
R
TRN03
Originating Company Identifier AN 10-10
R
S
TRN04
Reference Identification
TRN03 TRN04
Reference Identification
AN
1-30
2000D 1, 2
Code Change Usage change to Situational
AN
1-50
2000D 1, 2 Increase from 30 - 50
Increase from 30 - 50
S
NM1
DEPENDENT NAME
1
R
NM1
DEPENDENT NAME
1
R
NM101
Entity Identifier Code
ID
2-3
R
03
NM101
Entity Identifier Code
ID
2-3
R
03
NM102
ID
1-1
R
1
NM102
1-1
R
1
AN
1-35
S
NM103
Entity Type Qualifier Name Last or Organization Name
ID
NM103
Entity Type Qualifier Name Last or Organization Name
AN
1-60
S
Increase from 35 - 60
NM104
Name First
AN
1-25
S
NM104
Name First
AN
1-35
S
Increase from 25 - 35
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
2100D
1
Page 18 of 32
2100D
1
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
S
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
N/U
Code Deleted Usage change to Not Used Usage change to Not Used
271 4010A1
Min. Max.
Usage Reg.
MI, ZZ
NM109
Identification Code
AN
2-80
S
NM109
Identification Code
AN
2-80
N/U
Entity Relationship Code
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
N/U
NM111
Entity Identifier Code
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
REF
DEPENDENT ADDITIONAL IDENTIFICATION
9
S
DEPENDENT ADDITIONAL IDENTIFICATION
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
2100D 18, 1L, 1W, 49, 6P, A6, CT, EA, EJ, F6, CJ, HC, ID, IV, N4, ZZ
REF01
Reference Identification Qualifier
ID
2-3
R
R
REF02
Reference Identification
AN
1-50
R
S
REF03
Description
AN
1-80
S
N/U
REF04
REFERENCE IDENTIFIER
N3
DEPENDENT ADDRESS
1
S
N3
DEPENDENT ADDRESS
1
S
Address Information
AN
1-55
R
N301
Address Information
AN
1-55
R
N302
Address Information
AN
1-55
S
N302
Address Information
AN
1-55
S
N4
DEPENDENT CITY/STATE/ZIP CODE
1
S
N4
DEPENDENT CITY/STATE/ZIP CODE
1
S
2100D
2100D
N401
City Name
AN
2-30
S
N401
City Name
AN
2-30
R
N402
State or Province Code
ID
2-2
S
N402
State or Province Code
ID
2-2
S
N403
Postal Code
ID
3-15
S
N403
Postal Code
ID
3-15
S
N404
Country Code
ID
2-3
S
N404
Country Code
ID
2-3
S
N405
Location Qualifier
ID
1-2
N/U
N405
Location Qualifier
ID
1-2
N/U
N406
Location Qualifier
AN
1-30
N/U
N406
Location Qualifier
AN
1-30
N/U
N407
Country Subdivision Code
ID
1-3
PER
DEPENDENT CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name Communication Number Qualifier
AN
1-60
S
ID
2-2
S
HP, TE, WP
AN
1-80
S
AAABBBCCCC
PER05
Communication Number Communication Number Qualifier
ID
2-2
S
EX, HP, TE, WP
PER06
Communication Number
AN
1-80
S
AAABBBCCCC
PER04
Values
New Element
2100D 18, 1L, 49, 6P, CT, EA, EJ, F6, GH, HJ, IF, IG, MRC, N6, NQ, Q4, SY, Y4 Code Change Increase from 30 - 50
N/U
N301
PER03
Loop Repeat
271 5010
NM110
REF
Loop
2100D
2100D Usage change to Required
New Element
Segment Deleted
2100D IC
Page 19 of 32
ELIGIBILITY STATUS
4010A1 Description
PER07
Communication Number Qualifier
ID
2-2
S
HP, TE, WP
PER08
Communication Number
AN
1-80
S
AAABBBCCCC
PER09
Contact Inquiry Reference
AN
1-20
N/U
9
S
ID
Min. Max.
Usage Reg.
5010
Element Identifier
Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
AAA01
DEPENDENT REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA
2100D N, Y
Reject Reason Code
ID
2-2
R
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
AAA01
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
DMG01
ID
2-3
S
DMG02
Date Time Period
AN
1-35
S
DMG03 DMG04
Gender Code Marital Status Code
ID ID
1-1 1-1
S N/U
S
Loop
Loop Repeat
Values
2100D D8 F, M, U
9
S
2100D N, Y
AAA03
Reject Reason Code
ID
2-2
R
15, 35, 42, 43, 45, 47, 48, 49, 51, 52, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 71, 77 Code Added
AAA04
Follow-up Action Code
ID
1-1
R
C, N, R, S, W, X, Y
PRV
PROVIDER INFORMATION
1
S
R
2-3
S
PXC
1-50
S
PRV02
ID
PRV03
Reference Identification
AN
PRV04
ID
2-2
N/U
PRV05
State or Province Code PROVIDER SPECIALTY INFORMATION
PRV06
Provider Organization Code
ID
3-3
N/U
DMG
1
S
DMG01
DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier
ID
2-3
S
DMG02
Date Time Period
AN
1-35
S
DMG03 DMG04
ID ID
1-1 1-1
S N/U
ID
1-3
N/U
DMG05
Race or Ethnicity Code
ID
1-1
N/U
DMG05
Gender Code Marital Status Code COMPOSITE RACE OR ETHNICITY INFORMATION
DMG06
Citizenship Status Code
ID
1-2
N/U
DMG06
Citizenship Status Code
ID
1-2
N/U
DMG07
Country Code
ID
2-3
N/U
DMG07
Country Code
ID
2-3
N/U
DMG08
Basis of Verification Code
ID
1-2
N/U
DMG08
Basis of Verification Code
ID
1-2
N/U
DMG09
Quantity
R
1-15
N/U
DMG09
Quantity
R
1-15
N/U
Page 20 of 32
New Segment
2100D AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, SK, SU
Provider Code Reference Identification Qualifier
PRV01
1
Usage Reg.
DEPENDENT REQUEST VALIDATION Yes/No Condition or Response Code
AAA
AAA03
DMG
Min. Max.
271 5010
15, 42, 43, 45, 47, 48, 49, 51, 52, 56, 57, 58, 60, 61, 62, 63, 64, 65, 66, 67, 68, 71
DEPENDENT DEMOGRAPHIC INFORMATION Date Time Period Format Qualifier
ID
N/U
2100D D8 F, M, U
Name Change
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
DMG10
Code List Qalifier Code
ID
1-3
N/U
New Element
DMG11
Industry Code
AN
1-30
N/U
New Element
1
S
271 4010A1
INS01
DEPENDENT RELATIONSHIP Yes/No Condition or Response Code
INS02 INS03
INS
Usage Reg.
Loop
Loop Repeat
Values
271 5010
INS01
DEPENDENT RELATIONSHIP Yes/No Condition or Response Code
ID
1-1
R
01, 19, 21, 34
INS02
Individual Relationship Code
ID
2-2
R
001
INS03
Maintenance Type Code
ID
3-3
S
001
25
INS04
Maintenance Reason Code
ID
2-3
S
25
N/U
INS05
Benefit Status Code
ID
1-1
N/U
N/U
INS06
MEDICARE STATUS CODE
N/U
INS07
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying
ID
1-2
N/U
N/U
INS08
Employment Status Code
ID
2-2
N/U
F, N, P
INS09
Student Status Code
ID
1-1
N/U
Usage change to Not Used Code Deleted
N, Y
INS10
ID
1-1
N/U
Usage change to Not Used Code Deleted
N/U
1
S
ID
1-1
R
N
Individual Relationship Code
ID
2-2
R
Maintenance Type Code
ID
3-3
S
INS04
Maintenance Reason Code
ID
2-3
S
INS05
Benefit Status Code
ID
1-1
INS06
Medicare Plan Code
ID
1-1
INS07
Consolidated Omnibus Budget Reconcilliation Act (COBRA) Qualifying
ID
1-2
INS08
Employment Status Code
ID
2-2
INS09
Student Status Code
ID
1-1
S
2100D
INS
ID
1-1
S
INS11
Yes/No Condition or Response Code Date Time Period Format Qualifier
ID
2-3
N/U
INS12
Date Time Period
AN
1-35
N/U
INS13
Confidentiality Code
ID
1-1
N/U
INS14
City Name
AN
2-30
N/U
INS15
State or Province Code
ID
2-2
N/U
INS16
Country Code
ID
2-3
N/U
INS16
INS17
Number
N0
1-9
S
INS17
INS10
Min. Max.
INS11
ID
2-3
INS12
Date Time Period
AN
1-35
N/U
INS13
Confidentiality Code
ID
1-1
N/U
INS14
City Name
AN
2-30
N/U
INS15
State or Province Code
ID
2-2
N/U
Country Code
ID
2-3
N/U
Number
N0
1-9
S
1
S
HI01
DEPENDENT HEALTH CARE DIAGNOSIS CODE HEALTH CARE CODE INFORMATION Code List Qualifier Code
ID
1-3
R
HI01 - 2
AN
1-30
R
HI01 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI01 - 4
Date Time Period
AN
1-35
N/U
HI01 - 5
Monetary Amount
R
1-18
N/U N/U
HI01 - 6
Quantity
R
1-15
HI01 - 7
Version Identifier
AN
1-30
N/U
HI01 - 8
Industry Code Yes/No Condition or Response Code
AN
1-30
N/U
ID
1-1
N/U
Page 21 of 32
New Segment
2100D
R
HI01 - 1
HI01 - 9
N 01, 19, 20, 21, 39, 40, 53, G8 Code Change
N/U
Yes/No Condition or Response Code Date Time Period Format Qualifier
HI
2100D
ABK, BK
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
HI02
HEALTH CARE CODE INFORMATION
271 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010 S
HI02 - 1
Code List Qualifier Code
ID
1-3
R
HI02 - 2
AN
1-30
R
HI02 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI02 - 4
Date Time Period
AN
1-35
N/U
HI02 - 5
Monetary Amount
R
1-18
N/U N/U
HI02 - 6
Quantity
R
1-15
HI02 - 7
Version Identifier
AN
1-30
N/U
HI02 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI03 - 1
Code List Qualifier Code
ID
1-3
R
HI03 - 2
AN
1-30
R
HI03 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI03 - 4
Date Time Period
AN
1-35
N/U
HI03 - 5
Monetary Amount
R
1-18
N/U N/U
HI02 - 9 HI03
S
HI03 - 6
Quantity
R
1-15
HI03 - 7
Version Identifier
AN
1-30
N/U
HI03 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI04 - 1
Code List Qualifier Code
ID
1-3
R
HI04 - 2
AN
1-30
R
HI04 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI04 - 4
Date Time Period
AN
1-35
N/U
HI04 - 5
Monetary Amount
R
1-18
N/U
HI03 - 9 HI04
Quantity
R
1-15
N/U
HI04 - 7
Version Identifier
AN
1-30
N/U
HI04 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI05 - 1
Code List Qualifier Code
ID
1-3
R
HI05 - 2
Industry Code
AN
1-30
R
HI05
Page 22 of 32
ABF, BF
S
HI04 - 6
HI04 - 9
ABF, BF
ABF, BF
S ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
ID
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010 HI05 - 3
Date Time Period Format Qualifier
ID
2-3
HI05 - 4
Date Time Period
AN
1-35
N/U
HI05 - 5
Monetary Amount
R
1-18
N/U N/U
N/U
HI05 - 6
Quantity
R
1-15
HI05 - 7
Version Identifier
AN
1-30
N/U
HI05 - 8
Industry Code Yes/No Condition or Response Code HEALTH CARE CODE INFORMATION
AN
1-30
N/U
ID
1-1
N/U
HI06 - 1
Code List Qualifier Code
ID
1-3
R
HI06 - 2
AN
1-30
R
HI06 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI06 - 4
Date Time Period
AN
1-35
N/U
HI06 - 5
Monetary Amount
R
1-18
N/U N/U
HI05 - 9 HI06
S
HI06 - 6
Quantity
R
1-15
HI06 - 7
Version Identifier
AN
1-30
N/U
HI06 - 8
Industry Code Yes/No Condition or Response Code
AN
1-30
N/U
ID
1-1
N/U
HI06 - 9 HI07
HEALTH CARE CODE INFORMATION
S
HI07 - 1
Code List Qualifier Code
ID
1-3
R
HI07 - 2
AN
1-30
R
HI07 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI07 - 4
Date Time Period
AN
1-35
N/U
HI07 - 5
Monetary Amount
R
1-18
N/U
HI07 - 6
Quantity
R
1-15
N/U
HI07 - 7
Version Identifier
AN
1-30
N/U
HI07 - 8
Industry Code Yes/No Condition or Response Code
AN
1-30
N/U
ID
1-1
N/U
HI07 - 9 HI08
HEALTH CARE CODE INFORMATION
ABF, BF
S
HI08 - 1
Code List Qualifier Code
ID
1-3
R
HI08 - 2
AN
1-30
R
HI08 - 3
Industry Code Date Time Period Format Qualifier
ID
2-3
N/U
HI08 - 4
Date Time Period
AN
1-35
N/U
HI08 - 5
Monetary Amount
R
1-18
N/U
Page 23 of 32
ABF, BF
ABF, BF
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1 Quantity
R
1-15
N/U
HI08 - 7
Version Identifier
AN
1-30
N/U
HI08 - 8
Industry Code Yes/No Condition or Response Code
AN
1-30
N/U
ID
1-1
N/U
S
2100D
DTP01
Date/Time Qualifier
ID
3-3
R
102, 152, 291, 307, 318, 340, 341, 342, 343, 346, 347, 382, 435, 442, 458, 472, 539, 540, 636
DTP02
Date Time Period Format Qualifier
ID
2-3
R
D8, RD8
DTP03
Date Time Period
AN
1-35
R
HEALTH CARE CODE INFORMATION
Loop
Loop Repeat
Values
N/U
HI11
HEALTH CARE CODE INFORMATION HEALTH CARE CODE INFORMATION HEALTH CARE CODE
N/U
HI12
INFORMATION
N/U
DTP
DEPENDENT DATE
HI10
9
Usage Reg.
HI08 - 6
HI09
DEPENDENT DATE
Min. Max.
271 5010
HI08 - 9
DTP
ID
N/U
9
S
2100D 096, 102, 152, 291, 307, 318, 340, 341, 342, 343, 346, 347, 356 357, 382, 435, 442, 458, 472, 539, 540, 636, 771 Code Added
DTP01
Date Time Qualifier
ID
3-3
R
DTP02
Date Time Period Format Qualifier
ID
2-3
R
D8, RD8
R
CCYYMMDD, CCYYMMDDCCYYMMDD
DTP03
Date Time Period
MPI
DEPENDENT MILITARY PERSONNEL INFORMATION
MPI01
Information Status Code
MPI02
MPI03
Employment Status Code
AN
1-35
1
S
ID
1-1
R
A, C, L, O, P, S, T
R
AE, AO, AS, AT, AU, CC, DD, HD, IR, LX, PE, RE, RM, RR, RU
R
A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, Q, R, S, U, W
ID
Government Service Affiliation Code ID
Page 24 of 32
2-2
1-1
Code Deleted
New Segment
2100D
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
MPI04
Description
AN
1-80
S
MPI05
Military Service Rank Code
ID
2-2
S
A1, A2, A3, B1, B2, C1, C2, C3,
MPI06
Date Time Period Format Qualifier
ID
2-3
S
D8, RD8
MPI07
Date Time Period
AN
1-35
S
EB
DEPENDENT ELIGIBILITY/BENEFIT INFORMATION
1
2110D
271 4010A1
EB
EB01
EB02
DEPENDENT ELIGIBILITY/BENEFIT INFORMATION
Eligibility/ Benefit Information
Coverage Level Code
1
ID
ID
1-2
3-3
S
Min. Max.
Usage Reg.
Loop
Loop Repeat
Values
271 5010
2110D
>1
R
1, 2, 3, 4, 5, 6, 7, 8, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S,T, U, V, W, X, Y
S
CHD, DEP, ECH, ESP, FAM, IND, SPC, SPO
EB01
EB02
Eligibility or Benefit Information Code
Coverage Level Code
Page 25 of 32
ID
ID
1-2
3-3
>1
R
1, 2, 3, 4, 5, 6, 7, 8, A, B, C, CB, D, E, F, G, H, I, J, K, L, M, MC, N, O, P, Q, R, S, T, U, V, W, X, Y
S
CHD, DEP, ECH, EMP, ESP, FAM, IND, SPC, SPO Code Added
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
EB03
Service Type Code
ID
1-2
S
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, IP, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU
Insurance Type Code
ID
1-3
S
EB05
Plan Coverage Description
AN
1-50
S
Min. Max.
Usage Reg.
271 5010
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL, BM, BN, BP, BQ, BR, BS
EB04
ID
EB03
Service Type Code
ID
1-2
Loop Repeat
Values
S
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 44, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 99, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, A0, A1, A2, A3, A4, A5, A6, A7, A8, A9, AA, AB, AC, AD, AE, AF, AG, AH, AI, AJ, AK, AL, AM, AN, AO, AQ, AR, B1, B2, B3, BA, BB, BC, BD, BE, BF, BG, BH, BI, BJ, BK, BL BM, BN, BP, BQ, BR, BS, BT, BU, BV, BW, BX, BY, BZ, C1, CA, CB, CC, CD, CE, CF, CG, CH, CI, CJ, CK, CL, CM, CN, CO, CP, CQ, DG, DM, DS, GF, GY, IC, MH,
12, 13, 14, 15, 16, 41, 42, 43, 47, AP, C1, CO, CP, D, DB, EP, FF, GP, HM, HN, HS, IN, IP, LC, LD, LI, LT, MA, MB, MC, MH, MI, MP, OT, PE, PL, PP, PR, PS, QM, RP, SP, TF, WC, WU
EB04
Insuarance Type Code
ID
1-3
S
EB05
Plan Coverage Description
AN
1-50
S
Page 26 of 32
Loop
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
ID
Min. Max.
Usage Reg.
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36
Time Period Qualifier
ID
2-2
S
EB06
Time Period Qualifier
ID
1-2
S
EB07
Monetary Amount
R
1-18
S
EB07
Monetary Amount
R
1-18
S
EB08
Percent
R
1-10
S
EB08
Percentage as Decimal
R
1-10
S
99, CA, CE, DB, DY, HS, LA, LE, MN, P6, S7, S8, VS, YY
EB09
Quantity Qualifier
ID
2-2
S
EB10
Quantity Yes/No Condition or Response Code Yes/No Condition or Response Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
R
1-15
S
ID
1-1
S
N, U, Y
EB11
ID
1-1
S
N, U, Y
EB12
EB12 EB13
EB13 - 1 Product/Service ID Qualifier EB13 - 2
Product/Service ID
S ID
2-2
R
AN
1-48
R
Loop Repeat
Values
271 5010
EB06
EB11
Loop
8H, 99, CA, CE, D3, DB, DY, HS, LA, LE, M2, MN, P6, QA, S7, S8, VS, YY Code Added
EB09
Quantity Qualifier
ID
2-2
S
EB10
Quantity Yes/No Condition or Response Code Yes/No Condition or Response Code COMPOSITE MEDICAL PROCEDURE IDENTIFIER
R
1-15
S
ID
1-1
S
N,U,Y
ID
1-1
S
N,U,W,Y
Code Added
AD, CJ, HC, ID, IV, N4, ZZ
Code Change
EB13 AD, CJ, HC, ID, ND, ZZ
6, 7, 13, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36
EB13 - 1 Product/Service ID Qualifier EB13 - 2
Product/Service ID
S ID
2-2
R
AN
1-48
R
EB13 - 3
Procedure Modifier
AN
2-2
S
EB13 - 3
Procedure Modifier
AN
2-2
S
EB13 - 4
Procedure Modifier
AN
2-2
S
EB13 - 4
Procedure Modifier
AN
2-2
S
EB13 - 5
Procedure Modifier
AN
2-2
S
EB13 - 5
Procedure Modifier
AN
2-2
S
EB13 - 6
Procedure Modifier
AN
2-2
S
EB13 - 6
Procedure Modifier
AN
2-2
S
EB13 - 7
Description
AN
1-80
N/U
EB13 - 7
Description
AN
1-80
N/U
EB13 - 8
Product/Service ID COMPOSITE DIAGNOSIS CODE POINTER
AN
1-48
S S
New Element
Diagnosis Code Pointer
N0
1-2
R
New Element
EB14 EB14 - 1
HSD
HEALTH CARE SERVICES DELIVERY
9
S
HSD01
Quantity Qualifier
ID
2-2
S
HSD02
R
1-15
S
HSD03
Quantity Unit or Basis for Measurement Code
ID
2-2
S
HSD04
Sample Selection Modulus
R
1-6
S
HSD05
Time Period Qualifier
ID
1-2
S
2110D DY, FL, HS, MN, VS DA, MO, VS, WK, YR 6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35
New Element
EB14 - 2
Diagnosis Code Pointer
N0
1-2
S
New Element
EB14 - 3
Diagnosis Code Pointer
N0
1-2
S
New Element
EB14 - 4
Diagnosis Code Pointer
N0
1-2
S
New Element
9
2110C
HSD
HEALTH CARE SERVICES DELIVERY
HSD01
Quantity Qualifier
ID
2-2
S
HSD02
R
1-15
S
HSD03
Quantity Unit or Basis for Measurement Code
ID
2-2
S
HSD04
Sample Selection Modulus
R
1-6
S
HSD05
Time Period Qualifier
Page 27 of 32
ID
1-2
S
DY, FL, HS, MN, VS DA, MO, VS, WK, YR 6, 7, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
HSD06
Number of Periods
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
HSD06
Number of Periods
N0
271 4010A1
HSD08
Ship/Delivery or Calendar Pattern Code Ship/Delivery Pattern Time Code
REF
DEPENDENT ADDITIONAL IDENTIFICATION
HSD07
N0
1-3
1-2
S
ID
1-1
S
9
S
REF01
Reference Identification Qualifier
ID
2-3
R
REF02
Reference Identification
AN
1-30
REF03
Description
AN
1-80
REF04
REFERENCE IDENTIFIER
DTP
DEPENDENT ELIGIBILITY/BENEFIT DATE
DTP01
Date/Time Qualifier
DTP02
Date Time Period Format Qualifier
DTP03
Date Time Period
20
ID ID
AN
3-3 2-3
S
ID
1-1
S
9
S
ID
2-3
R
AN
1-50
R
S
REF03
Description
AN
1-80
S
N/U
REF04
REFERENCE IDENTIFIER
DTP
DEPENDENT ELIGIBILITY/BENEFIT DATE
2110D 193, 194, 198, 290, 292, 295, 304, 307, 318, 348, 349, 356, 357, 435, 472, 636, 771
R
D8, RD8
R
1-35
R
9
S
ID
1-1
R
ID
2-2
N/U
2-2
DEPENDENT ADDITIONAL IDENTIFICATION
1-2
Reference Identification
Agency Qualifier Code
ID
18, 1L, 1W, 49, 6P, 9F, A6, F6, G1, IG, N6, NQ
REF
ID
REF02
S
R
Loop
Loop Repeat
Values
S
R
AAA01
Reject Reason Code
2110D
HSD08
Ship/Delivery or Calendar Pattern Code Ship/Delivery Pattern Time Code
HSD07
1-3
Reference Identification Qualifier
AAA02
AAA03
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y A, B, C, D, E, F, G, Y
REF01
DEPENDENT REQUEST VALIDATION Yes/No Condition or Response Code
AAA
Usage Reg.
271 5010
S
ID
Min. Max.
15, 52, 53, 54, 55, 56, 57, 60, 61, 62, 63, 69, 70
18, 1L, 1W, 49, 6P, 9F, ALS, CLI, F6, FO, G1, IG, N6, NQ Code Change Increase from 30 - 50
N/U
20
S
2110D 096, 193, 194, 198, 290, 291, 292, 295, 304, 307, 318, 346, 348, 349, 356, 357, 435, 472, 636, 771
Date Time Qualifier
ID
3-3
R
DTP02
Date Time Period Format Qualifier
ID
2-3
R
D8, RD8
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
9
S
Date Time Period
AN
AAA01
DEPENDENT REQUEST VALIDATION Yes/No Condition or Response Code
ID
1-1
R
AAA02
Agency Qualifier Code
ID
2-2
N/U
AAA N, Y
2110D
DTP01
DTP03
2110D
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, SG, SL, SP, SX, SY, SZ, T, U, V, W, X, Y A, B, C, D, E, F, G, Y
AAA03
Reject Reason Code
Page 28 of 32
ID
2-2
R
Code Added
Code Added
2110D N, Y
15, 33, 52, 53, 54, 55, 56, 57, 60, 61, 62, 63, 69, 70, 98, AA, AE, AF, AG, AO, CI, E8, IA, MA Code Added
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
AAA04
Follow-up Action Code
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
ID
C, N, R, W, X, Y
AAA04
Follow-up Action Code
ID
271 4010A1 MSG
MESSAGE TEXT
MSG01
Free-Form Message Text
ID
1-1 10
AN 1-264
Usage Reg.
2110D
R
MSG
MESSAGE TEXT
MSG01
Free-Form Message Text
1-1 10
AN 1-264
S
Printer Carriage Control Code
ID
2-2
N/U
MSG02
Printer Carriage Control Code
ID
2-2
N/U
Number
N0
1-9
N/U
MSG03
Number
N0
1-9
N/U
III
DEPENDENT ELIGIBILITY/BENEFIT ADDITIONAL INFORMATION
III
DEPENDENT ELIGIBILITY/BENEFIT ADDITIONAL INFORMATION
1
S
III01
Code List Qualifier Code
III01
Code List Qualifier Code
ID
1-3
2115D
10
BF, BK, ZZ
R
III02
Industry Code
AN
1-30
R
III03
Code Category
ID
2-2
III04
Free-Form Message Text
III05
R
III06
Quantity COMPOSITE UNIT OF MEASURE
III07
Surface/Layer/Position Code
ID
III08
Surface/Layer/Position Code
III09
Surface/Layer/Position Code
LS
DEPENDENT ELIGIBILITY/ BENEFIT INFORMATION
LS01
Loop Identifier Code
NM1
DEPENDENT BENEFIT RELATED ENTITY NAME
If III01=ZZ: 11, 12, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 50, 51, 52, 53, 54, 55, 56, 60, 61, 62, 65, 71, 72, 81, 99
ID
1-3
Industry Code
AN
1-30
S
N/U
III03
Code Category
ID
2-2
S
N/U
III04
Free-Form Message Text
N/U
III05
R
N/U
III06
Quantity COMPOSITE UNIT OF MEASURE
2-2
N/U
III07
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III08
Surface/Layer/Position Code
ID
2-2
N/U
ID
2-2
N/U
III09
Surface/Layer/Position Code
ID
2-2
N/U
1
S
1
S
AN
1-6
R
AN
1-4
R
1
S
1
S
1-15
2110D 2120
2120D
1
LS
LOOP HEADER
LS01
Loop Identifier Code
NM1
DEPENDENT BENEFIT RELATED ENTITY NAME
Page 29 of 32
AN 1-264 1-15
C, N, R, W, X, Y 2110D
2115D
10
GR, NI, ZZ
S
III02
AN 1-264
Values
R
MSG02
S
Loop Repeat
R
MSG03
1
Loop
271 5010
R S
Min. Max.
Code Change Usage change to Situational
If III01=ZZ: 01, 03, 04, 05, 06, 07, 08, 11, 12, 13, 14, 15, 20, 21, 22, 23, 24, 25, 26, 31, 32, 33, 34, 41, 42, 49, 50, 51, 52, 53, 54, 55, Code Change 56, 57, 60, 61, 62, Usage change to 65, 71, 72, 81, 99 Situational
44
Code Added Usage change to Situational
N/U N/U N/U
2115D 2120
2120D
23
Decrease from 6 - 4
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
ID
Min. Max.
Usage Reg.
271 5010
NM101
Entity Identifier Code
ID
2-3
R
13, 1P, 2B, 36, 73, FA, GP, IL, LR, P3, P4, P5, PR, PRP, SEP, TTP, VN, X3
NM102
ID
1-1
R
1, 2
NM103
Entity Type Qualifier Name Last or Organization Name
AN
1-35
S
NM103
Entity Type Qualifier Name Last or Organization Name
NM104
Name First
AN
1-25
S
NM104
Name First
NM105
Name Middle
AN
1-25
S
NM105
Name Middle
AN
1-25
S
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
S
NM107
Name Suffix
AN
1-10
S
NM108
Identification Code Qualifier
ID
1-2
S
NM109
Identification Code
AN
2-80
S
24, 34, 46, FA, FI, MI, NI, PI, PP, SV, XV, XX, ZZ
ID
2-3
R
ID
1-1
R
AN
1-60
S
Increase from 35 - 60
AN
1-35
S
Increase from 25 - 35
NM108
Identification Code Qualifier
ID
1-2
S
NM109
Identification Code
AN
2-80
S
ID
2-2
N/U
NM110
Entity Relationship Code
ID
2-2
S
Entity Identifier Code
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112
Entity Identifier Code Name Last or Organization Name
AN
1-60
N/U
N3
DEPENDENT BENEFIT RELATED ENTITY ADDRESS
1
S
N3
DEPENDENT BENEFIT RELATED ENTITY ADDRESS
1
S
N301
Address Information
AN
1-55
R
N301
Address Information
AN
1-55
R
N302
Address Information
AN
1-55
S
N302
Address Information
AN
1-55
S
N4
DEPENDENT BENEFIT RELATED ENTITY CITY/STATE/ZIP CODE
N4
DEPENDENT BENEFIT RELATED ENTITY CITY/STATE/ZIP CODE
1
S
2120D
N401
City Name
AN
2-30
S
N401
City Name
AN
2-30
R
N402
State or Province Code
ID
2-2
S
N402
State or Province Code
ID
2-2
S
N403
Postal Code
ID
3-15
S
N403
Postal Code
ID
3-15
S
N404
Country Code
ID
2-3
S
N404
Country Code
ID
2-3
S
N405
Location Qualifier
ID
1-2
S
N406
Location Qualifier
AN
1-30
S
PER
DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name
AN
1-60
S
RJ
2120D IC
13, 1I, 1P, 2B, 36, 73, FA, GP, GW, I3, IL, LR, OC, P3, P4, PR, PRP, SEP, TTP, VN, VY, X3 Code Change
Entity Identifier Code
Entity Relationship Code
S
Values
NM102
NM110
2120D
Loop Repeat
NM101
NM111
1
Loop
N405
Location Qualifier
ID
1-2
S
N406
Location Qualifier
AN
1-30
S
N407
Country Subdivision Code
ID
1-3
S
PER
DEPENDENT BENEFIT RELATED ENTITY CONTACT INFORMATION
3
S
PER01
Contact Function Code
ID
2-2
R
PER02
Name
AN
1-60
S
Page 30 of 32
1, 2
24, 34, 46, FA, FI, II, MI, NI, PI, PP, SV, XV, XX Code Change Usage change to 01, 02, 27, 41, 48, Situational 65, 72 Code Added
New Element
2120D
2120D Usage change to Required
RJ New Element
2120D IC
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
PER03
Communication Number Qualifier
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
PER03
Communication Number Qualifier
271 4010A1 ID
2-2
S
Communication Number Communication Number Qualifier
AN
1-80
S
ID
2-2
S
AN
1-80
S
PER07
Communication Number Communication Number Qualifier
ID
2-2
PER08
Communication Number
AN
1-80
PER09
Contact Inquiry
AN
1-20
N/U
PRV
DEPENDENT BENEFIT RELATED PROVIDER INFORMATION
1
S
PER04 PER05 PER06
PRV01
Provider Code
PRV02
Reference Identification Qualifier
ID
ID
1-3
2-3
AAABBBCCCC ED, EM, EX, FX, TE, WP
PER04
PER06
S
AAABBBCCCC ED, EM, EX, FX, TE, WP
S
AAABBBCCCC
2120D
R
AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
R
9K, D3, EI, HPI, SY, TJ, ZZ
AN 1-256
PER07
Communication Number Communication Number Qualifier
PER08
Communication Number
AN 1-256
PER09
Contact Inquiry Reference
PRV
DEPENDENT BENEFIT RELATED PROVIDER INFORMATION
PER05
PRV01
Provider Code
PRV02
Reference Identification Qualifier
PRV06
Provider Organization Code
ID
3-3
1
S
AN
1-6
R
1
R
SE
N0
1-10
R
SE01
AN
4-9
R
SE02
LE
LOOP TRAILER Lopp Identifier Code
SE SE01 SE02
TRANSACTION SET TRAILER Number of Included Segments Transaction Set Control Number
N0
1-6
R
Group Control Number
N0
1-9
R
2120
ID AN
ID
ID
2-2
Values
2-2
S
S
AAABBBCCCC Increase from 80 - 256 ED, EM, EX, FX, TE, UR, WP Code Added
S
AAABBBCCCC
1-20
N/U
1
S
1-3
2-3
R
S
ID
3-3
1
S
AN
1-4
R
1
R
N0
1-10
R
AN
4-9
R
1
R
LE
LOOP TRAILER
LE01
Lopp Identifier Code
TRANSACTION SET TRAILER Number of Included Segments Transaction Set Control Number
1-50 2-2
Increase from 80 - 256
2120D AD, AT, BI, CO, CV, H, HH, LA, OT, P1, P2, PC, PE, R, RF, SB, SK, SU
PXC
Code Change Usage change to Situational Increase from 30 - 50 Usage change to Situational
S N/U N/U N/U
GE01
FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included
N0
1-6
R
GE02
Group Control Number
N0
1-9
R
Page 31 of 32
AAABBBCCCC Increase from 80 - 256 ED, EM, EX, FX, TE, UR, WP Code Added
S
Provider Organization Code
GE
Must=GS06
ID
PRV06
N/U
GE01
Loop Repeat
ED, EM, FX, TE, UR, WP Code Added
S
PRV05
N/U
GE02
Loop
S
AN ID
PRV03 PRV04
FUNCTIONAL GROUP TRAILER Number of Transaction Sets Included
GE
Usage Reg.
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
R N/U
2110D
2-2
AN 1-256
PRV05
LE01
ID
Communication Number Communication Number Qualifier
AN ID
1-30 2-2
Min. Max.
271 5010 ED, EM, FX, TE, WP
Reference Identification State or Province Code PROVIDER SPECIALTY INFORMATION
PRV03 PRV04
ID
2120
Decrease from 6 - 4
Code Deleted
ELIGIBILITY STATUS
4010A1 Element Identifier
Description
ID
Min. Max.
Usage Reg.
5010 Loop
Loop Repeat
Values
Element Identifier
Description
271 4010A1
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
N0
1-5
R
IEA02
Interchange Control Number
N0
9-9
R
IEA
ID
Min. Max.
Usage Reg.
271 5010
IEA01
INTERCHANGE CONTROL TRAILER Number of Included Functional Groups
IEA02
Interchange Control Number
IEA
Page 32 of 32
1
R
N0
1-5
R
N0
9-9
R
Loop
Loop Repeat
Values
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