834 Transaction Set Listing
008020X333 Benefit Enrollment and MaintenanceUsage
Repeats
- Loop 1000A - SPONSOR NAMERequired1
- Loop 1000B - PAYERRequired1
- Loop 1000C - TPA/BROKER NAMESituational2
- Loop 1100C - TPA/BROKER ACCOUNT INFORMATIONSituational1
- Loop 2000 - MEMBER LEVEL DETAILRequired>1
- Loop 2100A - MEMBER NAMERequired1
- Loop 2100B - INCORRECT MEMBER NAMESituational1
- Loop 2100C - MEMBER MAILING ADDRESSSituational1
- Loop 2100D - MEMBER EMPLOYERSituational3
- Loop 2100E - MEMBER SCHOOLSituational3
- Loop 2100F - CUSTODIAL PARENTSituational1
- Loop 2100G - RESPONSIBLE PERSONSituational13
- Loop 2100H - DROP OFF LOCATIONSituational1
- Loop 2200 - DISABILITY INFORMATIONSituational>1
- Loop 2300 - HEALTH COVERAGESituational99
- Loop 2310 - PROVIDER INFORMATIONSituational30
- Loop 2320 - COORDINATION OF BENEFITSSituational10
- Loop 2330 - COORDINATION OF BENEFITS RELATED ENTITYSituational3
- Loop 2500 - TAX ADVANTAGE ACCOUNTSituational10
- Loop 2700 - MEMBER REPORTING CATEGORIESSituational>1
- Loop 2750 - REPORTING CATEGORYRequired1
ISA - INTERCHANGE CONTROL HEADER
X12 Name:
Interchange Control Header
X12 Purpose:
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
- For compliant implementations under this implementation guide, ISA13, the interchange Control Number, must be a positive unsigned number. Therefore, the ISA segment can be considered a fixed record length segment.
- The first element separator defines the element separator to be used through the entire interchange.
- Spaces in the example interchanges are represented by "." for clarity.
- The ISA segment terminator defines the segment terminator used throughout the entire interchange.
- All positions within each of the data elements must be filled.
TR3 Example:
ISA✱00✱..........✱01✱SECRET....✱ZZ✱SENDERS.ID.....✱ZZ✱RECEIVERS.ID...✱030101✱1253✱^✱00802✱000000905✱0✱T✱:~
ISA
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
I01
Authorization Information Qualifier
M 1
ID
2
Code identifying the type of information in the Authorization Information
CODE
DEFINITION
00
No Authorization Information Present (No Meaningful Information in I02)
03
Additional Data Identification
Required
2
I02
Authorization Information
M 1
AN
10
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
This element is fixed in length with identical minimum and maximum lengths. Spaces are inserted to meet the minimum length in an AN data element. With the associated code 00 in ISA01 or ISA03, an all space value indicates no information.
Required
3
I03
Security Information Qualifier
M 1
ID
2
Code identifying the type of information in the Security Information
CODE
DEFINITION
00
No Security Information Present (No Meaningful Information in I04)
01
Password
Required
4
I04
Security Information
M 1
AN
10
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
This element is fixed in length with identical minimum and maximum lengths. Spaces are inserted to meet the minimum length in an AN data element. With the associated code 00 in ISA01 or ISA03, an all space value indicates no information.
Required
5
I05
Interchange ID Qualifier
M 1
ID
2
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
This ID qualifies the Sender in ISA06.
CODE
DEFINITION
01
Duns (Dun & Bradstreet)
14
Duns Plus Suffix
20
Health Industry Number (HIN)
CODE SOURCE: 121: Health Industry Number
27
Carrier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
28
Fiscal Intermediary Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
29
Medicare Provider and Supplier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
30
U.S. Federal Tax Identification Number
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
Required
6
I06
Interchange Sender ID
M 1
AN
15
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Required
7
I05
Interchange ID Qualifier
M 1
ID
2
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
This ID qualifies the Receiver in ISA08.
CODE
DEFINITION
01
Duns (Dun & Bradstreet)
14
Duns Plus Suffix
20
Health Industry Number (HIN)
CODE SOURCE: 121: Health Industry Number
27
Carrier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
28
Fiscal Intermediary Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
29
Medicare Provider and Supplier Identification Number as assigned by Centers for Medicare & Medicaid Services (CMS)
30
U.S. Federal Tax Identification Number
33
National Association of Insurance Commissioners Company Code (NAIC)
ZZ
Mutually Defined
Required
8
I07
Interchange Receiver ID
M 1
AN
15
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Required
9
I08
Interchange Date
M 1
DT
6
Date of the interchange
The date format is YYMMDD.
Required
10
I09
Interchange Time
M 1
TM
4
Time of the interchange
The time format is HHMM.
Required
11
I65
Repetition Separator
M 1
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
Required
12
I11
Interchange Control Version Number Code
M 1
ID
5
Code specifying the version number of the interchange control segments, the version of the data elements within the control segments, and the code values within those data elements.
INDUSTRY NAME: Interchange Control Version Number
CODE
DEFINITION
00802
00802 Standards Approved for Publication by ASC X12 Procedures Review Board through December 2020
Required
13
I12
Interchange Control Number
M 1
N
9
A control number assigned by the interchange sender
- The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.
- Must be a positive unsigned number and must be identical to the value in IEA02.
Required
14
I13
Acknowledgment Requested Code
M 1
ID
1
Code indicating sender's request for an interchange acknowledgment
INDUSTRY NAME: Acknowledgment Requested
X12.5 - Interchange Control Structure provides the purpose of the TA1 segment. The X12 Acknowledgment Reference Model provides considerable information about the TA1 segment.
CODE
DEFINITION
0
No Interchange Acknowledgment Requested
Use when the interchange contains ONLY acknowledgment Functional Groups (e.g. 999 or 824) or a TA1.
1
Interchange Acknowledgment Requested (TA1)
Use when batch process requires the return of a TA1 for the interchange.
2
Interchange Acknowledgment Requested only when Interchange is "Rejected Because Of Errors"
Use when the transaction is for real-time processing.
3
Interchange Acknowledgment Requested only when Interchange is "Rejected Because Of Errors" or "Accepted but Errors are Noted"
Use when batch processing requires the return of a TA1 for the interchange only when errors are noted.
Required
15
I14
Interchange Usage Indicator Code
M 1
ID
1
Code indicating whether data enclosed by this interchange envelope is test, production or information
INDUSTRY NAME: Interchange Usage Indicator
CODE
DEFINITION
I
Information
Use when the interchange contains ONLY a TA1.
P
Production Data
T
Test Data
Required
16
I15
Component Element Separator
M 1
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
GS*BE - FUNCTIONAL GROUP HEADER
X12 Name:
Functional Group Header
X12 Purpose:
To indicate the beginning of a functional group and to provide control information
X12 Comments:
A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of similar transaction sets enclosed by a functional group header and a functional group trailer.
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
GS✱XX✱SENDER CODE✱RECEIVER CODE✱19991231✱0802✱1✱X✱008020X333~
GS
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
479
Functional Identifier Code
M 1
ID
2
Code identifying a group of application related transaction sets
This is the 2-character Functional Identifier Code assigned to each transaction set by X12. The specific code for a transaction set defined by this implementation guide is presented in Section 1.2, Version Information.
CODE
DEFINITION
BE
Benefit Enrollment and Maintenance (834)
Required
2
142
Application Sender's Code
M 1
AN
2/15
Code identifying party sending transmission; codes agreed to by trading partners
Use this code to identify the unit sending the information.
Required
3
124
Application Receiver's Code
M 1
AN
2/15
Code identifying party receiving transmission; codes agreed to by trading partners
Use this code to identify the unit receiving the information.
Required
4
373
Date
M 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: GS04 is the group date.
Use this date for the functional group creation date.
Required
5
337
Time
M 1
TM
4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: GS05 is the group time.
Use this time for the creation time. The recommended format is HHMM.
Required
6
28
Group Control Number
M 1
N
1/9
Assigned number originated and maintained by the sender
SEMANTIC: The data interchange control number GS06 in this header must be identical to the same data element in the associated functional group trailer, GE02.
For implementations compliant with this guide, GS06 must be unique within a single transmission (that is, within a single ISA to IEA enveloping structure). The authors recommend that GS06 be unique within all transmissions over a period of time to be determined by the sender.
Required
7
455
Responsible Agency Code
M 1
ID
1/2
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
CODE
DEFINITION
X
Accredited Standards Committee X12
Required
8
480
Version / Release / Industry Identifier Code
M 1
AN
1/12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
INDUSTRY NAME: Version, Release, or Industry Identifier Code
This is the unique Version/Release/Industry Identifier Code assigned to an implementation by X12N. The specific code for a transaction set defined by this implementation guide is presented in Section 1.2, Version Information.
CODE SOURCE 881: Version / Release / Industry Identifier Code
CODE
DEFINITION
008020X333
Benefit Enrollment and Maintenance
ST*834 - TRANSACTION SET HEADER
X12 Name:
Transaction Set Header
X12 Purpose:
To indicate the start of a transaction set and to assign a control number
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
ST✱834✱0002✱008020X333~
ST
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
143
Transaction Set Identifier Code
M 1
ID
3
Code identifying a Transaction Set
SEMANTIC: The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
CODE
DEFINITION
834
Benefit Enrollment and Maintenance
Required
2
329
Transaction Set Control Number
M 1
AN
4/9
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
The Transaction Set Control Numbers in ST02 and SE02 must be identical and must be a numeric value. The number (i.e. numeric value) is assigned by the originator and must be unique within a functional group (GS-GE). For example, start with the numeric value 0001 and increment from there. The Transaction Set Control Number also aids in error resolution research.
Required
3
1705
Implementation Convention Reference
O 1
AN
1/35
Reference assigned to identify Implementation Convention
SEMANTIC: The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with the guide identifier named in Section 1.2.
- This field contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
CODE
DEFINITION
008020X333
Benefit Enrollment and Maintenance
BGN - BEGINNING SEGMENT
X12 Name:
Beginning Segment
X12 Purpose:
To indicate the beginning of a transaction set
X12 Syntax:
C0504
If BGN05 is present, then BGN04 is required.
If BGN05 is present, then BGN04 is required.
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
BGN✱00✱11227✱20220920✱1200✱ES✱✱✱2~
BGN
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
353
Transaction Set Purpose Code
M 1
ID
2
Code identifying purpose of transaction set
CODE
DEFINITION
00
Original
Use when the transaction is being sent for the first time.
Explanation: If the original transaction has already been processed, an incoming transaction using this code may be rejected by the receiver. The rejection will be identified to the sender by telephone or other direct contact.
Explanation: If the original transaction has already been processed, an incoming transaction using this code may be rejected by the receiver. The rejection will be identified to the sender by telephone or other direct contact.
15
Re-Submission
Use when the original transmission was incorrect, has yet to be processed by the receiver, and a new corrected transmission is being sent. This transmission can be pended by the receiver's translator for further review.
22
Information Copy
Use when the original transmission was lost or not processed, and the sender is passing another transmission that is the same as the original.
Required
2
127
Reference Identification
M 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEMANTIC: BGN02 is the transaction set reference number.
INDUSTRY NAME: Transaction Set Reference Number
- This element is the transaction set reference number assigned by the sender's application. It uniquely identifies this occurrence of the transaction for future reference.
- Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Required
3
373
Date
M 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SEMANTIC: BGN03 is the transaction set date.
INDUSTRY NAME: Transaction Set Creation Date
This element identifies the date that the submitter created the file.
Required
4
337
Time
X 1
TM
4/8
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
SEMANTIC: BGN04 is the transaction set time.
SEGMENT SYNTAX: C0504
INDUSTRY NAME: Transaction Set Creation Time
This element is used as a time stamp to uniquely identify the transmission.
Situational
5
623
Time Code
O 1
ID
2
Code identifying the time. In accordance with International Standards Organization standard 8601, time can be specified by a + or - and an indication in hours in relation to Universal Time Coordinate (UTC) time; since + is a restricted character, + and - are substituted by P and M in the codes that follow
SEMANTIC: BGN05 is the transaction set time qualifier.
SEGMENT SYNTAX: C0504
SITUATIONAL RULE: Required when the sender and receiver are not in the same time zone. If not required by this implementation guide, do not send.
INDUSTRY NAME: Time Zone Code
CODE SOURCE 94: International Organization for Standardization (Date and Time)
CODE
DEFINITION
01
Equivalent to ISO P01
02
Equivalent to ISO P02
03
Equivalent to ISO P03
04
Equivalent to ISO P04
05
Equivalent to ISO P05
06
Equivalent to ISO P06
07
Equivalent to ISO P07
08
Equivalent to ISO P08
09
Equivalent to ISO P09
10
Equivalent to ISO P10
11
Equivalent to ISO P11
12
Equivalent to ISO P12
13
Equivalent to ISO M12
14
Equivalent to ISO M11
15
Equivalent to ISO M10
16
Equivalent to ISO M09
17
Equivalent to ISO M08
18
Equivalent to ISO M07
19
Equivalent to ISO M06
20
Equivalent to ISO M05
21
Equivalent to ISO M04
22
Equivalent to ISO M03
23
Equivalent to ISO M02
24
Equivalent to ISO M01
AD
Alaska Daylight Time
AS
Alaska Standard Time
CD
Central Daylight Time
CS
Central Standard Time
CT
Central Time
ED
Eastern Daylight Time
ES
Eastern Standard Time
ET
Eastern Time
GM
Greenwich Mean Time
HD
Hawaii-Aleutian Daylight Time
HS
Hawaii-Aleutian Standard Time
HT
Hawaii-Aleutian Time
LT
Local Time
MD
Mountain Daylight Time
MS
Mountain Standard Time
MT
Mountain Time
ND
Newfoundland Daylight Time
NS
Newfoundland Standard Time
NT
Newfoundland Time
PD
Pacific Daylight Time
PS
Pacific Standard Time
PT
Pacific Time
TD
Atlantic Daylight Time
TS
Atlantic Standard Time
TT
Atlantic Time
UT
Universal Time Coordinate
Situational
6
127
Reference Identification
O 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEMANTIC: BGN06 is the transaction set reference number of a previously sent transaction affected by the current transaction.
SITUATIONAL RULE: Required when there is a previously sent transaction to cross-reference. If not required by this implementation guide, do not send.
INDUSTRY NAME: Original Transaction Set Reference Number
Not Used
7
640
Transaction Type Code
O 1
ID
2
Required
8
306
Action Code
O 1
ID
1/2
Code indicating type of action
See Section 1.4.6, Update, Versus Full File Audits, Versus Full File Replacements, for additional information.
CODE
DEFINITION
2
Change (Update)
Use when this transaction contains additions, terminations and changes to the current enrollment.
4
Verify
Use when sending a full enrollment transaction to verify that the sponsor's and payer's systems are synchronized.
RX
Replace
Use when sending a full enrollment transaction containing additions, terminations and changes that need to be applied to the payer's enrollment system.
Not Used
9
786
Security Level Code
O 1
ID
2
REF*38 - TRANSACTION SET POLICY NUMBER
X12 Name:
Reference Information
X12 Purpose:
To specify identifying information
X12 Syntax:
R0203
At least one of REF02 or REF03 is required.
At least one of REF02 or REF03 is required.
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when a Master Policy Number is specified by the insurance contract or trading partner agreement OR when the sender specifies a unique ID Number which applies to the group within this transaction set. If not required by this implementation guide, do not send.
TR3 Notes:
The definition of the Master Policy Number is determined by the issuer of the policy, the Payer/Plan Administrator. The Master Policy Number may be used to meet various business needs such as indicating the line of business under which the policy is defined.
TR3 Example:
REF✱38✱123456~
REF
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
38
Master Policy Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Master Policy Number
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
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1
DTP - FILE 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
Segment Usage:
Situational
Segment Repeat:
>1
Situational Rule:
Required when specified in the insurance contract or trading partner agreement. If not required by this implementation guide, do not send.
TR3 Example:
DTP✱007✱D8✱20221001~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
007
Effective
090
Report Start
091
Report End
303
Maintenance Effective
382
Enrollment
388
Payment Commencement
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
QTY - TRANSACTION SET CONTROL TOTALS
X12 Name:
Quantity Information
X12 Purpose:
To specify quantity information
X12 Syntax:
- R0204
At least one of QTY02 or QTY04 is required. - E0204
Only one of QTY02 or QTY04 may be present.
X12 Set Notes:
NOTE: The QTY segment is used to record the total number of subscribers and dependents in the transaction set.
Segment Usage:
Situational
Segment Repeat:
3
Situational Rule:
Required when specified in the insurance contract or trading partner agreement. If not required by this implementation guide, do not send.
TR3 Notes:
- This is intended to submit the total number of members within the file.
- The QTY02 values, when QTY01 = ET plus when QTY01 = DT, equals the QTY02 value when QTY01 = TO.
Count values: QTY02 + QTY02 = QTY02
When QTY01 = ET + DT = TO - Since an individual member's record may be transmitted more than once within the ST-SE, the quantity in QTY02 when QTY01 = TO, does not necessarily reflect a count of unique member records.
TR3 Example:
QTY✱TO✱10000~
QTY
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
673
Quantity Qualifier
M 1
ID
2
Code specifying the type of quantity
CODE
DEFINITION
DT
Dependent Total
Use when quantifying the total number of dependents (INS01 = N) within the ST-SE.
ET
Employee Total
Use when quantifying the total number of subscribers (INS01 = Y) within the ST-SE.
TO
Total
Use when quantifying the total number of Member Level Detail (2000 Loops) within the ST-SE.
Required
2
380
Quantity
X 1
R
1/15
Numeric value of quantity
SEGMENT SYNTAX: R0204, E0204
INDUSTRY NAME: Record Totals
Not Used
3
C001
Composite Unit of Measure
O 1
Not Used
4
61
Free-form Information
X 1
AN
1/30
N1*P5 - SPONSOR 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:
1
TR3 Notes:
This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.
TR3 Example:
N1✱P5✱✱FI✱12356799~
N1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
P5
Plan Sponsor
Situational
2
93
Name
X 1
AN
1/60
Free-form name
SEGMENT SYNTAX: R0203
SITUATIONAL RULE: Required when specified in the Insurance Contract or Trading Partner Agreement. If not required by this implementation guide, do not send.
INDUSTRY NAME: Plan Sponsor Name
Required
3
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: R0203, P0304, C0703
CODE
DEFINITION
24
Employer's Identification Number
Use when the identifier is the Employer Identification Number (EIN) issued by the IRS. The EIN has been adopted as the HIPAA Standard Unique Employer Identifier.
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
Required
4
67
Identification Code
X 1
AN
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: Sponsor Identifier
Not Used
5
706
Entity Relationship Code
O 1
ID
2
Not Used
6
98
Entity Identifier Code
O 1
ID
2/3
Not Used
7
C076
Composite Identification Codes
O 1
N1*IN - PAYER
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:
1
TR3 Notes:
This loop identifies the payer. See section 1.5 for the definition of payer.
TR3 Example:
N1✱IN✱✱FI✱99356791~
N1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
IN
Insurer
Situational
2
93
Name
X 1
AN
1/60
Free-form name
SEGMENT SYNTAX: R0203
SITUATIONAL RULE: Required when specified in the Insurance Contract or Trading Partner Agreement. If not required by this implementation guide, do not send.
INDUSTRY NAME: Insurer Name
Required
3
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: R0203, P0304, C0703
CODE
DEFINITION
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
XV
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)
Required
4
67
Identification Code
X 1
AN
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: Insurer Identification Code
Not Used
5
706
Entity Relationship Code
O 1
ID
2
Not Used
6
98
Entity Identifier Code
O 1
ID
2/3
Not Used
7
C076
Composite Identification Codes
O 1
N1 - TPA/BROKER 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:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when a TPA or a Broker is involved in this enrollment. See section 1.5 for definitions. If not required by this implementation guide, do not send.
TR3 Example:
N1✱TV✱MONEY TALKS BROKERAGE✱FI✱123356799~
N1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
BO
Broker or Sales Office
TV
Third Party Administrator (TPA)
Required
2
93
Name
X 1
AN
1/60
Free-form name
SEGMENT SYNTAX: R0203
INDUSTRY NAME: TPA or Broker Name
Required
3
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: R0203, P0304, C0703
CODE
DEFINITION
94
Code assigned by the organization that is the ultimate destination of the transaction set
FI
Federal Taxpayer's Identification Number
XV
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)
Required
4
67
Identification Code
X 1
AN
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: TPA or Broker Identification Code
Not Used
5
706
Entity Relationship Code
O 1
ID
2
Not Used
6
98
Entity Identifier Code
O 1
ID
2/3
Not Used
7
C076
Composite Identification Codes
O 1
ACT - TPA/BROKER ACCOUNT INFORMATION
X12 Name:
Account Identification
X12 Purpose:
To specify account information
X12 Syntax:
- P0304
If either ACT03 or ACT04 is present, then the other is required. - C0506
If ACT05 is present, then ACT06 is required. - C0705
If ACT07 is present, then ACT05 is required.
Loop:
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when the account number of the TPA or Broker is different than the account number for the sponsor. If not required by this implementation guide, do not send.
TR3 Example:
ACT✱1234✱✱✱✱✱23498765~
ACT
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
508
Account Number
M 1
AN
1/35
Account number assigned
INDUSTRY NAME: TPA or Broker Account Number
Not Used
2
93
Name
O 1
AN
1/60
Not Used
3
66
Identification Code Qualifier
X 1
ID
1/2
Not Used
4
67
Identification Code
X 1
AN
2/80
Not Used
5
569
Account Number Qualifier
X 1
ID
1/3
Situational
6
508
Account Number
X 1
AN
1/35
Account number assigned
COMMENT: ACT06 is an account associated with the account in ACT01.
SEGMENT SYNTAX: C0506
SITUATIONAL RULE: Required when more than 1 TPA or Broker Account Number applies to this transaction. If not required by this implementation guide, do not send.
INDUSTRY NAME: TPA or Broker Account Number
Not Used
7
352
Description
O 1
AN
1/80
Not Used
8
107
Payment Method Type Code
O 1
ID
1/2
Not Used
9
1216
Benefit Status Code
O 1
ID
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.
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:
1
TR3 Notes:
Subscriber information must precede the initial enrollment of dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission.
TR3 Example:
INS✱Y✱18✱021✱28✱A✱✱✱FT~
INS
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1073
Yes/No Condition or Response Code
M 1
ID
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: Member Indicator
CODE
DEFINITION
N
No
Y
Yes
Required
2
1069
Individual Relationship Code
M 1
ID
2
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
01
Spouse
03
Father or Mother
04
Grandfather or Grandmother
05
Grandson or Granddaughter
06
Uncle or Aunt
07
Nephew or Niece
08
Cousin
09
Adopted Child
10
Foster Child
11
Son-in-law or Daughter-in-law
12
Brother-in-law or Sister-in-law
13
Mother-in-law or Father-in-law
14
Brother or Sister
15
Ward
16
Stepparent
17
Stepson or Stepdaughter
18
Self
19
Child
23
Sponsored Dependent
Use when the dependent is age 26 or older; qualifications may vary depending on policy.
24
Dependent of a Minor Dependent
25
Ex-spouse
26
Guardian
31
Court Appointed Guardian
38
Collateral Dependent
Use when the dependent is a relative related by blood or marriage who resides in the home and depends on the insured for a major portion of their support.
53
Life Partner
Use when indicating a partner that acts like a spouse without a legal marriage commitment.
60
Annuitant
D2
Trustee
G8
Other Relationship
G9
Other Relative
Required
3
875
Maintenance Type Code
O 1
ID
3
Code identifying the specific type of item maintenance
CODE
DEFINITION
001
Change
Use when changing an existing subscriber or dependent record.
021
Addition
Use when adding a subscriber or dependent.
024
Cancellation or Termination
Use when reporting a termination of a subscriber or dependent.
025
Reinstatement
Use when reporting a reinstatement of a cancelled subscriber or dependent record.
030
Audit or Compare
Use when sending a full file (BGN08 = '4' or 'RX') to verify that the sponsor and payer databases are synchronized. See Section 1.4.6, Updates, Versus Full File Audits, Versus Full File Replacements, for additional information.
123
Canceled by Administrator
124
Canceled by Insured
Situational
4
1203
Maintenance Reason Code
O 1
ID
2/3
Code identifying the reason for the maintenance change
SITUATIONAL RULE: Required when obligated by the insurance contract to send the member maintenance reason. If not required by this implementation guide, do not send.
CODE
DEFINITION
01
Divorce
02
Birth
03
Death
04
Retirement
05
Adoption
06
Strike
07
Termination of Benefits
08
Termination of Employment
09
Consolidation Omnibus Budget Reconciliation Act (COBRA)
10
Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
11
Surviving Spouse
14
Voluntary Withdrawal
15
Primary Care Provider (PCP) Change
16
Quit
17
Fired
18
Suspended
20
Active
21
Disability
22
Plan Change
Use when a member changes from one Plan to a different Plan. This is not intended to report changes to a Plan.
25
Change in Identifying Data Elements
Use when a change has been made to the primary elements that identify a member. Such primary elements include the following: first name, last name, Social Security Number, date of birth, and employee identification number.
26
Declined Coverage
Use when a member declined to continue a previously active coverage.
27
Pre-Enrollment
Use when enrolling newborns prior to receiving the newborn's application.
28
Initial Enrollment
Use when reporting the member selected coverage with the Plan Sponsor for the first time.
29
Benefit Selection
Use when a member changes benefits within a Plan.
31
Legal Separation
32
Marriage
33
Personnel Data
Use when changing any data that is not included in any of the other allowed codes. An example would be change in Coordination of Benefits information.
37
Leave of Absence with Benefits
38
Leave of Absence without Benefits
39
Lay Off with Benefits
40
Lay Off without Benefits
41
Re-enrollment
43
Change of Location
Use when reporting a change of address.
59
Non Payment
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
AJ
Appointment Times not Met in a Timely Manner
AL
Algorithm Assigned Benefit Selection
EC
Member Benefit Selection
Use when reporting an initial and subsequent enrollment when an insurance carrier needs to recognize that a member made an explicit plan choice.
XN
Notification Only
Use when sending a complete enrollment transmission, for the full file audit.
XT
Transfer
Use when a member has an organizational change (i.e. a location change within the organization) with no change in benefits or plan.
Required
5
1216
Benefit Status Code
O 1
ID
1
Code identifying the type of coverage under which benefits are paid
CODE
DEFINITION
A
Active
C
Consolidated Omnibus Budget Reconciliation Act (COBRA)
S
Surviving Insured
T
Tax Equity and Fiscal Responsibility Act (TEFRA)
Situational
6
C052
Medicare Status Code
O 1
To provide Medicare coverage and associated reason for Medicare eligibility
SITUATIONAL RULE: Required when a member is being enrolled or disenrolled in Medicare, is currently in Medicare or has terminated or changed their Medicare enrollment. If not required by this implementation guide, do not send.
Required
6-1
1218
Medicare Plan Code
M 1
ID
1
Code identifying the Medicare Plan
CODE
DEFINITION
A
Medicare Part A
B
Medicare Part B
C
Medicare Part A and B
D
Medicare
E
No Medicare
F
Medicare Part D
G
Medicare Part A and D
H
Medicare Part B and D
I
Medicare Part A, B and D
Situational
6-2
1701
Eligibility Reason Code
O 1
ID
1
Code specifying reason for eligibility
SITUATIONAL RULE: Required when the reason for Medicare is provided to the sponsor by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Medicare Eligibility Reason Code
CODE
DEFINITION
0
Age
1
Disability
2
End Stage Renal Disease (ESRD)
Not Used
6-3
1701
Eligibility Reason Code
O 1
ID
1
Not Used
6-4
1701
Eligibility Reason Code
O 1
ID
1
Situational
7
1219
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying
O 1
ID
1/2
Code identifying a qualifying event which results in loss of coverage for a Qualified Beneficiary
SITUATIONAL RULE: Required when a member is being enrolled in or is enrolled for a benefit covered by COBRA. If not required by this implementation guide, do not send.
INDUSTRY NAME: Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code
CODE
DEFINITION
1
Termination of Employment
2
Reduction of work hours
3
Medicare
4
Death
5
Divorce
6
Separation
7
Ineligible Child
8
Bankruptcy of Retiree's Former Employer (26 U.S.C. 4980B(f)(3)(F))
9
Layoff
10
Leave of Absence
ZZ
Mutually Defined
Situational
8
584
Employment Status Code
O 1
ID
2
Code indicating the general employment status of an employee/claimant
SITUATIONAL RULE: Required when the member is the subscriber. If not required by this implementation guide, do not send.
If this insurance enrollment is through a non-employment based program such as Medicare or Medicaid then this data element will contain the status of the subscriber in that program, rather than their employment status. Codes for non-employment based programs will be limited to "AC", Active and "TE", Terminated.
CODE
DEFINITION
AC
Active
AO
Active Military - Overseas
AU
Active Military - USA
FT
Full-time
Use when the subscriber is a full-time active employee.
IA
Inactive
Use when the subscriber has employer coverage but does not meet the definition of an active employee e.g. full-time, part-time, etc. For example this would be someone on long term disability who still has employer sponsored coverage.
L1
Leave of Absence
PT
Part-time
Use when the subscriber is a part-time active employee.
RT
Retired
TE
Terminated
Situational
9
1220
Student Status Code
O 1
ID
1
Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured
SITUATIONAL RULE: Required when describing a non-spouse dependent whose age requires a qualifying condition for enrollment (e.g., being an active student). If not required by this implementation guide, do not send.
CODE
DEFINITION
F
Full-time
N
Not a Student
P
Part-time
Situational
10
1073
Yes/No Condition or Response Code
O 1
ID
1
Code indicating a Yes or No condition or response
SEMANTIC: INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value indicates an individual is not handicapped.
SITUATIONAL RULE: Required when the member is handicapped or to correct a previous report of handicapped status. If not required by this implementation guide, do not send.
INDUSTRY NAME: Handicap Indicator
CODE
DEFINITION
N
No
Y
Yes
Situational
11
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Code indicating the date format, time format, or date and time format
SEGMENT SYNTAX: P1112
SITUATIONAL RULE: Required when the Insured Individual Death Date is sent in INS12. If not required by this implementation guide, do not send.
CODE
DEFINITION
D8
Date Expressed in Format CCYYMMDD
Situational
12
1251
Date Time Period
X 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
SEMANTIC: INS12 is the date of death.
SEGMENT SYNTAX: P1112
SITUATIONAL RULE: Required when the Insured is known to be deceased. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Individual Death Date
Situational
13
1165
Confidentiality Code
O 1
ID
1
Code indicating the access to insured information
SITUATIONAL RULE: Required when the member has specified the access to their information. If not required by this implementation guide, do not send.
CODE
DEFINITION
R
Restricted Access
U
Unrestricted Access
Not Used
14
19
City Name
O 1
AN
2/30
Not Used
15
156
State or Province Code
O 1
ID
2
Not Used
16
26
Country Code
O 1
ID
2/3
Situational
17
1470
Number
O 1
N
1/9
A generic number
SEMANTIC: INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
SITUATIONAL RULE: Required when reporting family members with the same birth date if a birth sequence number is needed for proper reporting, tracking or response to benefits. If not required by this implementation guide, do not send.
INDUSTRY NAME: Birth Sequence Number
Not Used
18
1792
Changed Identifying Information Code
O 20
ID
1/2
Not Used
19
1793
Provider Network Status Information Code
O 1
ID
1/2
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.
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:
1
TR3 Notes:
This segment must contain a unique SUBSCRIBER identification number (SSN or other). This occurrence is identified by the 0F qualifier (REF01). This identifier is used for linking the subscriber with dependents as required under many policies.
TR3 Example:
REF✱0F✱920399398~
REF
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
0F
Subscriber Number
Use when reporting the Subscriber Number designated within the insurance contract.
Required
2
127
Reference Identification
X 1
AN
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
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1
REF*1L - MEMBER POLICY NUMBER
X12 Name:
Reference Information
X12 Purpose:
To specify identifying information
X12 Syntax:
R0203
At least one of REF02 or REF03 is required.
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:
1
Situational Rule:
Required when the policy or group number applies to all coverage data (all 2300 Loops for this member). If not required by this implementation guide, do not send.
TR3 Notes:
The policy number passed in this segment is an attribute of the contract relationship between the plan sponsor (sender) and the payer (receiver) and not an attribute of an individual's participation in any coverage passed in an HD loop.
TR3 Example:
REF✱1L✱9CC4123~
REF
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
1L
Group or Policy Number
Use when reporting the payer's pre-assigned Group or Policy Number.
Required
2
127
Reference Identification
X 1
AN
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 Health Coverage Number
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
3
352
Description
X 1
AN
1/80
Not Used
4
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.
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:
13
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
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
17
Client Reporting Category
Use when further identification of a member is required under the insurance contract between the sponsor and the payer, and is allowed by federal and state regulations.
1W
Member Identification Number
23
Client Number
Use when reporting a payer specific identifier for a member.
3H
Case Number
4A
Personal Identification Number (PIN)
Use when reporting a password that is associated with the member's record.
6O
Cross Reference Number
Use when further identification of a member is required for reporting, indexing or other purpose as mutually agreed upon between the sender and receiver of the transaction set.
ABB
Personal ID Number
D3
National Council for Prescription Drug Programs Pharmacy Number
CODE SOURCE: 307: National Council for Prescription Drug Programs Pharmacy Provider Identification Number
DX
Department/Agency Number
Use when members in a coverage group are set up in different departments or divisions under the terms of the insurance policy.
F6
Health Insurance Claim (HIC) Number
NQ
Medicaid Recipient Identification Number
P5
Position Code
Use when reporting the title of the member's employment position.
Q4
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.
QQ
Unit Number
Use when members in a coverage group are set up in different units under the terms of the insurance policy. Units may exist within another grouping such as division or department.
ZD
Family Member Identification
ZZ
Mutually Defined
Use when reporting the Medicare Beneficiary Identifier (MBI).
Required
2
127
Reference Identification
X 1
AN
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
3
352
Description
X 1
AN
1/80
Not Used
4
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:
31
Situational Rule:
Required when enrolling a member or when the sponsor is informed of a change to any insurance contract applicable date listed in DTP01.
TR3 Example:
DTP✱356✱D8✱20211001~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
050
Received
Use when reporting the date an enrollment application is received.
286
Retirement
296
Initial Disability Period Return To Work
297
Initial Disability Period Last Day Worked
300
Enrollment Signature Date
301
Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event
303
Maintenance Effective
Use when reporting the effective date of a change to an existing member's information, excluding changes made in Loop 2300.
336
Employment Begin
337
Employment End
338
Medicare Begin
Use when the date is a Medicare Part C (Medicare Advantage) Coverage Effective Date
339
Medicare End
Use when the date is a Medicare Part C (Medicare Advantage) Coverage Termination Date.
340
Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
341
Consolidated Omnibus Budget Reconciliation Act (COBRA) End
350
Education Begin
Use when reporting the student's start date at the current educational institution.
351
Education End
Use when reporting the student's expected graduation date at the current educational institution.
356
Eligibility Begin
Use when reporting the date a member could elect to enroll or begin benefits in any health care plan. This is not the actual begin date of coverage, which is conveyed in Loop 2300 Health Coverage Dates DTP.
357
Eligibility End
Use when reporting the last date of coverage for which the member's claims will be paid. For example, if a date of 02/28/2014 is reported then claims for this member will be paid through 11:59 p.m. on 02/28/2014
383
Adjusted Hire
385
Credited Service Begin
Use when reporting the start date from which an employee's length of service will be calculated, as defined in the plan document.
386
Credited Service End
Use when reporting the end date through which an employee's length of service will be calculated, as defined in the plan document.
393
Plan Participation Suspension
394
Rehire
473
Medicaid Begin
474
Medicaid End
AEC
Medicare Part A Coverage Effective Date
AED
Medicare Part A Termination Date
AEG
Medicare Part B Coverage Effective Date
AEH
Medicare Part B Termination Date
AFC
Medicare Part D Coverage Effective Date
AFD
Medicare Part D Termination Date
W02
Status Change
Use when a status is reported in the Employment Status Code (INS08) and an effective date of that status is needed.
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Status Information Effective Date
DTP*903 - ONLINE APPLICATION DATE/TIME
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:
1
Situational Rule:
Required when the online application date and time of submission is captured by the application system and applies to all coverages being reported. If not required by this implementation guide, do not send.
TR3 Example:
DTP✱903✱UN✱08012021132732001~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
903
Application Entry
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
UN
Unstructured
Use when date and time (to the millisecond) is reported, following the format MMDDCCYYHHMMSSTTT where MM is the month (01 to 12), DD is the day in the month, CC is the century, YY is the year, HH is the hour of the day based on a twenty-four hour clock, MM is the minutes within an hour, SS is the seconds within the minute and TTT is the milliseconds within the seconds.
Required
3
1251
Date Time Period
M 1
AN
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:
1
TR3 Example:
NM1✱IL✱1✱SMITH✱JOHN✱M✱✱SR~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
This code identifies if this is a correction to a previous enrollment or if it is a new, or update, enrollment transaction.
CODE
DEFINITION
74
Corrected Insured
Use when correcting the identifier information on a member already enrolled. Usage of this code requires sending an NM101 with code '70' in loop 2100B, with the associated incorrect values.
IL
Insured or Subscriber
Use when enrolling a new member or updating a member with no change in identifying information. The identifying information for a member is specified under the insurance contract between the sponsor and payer.
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
Required
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Member Last Name
Situational
4
1036
Name First
O 1
AN
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
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when supplied by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Middle Name
Situational
6
1038
Name Prefix
O 1
AN
1/10
Prefix to individual name
SITUATIONAL RULE: Required when supplied by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Name Prefix
Situational
7
1039
Name Suffix
O 1
AN
1/10
Suffix to individual name
SITUATIONAL RULE: Required when supplied by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Name Suffix
Situational
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when a Member Identifier is known and allowed under confidentiality regulations.
CODE
DEFINITION
34
Social Security Number
Use when reporting a 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.
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.
II
Standard Unique Health Identifier for each Individual in the United States
TI
Individual Taxpayer's Identification Number (ITIN)
Situational
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when a Member Identifier is known and allowed under confidentiality regulations. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
PER*IP - MEMBER COMMUNICATIONS NUMBERS CONTACT INFORMATION
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:
5
Situational Rule:
Required when enrolling subscribers, dependents with different contact information, or when changing a member's contact information and the information is provided to the sponsor for the member. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
- Send communication information in the order of preference when contacting the member.
TR3 Example:
PER✱IP✱✱HP✱8015554321~
PER
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
IP
Insured Party
Not Used
2
93
Name
O 1
AN
1/60
Required
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
FX
Facsimile
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Required
4
364
Communication Number
X 1
AN
1/2048
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
Situational
5
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Situational
6
364
Communication Number
X 1
AN
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
7
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Situational
8
364
Communication Number
X 1
AN
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
9
443
Contact Inquiry Reference
O 1
AN
1/20
N3 - MEMBER ADDRESS
X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when enrolling subscribers or when enrolling dependents with an address different from the subscriber's or when changing a member's address. If not required by this implementation guide, do not send.
TR3 Example:
N3✱50 ORCHARD STREET~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: Member Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when 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:
1
Situational Rule:
Required when enrolling subscribers or when enrolling dependents with an address different from the subscriber's or when changing a member's address. If not required by this implementation guide, do not send.
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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
2
156
State or Province Code
X 1
ID
2
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
3
116
Postal Code
X 1
ID
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
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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
5
309
Location Qualifier
X 1
ID
1/2
Code identifying type of location
SEGMENT SYNTAX: C0605
SITUATIONAL RULE: Required when obligated by the insurance contract to report location area or country information. If not required by this implementation guide, do not send.
CODE
DEFINITION
60
Area
CY
County/Parish
Situational
6
310
Location Identifier
O 1
AN
1/30
Code which identifies a specific location
SEGMENT SYNTAX: C0605
SITUATIONAL RULE: Required when obligated by the insurance contract to report location area or country information. If not required by this implementation guide, do not send.
Situational
7
1715
Country Subdivision Code
X 1
ID
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
8
1702
Postal Code-Formatted
X 1
AN
3/20
DMG*D8 - MEMBER DEMOGRAPHIC INFORMATION
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:
Situational
Segment Repeat:
1
Situational Rule:
Required when enrolling a new member, changing a member's demographic information, or terminating a member. If not required by this implementation guide, may be provided at the sender's discretion but cannot be required by the receiver.
TR3 Example:
DMG✱D8✱19620915✱F✱M✱^RET^2054-5~
DMG
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Code indicating the date format, time format, or date and time format
SEGMENT SYNTAX: P0102
CODE
DEFINITION
D8
Date Expressed in Format CCYYMMDD
Required
2
1251
Date Time Period
X 1
AN
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
3
1068
Gender Code
O 1
ID
1
Code indicating the sex of the individual
CODE
DEFINITION
A
Not Provided
Use when the gender cannot be sent due to reporting restrictions.
B
Not Applicable
Use when member self-reports as transgender.
F
Female
M
Male
U
Unknown
Use when the gender is unknown.
Situational
4
1067
Marital Status Code
O 1
ID
1
Code specifying the marital status of a person
SITUATIONAL RULE: Required when such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide, do not send.
CODE
DEFINITION
B
Registered Domestic Partner
D
Divorced
I
Single
M
Married
R
Unreported
S
Separated
U
Unmarried (Single or Divorced or Widowed)
W
Widowed
X
Legally Separated
Situational
5
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.
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 obligated under the insurance contract and not restricted by federal or state regulations. If not required by this implementation guide, do not send.
Not Used
5-1
1109
Race or Ethnicity Code
O 1
ID
1
Required
5-2
1270
Code List Qualifier Code
X 1
ID
1/3
Code identifying a specific industry code list
COMPOSITE SYNTAX: P0203
CODE
DEFINITION
RET
Classification of Race or Ethnicity
CODE SOURCE: 859: Classification of Race or Ethnicity
Required
5-3
1271
Industry Code
X 1
AN
1/30
Code indicating a code from a specific industry code list
COMPOSITE SYNTAX: P0203
INDUSTRY NAME: Race or Ethnicity Code
Situational
6
1066
Citizenship Status Code
O 1
ID
1/2
Code indicating citizenship status
SITUATIONAL RULE: Required when the member is the subscriber; and this information is required under the insurance contract between the sponsor and payer; and is allowed by federal and state regulations.
CODE
DEFINITION
1
U.S. Citizen
2
Non-Resident Alien
3
Resident Alien
4
Illegal Alien
5
Alien
6
U.S. Citizen - Non-Resident
7
U.S. Citizen - Resident
Not Used
7
26
Country Code
O 1
ID
2/3
Not Used
8
659
Basis of Verification Code
O 1
ID
1/2
Not Used
9
380
Quantity
O 1
R
1/15
Situational
10
1270
Code List Qualifier Code
X 1
ID
1/3
Code identifying a specific industry code list
SEGMENT SYNTAX: P1011
SITUATIONAL RULE: Required when obligated under the insurance contract to specify how the Information in DMG05, including any repeats, was collected. If not required by this implementation guide, do not send.
CODE
DEFINITION
REC
Race or Ethnicity Collection Code
CODE SOURCE: 860: Race or Ethnicity Collection Code
Situational
11
1271
Industry Code
X 1
AN
1/30
Code indicating a code from a specific industry code list
SEMANTIC: DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
SEGMENT SYNTAX: P1011, C1105
SITUATIONAL RULE: Required when obligated under the insurance contract to specify how the Information in DMG05, including any repeats, was collected. If not required by this implementation guide, do not send.
INDUSTRY NAME: Race or Ethnicity Collection Code
Situational
12
26
Country Code
O 1
ID
2/3
Code identifying the country
SEMANTIC: DMG12 is the country of residence.
SITUATIONAL RULE: Required when the insurance contract or trading partner agreement specifies that the country of birth be reported. If not required by this implementation guide do not send.
INDUSTRY NAME: Country of Birth Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
EC - MEMBER EMPLOYMENT CLASS
X12 Name:
Employment Class
X12 Purpose:
To provide class of employment information
Loop:
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
12
Situational Rule:
Required when sending additional employment class information on the member. If not required by this implementation guide, do not send.
TR3 Example:
EC✱04✱06✱07~
EC
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1176
Employment Class Code
O 1
ID
2/3
Code indicating category of employee
CODE
DEFINITION
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
Situational
2
1176
Employment Class Code
O 1
ID
2/3
Code indicating category of employee
SITUATIONAL RULE: Required when further classification information is needed. If not required by this implementation guide, do not send.
CODE
DEFINITION
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
Situational
3
1176
Employment Class Code
O 1
ID
2/3
Code indicating category of employee
SITUATIONAL RULE: Required when further classification information is needed. If not required by this implementation guide, do not send.
CODE
DEFINITION
01
Union
02
Non-Union
03
Executive
04
Non-Executive
05
Management
06
Non-Management
07
Hourly
08
Salaried
09
Administrative
10
Non-Administrative
11
Exempt
12
Non-Exempt
17
Highly Compensated
18
Key-Employee
19
Bargaining
20
Non-Bargaining
21
Owner
22
President
23
Vice President
Not Used
4
954
Percentage as Decimal
O 1
R
1/10
Not Used
5
1201
Information Status Code
O 1
ID
1
Not Used
6
1149
Occupation Code
O 1
ID
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:
1
Situational Rule:
Required when obligated by the insurance contract. If not required by this implementation guide, do not send.
TR3 Example:
ICM✱1✱425.25✱40~
ICM
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
594
Frequency Code
M 1
ID
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
1
Weekly
2
Biweekly
3
Semimonthly
4
Monthly
6
Daily
7
Annual
8
Two Calendar Months
9
Lump-Sum Separation Allowance
B
Year-to-Date
C
Single
H
Hourly
Q
Quarterly
S
Semiannual
U
Unknown
Required
2
782
Monetary Amount
M 1
R
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
3
380
Quantity
O 1
R
1/15
Numeric value of quantity
SEMANTIC: ICM03 is the weekly hours.
SITUATIONAL RULE: Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
INDUSTRY NAME: Work Hours Count
This is the maximum number of hours worked in one calendar week. Report 168 hours or less (24 hours/day x 7 days/week).
Situational
4
310
Location Identifier
O 1
AN
1/30
Code which identifies a specific location
SEMANTIC: ICM04 is the employer location qualifier such as a department number.
SITUATIONAL RULE: Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
INDUSTRY NAME: Location Identification Code
Situational
5
1214
Salary Grade
O 1
AN
1/5
The salary grade code assigned by the employer
SITUATIONAL RULE: Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
INDUSTRY NAME: Salary Grade Code
Not Used
6
100
Currency Code
O 1
ID
3
AMT - MEMBER POLICY AMOUNTS
X12 Name:
Monetary Amount Information
X12 Purpose:
To indicate the total monetary amount
Loop:
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
7
Situational Rule:
Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.
TR3 Example:
AMT✱D2✱100~
AMT
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
522
Amount Qualifier Code
M 1
ID
1/3
Code specifying the amount qualifier
CODE
DEFINITION
B9
Co-insurance - Actual
Use when reporting the co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract.
C1
Co-Payment Amount
D2
Deductible Amount
EBA
Expected Expenditure Amount
FK
Other Unlisted Amount
P3
Premium Amount
R
Spend Down
Required
2
782
Monetary Amount
M 1
R
1/18
Monetary amount
INDUSTRY NAME: Contract 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.
Not Used
3
478
Credit/Debit Flag Code
O 1
ID
1
HLH - MEMBER HEALTH INFORMATION
X12 Name:
Health Information
X12 Purpose:
To provide health information
Loop:
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when an initial enrollment of a member and appropriate medical information about the member is available
Or
Required when an enrollment update and a member's medical information has changed and is available. If not required by this implementation guide, do not send.
Or
Required when an enrollment update and a member's medical information has changed and is available. If not required by this implementation guide, do not send.
TR3 Example:
HLH✱P:Y:ABC:20211215✱74✱210~
HLH
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Situational
1
C061
Member Health and Treatment Information
O 10
To identify member health and treatment information
SITUATIONAL RULE: Required when an initial enrollment to report tobacco use, substance abuse or pregnancy status when the member's information is available.ORRequired on an enrollment update to report a change in tobacco use, substance abuse or pregnancy status when the member's information is available.If not required by this implementation guide, do not send.
Situational
1-1
1212
Health-Related Code
O 1
ID
1
Code indicating a specific health situation
SITUATIONAL RULE: Required when an initial enrollment to report tobacco use, substance abuse or pregnancy status when the member's information is available.ORRequired on an enrollment update to report a change in tobacco use, substance abuse or pregnancy status when the member's information is available.If not required by this implementation guide, do not send.
INDUSTRY NAME: Health Related Code
CODE
DEFINITION
N
None
P
Pregnancy
S
Substance Abuse
T
Tobacco Use
U
Unknown
Situational
1-2
1073
Yes/No Condition or Response Code
O 1
ID
1
Code indicating a Yes or No condition or response
SITUATIONAL RULE: Required when a 'P', 'S', or 'T' is sent in the health related code. If not required by this implementation guide, do not send.
INDUSTRY NAME: Yes No Condition or Response Code
Use to report a health related condition is present, not present (N) or unknown.
CODE
DEFINITION
N
No
U
Unknown
Y
Yes
Situational
1-3
374
Date/Time Qualifier
X 1
ID
3
Code specifying type of date or time, or both date and time
SITUATIONAL RULE: Required when a status effective date for tobacco use or substance abuse is available.OrRequired when an estimated pregnancy due date is available.If not required by this implementation guide, do not send.
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
771
Status
Use when reporting a tobacco use or substance abuse status for the first time.
ABC
Estimated Date of Birth
Use when reporting the estimated date of birth for the first time.
W02
Status Change
Use when reporting a change in tobacco use or substance abuse status or when reporting a change of estimated date of birth.
Situational
1-4
373
Date
X 1
DT
8
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
SITUATIONAL RULE: Required when HLH01-03 is populated. If not required by this implementation guide, do not send.
INDUSTRY NAME: Health Related Code Status Date
Not Used
1-5
373
Date
X 1
DT
8
Situational
2
65
Height
O 1
R
1/8
Vertical dimension of an object measured when the object is in the upright position
SITUATIONAL RULE: Required when available. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Height
The height must be reported in inches.
Situational
3
81
Weight
O 1
R
1/10
Numeric value of weight
SEMANTIC: HLH03 is the current weight in pounds.
SITUATIONAL RULE: Required when available. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Weight
Not Used
4
81
Weight
O 1
R
1/10
Not Used
5
352
Description
O 1
AN
1/80
Not Used
6
1213
Current Health Condition Code
O 1
ID
1
Not Used
7
352
Description
O 1
AN
1/80
LUI - 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 Usage:
Required
Segment Usage:
Situational
Segment Repeat:
>1
Situational Rule:
Required when the sponsor collects the member's preferred language and is legally allowed to share it. If not required by this implementation guide do not send.
TR3 Notes:
Any need to collect this information will be due to a requirement external to the transaction (e.g. Trading partner agreement, legal requirement, program requirement).
TR3 Example:
LUI✱LD✱123✱✱8~
LUI
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Situational
1
66
Identification Code Qualifier
X 1
ID
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
LD
NISO Z39.53 Language Codes
CODE SOURCE: 457: NISO Z39.53 Language Code List
LE
ISO 639 Language Codes
CODE SOURCE: 102: Languages
Situational
2
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEMANTIC: LUI02 is the language code.
SEGMENT SYNTAX: P0102, L040203
SITUATIONAL RULE: Required when the sponsor is able to codify the language identification. If not required by this implementation guide, do not send.
INDUSTRY NAME: Language Code
Situational
3
352
Description
X 1
AN
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 sender is unable to codify the necessary language identification in LUI01 and LUI02. If not required by this implementation guide, do not send.
INDUSTRY NAME: Language Description
Situational
4
1303
Use of Language Indicator Code
O 1
ID
1/2
Code indicating the use of a language
SEGMENT SYNTAX: L040203
SITUATIONAL RULE: Required when supplied by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Language Use Indicator
CODE
DEFINITION
5
Language Reading
6
Language Writing
7
Language Speaking
8
Native Language
Not Used
5
1476
Language Proficiency Indicator Code
O 1
ID
1
NM1*70 - INCORRECT 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:
1
Situational Rule:
Required when a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If not required by this implementation guide, do not send.
TR3 Notes:
If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70.
TR3 Example:
NM1✱70✱1✱SMYTH✱JON~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
70
Prior Incorrect Insured
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
Situational
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
SITUATIONAL RULE: Required when a corrected last name is submitted in Loop 2100A (Member Name). If not required by this implementation guide, do not send.
INDUSTRY NAME: Prior Incorrect Member Last Name
Situational
4
1036
Name First
O 1
AN
1/35
Individual first name
SITUATIONAL RULE: Required when a corrected first name is submitted in Loop 2100A (Member Name). If not required by this implementation guide, do not send.
INDUSTRY NAME: Prior Incorrect Member First Name
Situational
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when a corrected middle name is submitted in Loop 2100A (Member Name). If not required by this implementation guide, do not send.
INDUSTRY NAME: Prior Incorrect Member Middle Name
Situational
6
1038
Name Prefix
O 1
AN
1/10
Prefix to individual name
SITUATIONAL RULE: Required when a corrected name prefix is submitted in Loop 2100A (Member Name). If not required by this implementation guide, do not send.
INDUSTRY NAME: Prior Incorrect Member Name Prefix
Situational
7
1039
Name Suffix
O 1
AN
1/10
Suffix to individual name
SITUATIONAL RULE: Required when a corrected name suffix is submitted in Loop 2100A (Member Name). If not required by this implementation guide, do not send.
INDUSTRY NAME: Prior Incorrect Member Name Suffix
Situational
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when there was a previous error reported in the NM109 element. If not required by this implementation guide, do not send.
CODE
DEFINITION
34
Social Security Number
Use when reporting a 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.
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.
II
Standard Unique Health Identifier for each Individual in the United States
TI
Individual Taxpayer's Identification Number (ITIN)
Situational
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when there was a previous error. If not required by this implementation guide, do not send.
INDUSTRY NAME: Prior Incorrect Member Identifier
NM109 is the identifier that was previously sent in error. This allows matching with data on receiver's system.
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
DMG*D8 - INCORRECT MEMBER DEMOGRAPHIC INFORMATION
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:
1
Situational Rule:
Required when there is a change to the previously supplied demographic information. If not required by this implementation guide, do not send.
TR3 Example:
DMG✱D8✱19890815✱M~
DMG
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Situational
1
1250
Date Time Period Format Qualifier
X 1
ID
2/3
Code indicating the date format, time format, or date and time format
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.
CODE
DEFINITION
D8
Date Expressed in Format CCYYMMDD
Situational
2
1251
Date Time Period
X 1
AN
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: Prior Incorrect Insured Birth Date
Situational
3
1068
Gender Code
O 1
ID
1
Code indicating the sex of the individual
SITUATIONAL RULE: Required when the member's gender is being corrected. If not required by this implementation guide, do not send.
INDUSTRY NAME: Prior Incorrect Insured Gender Code
CODE
DEFINITION
A
Not Provided
Use when the gender cannot be sent due to reporting restrictions.
B
Not Applicable
Use when member self-reports as transgender.
F
Female
M
Male
U
Unknown
Use when the gender is unknown.
Situational
4
1067
Marital Status Code
O 1
ID
1
Code specifying the marital status of a person
SITUATIONAL RULE: Required when the member's Marital Status Code is being corrected. If not required this implementation guide, do not send.
CODE
DEFINITION
B
Registered Domestic Partner
D
Divorced
I
Single
M
Married
R
Unreported
S
Separated
U
Unmarried (Single or Divorced or Widowed)
W
Widowed
X
Legally Separated
Situational
5
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.
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 Information is being corrected. If not required by this implementation guide, do not send.
Not Used
5-1
1109
Race or Ethnicity Code
O 1
ID
1
Required
5-2
1270
Code List Qualifier Code
X 1
ID
1/3
Code identifying a specific industry code list
COMPOSITE SYNTAX: P0203
CODE
DEFINITION
RET
Classification of Race or Ethnicity
CODE SOURCE: 859: Classification of Race or Ethnicity
Required
5-3
1271
Industry Code
X 1
AN
1/30
Code indicating a code from a specific industry code list
COMPOSITE SYNTAX: P0203
INDUSTRY NAME: Race or Ethnicity Code
Situational
6
1066
Citizenship Status Code
O 1
ID
1/2
Code indicating citizenship status
SITUATIONAL RULE: Required when the member's Citizenship Status Code is being corrected. If not required by this implementation guide, do not send.
CODE
DEFINITION
1
U.S. Citizen
2
Non-Resident Alien
3
Resident Alien
4
Illegal Alien
5
Alien
6
U.S. Citizen - Non-Resident
7
U.S. Citizen - Resident
Not Used
7
26
Country Code
O 1
ID
2/3
Not Used
8
659
Basis of Verification Code
O 1
ID
1/2
Not Used
9
380
Quantity
O 1
R
1/15
Situational
10
1270
Code List Qualifier Code
X 1
ID
1/3
Code identifying a specific industry code list
SEGMENT SYNTAX: P1011
SITUATIONAL RULE: Required when the member's Race or Ethnicity Information is being corrected. If not required by this implementation guide, do not send.
CODE
DEFINITION
REC
Race or Ethnicity Collection Code
CODE SOURCE: 860: Race or Ethnicity Collection Code
Situational
11
1271
Industry Code
X 1
AN
1/30
Code indicating a code from a specific industry code list
SEMANTIC: DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.
SEGMENT SYNTAX: P1011, C1105
SITUATIONAL RULE: Required when the member's Race or Ethnicity Information is being corrected. If not required by this implementation guide, do not send.
INDUSTRY NAME: Race or Ethnicity Collection Code
Situational
12
26
Country Code
O 1
ID
2/3
Code identifying the country
SEMANTIC: DMG12 is the country of residence.
SITUATIONAL RULE: Required when the insurance contract or trading partner agreement specifies that the country of birth be reported. If not required by this implementation guide do not send.
INDUSTRY NAME: Country of Birth Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
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:
1
Situational Rule:
Required when the member's 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 mailing address. If not required by this implementation guide, do not send.
TR3 Example:
NM1✱31✱1~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
31
Postal Mailing Address
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
Not Used
3
1035
Name Last or Organization Name
X 1
AN
1/80
Not Used
4
1036
Name First
O 1
AN
1/35
Not Used
5
1037
Name Middle
O 1
AN
1/25
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Not Used
7
1039
Name Suffix
O 1
AN
1/10
Not Used
8
66
Identification Code Qualifier
X 1
ID
1/2
Not Used
9
67
Identification Code
X 1
AN
2/80
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
N3 - MEMBER MAIL ADDRESS
X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
N3✱123 MAIN STREET~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: Member Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Address Line
N4 - MEMBER MAIL 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:
Required
Segment Repeat:
1
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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 Mail City Name
Situational
2
156
State or Province Code
X 1
ID
2
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 Mail State Code
CODE SOURCE 22: States and Provinces
Situational
3
116
Postal Code
X 1
ID
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 Mail Postal Zone or ZIP Code
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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 Mail Country Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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 Mail Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
8
1702
Postal Code-Formatted
X 1
AN
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:
1
Situational Rule:
Required when the member is employed by someone other than the sponsor and the insurance contract requires the payer to be notified of such employment. 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 the 2320 loop.
TR3 Example:
NM1✱36✱2✱ABC CORP.~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
36
Employer
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
2
Non-Person Entity
Situational
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
SITUATIONAL RULE: Required when NM101 = 1 OR when NM101=2 and the National Employer Identifier is not reportable under confidentiality regulations.
INDUSTRY NAME: Member Employer Name
Situational
4
1036
Name First
O 1
AN
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 Employer First Name
Situational
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when 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
6
1038
Name Prefix
O 1
AN
1/10
Prefix to individual name
SITUATIONAL RULE: Required when 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
7
1039
Name Suffix
O 1
AN
1/10
Suffix to individual name
SITUATIONAL RULE: Required when 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
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when available and allowed under confidentiality regulations. If not required by this implementation guide, do not send.
CODE
DEFINITION
24
Employer's Identification Number
Use when the identifier is the Employer Identification Number (EIN) issued by the IRS. The EIN has been adopted as the HIPAA Standard Unique Employer Identifier.
34
Social Security Number
Situational
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when available and allowed under confidentiality regulations. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Employer Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
PER*EP - MEMBER EMPLOYER COMMUNICATIONS NUMBERS CONTACT INFORMATION
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:
1
Situational Rule:
Required when the member's employer contact information is provided to the sponsor.
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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
TR3 Example:
PER✱EP✱✱TE✱8001234567~
PER
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
EP
Employer Contact
Situational
2
93
Name
O 1
AN
1/60
Free-form name
SITUATIONAL RULE: Required when the member's employer contact information is provided to the sponsor.
INDUSTRY NAME: Member Employer Communications Contact Name
Required
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
CODE
DEFINITION
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
FX
Facsimile
TE
Telephone
Required
4
364
Communication Number
X 1
AN
1/2048
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
Situational
5
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Situational
6
364
Communication Number
X 1
AN
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
7
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Situational
8
364
Communication Number
X 1
AN
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
9
443
Contact Inquiry Reference
O 1
AN
1/20
N3 - MEMBER EMPLOYER ADDRESS
X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the member's employer's address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
TR3 Example:
N3✱50 ORCHARD STREET~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: Member Employer Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Employer Address Line
N4 - MEMBER EMPLOYER 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:
1
Situational Rule:
Required when the member's employer's address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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 Employer City Name
Situational
2
156
State or Province Code
X 1
ID
2
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 Employer State Code
CODE SOURCE 22: States and Provinces
Situational
3
116
Postal Code
X 1
ID
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 Employer Postal Zone or ZIP Code
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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 Employer Country Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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 Employer Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
8
1702
Postal Code-Formatted
X 1
AN
3/20
NM1*M8 - MEMBER SCHOOL
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:
1
Situational Rule:
Required when the member is enrolled in school and the payer is required to be notified under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.
TR3 Example:
NM1✱M8✱2✱University of Utah~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
M8
Educational Institution
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
2
Non-Person Entity
Required
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: School Name
Not Used
4
1036
Name First
O 1
AN
1/35
Not Used
5
1037
Name Middle
O 1
AN
1/25
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Not Used
7
1039
Name Suffix
O 1
AN
1/10
Not Used
8
66
Identification Code Qualifier
X 1
ID
1/2
Not Used
9
67
Identification Code
X 1
AN
2/80
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
PER*SK - MEMBER SCHOOL COMMUNICATIONS NUMBERS CONTACT INFORMATION
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:
1
Situational Rule:
Required when the member's school contact information is provided to the sponsor. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
- Send communication information in the order of preference when contacting the member.
TR3 Example:
PER✱SK✱✱TE✱8001234567~
PER
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
SK
School Clerk
Situational
2
93
Name
O 1
AN
1/60
Free-form name
SITUATIONAL RULE: Required when a member's school communication contact name is supplied by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member School Communications Contact Name
Required
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
CODE
DEFINITION
EM
Electronic Mail
FX
Facsimile
TE
Telephone
Required
4
364
Communication Number
X 1
AN
1/2048
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
Situational
5
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Situational
6
364
Communication Number
X 1
AN
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
7
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
Situational
8
364
Communication Number
X 1
AN
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
9
443
Contact Inquiry Reference
O 1
AN
1/20
N3 - MEMBER SCHOOL ADDRESS
X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
TR3 Example:
N3✱P.O. Box 1234~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: School Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.
INDUSTRY NAME: School Address Line
N4 - MEMBER SCHOOL 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:
1
Situational Rule:
Required when the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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 School City Name
Situational
2
156
State or Province Code
X 1
ID
2
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 School State Code
CODE SOURCE 22: States and Provinces
Situational
3
116
Postal Code
X 1
ID
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 School Postal Zone or ZIP Code
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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 School Country Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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 School Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
8
1702
Postal Code-Formatted
X 1
AN
3/20
NM1*S3 - CUSTODIAL PARENT
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:
1
Situational Rule:
Required when the custodial parent of a minor dependent is someone other than the subscriber. If not required by this implementation guide, do not send.
TR3 Notes:
Any other situation, (examples: Guardianship, Legal Indemnity, Power of Attorney, and/or Separation Agreements) would be handled under the Responsible Party NM1 segment.
TR3 Example:
NM1✱S3✱1✱JONES✱MARY~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
S3
Custodial Parent
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
Required
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Custodial Parent Last Name
Situational
4
1036
Name First
O 1
AN
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: Custodial Parent First Name
Situational
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when supplied by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Custodial Parent Middle Name
Situational
6
1038
Name Prefix
O 1
AN
1/10
Prefix to individual name
SITUATIONAL RULE: Required when supplied by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Custodial Parent Name Prefix
Situational
7
1039
Name Suffix
O 1
AN
1/10
Suffix to individual name
SITUATIONAL RULE: Required when supplied by the member. If not required by this implementation guide, do not send.
INDUSTRY NAME: Custodial Parent Name Suffix
Situational
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when available and allowed under confidentiality regulations. If not required by this implementation guide, do not send.
CODE
DEFINITION
34
Social Security Number
Use when reporting a 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.
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.
II
Standard Unique Health Identifier for each Individual in the United States
TI
Individual Taxpayer's Identification Number (ITIN)
Situational
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when available and allowed under confidentiality regulations. If not required by this implementation guide, do not send.
INDUSTRY NAME: Custodial Parent Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
PER*PQ - CUSTODIAL PARENT COMMUNICATIONS NUMBERS CONTACT INFORMATION
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:
5
Situational Rule:
Required when the Custodial Parent contact information is provided to the sponsor. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
- Send communication information in the order of preference when contacting the Custodial Parent.
TR3 Example:
PER✱PQ✱✱TE✱8001234567~
PER
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
PQ
Parent or Guardian
Not Used
2
93
Name
O 1
AN
1/60
Required
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
FX
Facsimile
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Required
4
364
Communication Number
X 1
AN
1/2048
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
Situational
5
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Situational
6
364
Communication Number
X 1
AN
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
7
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
EX
Telephone Extension
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Situational
8
364
Communication Number
X 1
AN
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
9
443
Contact Inquiry Reference
O 1
AN
1/20
N3 - CUSTODIAL PARENT ADDRESS
X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the information is provided to the sponsor. If not required by this implementation guide, do not send.
TR3 Example:
N3✱50 ORCHARD STREET~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: Custodial Parent Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.
INDUSTRY NAME: Custodial Parent Address Line
N4 - CUSTODIAL PARENT 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:
1
Situational Rule:
Required when the information is provided to the sponsor. If not required by this implementation guide, do not send.
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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: Custodial Parent City Name
Situational
2
156
State or Province Code
X 1
ID
2
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: Custodial Parent State Code
CODE SOURCE 22: States and Provinces
Situational
3
116
Postal Code
X 1
ID
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: Custodial Parent Postal Zone or ZIP Code
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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: Custodial Parent Country Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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: Custodial Parent Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
8
1702
Postal Code-Formatted
X 1
AN
3/20
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:
1
Situational Rule:
Required when identifying 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
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
6Y
Case Manager
9K
Key Person
E1
Person or Other Entity Legally Responsible for a Child
Use when a Qualified Medical Child Support Order (QMSCO) is present. Explanation: Identifies a legal indemnification situation.
EI
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 the separated spouse under a separation agreement or when the self-responsible divorced spouse is the member, but not to identify the divorced custodial parent for dependent children.
GB
Other Insured
GD
Guardian
J6
Power of Attorney
LR
Legal Representative
QD
Responsible Party
S1
Parent
TZ
Significant Other
X4
Spouse
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
2
Non-Person Entity
Required
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
INDUSTRY NAME: Responsible Party Last or Organization Name
Situational
4
1036
Name First
O 1
AN
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 Party First Name
Situational
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when NM101 equal to '1' and is provided to the sponsor. If not required by this implementation guide, do not send.
INDUSTRY NAME: Responsible Party Middle Name
Situational
6
1038
Name Prefix
O 1
AN
1/10
Prefix to individual name
SITUATIONAL RULE: Required when NM101 equal to '1' and is provided to the sponsor. If not required by this implementation guide, do not send.
INDUSTRY NAME: Responsible Party Name Prefix
Situational
7
1039
Name Suffix
O 1
AN
1/10
Suffix to individual name
SITUATIONAL RULE: Required when NM101 equal to '1' and is provided to the sponsor. If not required by this implementation guide, do not send.
INDUSTRY NAME: Responsible Party Suffix Name
Situational
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when available and allowed under confidentiality regulations. If not required by this implementation guide, do not send.
CODE
DEFINITION
34
Social Security Number
Use when reporting a 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.
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.
II
Standard Unique Health Identifier for each Individual in the United States
TI
Individual Taxpayer's Identification Number (ITIN)
Situational
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when available and allowed under confidentiality regulations. If not required by this implementation guide, do not send.
INDUSTRY NAME: Responsible Party Identifier
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
PER*RP - RESPONSIBLE PERSON COMMUNICATIONS NUMBERS CONTACT INFORMATION
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:
5
Situational Rule:
Required when the Responsible Person contact information is provided to the sponsor. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
- Send communication information in the order of preference when contacting the Responsible Person.
TR3 Example:
PER✱RP✱✱HP✱8015554321~
PER
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
RP
Responsible Person
Not Used
2
93
Name
O 1
AN
1/60
Required
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
FX
Facsimile
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Required
4
364
Communication Number
X 1
AN
1/2048
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
Situational
5
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Situational
6
364
Communication Number
X 1
AN
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
7
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
Use when reporting the phone number for the individual's closest relative.
BN
Beeper Number
CP
Cellular Phone
Use when the cellular phone ownership is unknown.
EA
Internet Email Address
Use when reporting a secondary or alternate email address.
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
NP
Night Telephone
OT
Other Residential Telephone Number
Use when reporting a TTY communication number.
PC
Personal Cellular
PP
Personal Phone
TE
Telephone
Use when identifying the primary phone number.
TS
Text Message Address
WC
Work Cellular
WP
Work Phone Number
Situational
8
364
Communication Number
X 1
AN
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
9
443
Contact Inquiry Reference
O 1
AN
1/20
N3 - RESPONSIBLE PERSON ADDRESS
X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the information is provided to the sponsor. If not required by this implementation guide, do not send.
TR3 Example:
N3✱50 ORCHARD STREET~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: Responsible Party Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.
INDUSTRY NAME: Responsible Party 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:
1
Situational Rule:
Required when the information is provided to the sponsor. If not required by this implementation guide, do not send.
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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
2
156
State or Province Code
X 1
ID
2
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
3
116
Postal Code
X 1
ID
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: Responsible Person Postal Zone or ZIP Code
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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: 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
8
1702
Postal Code-Formatted
X 1
AN
3/20
NM1*45 - DROP OFF LOCATION
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:
1
Situational Rule:
Required when the member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send.
TR3 Example:
NM1✱45✱2✱Blue School~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
45
Drop-off Location
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
2
Non-Person Entity
Not Used
3
1035
Name Last or Organization Name
X 1
AN
1/80
Not Used
4
1036
Name First
O 1
AN
1/35
Not Used
5
1037
Name Middle
O 1
AN
1/25
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Not Used
7
1039
Name Suffix
O 1
AN
1/10
Not Used
8
66
Identification Code Qualifier
X 1
ID
1/2
Not Used
9
67
Identification Code
X 1
AN
2/80
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
N3 - DROP OFF LOCATION ADDRESS
X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
N3✱50 ORCHARD STREET~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: Drop Off Location Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.
INDUSTRY NAME: Drop Off Location Address Line
N4 - DROP OFF LOCATION 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:
Required
Segment Repeat:
1
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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: Drop Off Location City Name
Situational
2
156
State or Province Code
X 1
ID
2
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: Drop Off Location State Code
CODE SOURCE 22: States and Provinces
Situational
3
116
Postal Code
X 1
ID
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: Drop Off Location Postal Zone or ZIP Code
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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: Drop Off Location Country Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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: Drop Off Location Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
8
1702
Postal Code-Formatted
X 1
AN
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.
If either DSB07 or DSB08 is present, then the other is required.
Loop:
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when enrolling a disabled member or when disability information about an existing member is added or changed. If not required by this implementation guide, do not send.
TR3 Notes:
Do not transmit the decimal points in the diagnosis codes. The decimal point is implied.
TR3 Example:
DSB✱2✱✱✱✱✱✱DC✱G82.50~
DSB
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1146
Disability Type Code
M 1
ID
1
Code identifying the disability status of the individual
CODE
DEFINITION
1
Short Term Disability
2
Long Term Disability
3
Permanent or Total Disability
4
No Disability
5
Partial Disability
Not Used
2
380
Quantity
O 1
R
1/15
Not Used
3
1149
Occupation Code
O 1
ID
4/6
Not Used
4
1154
Work Intensity Code
O 1
ID
1
Not Used
5
1161
Product Option Code
O 1
ID
1/2
Not Used
6
782
Monetary Amount
O 1
R
1/18
Situational
7
235
Product/Service ID Qualifier
X 1
ID
2
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: Product or Service ID Qualifier
CODE
DEFINITION
DC
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)
DX
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis
CODE SOURCE: 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)
Situational
8
1137
Medical Code Value
X 1
AN
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 DSB01 equals 1, 2 or 3 and reporting the diagnosis code is obligated by the insurance contract. If not required by this implementation guide, do not send.
INDUSTRY NAME: Diagnosis Code
DTP - DISABILITY ELIGIBILITY 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:
Situational
Segment Usage:
Situational
Segment Repeat:
2
Situational Rule:
Required when enrolling a disabled member or when disability dates change for an existing member, and the disability dates are known by the sponsor. If not required by this implementation guide, do not send.
TR3 Notes:
This segment is used to send the first and last date of disability.
TR3 Example:
DTP✱360✱D8✱20220108~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
360
Initial Disability Period Start
361
Initial Disability Period End
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Disability Eligibility Date
HD - HEALTH COVERAGE
X12 Name:
Health Coverage
X12 Purpose:
To provide information on health coverage
Loop:
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when enrolling a new member or when adding, updating, removing coverage or auditing an existing member. If not required by this implementation guide, do not send.
TR3 Notes:
Refer to section 1.4.5 "Termination" for additional information relative to removing a member's coverage.
TR3 Example:
HD✱021✱✱HLT✱PLAN A BCD✱FAM~
HD
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
875
Maintenance Type Code
M 1
ID
3
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 deleting an incorrect coverage record.
021
Addition
024
Cancellation or Termination
Use when cancelling/terminating a coverage.
025
Reinstatement
026
Correction
Use when correcting a record.
030
Audit or Compare
032
Employee Information Not Applicable
Use when dependents of an ineligible subscriber are eligible for coverage.
Explanation: Certain situations, such as military duty and TRICARE, classify the subscriber as ineligible for coverage or benefits. However, dependents of the subscriber are still eligible for coverage or benefits under the subscriber. Subscriber identifying elements are needed to accurately identify dependents.
Explanation: Certain situations, such as military duty and TRICARE, classify the subscriber as ineligible for coverage or benefits. However, dependents of the subscriber are still eligible for coverage or benefits under the subscriber. Subscriber identifying elements are needed to accurately identify dependents.
Situational
2
1203
Maintenance Reason Code
O 1
ID
2/3
Code identifying the reason for the maintenance change
SITUATIONAL RULE: Required when obligated by the insurance contract to send the member maintenance reason. If not required by this implementation guide, do not send.
CODE
DEFINITION
01
Divorce
02
Birth
03
Death
04
Retirement
05
Adoption
06
Strike
07
Termination of Benefits
08
Termination of Employment
09
Consolidation Omnibus Budget Reconciliation Act (COBRA)
10
Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
11
Surviving Spouse
14
Voluntary Withdrawal
15
Primary Care Provider (PCP) Change
16
Quit
17
Fired
18
Suspended
19
Sabbatical
20
Active
21
Disability
22
Plan Change
Use when a member changes from one Plan to a different Plan. This is not intended to report changes to a Plan.
25
Change in Identifying Data Elements
Use when a change has been made to the primary elements that identify a member. Such primary elements include the following: first name, last name, Social Security Number, date of birth, and employee identification number.
26
Declined Coverage
Use when a member declined to continue a previously active coverage.
27
Pre-Enrollment
Use when enrolling newborns prior to receiving the newborn's application.
28
Initial Enrollment
Use when reporting the member selected coverage with the Plan Sponsor for the first time.
29
Benefit Selection
Use when a member changes benefits within a Plan.
31
Legal Separation
32
Marriage
33
Personnel Data
Use when changing any data that is not included in any of the other allowed codes. An example would be change in Coordination of Benefits information.
37
Leave of Absence with Benefits
38
Leave of Absence without Benefits
39
Lay Off with Benefits
40
Lay Off without Benefits
41
Re-enrollment
43
Change of Location
Use when reporting a change of address.
59
Non Payment
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
AJ
Appointment Times not Met in a Timely Manner
AL
Algorithm Assigned Benefit Selection
EC
Member Benefit Selection
Use when reporting an initial and subsequent enrollment when an insurance carrier needs to recognize that a member made an explicit plan choice.
XN
Notification Only
Use when sending a complete enrollment transmission, for the full file audit. Required when HD01 is equal to 030 (Audit or Compare).
XT
Transfer
Use when a member has an organizational change (i.e. a location change within the organization) with no change in benefits or plan.
Required
3
1205
Insurance Line Code
O 1
ID
2/3
Code identifying a group of insurance products
CODE
DEFINITION
AG
Preventative Care/Wellness
AH
24 Hour Care
AJ
Medicare Risk
AK
Mental Health
CDV
Combined Dental and Vision
COM
Combined other than Dental and Vision
Use when identifying combined insurance lines other than dental and vision that are not QHP Products under Exchange business.
DCP
Dental Capitation
Use when identifying a dental managed care organization (DMO).
DEN
Dental
EPO
Exclusive Provider Organization
FAC
Facility
HE
Hearing
HLT
Health
Use when reporting hospital or professional coverage.
HMO
Health Maintenance Organization
LTC
Long-Term Care
LTD
Long-Term Disability
MM
Major Medical
MOD
Mail Order Drug
PDG
Prescription Drug
POS
Point of Service
PPO
Preferred Provider Organization
PRA
Practitioners
STD
Short-Term Disability
UR
Utilization Review
VIS
Vision
Situational
4
1204
Plan Coverage Description
O 1
AN
1/50
A description or number that identifies the plan or coverage
SITUATIONAL RULE: Required when additional information is needed to describe the exact type of coverage. If not required by this implementation guide, do not send.
Situational
5
1207
Coverage Level Code
O 1
ID
3
Code indicating the level of coverage being provided for this insured
SITUATIONAL RULE: Required when obligated by the insurance contract. 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.
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
SPC
Spouse and Children
SPO
Spouse Only
TWO
Two Party
Not Used
6
609
Count
O 1
N
1/9
Not Used
7
609
Count
O 1
N
1/9
Not Used
8
1209
Underwriting Decision Code
O 1
ID
1
Situational
9
1073
Yes/No Condition or Response Code
O 1
ID
1
Code indicating a Yes or No condition or response
SEMANTIC: HD09 is a late enrollee indicator. A "Y" value indicates the insured is a late enrollee, which can result in a reduction of benefits; an "N" value indicates the insured is a regular enrollee.
SITUATIONAL RULE: Required when obligated by the insurance contract. If not required by this implementation guide, do not send.
INDUSTRY NAME: Late Enrollment Indicator
CODE
DEFINITION
N
No
Y
Yes
Not Used
10
1211
Drug House Code
O 1
ID
2/3
Not Used
11
1073
Yes/No Condition or Response Code
O 1
ID
1
DTP - HEALTH COVERAGE 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:
Situational
Segment Usage:
Required
Segment Repeat:
8
TR3 Notes:
Date ranges are reported with the first occurrence of CCYYMMDD as the beginning date and the second occurrence as the ending date.
TR3 Example:
DTP✱348✱D8✱20211001~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
300
Enrollment Signature Date
303
Maintenance Effective
Use when reporting the effective date of a change where a member's coverage is not being added or removed.
343
Premium Paid to Date End
348
Benefit Begin
Use when reporting the effective date of coverage. This code must always be sent when adding or reinstating coverage.
349
Benefit End
Use when reporting the last date of coverage for which the member's claims will be paid. For example, if a date of 02/28/2014 is reported then claims for this member will be paid through 11:59 p.m. on 02/28/2014.
543
Last Premium Paid Date
606
Certification Period Start
Use when reporting the member's date of certification or qualification for the coverage being sent in Loop 2300. Benefit Begin Date is reported using code value 348. Certification Period Start and Benefit Begin Date may or may not be the same.
695
Previous Period
Use when DTP01 is equal to 695 - Previous Period.
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Coverage Period
DTP*903 - ONLINE APPLICATION DATE/TIME
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:
1
Situational Rule:
Required when the online application date and time of submission is captured by the application system and was not reported in Loop 2000. If not required by this implementation guide, do not send.
TR3 Notes:
Date ranges are reported with the first occurrence of CCYYMMDD as the beginning date and the second occurrence as the ending date.
TR3 Example:
DTP✱903✱UN✱08012021132732001~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
903
Application Entry
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
UN
Unstructured
Use when date and time (to the millisecond) is reported, following the format MMDDCCYYHHMMSSTTT where MM is the month (01 to 12), DD is the day in the month, CC is the century, YY is the year, HH is the hour of the day based on a twenty-four hour clock, MM is the minutes within an hour, SS is the seconds within the minute and TTT is the milliseconds within the seconds.
Required
3
1251
Date Time Period
M 1
AN
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:
Situational
Segment Usage:
Situational
Segment Repeat:
7
Situational Rule:
Required when obligated by the insurance contract. If not required by this implementation guide, do not send.
TR3 Example:
AMT✱C1✱20~
AMT
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
522
Amount Qualifier Code
M 1
ID
1/3
Code specifying the amount qualifier
CODE
DEFINITION
B9
Co-insurance - Actual
Use when reporting the co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract.
C1
Co-Payment Amount
D2
Deductible Amount
EBA
Expected Expenditure Amount
FK
Other Unlisted Amount
P3
Premium Amount
R
Spend Down
Required
2
782
Monetary Amount
M 1
R
1/18
Monetary amount
INDUSTRY NAME: Contract 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.
Not Used
3
478
Credit/Debit Flag Code
O 1
ID
1
REF - HEALTH COVERAGE NUMBERS
X12 Name:
Reference Information
X12 Purpose:
To specify identifying information
X12 Syntax:
R0203
At least one of REF02 or REF03 is required.
At least one of REF02 or REF03 is required.
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
14
Situational Rule:
Required when such transmission is required under the trading partner agreement between the sponsor and the payer. If not required by this implementation guide, do not send.
TR3 Example:
REF✱1L✱123456~
REF
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
17
Client Reporting Category
1L
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 contract between the sponsor (sender) and payer (receiver).
9V
Payment Category
CE
Class of Contract Code
E8
Service Contract (Coverage) Number
M7
Medical Assistance Category
PID
Program Identification Number
RB
Rate code number
X9
Internal Control Number
XM
Issuer Number
XX1
Special Program Code
XX2
Service Area Code
ZX
County Code
ZZ
Mutually Defined
Use when reporting the Payment Plan Type Code (Annual or Quarterly) until a standard code is assigned.
Required
2
127
Reference Identification
X 1
AN
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 Health Coverage Number
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
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1
REF*QQ - PRIOR COVERAGE MONTHS
X12 Name:
Reference Information
X12 Purpose:
To specify identifying information
X12 Syntax:
R0203
At least one of REF02 or REF03 is required.
At least one of REF02 or REF03 is required.
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when there are prior months of health coverage that meet the certification requirements of the portability provisions within the Health Insurance Portability and Accountability Act. If not required by this implementation guide, do not send.
TR3 Example:
REF✱QQ✱0~
REF
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
QQ
Unit Number
Use when required to indicate the number of months of prior health coverage under the portability provisions of HIPAA.
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Prior Coverage Month Count
- This field will contain the number of months of prior health insurance coverage that meets the portability requirements of the HIPAA certification requirements. To be sent on new enrollments when available.
- 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
3
352
Description
X 1
AN
1/80
Not Used
4
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:
Situational
Segment Usage:
Situational
Segment Repeat:
3
Situational Rule:
Required when requesting the production of an identification card. If not required by this implementation guide, do not send.
TR3 Example:
IDC✱12345✱H~
IDC
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1204
Plan Coverage Description
M 1
AN
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
2
1215
Identification Card Type Code
M 1
ID
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
D
Dental Insurance
H
Health Insurance
P
Prescription Drug Service Drug Insurance
Situational
3
380
Quantity
O 1
R
1/15
Numeric value of quantity
SEMANTIC: IDC03 is the number of cards being requested.
SITUATIONAL RULE: Required when the number of cards requested is greater than 1. If not required by this implementation guide, do not send.
INDUSTRY NAME: Identification Card Count
Only non-negative integer values are to be sent.
Situational
4
306
Action Code
O 1
ID
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 when the sender knows the reason for the card request. If not required by this implementation guide, do not send.
CODE
DEFINITION
1
Add
2
Change (Update)
RX
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:
1
Situational Rule:
Revised when providing information about the primary care or capitated physicians and pharmacies chosen by the member in a managed care plan when that selection is made through the sponsor. If not required by this implementation guide, do not send.
TR3 Notes:
- The primary care provider effective date is defaulted to the effective date of the product identified in the DTP segment of the 2300 loop. When an enrollee switches from one primary care provider to another through the sponsor, the new provider must be listed with the effective date of change.
- Use one iteration of the loop to identify each applicable health care service provider.
TR3 Example:
LX✱1~
LX
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
554
Assigned Number
M 1
N
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:
1
TR3 Example:
NM1✱P3✱1✱✱✱✱✱✱SV✱25341234567✱25~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
1X
Laboratory
3D
Obstetrics and Gynecology Facility
80
Hospital
FA
Facility
OD
Doctor of Optometry
P3
Primary Care Provider
QA
Pharmacy
QN
Dentist
Y2
Managed Care Organization
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
1
Person
2
Non-Person Entity
Situational
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
SITUATIONAL RULE: Required when the sponsor is not able to provide the standard ID in element NM109. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider Last or Organization Name
Situational
4
1036
Name First
O 1
AN
1/35
Individual first name
SITUATIONAL RULE: Required when NM102 is equal to '1' and the sponsor is not able to provide the standard ID in element NM109. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider First Name
Situational
5
1037
Name Middle
O 1
AN
1/25
Individual middle name or initial
SITUATIONAL RULE: Required when NM102 is equal to '1' and the sponsor is not able to provide the standard ID in element NM109 and has this information. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider Middle Name
Situational
6
1038
Name Prefix
O 1
AN
1/10
Prefix to individual name
SITUATIONAL RULE: Required when NM102 is equal to '1' and the sponsor is not able to provide the standard ID in element NM109 and has this information. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider Name Prefix
Situational
7
1039
Name Suffix
O 1
AN
1/10
Suffix to individual name
SITUATIONAL RULE: Required when NM102 is equal to '1' and the sponsor is not able to provide the standard ID in element NM109 and has this information. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider Name Suffix
Situational
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when the provider is mandated to obtain a National Provider ID or when an atypical provider has an alternate identification number that has been assigned by the payer. If not required by this implementation guide, do not send.
CODE
DEFINITION
SV
Service Provider Number
Use when identifying a provider number assigned by the payer.
XX
Standard Unique Health Identifier for Health Care Providers (NPI)
Use when the sender is a covered entity as defined by HIPAA, and the provider is NPI eligible.
CODE SOURCE: 537: National Provider Identifier (NPI)
Situational
9
67
Identification Code
X 1
AN
2/80
Code identifying a party or other code
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when the provider is mandated to obtain a National Provider ID or when an atypical provider has an alternate identification number that has been assigned by the payer. If not required by this implementation guide, do not send.
INDUSTRY NAME: Provider Identifier
Required
10
706
Entity Relationship Code
X 1
ID
2
Code specifying entity relationship
COMMENT: NM110 and NM111 further define the type of entity in NM101.
SEGMENT SYNTAX: C1110
This element indicates whether or not the member is an existing patient of the provider.
CODE
DEFINITION
25
Established Patient
26
Not Established Patient
72
Unknown
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
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:
1
Situational Rule:
Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.
TR3 Example:
N3✱123 MAIN STREET~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
INDUSTRY NAME: Provider Address Line
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when 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:
1
Situational Rule:
Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send.
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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
2
156
State or Province Code
X 1
ID
2
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
3
116
Postal Code
X 1
ID
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: Provider Postal Zone or ZIP Code
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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: Provider Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
8
1702
Postal Code-Formatted
X 1
AN
3/20
PER*IC - PROVIDER COMMUNICATIONS NUMBERS CONTACT INFORMATION
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:
2
Situational Rule:
Required when the Provider contact information is provided to the sponsor. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
- Send communication information in the order of preference when contacting the provider.
TR3 Example:
PER✱IC✱✱HP✱8015554321~
PER
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
IC
Information Contact
Not Used
2
93
Name
O 1
AN
1/60
Required
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
CODE
DEFINITION
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
Required
4
364
Communication Number
X 1
AN
1/2048
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
Situational
5
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0506
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
Situational
6
364
Communication Number
X 1
AN
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
7
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0708
SITUATIONAL RULE: Required when additional communication numbers are available. If not required by this implementation guide, do not send.
CODE
DEFINITION
AP
Alternate Telephone
BN
Beeper Number
CP
Cellular Phone
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
HP
Home Phone Number
TE
Telephone
WP
Work Phone Number
Situational
8
364
Communication Number
X 1
AN
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
9
443
Contact Inquiry Reference
O 1
AN
1/20
PLA*2 - 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:
Situational
Segment Repeat:
1
Situational Rule:
Required when reporting a provider change in Loop 2310 NM1 to identify the change reason and effective date of the change. If not required by this implementation guide, do not send.
TR3 Example:
PLA✱2✱1P✱20210628✱✱AI~
PLA
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
306
Action Code
M 1
ID
1/2
Code indicating type of action
CODE
DEFINITION
2
Change (Update)
Required
2
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
1P
Provider
Required
3
373
Date
M 1
DT
8
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 PCP.
Not Used
4
337
Time
O 1
TM
4/8
Required
5
1203
Maintenance Reason Code
O 1
ID
2/3
Code identifying the reason for the maintenance change
CODE
DEFINITION
14
Voluntary Withdrawal
22
Plan Change
46
Current Customer Information File in Error
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
Use when no other maintenance reasons are applicable.
AJ
Appointment Times not Met in a Timely Manner
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:
1
Situational Rule:
Required when an individual has another insurance plan with benefits similar to those covered by the insurance product specified in this occurrence of Loop ID 2300. If not required by this implementation guide, do not send.
TR3 Example:
COB✱P✱XYZ123✱1~
COB
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
1138
Payer Responsibility Sequence Number Code
O 1
ID
1
Code identifying the insurance carrier's level of responsibility for a payment of a claim
INDUSTRY NAME: Payer Responsibility Sequence Code
CODE
DEFINITION
P
Primary
S
Secondary
T
Tertiary
U
Unknown
Situational
2
127
Reference Identification
O 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEMANTIC: COB02 is the policy number.
SITUATIONAL RULE: Required when the member's group or policy number is available. If not required by this implementation guide, do not send.
INDUSTRY NAME: Member Health Coverage Number
Required
3
1143
Coordination of Benefits Code
O 1
ID
1
Code identifying whether there is a coordination of benefits
CODE
DEFINITION
1
Coordination of Benefits
5
Unknown
6
No Coordination of Benefits
Use when it has been determined there is no COB.
Situational
4
1365
Service Type Code
O 9
ID
1/2
Code identifying the classification of service
SITUATIONAL RULE: Required when obligated by the insurance contract to send detailed COB coverage. If not required by this implementation guide, do not send.
CODE
DEFINITION
1
Medical Care
35
Dental Care
48
Hospital - Inpatient
50
Hospital - Outpatient
54
Long Term Care
89
Free Standing Prescription Drug
90
Mail Order Prescription Drug
A4
Psychiatric
AG
Skilled Nursing Care
AL
Vision (Optometry)
BB
Partial Hospitalization (Psychiatric)
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.
At least one of REF02 or REF03 is required.
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
2
Situational Rule:
Required when additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.
TR3 Example:
REF✱6P✱GRP123~
REF
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
60
Account Suffix Code
6P
Group Number
Required
2
127
Reference Identification
X 1
AN
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 Health Coverage Number
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
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1
DTP - COORDINATION OF BENEFITS ELIGIBILITY 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:
Situational
Segment Usage:
Situational
Segment Repeat:
2
Situational Rule:
Required when the submitter needs to send effective dates for coordination of benefits. If not required by this implementation guide, may be provided by the sender's discretion but cannot be required by the receiver.
TR3 Example:
DTP✱344✱D8✱20220401~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
344
Coordination of Benefits Begin
345
Coordination of Benefits End
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Coordination of Benefits Date
NM1 - COORDINATION OF BENEFITS RELATED ENTITY
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:
1
Situational Rule:
Required when information identifying the Coordination of Benefits Related Entity is provided to the sponsor. If not required by this implementation guide, do not send.
TR3 Example:
NM1✱IN✱2✱ALLSTATE~
NM1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
36
Employer
GW
Group
IN
Insurer
Required
2
1065
Entity Type Qualifier
M 1
ID
1
Code identifying the type of entity
SEMANTIC: NM102 qualifies NM103.
CODE
DEFINITION
2
Non-Person Entity
Situational
3
1035
Name Last or Organization Name
X 1
AN
1/80
Individual last name or organizational name
SEGMENT SYNTAX: C1203
SITUATIONAL RULE: Required when no standard identifier is available in NM109. If not required by this implementation guide, do not send.
INDUSTRY NAME: Coordination of Benefits Insurer Name
Not Used
4
1036
Name First
O 1
AN
1/35
Not Used
5
1037
Name Middle
O 1
AN
1/25
Not Used
6
1038
Name Prefix
O 1
AN
1/10
Not Used
7
1039
Name Suffix
O 1
AN
1/10
Situational
8
66
Identification Code Qualifier
X 1
ID
1/2
Code specifying the system/method of code structure used for Identification Code (67)
SEGMENT SYNTAX: P0809
SITUATIONAL RULE: Required when supplied by the employee to the sponsor. If not required by this implementation guide, do not send.
CODE
DEFINITION
24
Employer's Identification Number
FI
Federal Taxpayer's Identification Number
NI
National Association of Insurance Commissioners (NAIC) Identification
XV
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
9
67
Identification Code
X 1
AN
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.
INDUSTRY NAME: Coordination of Benefits Insurer Identification Code
Not Used
10
706
Entity Relationship Code
X 1
ID
2
Not Used
11
98
Entity Identifier Code
O 1
ID
2/3
Not Used
12
1035
Name Last or Organization Name
O 1
AN
1/80
N3 - COORDINATION OF BENEFITS RELATED ENTITY ADDRESS
X12 Name:
Party Location
X12 Purpose:
To specify the location of the named party
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when obligated by the insurance contract to send detailed COB coverage. If not required by this implementation guide, do not send.
TR3 Example:
N3✱50 ORCHARD STREET~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
166
Address Information
M 1
AN
1/55
Address information
Situational
2
166
Address Information
O 1
AN
1/55
Address information
SITUATIONAL RULE: Required when a second address line exists. If not required by this implementation guide, do not send.
N4 - COORDINATION OF BENEFITS OTHER INSURANCE COMPANY 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:
1
Situational Rule:
Required when obligated by the insurance contract to send detailed COB coverage. If not required by this implementation guide, do not send.
TR3 Example:
N4✱KANSAS CITY✱MO✱64108~
N4
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
19
City Name
O 1
AN
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: Coordination of Benefits Other Insurance Company City Name
Situational
2
156
State or Province Code
X 1
ID
2
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: Coordination of Benefits Other Insurance Company State Code
CODE SOURCE 22: States and Provinces
Situational
3
116
Postal Code
X 1
ID
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: Coordination of Benefits Other Insurance Company Postal Zone or ZIP Code
- CODE SOURCE 51: ZIP Code
- CODE SOURCE 932: Universal Postal Codes
Situational
4
26
Country Code
X 1
ID
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: Coordination of Benefits Other Insurance Company Country Code
Use the alpha-2 country codes from Part 1 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
5
309
Location Qualifier
X 1
ID
1/2
Not Used
6
310
Location Identifier
O 1
AN
1/30
Situational
7
1715
Country Subdivision Code
X 1
ID
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: Coordination of Benefits Other Insurance Company Country Subdivision Code
Use the country subdivision codes from Part 2 of ISO 3166.
CODE SOURCE 5: Countries, Currencies and Funds
Not Used
8
1702
Postal Code-Formatted
X 1
AN
3/20
PER*CN - ADMINISTRATIVE COMMUNICATIONS CONTACT INFORMATION
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:
1
Situational Rule:
Required when obligated by the insurance contract to send detailed COB coverage. 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 must always include 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. Therefore, the following telephone number (555) 555-1234 would be represented as 5555551234. Do not submit long distance access numbers, such as 1, in the telephone number. Telephone extensions, when applicable, must be submitted in the next element immediately following the telephone number. When submitting telephone extensions, only submit the numeric extension, do not include data that indicates an extension, such as "ext" or "x-".
TR3 Example:
PER✱CN✱✱TE✱8015554321~
PER
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
366
Contact Function Code
M 1
ID
2
Code identifying the major duty or responsibility of the person or group named
CODE
DEFINITION
CN
General Contact
Not Used
2
93
Name
O 1
AN
1/60
Required
3
365
Communication Number Qualifier
X 1
ID
2
Code identifying the type of communication number
SEGMENT SYNTAX: P0304
CODE
DEFINITION
TE
Telephone
Required
4
364
Communication Number
X 1
AN
1/2048
Complete communications number including country or area code when applicable
SEGMENT SYNTAX: P0304
Not Used
5
365
Communication Number Qualifier
X 1
ID
2
Not Used
6
364
Communication Number
X 1
AN
1/2048
Not Used
7
365
Communication Number Qualifier
X 1
ID
2
Not Used
8
364
Communication Number
X 1
AN
1/2048
Not Used
9
443
Contact Inquiry Reference
O 1
AN
1/20
FSA - TAX ADVANTAGE ACCOUNT
X12 Name:
Tax Advantage Account
X12 Purpose:
To report Health Insurance Tax Advantage Account information
X12 Set Notes:
NOTE: Loop 2500 may only appear for the Subscriber.
Loop:
Loop Usage:
Situational
Segment Usage:
Required
Segment Repeat:
1
Situational Rule:
Required when enrolling a member in a Tax Advantage Account
OR
adding, updating or removing a member's Tax Advantage Account
OR
auditing a member with a Tax Advantage Account.
If not required by this implementation guide, do not send.
OR
adding, updating or removing a member's Tax Advantage Account
OR
auditing a member with a Tax Advantage Account.
If not required by this implementation guide, do not send.
TR3 Example:
FSA✱021✱H✱28✱HS:555111✱2~
FSA
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
875
Maintenance Type Code
M 1
ID
3
Code identifying the specific type of item maintenance
CODE
DEFINITION
001
Change
002
Delete
021
Addition
024
Cancellation or Termination
025
Reinstatement
026
Correction
030
Audit or Compare
Situational
2
1202
Flexible Spending Account Selection Code
O 1
ID
1
Code indicating selection of a type of Flexible Spending Account
SITUATIONAL RULE: Required when the tax advantage account is a Flexible Spending Account. If not required by this implementation guide, do not send.
CODE
DEFINITION
D
Dependent Care
E
Education
H
Healthcare
L
Legal
Z
Mutually Defined
Use when the flexible spending account type is different than the other listed types and is defined in the insurance contract.
Situational
3
1203
Maintenance Reason Code
O 1
ID
2/3
Code identifying the reason for the maintenance change
SITUATIONAL RULE: Required when the payer needs to know the reason for the change. If not required by this implementation guide, do not send.
CODE
DEFINITION
01
Divorce
02
Birth
03
Death
04
Retirement
05
Adoption
06
Strike
07
Termination of Benefits
08
Termination of Employment
09
Consolidation Omnibus Budget Reconciliation Act (COBRA)
10
Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
11
Surviving Spouse
14
Voluntary Withdrawal
15
Primary Care Provider (PCP) Change
16
Quit
17
Fired
18
Suspended
20
Active
21
Disability
22
Plan Change
Use when a member changes from one Plan to a different Plan. This is not intended to report changes to a Plan.
25
Change in Identifying Data Elements
Use when a change has been made to the primary elements that identify a member. Such primary elements include the following: first name, last name, Social Security Number, date of birth, and employee identification number.
26
Declined Coverage
Use when a member declined to continue a previously active coverage.
27
Pre-Enrollment
Use when enrolling newborns prior to receiving the newborn's application.
28
Initial Enrollment
Use when reporting the member selected coverage with the Plan Sponsor for the first time.
29
Benefit Selection
Use when a member changes benefits within a Plan.
31
Legal Separation
32
Marriage
33
Personnel Data
Use when changing any data that is not included in any of the other allowed codes. An example would be change in Coordination of Benefits information.
37
Leave of Absence with Benefits
38
Leave of Absence without Benefits
39
Lay Off with Benefits
40
Lay Off without Benefits
41
Re-enrollment
43
Change of Location
Use when reporting a change of address.
47
Account Balance Reporting
59
Non Payment
AA
Dissatisfaction with Office Staff
AB
Dissatisfaction with Medical Care/Services Rendered
AC
Inconvenient Office Location
AD
Dissatisfaction with Office Hours
AE
Unable to Schedule Appointments in a Timely Manner
AF
Dissatisfaction with Physician's Referral Policy
AG
Less Respect and Attention Time Given than to Other Patients
AH
Patient Moved to a New Location
AI
No Reason Given
AJ
Appointment Times not Met in a Timely Manner
AL
Algorithm Assigned Benefit Selection
EC
Member Benefit Selection
Use when reporting an initial and subsequent enrollment when an insurance carrier needs to recognize that a member made an explicit plan choice.
XN
Notification Only
Use when sending a complete enrollment transmission, for the full file audit. This is used when FSA01 is equal to 030 (Audit or Compare).
XT
Transfer
Use when a member has an organizational change (i.e. a location change within the organization) with no change in benefits or plan.
Required
4
C062
Tax Advantage Account Information
O 1
To identify the type of Healthcare Tax Advantage Account and the related account number
SEMANTIC: FSA04 is the Tax Advantage Account Information.
Required
4-1
1636
Account Relationship Code
M 1
ID
1/2
Code indicating relationship or type of account an entity maintains with a vendor or financial institution
CODE
DEFINITION
2
Investment Account
6
Special Account
FS
Flexible Spending Account
HR
Health Reimbursement Account
HS
Health Savings Account
Z
Mutually Defined
Use when the tax advantage account type is different than the other listed types and is defined in the insurance contract.
Situational
4-2
508
Account Number
O 1
AN
1/35
Account number assigned
SITUATIONAL RULE: Required when the insurance contract or trading partner agreement specifies reporting the tax advantage account number. If not required by this implementation guide, do not send.
Situational
5
594
Frequency Code
O 1
ID
1
Code indicating frequency or type of activities or actions being reported
SEMANTIC: FSA05 specifies the frequency of contribution.
SITUATIONAL RULE: Required when the insurance contract requires reporting the Tax Advantage Account Amount and current contributions are reported in AMT01 (codes equal 'E3' or 'E5') in this loop. If not required by this implementation guide, do not send.
CODE
DEFINITION
1
Weekly
2
Biweekly
3
Semimonthly
4
Monthly
6
Daily
7
Annual
8
Two Calendar Months
9
Lump-Sum Separation Allowance
B
Year-to-Date
C
Single
H
Hourly
Q
Quarterly
S
Semiannual
Situational
6
1204
Plan Coverage Description
O 1
AN
1/50
A description or number that identifies the plan or coverage
SITUATIONAL RULE: Required when additional information is needed to describe tax advantage account. If not required by this implementation guide, do not send.
Situational
7
1161
Product Option Code
O 1
ID
1/2
Code indicating an option chosen for the product
SITUATIONAL RULE: Required when the insurance contract requires reporting a Bank Account. If not required by this implementation guide, do not send.
CODE
DEFINITION
BA
Bank Account
Not Used
8
1161
Product Option Code
O 1
ID
1/2
Not Used
9
1161
Product Option Code
O 1
ID
1/2
AMT - TAX ADVANTAGE ACCOUNT AMOUNT
X12 Name:
Monetary Amount Information
X12 Purpose:
To indicate the total monetary amount
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
5
Situational Rule:
Required when such transmission is required under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.
TR3 Example:
AMT✱E3✱42~
AMT
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
522
Amount Qualifier Code
M 1
ID
1/3
Code specifying the amount qualifier
CODE
DEFINITION
E2
Employee Annual Pledge Amount
E3
Employee Current Contribution
E5
Employer Current Contribution
ECI
Reported Amount
Z5
Remaining Pool Balance
Required
2
782
Monetary Amount
M 1
R
1/18
Monetary 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.
Not Used
3
478
Credit/Debit Flag Code
O 1
ID
1
DTP - TAX ADVANTAGE ACCOUNT 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:
2
Situational Rule:
Required when such transmission is required under the insurance contract between the sponsor and payer to report the effective date of the Tax Advantage Account. If not required by this implementation guide, do not send.
TR3 Example:
DTP✱348✱D8✱20220101~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
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
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
1/35
Expression of a date, a time, or range of dates, times or dates and times
INDUSTRY NAME: Tax Advantage Account Date
REF*A8 - TAX ADVANTAGE ACCOUNT INFORMATION
X12 Name:
Reference Information
X12 Purpose:
To specify identifying information
X12 Syntax:
R0203
At least one of REF02 or REF03 is required.
At least one of REF02 or REF03 is required.
Loop:
Loop Usage:
Situational
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when such transmission is required under the insurance contract between the sponsor and payer to provide the Tax Account Health Insurance Policy Number. If not required by this implementation guide, do not send.
TR3 Example:
REF✱A8✱123456~
REF
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
A8
Tax Advantage Account Health Insurance Policy Number
Required
2
127
Reference Identification
X 1
AN
1/80
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Tax Advantage Account Health Insurance Policy Number
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
3
352
Description
X 1
AN
1/80
Not Used
4
C040
Reference Identifier
O 1
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 Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
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~
LS
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
447
Loop Identifier Code
M 1
AN
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:
1
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~
LX
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
554
Assigned Number
M 1
N
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*75 - 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:
1
TR3 Notes:
Use to specify the name of the reporting category of the member's participating entity.
TR3 Example:
N1✱75✱SOUTHEASTERN UNION~
N1
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
98
Entity Identifier Code
M 1
ID
2/3
Code identifying an organizational entity, a physical location, property or an individual
CODE
DEFINITION
75
Participant
Required
2
93
Name
X 1
AN
1/60
Free-form name
SEGMENT SYNTAX: R0203
INDUSTRY NAME: Member Reporting Category Name
Not Used
3
66
Identification Code Qualifier
X 1
ID
1/2
Not Used
4
67
Identification Code
X 1
AN
2/80
Not Used
5
706
Entity Relationship Code
O 1
ID
2
Not Used
6
98
Entity Identifier Code
O 1
ID
2/3
Not Used
7
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.
At least one of REF02 or REF03 is required.
Loop:
Loop Usage:
Required
Segment Usage:
Required
Segment Repeat:
1
TR3 Notes:
This specifies the reference identifier associated with the reporting category of the member's participating entity.
TR3 Example:
REF✱26✱442~
REF
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
128
Reference Identification Qualifier
M 1
ID
2/3
Code identifying the Reference Identification
CODE
DEFINITION
00
Contracting District Number
17
Client Reporting Category
18
Plan Number
19
Division Identifier
26
Union Number
3L
Branch Identifier
6M
Application Number
9V
Payment Category
9X
Account Category
GE
Geographic Number
LU
Location Number
PID
Program Identification Number
XX1
Special Program Code
XX2
Service Area Code
YY
Geographic Key
ZZ
Mutually Defined
Required
2
127
Reference Identification
X 1
AN
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.
Not Used
3
352
Description
X 1
AN
1/80
Not Used
4
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:
1
Situational Rule:
Required when obligated by the insurance contract. 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.
- Date ranges are reported with the first occurrence of CCYYMMDD as the beginning date and the second occurrence as the ending date.
TR3 Example:
DTP✱007✱RD8✱20220101-20220531~
DTP
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
374
Date/Time Qualifier
M 1
ID
3
Code specifying type of date or time, or both date and time
INDUSTRY NAME: Date Time Qualifier
CODE
DEFINITION
007
Effective
Required
2
1250
Date Time Period Format Qualifier
M 1
ID
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
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Required
3
1251
Date Time Period
M 1
AN
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:
Loop Usage:
Required
Segment Usage:
Situational
Segment Repeat:
1
Situational Rule:
Required when the LS segment in position 6880 is sent. If not required by this implementation guide, do not send.
TR3 Example:
LE✱2700~
LE
✱
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
447
Loop Identifier Code
M 1
AN
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.
SE - TRANSACTION SET TRAILER
X12 Name:
Transaction Set Trailer
X12 Purpose:
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
X12 Comments:
SE is the last segment of each transaction set.
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
SE✱1230✱0002~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
96
Number of Included Segments
M 1
N
1/10
Total number of segments included in a transaction set including ST and SE segments
INDUSTRY NAME: Transaction Segment Count
Required
2
329
Transaction Set Control Number
M 1
AN
4/9
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
The Transaction Set Control Number in ST02 and SE02 must be identical.
GE - FUNCTIONAL GROUP TRAILER
X12 Name:
Functional Group Trailer
X12 Purpose:
To indicate the end of a functional group and to provide control information
X12 Comments:
The use of identical data interchange control numbers in the associated functional group header and trailer is designed to maximize functional group integrity. The control number is the same as that used in the corresponding header.
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
GE✱1✱1~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
97
Number of Transaction Sets Included
M 1
N
1/6
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Required
2
28
Group Control Number
M 1
N
1/9
Assigned number originated and maintained by the sender
SEMANTIC: The data interchange control number GE02 in this trailer must be identical to the same data element in the associated functional group header, GS06.
IEA - INTERCHANGE CONTROL TRAILER
X12 Name:
Interchange Control Trailer
X12 Purpose:
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Segment Usage:
Required
Segment Repeat:
1
TR3 Example:
IEA✱1✱000000905~
USAGE
SEQ
D.E. NUM
NAME
ATTRIBUTES
Required
1
I16
Number of Included Functional Groups
M 1
N
1/5
A count of the number of functional groups included in an interchange
Required
2
I12
Interchange Control Number
M 1
N
9
A control number assigned by the interchange sender
The Value in IEA02 must be identical to the value in ISA13.
 | 834 Benefit Enrollment and Maintenance (008020X333)NOVEMBER 2021 Copyright © 2008-21, X12 Incorporated, Format © 2008-21 Washington Publishing Company. Exclusively published by the Washington Publishing Company. No part of this publication may be distributed, posted, reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior written permission of the copyright owner. All rights reserved. Abstract The Benefit Enrollment and Maintenance Implementation Guide describes the use of the X12 Benefit Enrollment and Maintenance (834) transaction set and addresses the enrollment and maintenance of human resources benefit plans including:
|
PrefaceX12 standards are developed to identify the broadest data requirements for a transaction set. Type 3 Technical Reports (TR3), also known as implementation guides, define the explicit data requirements for a specific business purpose. Trading partners who implement according to the instructions in this TR3 can exchange data consistently with multiple trading partners. As X12 does not define transport requirements, trading partners define their specific transport requirements separately. |
1.1 Implementation Purpose and ScopeFor the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed and need to be implemented consistently by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical. The purpose of this implementation guide is to provide standardized data requirements and content to users of Version 008020 of X12, Benefit Enrollment and Maintenance (834). The 834 is used to transfer enrollment information from the sponsor of the insurance coverage, benefits, or policy to a payer. The intent of this implementation guide is to meet the health care industry's specific need for the initial enrollment and subsequent maintenance of individuals who are enrolled in insurance products. This implementation guide specifically addresses the enrollment, maintenance of health care products, and tax advantage account products. |
1.2 Version InformationThis implementation guide is based on the October 2020 X12 standards, referred to as Version 8, Release 2 (008020). The unique Version/Release/Industry Identifier Code for transaction sets that are defined by this implementation guide is 008020X333. The two-character Functional Identifier Code for the transaction set included in this implementation guide:
The Version/Release/Industry Identifier Code and the applicable Functional Identifier Code must be transmitted in the Functional Group Header (GS segment) that begins a functional group of these transaction sets. For more information, see the descriptions of GS01 and GS08 in Appendix C EDI Control Directory. |
1.3.1 Batch and Real-Time UsageThere are multiple methods available for sending and receiving business transactions electronically. Two common modes for EDI transactions are batch and real-time. Batch - In a batch mode the sender does not remain connected while the receiver processes the transactions. Processing is usually completed according to a set schedule. If there is an associated business response transaction (such as a 271 Response to a 270 Request for Eligibility), the receiver creates the response transaction and stores it for future delivery or transmits the response transaction back to the sender of the original transaction. The sender of the original transmission reconnects at a later time and picks up the response transaction. Note: The sender of the original transmission may not always be the entity that picks up the response transaction at a later time (e.g. Provider submitting through a clearinghouse.) Real-Time - In real-time mode the sender remains connected while the receiver processes the transactions and returns a response transaction to the sender. This implementation guide does not set specific response time parameters for implementers. This implementation guide was based on requirements for batch mode. Willing trading partners may use batch or real-time mode. |
1.3.2 Other Usage LimitationsThere are no other usage limitations. Any response back to the Sponsor from the received transaction is outside the scope of the 834 and is the responsibility of the sponsor and payer. |
1.4.1 Health Care Transaction FlowEach X12 implementation guide explains how to use X12 transaction sets to meet a single defined business purpose. The diagrams found at https://www.x12.org/flow depict the business functions supported by the X12 health care implementation guides. |
1.4.2 Information FlowsFigure 1.1 - Health Care Transaction sets included in the information flow diagram:
|
1.4.3 Location of Insurance Product IdentifiersThe 834 allows three locations for Insurance Product Identifiers, such as policy numbers and group numbers:
The work group found that there was no consistent use for the Insurance Product Identifier at any level. For this reason, the consensus by the work group was to make the Insurance Product Identifier situational at all the levels. However, at least one REF segment containing the Insurance Product Identifier must be present for each Insurance Product either at the Transaction, Member, or Health Coverage level. The work group selected code "38", Master Policy Number, at the Transaction level. This identifier is to be sent when the Insurance Product Identifier applies to all the Insurance Products in the Transaction. The work group found that most of the time the Insurance Product Identifier is communicated at the Member level (loop 2000). The work group selected code "1L", Group or Policy Number, at this level. The Group or Policy Number applies to all the Health Coverage iterations (loop 2300) for the member named in loop 2000. Other iterations of the REF segment with other qualifiers are included to support business needs under the specific policy. The developers of this implementation guide were not able to limit the sender to a single code because of the variety of different insurance plans. At the Health Coverage level (loop 2300), the sender also has the option of sending the Group or Policy Number. The work group selected code "1L", Group or Policy Number, at this level. This applies when different policy numbers exist for each Insurance Product specified in the HD segments. |
1.4.4 Linking a Dependent to a SubscriberSubscribers and dependents are sent as separate occurrences of Loop ID-2000. The initial enrollment for the subscriber must be sent before sending the initial enrollment for any of the subscriber's dependents. The enrollment of a dependent may follow the subscriber's enrollment in the same transmission, or it may be sent separately in a later transmission. Maintaining the existing enrollments of a subscriber and dependents can occur in any sequence. Payers use various means to link dependents to the subscriber. The most common method is to use the subscriber's Social Security Number (SSN). To allow linking between subscribers and dependents without making assumptions about the receiving system, use the code "0F," Subscriber Number, in the REF segment, Loop ID-2000, position 0200. The subscriber's unique identifier is sent in this segment in both the subscriber's and the dependent's Loop ID-2000. The individual's SSN is sent and identified as such in NM108, Loop ID-2100A, position 0300. This applies to both subscribers and dependents. If the SSN is used for linking, then the subscriber's SSN is sent in both locations on the subscriber's Loop ID-2000. |
1.4.5 TerminationThe content of transactions intended to terminate coverage for subscribers and/or related members was the subject of extensive discussion during development of this implementation guide. The work group attempted to strike a balance between the systemic and operational benefits of highly detailed, rich data content and the reality of a current practice in which many plan sponsors and other originators of this transaction may have less than complete data on hand. To accommodate the greatest possible number of users, the work group adopted a guiding principle that only the minimum necessary data would be required for a given type of termination, but that additional data could be sent at the sender's discretion. Trading partners should agree on their approach to communicating terminations in their trading partner agreement. Regardless of additional data and trading partner agreements, transactions of certain format and content must cause very specific outcomes in receiver systems. A termination date passed at the INS level for an individual who is the subscriber (That is, a termination date passed in the DTP segment in position 0250 in the 2000 loop for an INS segment with INS01 = 'Y') indicates that all coverages for that subscriber and any associated dependents are to be terminated in the receiver's system on the indicated date. Said another way, if a subscriber, spouse and two children are all enrolled in medical, prescription and vision coverages in the receiver's system, an "Eligibility End" date passed in that DTP segment for the subscriber must cause the termination of all three coverages for all four individuals in the receiver's system on the date provided in DTP03. A termination date passed at the INS level for an individual who is not the subscriber (That is, a termination date passed in the DTP segment in position 0250 in the 2000 loop for an INS segment with INS01 = 'N') indicates that all coverages for that individual are to be terminated in the receiver's system on the indicated date. If a subscriber, spouse and two children are all enrolled in medical, prescription and vision coverages in the receiver's system, an "Eligibility End" date passed in that DTP segment for the spouse must cause the termination of all three coverages for one individual (the spouse). A termination date passed at the HD level (that is, a termination date passed in the DTP segment in position 2700 in the 2300 loop for an HD loop of any coverage type) applies singly to an individual and a coverage. If a subscriber, spouse and two children are all enrolled in medical, prescription and vision coverages in the receiver's system, a "Benefit End" date passed in the DTP segment subordinate to the vision coverage for the spouse indicates that the last day of the spouse's vision coverage is the date provided in that segment's DTP03. Coverage for other lines of coverage for the member will not be affected, nor will any coverage for any other member linked to the same subscriber. Termination dates are not to be sent at both the HD and INS levels for a particular occurrence of loop 2000. For an individual who is not the subscriber, terminating all lines of coverage at the HD level is the equivalent of terminating that dependent at the INS level. For a subscriber, terminating all insurance products at the HD level is not equivalent to passing the termination at the INS level. Passing terminations at the INS level for a subscriber causes all coverages for all linked dependents to be terminated. Passing terminations at the HD level for a subscriber does not affect the coverages of other individuals linked to that subscriber - dependents may continue to be covered in dependent-only coverage. A change of coverage or an addition of coverage may not automatically result in the termination of existing coverage unless this is clearly agreed upon in the trading partner agreement. Member records that were previously reported as covered and subsequently omitted from the full file replacement can be terminated by the receiver if the process is clearly agreed upon in the trading partner agreement. |
1.4.6 Updates, Versus Full File Audits, Versus Full File ReplacementsThe 834 transaction can be used to provide either updates to the enrollment database, full file audits of the 834 enrollment process, or full file replacements. An update is either an "add", "terminate" or "change" request. The transaction only contains information about the changed members. This is identified in BGN08 by a code value of '2', Change (Update). A full file audit lists all current members, whether involved in a change or not. This facilitates keeping the sponsor's and payer's systems in sync. This is not intended to contain a history of all previous enrollments. The full file audit is intended to identify all active members, at a given point in time and may or may not include terminated members based on your trading partner agreement. The full file audit is not intended to be used to make any changes to the enrollment database. This type of transaction is identified by a BGN08 code value of '4', Verify. Any response back to the sponsor from the received transactions are outside the scope of the 834 and are the responsibility of the sponsor and payer. In addition, INS03 in Loop 2000 and HD01 in Loop 2300 must be set to a value of '030', Audit or Compare. This transaction allows a payer to identify additions, terminations, and changes that need to be applied to the payer's system. A full file identified in BGN08 by a code value of 'RX', Replace, is intended to identify all active members, at a given point in time and may or may not include terminated members based on your Trading Partner Agreement. In addition, INS03 in Loop 2000 and HD01 in Loop 2300 must be set to a value of '030', Audit or Compare. |
1.4.7 Coverage Levels and DependentsDifferences exist in how Payers handle Dependents. Some Payers identify a Coverage Level (HD05) for the Subscriber which defines the coverage for eligible Dependents as well. Other Payers need detailed information on each Dependent in order to maintain their databases. Still other Payers require both types of information. The trading partner agreement between the Payer and the Sponsor must identify the member reporting requirements for the Enrollment transaction. When the trading partner agreement requires the Coverage Level code and no Dependent information, HD05 is required for all initial enrollment or changes to the Coverage Level Code. When Dependent information is required without the Coverage Level Codes, separate INS loops are required for enrollment or change for each Dependent. See the Termination section for more information. HD05 is not used for any Dependent. When the Dependent information and Coverage Level Code are Required, the Coverage Level Code (HD05) must be used for all Subscriber initial enrollments or when the Subscriber's Coverage Level Code changes. This change applies to all covered Dependents of the Subscriber. The Coverage Level Code is not used with Dependent enrollment, changes or terminations. Note: If a Dependent addition or termination effectively changes the Coverage Level Code of a Subscriber, the Subscriber must be changed directly if the trading partner agreement requires use of the Coverage Level Code. |
1.5 Business TerminologyTo ensure consistent use of terms, definitions, and acronyms across X12 products, X12 maintains the Wordbook, a comprehensive corporate glossary. The included terms are either proprietary to X12, cite definitions published by another authority, or represent common terms and definitions that are relevant to X12's work. The terms and definitions defined in the Wordbook are used in X12 work products when applicable, without modification or revision. The Wordbook can be referenced online at wordbook.x12.org. |
1.5.1 Date TerminologyUsers of past 834 implementation guides encountered considerable confusion about what codes should be used for dates related to the insured in Loop ID-2000 and to the insurance coverage in Loop ID-2300. This confusion resulted because several codes with very similar uses were available. These codes include the following: effective date, eligibility date, enrollment date, plan date, coverage date, and benefit date. The tendency has been to try to use the same terminology as that used in the application systems. Lengthy discussion was required to reach a resolution because the application systems' terminology often differed among different systems. To facilitate communications between different systems, the developers of this implementation guide have limited the codes in Loop ID-2300 DTP, with the term "benefit" being used for actual dates of coverage. The developers of this implementation guide recommend that the term "Eligibility" is used from the point of view of the plan sponsor. That is, an individual's "eligibility" dates are those during which he or she may choose to be covered by the sponsor's benefits. The developers further recommend that the term "enrollment" be used from the point of view of the payer. In this case, an individual's "enrollment" dates are those dates during which he or she is covered by a particular benefit. Many more codes are listed in the DTP segment in Loop ID-2000. The developers of this implementation guide recommend that the term "eligibility" be used to refer to the dates on which an insured individual may choose to be covered. |
1.6 Transaction AcknowledgmentsThe purpose of transaction acknowledgments is to report to the sender whether the transaction being acknowledged was accepted or rejected. The X12 Technical Report Type 2, Acknowledgment Reference Model provides guidance on several control structures and transaction set standards intended to augment EDI auditing and control systems. |
1.7 Related TransactionsThere are no transactions related to the transactions described in this implementation guide. |
1.8 Trading Partner AgreementsTrading partner agreements are used to establish and document the relationship between trading partners. A trading partner agreement must not override the specifications in this implementation guide if a transmission is reported in GS08 to be a product of this implementation guide. |
1.9 Transaction ComplianceThere are three types of compliance that may be relevant to a transmitted transaction. Compliance with implementation guide requirements Compliance with state and federal regulation Compliance with trading partner contractual agreements |
1.9.1 Transaction Compliance with Implementation Guide RequirementsA transaction complies with X12 implementation guide requirements if the transaction satisfies all format and content rules and constraints specified in the applicable X12 standards and the implementation guide (also known as a TR3) itself. Should additional clarification of an X12 implementation guide requirement be desired, two options are available.
X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that are not TR3-compliant based on its own business process. A receiver may specify its business rules in a trading partner agreement or companion document. As stated in §1.8, these documents do not override TR3 requirements, nor change how transaction compliance with this TR3 is determined. |
1.9.2 Transaction Compliance with State and Federal RegulationsThis implementation guide has been developed for use as an insurance industry implementation guide. At the time of publication it has not been adopted as a state or federal standard. Should this implementation guide be adopted as a standard, the adopting authority will establish compliance dates for its use by impacted entities. X12 is not the authority for determining compliance with regulatory requirements that might further constrain implementation guide requirements. Questions of compliance for regulatory requirements should be directed to the governing authority. X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that do not comply with applicable regulatory requirements as specified by the applicable regulation(s) or governing authority. |
1.9.3 Transaction Compliance with Contractual RequirementsX12 is not the authority for determining compliance with contractual requirements that might further constrain implementation guide requirements. Questions of compliance for contractual requirements should be directed to the contracting entity. X12 does not specify the business rules that the receiving entity must use to decide when to accept or reject a transaction. The receiver will handle transactions that do not comply with contractual requirements as specified by the applicable contract or contracting entity. |
2.1 Presentation ExamplesThe X12 standards are generic. For example, multiple trading communities use the same PER segment to specify administrative communication contacts. Each community decides which elements to use and which code values in those elements are applicable. This implementation guide uses a format that depicts both the generalized standard and the insurance industry-specific implementation. In this implementation guide, IMPLEMENTATION specifies the requirements for this implementation. X12 STANDARD is included as a reference only. The transaction set presentation is comprised of two main sections with subsections within the main sections: Transaction Set Listing There are two sub-sections under this general title. The first sub-section concerns this implementation of a generic X12 transaction set. The second sub-section concerns the generic X12 standard itself. This section lists the levels, loops, and segments contained in this implementation. It also serves as an index to the segment detail. This section is included as a reference. Segment Detail There are three sub-sections under this general title. This section repeats once for each segment used in this implementation providing segment specific detail and X12 standard detail. This section is included as a reference. This section is included as a reference. It provides a pictorial view of the standard and shows which elements are used in this implementation. This section specifies the implementation details of each data element. These illustrations (Figures 2.1 through 2.5) are examples and are not extracted from the Section 2 detail in this implementation guide. Annotated illustrations, presented below in the same order they appear in this implementation guide, describe the format of the transaction set that follows. Figure 2.1 - Transaction Set Key - Implementation Figure 2.2 - Transaction Set Key - Standard Figure 2.3 - Segment Key - Implementation Figure 2.4 - Segment Key - Diagram Figure 2.5 - Segment Key - Element Summary |
2.2.1 Industry UsageIndustry Usage describes when loops, segments, and elements are to be sent when complying with this implementation guide. The three choices for Usage are required, not used, and situational. To avoid confusion, these are named differently than the X12 standard Condition Designators (mandatory, optional, and relational).
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2.2.1.1 Determining Transaction Compliance with Industry Usage RequirementsA transmitted transaction complies with the governing implementation guide when it satisfies the requirements as defined within the implementation guide. Specifically, the presence or absence of an item (loop, segment, or element) complies with the industry usage specified by this implementation guide according to the following table.
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2.2.2 LoopsLoop requirements depend on the context or location of the loop within the transaction. See Appendix B for more information on loops.
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3. ExamplesBusiness scenario examples for use of this transaction can be found on the X12 Examples website at http://examples.x12.org. The X12 Examples website provides convenient access to examples of X12 transaction transmissions, including the data stream and a description of the associated scenario. |
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Appendix A. External Code SourcesPrior to this publication, X12 TR3s contained a subset of the overall Code Source Directory, formerly known as Appendix A of X12.3. External code lists are not part of the X12 standard and are provided for information purposes only. The full listing is available in Glass, X12's On-Line viewer. Read more about Glass here: https://glasshelp.x12.org/. Where an external code source is referenced in this publication, the implementer is required to use only the codes from that list. Codes must be reported as listed in the code source (e.g. with leading zeroes). Implementers must follow the instructions for code use that are supplied by the code set owner. | ||||
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B.1.1 Referenced and Related StandardsThis technical report is based on the X12 EDI standard which comprises a series of interdependent publications. Implementers are advised to consult these publications when using this technical report. The following standards are required to interpret, understand, and use this technical report:
The following guideline is useful to interpret, understand, and use this technical report:
The following reference model is useful to interpret, understand, and use this technical report:
All of the documents above are available online using links to X12's Online Viewer. | ||||
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B.1.1.1 Transmission Control SchematicRefer to X12.5 - Interchange Control Structures, Section 3.5 - Order of Control Segments, and Chapter 5 Interchange Segment Specifications. Similar transaction sets, called "functional groups," can be sent together within a transmission. Each functional group is prefaced by a group start segment; and a functional group is terminated by a group end segment. One or more functional groups are prefaced by an interchange header and followed by an interchange trailer. Figure B.1 - Transmission Control Schematic, illustrates this interchange control. Figure B.1 - Transmission Control Schematic | ||||
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B.1.1.2 Constraints applicable to the suite of TR3sRefer to X12.6 - Application Control Structure, Section 3.2.8 - Minimums/Maximums. Data element minimum and maximum lengths are set by the X12 standard. This implementation guide may further restrict minimum and maximum lengths within the bounds set by the standard. Such restrictions may occur implicitly by virtue of the allowed qualifier for the data element, or they may be stated explicitly in a note attached to the element or in the general limitations below. | ||||
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B.1.1.2.1 Maximum Length of Data Element 127 Reference IdentificationThe current X12 standard allows a maximum length greater than 50 characters for data element 127. For implementations governed by this implementation guide, unless another value is specified in an attached note, the maximum length of each occurrence of this data element is constrained to 50 characters. | ||||
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B.1.1.2.2 Maximum Length of Data Element 782 Monetary AmountFor implementations governed by this implementation guide, unless another value is specified for an instance of Data Element 782 within Section 2 (Transaction Set), each occurrence of Data Element 782 (Monetary Amount) will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). Note that the decimal point and leading sign, if sent, are not part of the character count. EXAMPLE
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B.1.1.3 DecimalWhile the X12 standard supports usage of exponential notation, this guide prohibits that usage. | ||||
Appendix D. Change SummaryThis Implementation Guide (008020X333) defines the X12 requirements for the Benefit Enrollment and Maintenance. It is based on version/release/subrelease 008020 of the X12 standards. |