834 Plan Member Reporting (008020X318)

Loop 1000A - SUBMITTER NAME

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

N1*41 - SUBMITTER NAME

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

X12 Set Notes:

NOTE: At least one iteration of loop 1000 is required to identify the sender or receiver.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The submitter is the entity responsible for the creation and formatting of this transaction.

TR3 Example:

N1✱41✱ABCSUBMITTER✱46✱12356799~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Submitter

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Submitter Name

Required

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Federal Taxpayer's Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

COMMENT: This segment, used alone, provides the most efficient method of providing organizational identification. To obtain this efficiency the "ID Code" (N104) must provide a key to the table maintained by the transaction processing party.

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Submitter Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N1*40 - RECEIVER NAME

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

X12 Set Notes:

NOTE: At least one iteration of loop 1000 is required to identify the sender or receiver.

Loop:

Loop 1000B - RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This loop identifies the Information Receiver of this transaction set.

TR3 Example:

N1✱40✱XYZ RECEIVER✱FI✱123567999~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Receiver

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Receiver Name

Required

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Federal Taxpayer's Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Receiver Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N1*ACV - INFORMATION SOURCE

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

X12 Set Notes:

NOTE: At least one iteration of loop 1000 is required to identify the sender or receiver.

Loop:

Loop 1000C - INFORMATION SOURCE

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the information source is different from the submitter. If not required by this implementation guide, do not send.

TR3 Notes:

See section 1.5 for definition of Information Source.

TR3 Example:

N1✱ACV✱ABC INFORMATION SOURCE✱FI✱123356799~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

ACV

Information Source

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Information Source Name

Required

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Code assigned by the organization that is the ultimate destination of the transaction set

Federal Taxpayer's Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Information Source Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

INS - MEMBER LEVEL DETAIL

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit, characteristics, and identification information on insured entities.

X12 Syntax:

P1112
If either INS11 or INS12 is present, then the other is required.

X12 Set Notes:

NOTE: A Subscriber is a person who elects the benefits and is affiliated with the employer or the insurer. A Dependent is a person who is affiliated with the subscriber, such as a spouse, child, etc., and is therefore entitled to benefits. Subscriber information must come before dependent information. The INS segment is used to note if information being submitted is subscriber information or dependent information.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

INS✱Y✱18✱021✱28✱A✱✱✱FT~

INS

✱

1073

M 1

✱

1069

Individual
Relat Code

M 1

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

1/2

✱

584

Employment
Status Code

✱

✱

✱

1250

✱

✱

✱

✱

✱

✱

✱

Chge Identi
Info Code

O 20

1/2

✱

1793

Prov Netwrk
Info Code

1/2

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

SEMANTIC: INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

INDUSTRY NAME: Subscriber Indicator

CODE

DEFINITION

Yes

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

The value 18 must be used for the subscriber.
For dependents, this value identifies their relationship to the subscriber. For example, a daughter would be value 19.

CODE

DEFINITION

Spouse

Father or Mother

Grandfather or Grandmother

Grandson or Granddaughter

Uncle or Aunt

Nephew or Niece

Cousin

Adopted Child

Foster Child

Son-in-law or Daughter-in-law

Brother-in-law or Sister-in-law

Mother-in-law or Father-in-law

Brother or Sister

Ward

Stepparent

Stepson or Stepdaughter

Self

Child

REF*0F - SUBSCRIBER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

NOTE: The REF segment is required to link the dependent(s) to the subscriber.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment must contain a unique SUBSCRIBER identification number. This identifier is used for linking the subscriber with dependents as required under many policies.

TR3 Example:

REF✱0F✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Subscriber Number

Use when established by the Trading Partner Agreement

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - MEMBER TAXPAYER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

NOTE: The REF segment is required to link the dependent(s) to the subscriber.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Member's Taxpayer Identifier (social security number or ITIN) is allowed to be used for this purpose under applicable law or regulation.

AND

The Member's Taxpayer Identifier (social security number or ITIN) is available in the Information Source's system.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱SY✱111002222~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Social Security Number

Federal Taxpayer's Identification Number

Use when reporting Individual Taxpayer Identification Number (ITIN).

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - MEMBER SUPPLEMENTAL IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

NOTE: The REF segment is required to link the dependent(s) to the subscriber.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when sending additional identifying information on the member. If not required by this implementation guide, do not send.

TR3 Example:

REF✱17✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Client Reporting Category

Use when established by the Trading Partner Agreement.

Client Number

Use when passing a payer specific identifier for a member.

Case Number

Cross Reference Number

Use when further identification of a member is required for reporting, indexing, or other purpose as mutually agreed upon between the submitter and receiver of the transaction set.

ABB

Personal ID Number

Department/Agency Number

Use when members in a coverage group are set up as different departments or divisions under the terms of the insurance policy.

Health Insurance Claim (HIC) Number

Use when reporting Medicare eligibility for a member.

Medicaid Recipient Identification Number

Prior Identifier Number

Use when passing the Identifier Number under which the member had previous coverage with the payer. This could be the result of a change in employment or coverage that resulted in a new ID number being assigned but left the member covered by the same payer.

Unit Number

Use when members in a coverage group are set up as different units under the terms of the insurance policy. Units may exist within another grouping such as division or department.

Mutually Defined

Use when established by the Trading Partner Agreement.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Supplemental Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*PID - MEMBER PROGRAM/PLAN IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

NOTE: The REF segment is required to link the dependent(s) to the subscriber.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by terms of the trading partner agreement. If not required by this implementation guide, do not send.

TR3 Example:

REF✱PID✱ABC123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

PID

Program Identification Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Program/Plan Identifier

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP - MEMBER LEVEL DATES

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Notes:

This loop is used to report eligibility dates. Use Loop 2300 to report coverage dates.
When an end date is reported, it represents that day through 11:59 pm.

TR3 Example:

DTP✱356✱D8✱20150705~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

286

Retirement

296

Initial Disability Period Return To Work

297

Initial Disability Period Last Day Worked

301

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event

336

Employment Begin

337

Employment End

338

Medicare Begin

339

Medicare End

356

Eligibility Begin

Use when reporting the date a member could elect to enroll or begin benefits in any health care plan with this Information Source. The actual begin date of coverage is conveyed in the DTP segment in Loop 2300.

357

Eligibility End

Use when member's eligibility has been terminated. The eligibility end date represents the last date of eligibility. For example, if a date of 02/28/2017 is passed then eligibility for this individual will be through 11:59 p.m. on 02/28/2017. See section 1.4.5 for further information on termination.

394

Rehire

473

Medicaid Begin

474

Medicaid End

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

DTP*303 - MEMBER LEVEL MAINTENANCE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting the effective date of a change to an existing member's information. If not required by this implementation guide, do not send.

TR3 Notes:

The use of this segment is intended to convey member level changes. The DTP segments in Loop 2300 are to be used to convey changes in coverage only.

TR3 Example:

DTP✱303✱D8✱20170705~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

303

Maintenance Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

DTP*393 - MEMBER LEVEL PLAN PARTICIPATION SUSPENSION DATES

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the member has been suspended from plan participation. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱393✱D8✱20150701~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

393

Plan Participation Suspension

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

NM1 - MEMBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱IL✱1✱SMITH✱JOHN✱M✱✱SR✱34✱123456789~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Corrected Insured

Use when correcting member information previously sent in NM1 or DMG in Loop 2100A.

Insured or Subscriber

Use when code values `74' and `PJ' do not apply.

Party to Receive Correspondence

Use when access to an individual's information must be limited due to their status of At Risk.

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Member Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 is equal to "1" (person) and the person has a middle name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when person has a prefix. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when person has a suffix. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Name Suffix

Required

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Social Security Number

The Social Security Number must be a string of exactly nine numbers with no separators. For example, sending "111002222" would be valid, while sending "111-00-2222 would be invalid".

Member Identification Number

Taxpayer ID Number

Use when reporting Individual Taxpayer Identification Number (ITIN).

Mutually Defined

Use when established by the Trading Partner Agreement and the other code values are not applicable.

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Member Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*IP - MEMBER COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Notes:

When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).

TR3 Example:

PER✱IP✱✱HP✱8015554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

Insured Party

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Other Residential Telephone Number

Use when reporting a TTY communication number.

Telephone

Use when identifying the primary phone number.

Work Phone Number

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a value is being reported in the PER06 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's alternative contact.

Electronic Mail

Telephone Extension

Other Residential Telephone Number

Use when reporting a TTY communication number.

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a value is being reported in the PER08 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's alternative contact.

Electronic Mail

Telephone Extension

Other Residential Telephone Number

Use when reporting a TTY communication number.

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - MEMBER RESIDENCE STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the member is the subscriber or when a dependent has a different address from the subscriber. If not required by this implementation guide, do not send.

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Member Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required if a second address line exists. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Address Line

N4 - MEMBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when sending subscribers, or when dependent has a different address. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Member City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

COMMENT: N403 contains the postal code in an unstructured format. N408 contains the postal code in a structured format. When a postal code data field is used, the parties shall agree as to which data element (N403 or N408) shall be used in the transaction set.

SEGMENT SYNTAX: E0308

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Postal Zone or Zip Code

Use 9 digit Zip code for U.S. addresses when available in Information Source's system.

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Situational

309

Location Qualifier

X 1

1/2

Code identifying type of location

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when N406 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Area

County/Parish

Mutually Defined

Use when address reported is not to be used. (For example Member is homeless or At Risk and true physical address cannot be reported).

Situational

310

Location Identifier

O 1

1/30

Code which identifies a specific location

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

SITUATIONAL RULE: Required when the address is not in the United States of America, including its territories, or Canada, and the country in N404 has administrative subdivisions such as but not limited to states, provinces, cantons, etc. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

DMG*D8 - MEMBER DEMOGRAPHICS

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DMG✱D8✱19750915✱F✱M~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Member Birth Date

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

CODE

DEFINITION

Female

Male

Unknown

Use when the gender is unknown or when it can not be sent due to reporting restrictions.

Situational

1067

Marital Status Code

O 1

Code specifying the marital status of a person

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

CODE

DEFINITION

Registered Domestic Partner

Divorced

Single

Married

Unreported

Separated

Unmarried (Single or Divorced or Widowed)

This code should be used if the previous status is unknown.

Widowed

Legally Separated

Situational

C056

Composite Race or Ethnicity Information

X 25

To send general and detailed information on race or ethnicity

X12 COMPOSITE SYNTAX NOTES: P0203
If either C05602 or C05603 is present, then the other is required.

X12 COMPOSITE SEMANTIC NOTES: C056-02 and C056-03 are used to specify detailed information about race or ethnicity.

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

Race or Ethnicity information is reported in either DMG05-01 or DMG05-02 and DMG05-03.

Situational

5-1

1109

Race or Ethnicity Code

O 1

Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes

SITUATIONAL RULE: Required when reporting the Race or Ethnicity code from the DMG05-01 list of code values. If not required by this implementation guide, do not send.

CODE

DEFINITION

Not Provided

Not Applicable

Asian or Pacific Islander

Black

Caucasian

Subcontinent Asian American

Other Race or Ethnicity

Asian Pacific American

Native American

Hispanic

American Indian or Alaskan Native

Native Hawaiian

Black (Non-Hispanic)

White (Non-Hispanic)

Pacific Islander

Mutually Defined

Situational

5-2

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

COMPOSITE SYNTAX: P0203

SITUATIONAL RULE: Required when the Classification of Race or Ethnicity code set is being used to report Race or Ethnicity data. If not required by this implementation guide, do not send.

CODE

DEFINITION

RET

Classification of Race or Ethnicity

CODE SOURCE: 859: Classification of Race or Ethnicity

Situational

5-3

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203

SITUATIONAL RULE: Required when reporting the Race or Ethnicity code obtained from the Classification of Race or Ethnicity code. If not required by this implementation guide, do not send.

INDUSTRY NAME: Race or Ethnicity Code

CODE SOURCE 859: Classification of Race or Ethnicity

Situational

1066

Citizenship Status Code

O 1

1/2

Code indicating citizenship status

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

CODE

DEFINITION

U.S. Citizen

Non-Resident Alien

Resident Alien

Illegal Alien

Alien

U.S. Citizen - Non-Resident

U.S. Citizen - Resident

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

Not Used

Country Code

O 1

2/3

EC - EMPLOYMENT CLASS

X12 Name:

Employment Class

X12 Purpose:

To provide class of employment information

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

EC✱04✱06✱07~

✱

1176

Employment
Class Code

2/3

✱

1176

Employment
Class Code

2/3

✱

1176

Employment
Class Code

✱

✱

Information
Status Code

✱

Required

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Situational

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

SITUATIONAL RULE: Required if further classification information is needed. If not required by this implementation guide, do not send.

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Situational

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

SITUATIONAL RULE: Required if further classification information is needed. If not required by this implementation guide, do not send.

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Not Used

954

Percentage as Decimal

O 1

1/10

Not Used

1201

Information Status Code

O 1

Not Used

1149

Occupation Code

O 1

4/6

ICM - MEMBER INCOME

X12 Name:

Individual Income

X12 Purpose:

To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

ICM✱1✱40000✱40~

ICM

✱

✱

✱

✱

✱

✱

Required

594

Frequency Code

M 1

Code indicating frequency or type of activities or actions being reported

SEMANTIC: ICM01 is the frequency at which an individual's wages are paid.

CODE

DEFINITION

Weekly

Biweekly

Semimonthly

Monthly

Daily

Annual

Two Calendar Months

Lump-Sum Separation Allowance

Year-to-Date

Single

Hourly

Quarterly

Semiannual

Unknown

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: ICM02 is the yearly wages amount.

INDUSTRY NAME: Wage Amount

Refer to Appendix B.1.1.2.2 Maximum Length of Data Element 782 Monetary Amount for more information about this data element length.

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: ICM03 is the weekly hours.

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

INDUSTRY NAME: Work Hours Count

Situational

310

Location Identifier

O 1

1/30

Code which identifies a specific location

SEMANTIC: ICM04 is the employer location qualifier such as a department number.

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

INDUSTRY NAME: Location Identification Code

Situational

1214

Salary Grade

O 1

1/5

The salary grade code assigned by the employer

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

INDUSTRY NAME: Salary Grade Code

Not Used

100

Currency Code

O 1

HLH - MEMBER HEALTH INFORMATION

X12 Name:

Health Information

X12 Purpose:

To provide health information

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

HLH✱T~

HLH

✱

C061

Membr Healt
Treat Info

✱

✱

✱

✱

✱

✱

Required

C061

Member Health and Treatment Information

O 10

To identify member health and treatment information

X12 COMPOSITE SYNTAX NOTES:

L030405
If C06103 is present, then at least one of C06104 or C06105 are required.
C0403
If C06104 is present, then C06103 is required.
C0503
If C06105 is present, then C06103 is required.

X12 COMPOSITE SEMANTIC NOTES:

C061-04 is the beginning date related to the type of date identified in C061-03.
C061-05 is the end date related to the type of date identified in C061-03.

Required

1-1

1212

Health-Related Code

O 1

Code indicating a specific health situation

INDUSTRY NAME: Health Related Code

CODE

DEFINITION

None

Substance Abuse

Tobacco Use

Unknown

Not Used

1-2

1073

Yes/No Condition or Response Code

O 1

Not Used

1-3

374

Date/Time Qualifier

X 1

Not Used

1-4

373

Date

X 1

Not Used

1-5

373

Date

X 1

Not Used

Height

O 1

1/8

Not Used

Weight

O 1

1/10

Not Used

Weight

O 1

1/10

Not Used

352

Description

O 1

1/80

Not Used

1213

Current Health Condition Code

O 1

Not Used

352

Description

O 1

1/80

LUI*LE - MEMBER LANGUAGE

X12 Name:

Language Use

X12 Purpose:

To specify language, type of usage, and proficiency or fluency

X12 Syntax:

P0102
If either LUI01 or LUI02 is present, then the other is required.
L040203
If LUI04 is present, then at least one of LUI02 or LUI03 are required.

Loop:

Loop 2100B - PREVIOUSLY SUBMITTED MEMBER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

LUI✱LE✱SPA✱✱8~

LUI

✱

✱

✱

✱

✱

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when a value is being reported in the LUI02 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

ISO 639 Language Codes

CODE SOURCE: 102: Languages

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEMANTIC: LUI02 is the language code.

SEGMENT SYNTAX: P0102, L040203

SITUATIONAL RULE: Required when the information source is able to code the language identification. If not required by this implementation guide, do not send.

INDUSTRY NAME: Language Code

Situational

352

Description

X 1

1/80

A free-form description to clarify the related data elements and their content

SEMANTIC: LUI03 is the name of the language.

SEGMENT SYNTAX: L040203

SITUATIONAL RULE: Required when the information source is unable to code the necessary language identification in LUI01 and LUI02. If not required by this implementation guide, do not send.

INDUSTRY NAME: Language Description

Situational

1303

Use of Language Indicator Code

O 1

1/2

Code indicating the use of a language

SEGMENT SYNTAX: L040203

SITUATIONAL RULE: Required when available in the information source's system. If not required by this implementation guide, do not send.

INDUSTRY NAME: Language Use Indicator

CODE

DEFINITION

Language Reading

Language Writing

Language Speaking

Native Language

Not Used

1476

Language Proficiency Indicator Code

O 1

NM1*70 - PREVIOUSLY SUBMITTED MEMBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when NM101 in Loop 2100A is equal to `74'. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is used when updating previously submitted member information.

TR3 Example:

NM1✱70✱1✱SMYTH✱JON~

NM1

✱

✱

Loop 2100B - PREVIOUSLY SUBMITTED MEMBER NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Prior Incorrect Insured

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Previously Submitted Member Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when the person has a first name which was previously submitted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when the person has a middle name which was previously submitted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when the person has a prefix which was previously submitted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when the person has a suffix which was previously submitted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when a value is being reported in the NM109 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Social Security Number

Member Identification Number

Taxpayer ID Number

Use when reporting Individual Taxpayer Identification Number (ITIN).

Mutually Defined

Use when established by the Trading Partner Agreement and the other code values are not applicable.

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when the member's identifier was previously submitted. If not required by this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Identifier

NM109 is the identifier that was previously submitted.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

DMG*D8 - PREVIOUSLY SUBMITTED MEMBER DEMOGRAPHICS

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

P0102
If either DMG01 or DMG02 is present, then the other is required.
P1011
If either DMG10 or DMG11 is present, then the other is required.
C1105
If DMG11 is present, then DMG05 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there is a change to the previously submitted demographic information. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is used to change or correct demographic information. Only send the information that is being changed or corrected.

TR3 Example:

DMG✱D8✱19750915✱F✱M~

DMG

✱

1250

Loop 2100C - MEMBER MAILING ADDRESS

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Situational

1250

Date Time Period Format Qualifier

X 1

2/3

Code indicating the date format, time format, or date and time format

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when DMG02 is used. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

1251

Date Time Period

X 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the member's birth date is being corrected. If not required by this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

SITUATIONAL RULE: Required when the members gender is being corrected. If not required by this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Gender

CODE

DEFINITION

Female

Male

Unknown

Situational

1067

Marital Status Code

O 1

Code specifying the marital status of a person

SITUATIONAL RULE: Required when the members Marital Status Code is being corrected. If not required this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Marital Status

CODE

DEFINITION

Registered Domestic Partner

Divorced

Single

Married

Unreported

Separated

Unmarried (Single or Divorced or Widowed)

Widowed

Legally Separated

Situational

C056

Composite Race or Ethnicity Information

X 25

To send general and detailed information on race or ethnicity

X12 COMPOSITE SYNTAX NOTES: P0203
If either C05602 or C05603 is present, then the other is required.

X12 COMPOSITE SEMANTIC NOTES: C056-02 and C056-03 are used to specify detailed information about race or ethnicity.

SITUATIONAL RULE: Required when the member's Race or Ethnicity is being corrected. If not required this implementation guide, do not send.

Situational

5-1

1109

Race or Ethnicity Code

O 1

Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes

SITUATIONAL RULE: Required when the member's Race or Ethnicity is being corrected. If not required this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Race or Ethnicity Code

CODE

DEFINITION

Not Provided

Not Applicable

Asian or Pacific Islander

Black

Caucasian

Subcontinent Asian American

Other Race or Ethnicity

Asian Pacific American

Native American

Hispanic

American Indian or Alaskan Native

Native Hawaiian

Black (Non-Hispanic)

White (Non-Hispanic)

Pacific Islander

Mutually Defined

Situational

5-2

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

COMPOSITE SYNTAX: P0203

SITUATIONAL RULE: Required when the member's Race or Ethnicity is being corrected. If not required this implementation guide, do not send.

CODE

DEFINITION

RET

Classification of Race or Ethnicity

CODE SOURCE: 859: Classification of Race or Ethnicity

Situational

5-3

1271

Industry Code

X 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203

SITUATIONAL RULE: Required when the member's Race or Ethnicity is being corrected. If not required this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Race or Ethnicity Code

Situational

1066

Citizenship Status Code

O 1

1/2

Code indicating citizenship status

SITUATIONAL RULE: Required when the member's citizenship is being corrected. If not required this implementation guide, do not send.

INDUSTRY NAME: Previously Submitted Member Citizenship Status Code

CODE

DEFINITION

U.S. Citizen

Non-Resident Alien

Resident Alien

Illegal Alien

Alien

U.S. Citizen - Non-Resident

U.S. Citizen - Resident

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Not Used

1270

Code List Qualifier Code

X 1

1/3

Not Used

1271

Industry Code

X 1

1/30

Not Used

Country Code

O 1

2/3

NM1*31 - MEMBER MAILING ADDRESS

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the member mailing address is different from the residence address sent in Loop 2100A or when the dependent's mailing address is different from the Subscriber's. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱31✱1~

NM1

✱

✱

Loop 2100C - MEMBER MAILING ADDRESS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Postal Mailing Address

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Not Used

1035

Name Last or Organization Name

X 1

1/80

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - MEMBER MAILING STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱P.O. Box 1234~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Member Mailing Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required if a second address line exists. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Mailing Address Line

N4 - MEMBER MAILING CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop 2100C - MEMBER MAILING ADDRESS

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2100D - MEMBER EMPLOYER

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Member Mailing City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Mailing State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Member Mailing Postal Zone or ZIP Code

Use 9 digit Zip code for U.S. addresses when available in Information Source's system.

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Mailing Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Member Mailing Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

NM1*36 - MEMBER EMPLOYER

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is not used to collect Coordination of Benefits (COB) information. COB information must be passed in Loop 2320.

TR3 Example:

NM1✱36✱2✱ABC CORP.~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Employer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Member Employer Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 is equal to `1' (Person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Employer First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required if supplied by the member and NM102 equals `1'. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Employer Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required if supplied by the member and NM102 equals `1'. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Employer Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required if supplied by the member and NM102 equals `1'. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Employer Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when a value is being reported in the NM109 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Employer's Identification Number

Social Security Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Employer Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

NM1 - RESPONSIBLE PERSON

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required to identify the person(s), other than the subscriber, who are responsible for the member. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱QD✱1✱CASE✱JOHN~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Case Manager

Person or Other Entity Legally Responsible for a Child

Use when identifying a legal indemnity situation.
This code is used when a Qualified Medical Child Support Order (QMSCO) is present.

Executor of Estate

Use when the subscriber is deceased and the executor/responsible party is other than a surviving spouse.

EXS

Ex-spouse

Use when identifying a separated spouse under a separation agreement, or that the member is the divorced spouse and self responsible. This is NOT USED to identify the custodial parent for dependent children after a divorce.

Other Insured

Guardian

Power of Attorney

Legal Representative

Responsible Party

Parent

Custodial Parent

Significant Other

Spouse

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Responsible Person Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 is equal to "1" (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 is equal to "1" (person) and the person has a middle name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required when person has a prefix. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when person has a suffix. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Suffix Name

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when a value is being reported in the NM109 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Social Security Number

Mutually Defined

Use when established by the Trading Partner Agreement and the other code values are not applicable.

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*RP - RESPONSIBLE PERSON COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱RP✱✱HP✱8015554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

Responsible Person

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Cellular Phone

Electronic Mail

Home Phone Number

Telephone

Work Phone Number

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a value is being reported in the PER06 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Alternate Telephone

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Telephone

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a value is being reported in the PER08 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Alternate Telephone

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Telephone

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - RESPONSIBLE PERSON STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Responsible Person Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required if a second address line exists. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Address Line

N4 - RESPONSIBLE PERSON CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when N3 segment is sent. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2200 - DISABILITY INFORMATION

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Responsible Person City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Responsible Person Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Responsible Person Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

DSB - DISABILITY INFORMATION

X12 Name:

Disability Information

X12 Purpose:

To supply disability information

X12 Syntax:

P0708
If either DSB07 or DSB08 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when disability information about a member is added or changed. If not required by this implementation guide, do not send.

TR3 Notes:

If disability was previously reported in error, see section 1.4.9 for instructions on how to correct.

TR3 Example:

DSB✱2✱✱✱✱✱✱DC✱N189~

DSB

✱

✱

✱

✱

✱

✱

✱

✱

Required

1146

Disability Type Code

M 1

Code identifying the disability status of the individual

CODE

DEFINITION

Short Term Disability

Long Term Disability

Permanent or Total Disability

No Disability

Partial Disability

Not Used

380

Quantity

O 1

1/15

Not Used

1149

Occupation Code

O 1

4/6

Not Used

1154

Work Intensity Code

O 1

Not Used

1161

Product Option Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Situational

235

Product/Service ID Qualifier

X 1

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a value is being reported in the DSB08 element. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Type Code

CODE

DEFINITION

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

CODE SOURCE: 897: International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

Situational

1137

Medical Code Value

X 1

1/15

Code value for describing a medical condition or procedure

SEMANTIC: DSB08 is the functional status code for the disability.

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

INDUSTRY NAME: Diagnosis Code

DTP*360 - DISABILITY ELIGIBILITY BEGIN DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop 2200 - DISABILITY INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting a disabled member (DSB01 is `1', `2', `3' or `5') and the disability begin date is known by the sender.
Or
Required when disability begin date changes for a previously reported member, and the disability begin date is known by the sender.

If not required by this implementation guide, do not send.

TR3 Notes:

This segment is used to send the first date of disability.
If disability was previously reported in error, see section 1.4.9 for instructions on how to correct.

TR3 Example:

DTP✱360✱D8✱19961001~

DTP

✱

✱

Loop 2200 - DISABILITY INFORMATION

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

360

Initial Disability Period Start

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

DTP*361 - DISABILITY ELIGIBILITY END DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when reporting a disabled member (DSB01 is `1', `2', `3' or `5') and the disability end date is known by the sender.
Or
Required when disability end date changes for a previously reported member, and the disability end date is known by the sender.
Or
Required when DSB01 is equal to 4 and member is no longer on disability and the disability end date is known by the sender.

If not required by this implementation guide, do not send.

TR3 Notes:

This segment is used to send the last date of disability.
If disability was previously reported in error, see section 1.4.9 for instructions on how to correct.

TR3 Example:

DTP✱361✱D8✱20170701~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

361

Initial Disability Period End

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

HD - BENEFIT COVERAGE

X12 Name:

Health Coverage

X12 Purpose:

To provide information on health coverage

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Refer to section 1.4.4 "Termination" for additional information relative to reporting termination of a member's coverage.

TR3 Example:

HD✱021✱✱HLT✱PLAN A BCD✱FAM~

✱

875

Maintenance
Type Code

✱

✱

✱

Plan Cvrg
Description

✱

✱

✱

✱

Underwrite
Decide Code

✱

1073

✱

✱

Required

875

Maintenance Type Code

M 1

Code identifying the specific type of item maintenance

Required to identify the specific type of item maintenance.

CODE

DEFINITION

001

Change

002

Delete

Use when reporting deletion of an incorrect coverage record.

021

Addition

024

Cancellation or Termination

Use when reporting a cancelation/termination of coverage.

025

Reinstatement

026

Correction

Use when reporting correction to previously reported information.

030

Audit or Compare

ZZZ

Mutually Defined

Use when established by the Trading Partner Agreement.

Not Used

1203

Maintenance Reason Code

O 1

2/3

Required

1205

Insurance Line Code

O 1

2/3

Code identifying a group of insurance products

CODE

DEFINITION

Preventative Care/Wellness

24 Hour Care

Medicare Risk

Mental Health

DCP

Dental Capitation

Use when identifying a dental managed care organization (DMO).

DEN

Dental

EPO

Exclusive Provider Organization

FAC

Facility

Hearing

HLT

Health

Use when reporting hospital or professional coverage.

HMO

Health Maintenance Organization

LTC

Long-Term Care

LTD

Long-Term Disability

Major Medical

MOD

Mail Order Drug

PDG

Prescription Drug

POS

Point of Service

PPO

Preferred Provider Organization

PRA

Practitioners

STD

Short-Term Disability

Utilization Review

VIS

Vision

Situational

1204

Plan Coverage Description

O 1

1/50

A description or number that identifies the plan or coverage

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

INDUSTRY NAME: Benefit Coverage Description

Situational

1207

Coverage Level Code

O 1

Code indicating the level of coverage being provided for this insured

SITUATIONAL RULE: Required when member is subscriber. If not required by this implementation guide, do not send.

See section 1.4.7, Coverage Levels and Dependents, for additional information.

CODE

DEFINITION

CHD

Children Only

DEP

Dependents Only

E1D

Employee and One Dependent

Use when the dependent is a non-spouse dependent. This code is not used for identification of Employee and Spouse. See code ESP.

E2D

Employee and Two Dependents

E3D

Employee and Three Dependents

E5D

Employee and One or More Dependents

E6D

Employee and Two or More Dependents

E7D

Employee and Three or More Dependents

E8D

Employee and Four or More Dependents

E9D

Employee and Five or More Dependents

ECH

Employee and Children

EMP

Employee Only

ESP

Employee and Spouse

FAM

Family

IND

Individual

S1C

Subscriber and 1 child

S5C

Subscriber and 1 or more children

S6C

Subscriber and 2 or more children

SPC

Spouse and Children

SPO

Spouse Only

SS1

Subscriber, spouse, and 1 child

SS5

Subscriber, spouse, and 1 or more children

SS6

Subscriber, spouse, and 2 or more children

SSP

Subscriber and spouse

TWO

Two Party

Not Used

609

Count

O 1

1/9

Not Used

609

Count

O 1

1/9

Not Used

1209

Underwriting Decision Code

O 1

Not Used

1073

Yes/No Condition or Response Code

O 1

Not Used

1211

Drug House Code

O 1

2/3

Not Used

1073

Yes/No Condition or Response Code

O 1

DTP*300 - ENROLLMENT SIGNATURE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱300✱D8✱20161001~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

300

Enrollment Signature Date

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

DTP - PREMIUM PAYMENT DATES

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱343✱D8✱20161001~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

343

Premium Paid to Date End

543

Last Premium Paid Date

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

DTP*303 - MAINTENANCE EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱303✱D8✱20161001~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

303

Maintenance Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

DTP - BENEFIT DATES

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

The Benefit Begin Date must always be reported. The Benefit End date is only reported when there is an end date or benefit was reported in error.

TR3 Example:

DTP✱348✱D8✱20161001~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

348

Benefit Begin

349

Benefit End

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

DTP*695 - PREVIOUS PERIOD DATES

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱695✱RD8✱20151001-20151231~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

695

Previous Period

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

AMT - HEALTH COVERAGE POLICY AMOUNT

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

AMT✱C1✱20~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Co-insurance - Actual

Co-Payment Amount

Deductible Amount

Premium Amount

Mutually Defined

Use when established by the Trading Partner Agreement.

Required

782

Monetary Amount

M 1

1/18

Monetary amount

Not Used

478

Credit/Debit Flag Code

O 1

REF - BENEFIT COVERAGE POLICY RELATED INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

REF✱1L✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Client Reporting Category

Group or Policy Number

Use when a group number that applies to this individual's participation in the coverage passed in this HD loop is required by the terms of the Trading Partner Agreement.

Payment Category

Class of Contract Code

Service Contract (Coverage) Number

Medical Assistance Category

PID

Program Identification Number

Rate code number

Internal Control Number

Issuer Number

XX1

Special Program Code

XX2

Service Area Code

County Code

Mutually Defined

Use when established by the Trading Partner Agreement.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

IDC - IDENTIFICATION CARD

X12 Name:

Identification Card

X12 Purpose:

To provide notification to produce replacement identification card(s)

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting the production of an identification card as allowed under the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

IDC✱12345✱H~

IDC

✱

1204

Plan Cvrg
Description

✱

✱

✱

Required

1204

Plan Coverage Description

M 1

1/50

A description or number that identifies the plan or coverage

If no additional information is needed, this element will be sent as a single zero.

Required

1215

Identification Card Type Code

M 1

Code identifying the type of identification card

This code is used to identify that the card issued will be specific to the coverage identified in the related HD segment.

CODE

DEFINITION

Dental Insurance

Hearing Benefit

Health Insurance

Prescription Drug Service Drug Insurance

Vision Benefit

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: IDC03 is the number of cards being requested.

SITUATIONAL RULE: Required if the number of card requests is greater than 1. If not required by this implementation guide, do not send.

INDUSTRY NAME: Identification Card Count

Only integer values are to be sent.

Situational

306

Action Code

O 1

1/2

Code indicating type of action

SEMANTIC: IDC04 is the reason for the card being requested, i.e., add or a change.

SITUATIONAL RULE: Required if the sender knows the reason for the card request. If not required by this implementation guide, do not send.

CODE

DEFINITION

Add

Change (Update)

Replace

Use when requesting replacement cards with no change to data.

LX - PROVIDER INFORMATION

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

X12 Set Notes:

NOTE: Loop 2310 contains information about the primary care providers for the subscriber or the dependent, and about the beneficiaries of any employer-sponsored life insurance for the subscriber.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when information about the primary care or other provider (for example pharmacy) chosen by the enrollee is available in the information source system. If not required by this implementation guide, do not send.

TR3 Notes:

The LX segment must begin with one and is incremented by one for each additional health care service provider reported.

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/9

Number assigned for differentiation within a transaction set

This is a sequential number representing the number of loops for this insured person. Begin with 1 for each insured person.

NM1 - PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

X12 Set Notes:

NOTE: Either NM1 or N1 will be included depending on whether an individual or organization is being specified.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱P3✱1✱SMITH✱JOHN✱✱✱✱SV✱25341234567~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Obstetrics and Gynecology Facility

Use when an Obstetrician/Gynecologist is chosen.

Hospital

Doctor of Optometry

Primary Care Provider

Use when reporting a primary care physician related to the benefit coverage reported in HD03.

Pharmacy

Dentist

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Provider Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a middle name or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Middle Name

Not Used

1038

Name Prefix

O 1

1/10

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required when NM102 = 1 (person) and the person has a name suffix or initial of the person is needed to identify the individual. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Name Suffix

Required

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

CODE

DEFINITION

Employer's Identification Number

Social Security Number

Federal Taxpayer's Identification Number

Provider Commercial Number

Service Provider Number

Use when submitting a provider number assigned by the payer.

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

INDUSTRY NAME: Provider Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the location of the named provider needs to be reported based on the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Provider Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required if a second address line exists. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Address Line

N4 - PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the location of the named provider needs to be reported based on the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

INDUSTRY NAME: Provider City Name

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Provider Postal Zone or ZIP Code

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Country Code

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

INDUSTRY NAME: Provider Country Subdivision Code

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PER*IC - PROVIDER COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

To identify a person or office to whom administrative communications should be directed

X12 Syntax:

P0304
If either PER03 or PER04 is present, then the other is required.
P0506
If either PER05 or PER06 is present, then the other is required.
P0708
If either PER07 or PER08 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱IC✱✱WP✱80155504321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Contact Inq
Reference

1/20

Required

366

Contact Function Code

M 1

Code identifying the major duty or responsibility of the person or group named

CODE

DEFINITION

Information Contact

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Facsimile

Work Phone Number

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when a value is being reported in the PER06 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when a value is being reported in the PER08 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.

Not Used

443

Contact Inquiry Reference

O 1

1/20

PRV*OT - PROVIDER TAXONOMY INFORMATION

X12 Name:

Provider Information

X12 Purpose:

To specify the identifying characteristics of a provider

X12 Syntax:

P0203
If either PRV02 or PRV03 is present, then the other is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

PRV✱OT✱PXC✱2086H0002X~

PRV

✱

✱

✱

✱

✱

✱

Required

1221

Provider Code

M 1

1/3

Code identifying the type of provider

CODE

DEFINITION

Other Physician

Required

128

Reference Identification Qualifier

X 1

2/3

Code identifying the Reference Identification

SEGMENT SYNTAX: P0203

CODE

DEFINITION

PXC

Health Care Provider Taxonomy Code

CODE SOURCE: 682: Health Care Provider Taxonomy

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: P0203

INDUSTRY NAME: Provider Taxonomy Code

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

156

State or Province Code

O 1

Not Used

C035

Provider Specialty Information

O 1

Not Used

1223

Provider Organization Code

O 1

PLA - PROVIDER CHANGE REASON

X12 Name:

Place or Location

X12 Purpose:

To indicate action to be taken for the location specified and to qualify the location specified

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

If there is no change for this provider loop, use value ND in PLA01 and report the initial effective date in PLA03.

TR3 Example:

PLA✱2✱P3✱20150628~

PLA

✱

✱

✱

✱

✱

Required

306

Action Code

M 1

1/2

Code indicating type of action

CODE

DEFINITION

Add

Change (Update)

Delete

No Change

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Obstetrics and Gynecology Facility

Use when an Obstetrician/Gynecologist is chosen

Hospital

Doctor of Optometry

Primary Care Provider

Use when reporting a primary care physician related to the benefit coverage reported in HD03.

Pharmacy

Dentist

Required

373

Date

M 1

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

SEMANTIC: PLA03 is the effective date for the action identified in PLA01.

INDUSTRY NAME: Provider Effective Date

This is the effective date of the change of health care service provider

Not Used

337

Time

O 1

4/8

Not Used

1203

Maintenance Reason Code

O 1

2/3

COB - COORDINATION OF BENEFITS

X12 Name:

Coordination of Benefits

X12 Purpose:

To supply information on coordination of benefits

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement and the information source has information related to a member's separate policy or group number with similar coverage to the HD03 (Insurance Coverage Line) in Loop 2300. It not required by this implementation guide, do not send.

TR3 Notes:

If using this loop, the Information Source must identify their sequence as well as other payers' sequences.

TR3 Example:

COB✱P✱✱1~

COB

✱

1138

Payer Resp
Seq No Code

✱

✱

✱

Required

1138

Payer Responsibility Sequence Number Code

O 1

Code identifying the insurance carrier's level of responsibility for a payment of a claim

CODE

DEFINITION

Primary

Secondary

Tertiary

Unknown

Not Used

127

Reference Identification

O 1

1/80

Required

1143

Coordination of Benefits Code

O 1

Code identifying whether there is a coordination of benefits

CODE

DEFINITION

Coordination of Benefits

No Coordination of Benefits

Use when the payer related to this iteration of Loop ID 2320 is the Information Source for this transaction.

Not Used

1365

Service Type Code

O 9

1/2

REF - ADDITIONAL COORDINATION OF BENEFITS IDENTIFIERS

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6P✱AZ12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Member Identification Number

Account Suffix Code

Group Number

Provider Identifier

Social Security Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*344 - COORDINATION OF BENEFITS BEGIN DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱344✱D8✱20150401~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

344

Coordination of Benefits Begin

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Coordination of Benefits Begin Date

DTP*345 - COORDINATION OF BENEFITS END DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when available in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱345✱D8✱20150401~

DTP

✱

✱

Loop 2330 - COORDINATION OF BENEFITS RELATED PAYER

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

345

Coordination of Benefits End

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Coordination of Benefits End Date

NM1 - COORDINATION OF BENEFITS RELATED PAYER

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

P0809
If either NM108 or NM109 is present, then the other is required.
C1110
If NM111 is present, then NM110 is required.
C1203
If NM112 is present, then NM103 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement and available in the Information Source's system. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱IN✱2✱ABC INSURANCE CO~

NM1

✱

✱

Loop 2330 - COORDINATION OF BENEFITS RELATED PAYER

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

Employer

Group

Insurer

Payer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Situational

Identification Code Qualifier

X 1

1/2

Code specifying the system/method of code structure used for Identification Code (67)

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when a value is being reported in the NM109 element. If not required by this implementation guide, do not send.

CODE

DEFINITION

Employer's Identification Number

Federal Taxpayer's Identification Number

National Association of Insurance Commissioners (NAIC) Identification

Standard Unique Health Plan Identifier (HPID)

Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

CODE SOURCE: 540: Health Plan Identifier (HPID)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when supplied by the employee to the sponsor. If not required by this implementation guide, do not send.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - COORDINATION OF BENEFITS RELATED PAYER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement and available in the information source's system. If not required by this implementation guide, do not send.

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required if a second address line exists. If not required by this implementation guide, do not send.

N4 - COORDINATION OF BENEFITS RELATED PAYER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
E0308
Only one of N403 or N408 may be present.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop 2330 - COORDINATION OF BENEFITS RELATED PAYER

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when N3 segment is sent. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.

Situational

156

State or Province Code

X 1

Code specifying the Standard State/Province as defined by appropriate government agency

SEGMENT SYNTAX: E0207

SITUATIONAL RULE: Required when the address is in the United States of America, including its territories, or Canada. If not required by this implementation guide, do not send.

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

Code specifying international postal zone code excluding punctuation and blanks (zip code for United States)

SEGMENT SYNTAX: E0308

CODE SOURCE 51: ZIP Code
CODE SOURCE 932: Universal Postal Codes

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

SITUATIONAL RULE: Required when the address is outside the United States of America. If not required by this implementation guide, do not send.

Use the alpha-2 country codes from Part 1 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

Use the country subdivision codes from Part 2 of ISO 3166.

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

LS - ADDITIONAL REPORTING CATEGORIES

X12 Name:

Loop Header

X12 Purpose:

To indicate that the next segment begins a loop

X12 Comments:

See Figures Appendix for an explanation of the use of the LS and LE segments.

Loop:

Loop 2700 - MEMBER REPORTING CATEGORIES

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send.

TR3 Example:

LS✱2700~

✱

Required

447

Loop Identifier Code

M 1

1/6

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

Use the value 2700.

LX - MEMBER REPORTING CATEGORIES

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send.

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/9

Number assigned for differentiation within a transaction set

Use this sequential non-negative integer for LX loops for this member's additional reporting categories.

N1*IAE - REPORTING CATEGORY

X12 Name:

Party Identification

X12 Purpose:

To identify a party by type of organization, name, and code

X12 Syntax:

R0203
At least one of N102 or N103 is required.
P0304
If either N103 or N104 is present, then the other is required.
C0703
If N107 is present, then N103 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱IAE✱SOUTHEASTERN UNION~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

Code identifying an organizational entity, a physical location, property or an individual

CODE

DEFINITION

IAE

Member

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Reporting Category Name

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

REF - REPORTING CATEGORY REFERENCE

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱26✱442✱LOCAL UNION~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Contracting District Number

Client Reporting Category

Plan Number

Division Identifier

Union Number

Case Number

Branch Identifier

Application Number

Payment Category

Account Category

Geographic Number

Location Number

PID

Program Identification Number

XX1

Special Program Code

XX2

Service Area Code

Geographic Key

Mutually Defined

Use when established by the Trading Partner Agreement.

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Reporting Category Reference ID

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Situational

352

Description

X 1

1/80

A free-form description to clarify the related data elements and their content

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Reporting Category Reference ID

Not Used

C040

Reference Identifier

O 1

REF*F8 - MEMBER RECORD CONTROL NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Notes:

Used when a trading partner must assign a unique number (not PHI or PII) to a member's record for reporting.

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Original Reference Number

Required

127

Reference Identification

X 1

1/80

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

SEGMENT SYNTAX: R0203

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*007 - REPORTING CATEGORY DATE

X12 Name:

Date or Time or Period

X12 Purpose:

To specify any or all of a date, a time, or a time period

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified by the terms of the Trading Partner Agreement. If not required by this implementation guide, do not send.

TR3 Notes:

Use this segment to associate a date or date range with a reporting category.

TR3 Example:

DTP✱007✱RD8✱20150101-20150531~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

Code specifying type of date or time, or both date and time

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

A range of dates expressed in the format CCYYMMDD-CCYYMMDD where CCYY is the numerical expression of the century CC and year YY. MM is the numerical expression of the month within the year, and DD is the numerical expression of the day within the year; the first occurrence of CCYYMMDD is the beginning date and the second occurrence is the ending date.

Required

1251

Date Time Period

M 1

1/35

Expression of a date, a time, or range of dates, times or dates and times

INDUSTRY NAME: Member Reporting Category Effective Date(s)

LE - ADDITIONAL REPORTING CATEGORIES LOOP TERMINATION

X12 Name:

Loop Trailer

X12 Purpose:

To indicate that the loop immediately preceding this segment is complete

X12 Comments:

See Figures Appendix for an explanation of the use of the LE and LS segments.

Loop: