834 Health Insurance Exchange: Enrollment (008020X346)

2/15

✱

124

Application
Rec's Code

✱

✱

✱

✱

Responsible
Agency Code

✱

Required

479

Functional Identifier Code

M 1

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

Benefit Enrollment and Maintenance (834)

Required

142

Application Sender's Code

M 1

2/15

Code identifying party sending transmission; codes agreed to by trading partners

Use this code to identify the unit sending the information.

Required

124

Application Receiver's Code

M 1

2/15

Code identifying party receiving transmission; codes agreed to by trading partners

Use this code to identify the unit receiving the information.

Required

373

Date

M 1

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

337

Time

M 1

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

Group Control Number

M 1

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

455

Responsible Agency Code

M 1

1/2

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

CODE

DEFINITION

Accredited Standards Committee X12

Required

480

Version / Release / Industry Identifier Code

M 1

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

008020X346

Health Insurance Exchange: Enrollment

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:

TR3 Example:

ST✱834✱0002✱008020X346~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

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

329

Transaction Set Control Number

M 1

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

1705

Implementation Convention Reference

O 1

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 (STSE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.

CODE

DEFINITION

008020X346

Health Insurance Exchange: Enrollment

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.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BGN✱00✱11227✱20220101✱1200✱ET✱✱✱2~

BGN

✱

✱

✱

✱

✱

✱

✱

Transaction
Type Code

✱

✱

Required

353

Transaction Set Purpose Code

M 1

Code identifying purpose of transaction set

CODE

DEFINITION

Original

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.

The "00" indicates the first time the transaction is sent.

Re-Submission

Send the "15" 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 then be pended by the receiver's translator for further review.

Information Copy

Send the "22" when the original transmission was lost or not processed, and the sender is passing another transmission that is the same as the original.

Required

127

Reference Identification

M 1

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

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

Required

373

Date

M 1

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

337

Time

X 1

4/8

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

623

Time Code

O 1

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

Alaska Time

Central Time

Eastern Time

Greenwich Mean Time

Hawaii-Aleutian Time

Mountain Time

Newfoundland Time

Pacific Time

Atlantic Time

Situational

127

Reference Identification

O 1

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.

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

640

Transaction Type Code

O 1

Required

306

Action Code

O 1

1/2

Code indicating type of action

CODE

DEFINITION

Change (Update)

Used to identify a transaction of additions, terminations and changes to the current enrollment.

Verify

Used to identify a full enrollment transaction to verify that the Exchange's and issuer's systems are synchronized.

Replace

Used to identify a full enrollment transmission to be used to identify additions, terminations and changes that need to be applied to the payer's enrollment system.

Not Used

786

Security Level Code

O 1

REF*38 - EXCHANGE ASSIGNED QUALIFIED HEALTH PLAN IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when all enrollees within this transaction apply to a single QHP. If not required by this implementation guide, do not send.

TR3 Notes:

Traditionally, this identifier represents a combination of the plan/product selected and the employer. In this implementation, the QHP identifier is the same for all employer groups within the SHOP market.

TR3 Example:

REF✱38✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Master Policy Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned Qualified Health Plan Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*TV - ISSUER ASSIGNED QUALIFIED HEALTH PLAN IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when all enrollees within this transaction apply to a single QHP, the issuer has assigned an identifier to that QHP, and the identifier is known to the submitter.
If not required by this implementation guide, do not send.

TR3 Notes:

Traditionally, this identifier represents a combination of the plan/product selected and the employer. In this implementation, the QHP identifier is the same for all employer groups within the SHOP market.
The QHP identified at this level may be overridden at the enrollee level when necessary.

TR3 Example:

REF✱TV✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Line of Business

CODE SOURCE: 244: Line of Business

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Issuer Assigned Qualified Health Plan Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*18 - EXCHANGE ASSIGNED EMPLOYER GROUP IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the enrollment is from a SHOP exchange and all enrollees within this transaction apply to a single employer group. If not required by this implementation guide, do not send.

TR3 Example:

REF✱18✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Plan Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned Employer Group Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*1L - ISSUER ASSIGNED EMPLOYER GROUP IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when:

all enrollees within this transaction apply to a single employer group,
the issuer has assigned an identifier to that employer group,
and the identifier is known to the submitter.

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

TR3 Example:

REF✱1L✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Issuer Assigned Employer Group Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*007 - 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:

Required

Segment Repeat:

TR3 Notes:

The Effective Date reported at this level applies to all records within the transaction unless overridden at the enrollee level.

TR3 Example:

DTP✱007✱D8✱20220101~

DTP

✱

✱

Loop 1000A - SUBMITTER NAME

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Effective Date

QTY*TO - 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:

Required

Segment Repeat:

TR3 Notes:

The Transaction Set Totals for Dependents and Subscribers reported in QTY segments at this level must add up to the Total reported in this segment.
The Transaction Set Total is a sum of all INS segments included in this transaction (ST/SE).
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

✱

✱

✱

Composite
Unit of Mea

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Total

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Record Totals

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

QTY*DT - DEPENDENT RECORD COUNT

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:

Situational Rule:

Required when this transaction contains records for dependents. If not required by this implementation guide, do not send.

TR3 Notes:

The number of dependent records equals the number of instances of loop 2000 where INS01 = N.

TR3 Example:

QTY✱DT✱10000~

QTY

✱

✱

✱

Composite
Unit of Mea

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Dependent Total

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Dependent Record Count

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

QTY*ET - SUBSCRIBER RECORD COUNT

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:

Situational Rule:

Required when this transaction contains subscriber records.

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

TR3 Notes:

The number of subscriber records equals the number of instances of loop 2000 where INS01 = Y.

TR3 Example:

QTY✱ET✱10000~

QTY

✱

✱

✱

Composite
Unit of Mea

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Employee Total

This code is intended to represent the number of subscribers.

Required

380

Quantity

X 1

1/15

Numeric value of quantity

SEGMENT SYNTAX: R0204, E0204

INDUSTRY NAME: Subscriber Record Count

Not Used

C001

Composite Unit of Measure

O 1

Not Used

Free-form Information

X 1

1/30

N1*41 - SUBMITTER NAME

X12 Name:

Party Identification

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱41✱ABC EXCHANGE✱46✱123567999~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Submitter

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Submitter Name

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement.

Required

Identification Code

X 1

2/80

Code identifying a party or other code

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

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Submitter Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N1*40 - RECEIVER NAME

X12 Name:

Party Identification

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop 1000B - RECEIVER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱40✱Health Group✱46✱12356789~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Receiver

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Receiver Name

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Electronic Transmitter Identification Number (ETIN)

Established by trading partner agreement.

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Receiver Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N1*IN - QHP ISSUER

X12 Name:

Party Identification

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop 1000C - QHP ISSUER

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱IN✱ABC Issuer✱FI✱12356799~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insurer

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Insurer Name

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Federal Taxpayer's Identification Number

Use when reporting Tax ID.

Payor Identification

Use when reporting Payer ID.

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

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Insurer Identification Code

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N1*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 1000D - SPONSOR NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when this transaction (ST/SE) contains SHOP enrollments only, and all enrollees share the same sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.
SHOP related transactions will identify the employer as the sponsor.

TR3 Example:

N1✱P5✱ABC Employer✱24✱123567999~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Plan Sponsor

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Plan Sponsor Name

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Employer's Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Sponsor Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N1*62 - SPONSOR/EMPLOYER GROUP SETUP - 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:

Situational Rule:

Required when this transaction (ST/SE) contains an initial enrollment for a Sponsor/Employer Group or when the Sponsor's/Employer Group's information is being updated. If not required by this implementation guide, do not send.

TR3 Notes:

When this loop is used, it is preferred this transaction (ST/SE) be limited to enrollees that are part of this employer group. If this option is not selected, the design and intent is issuers will be able to know which enrollees are linked to this employer group using the Exchange Assigned Employer Group Identifier reported in this loop to the Exchange Assigned Employer Group Identifier reported in Loop 2000.
In this context, initial enrollment means the first time an exchange presents an employer group to an issuer.

TR3 Example:

N1✱62✱ABC EMPLOYER✱24✱123456789~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Applicant's Employer

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Sponsor Name

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Employer's Identification Number

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Sponsor Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

N3 - PRIMARY BILLING ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱P.O. Box 1234~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Billing Address Line

Situational

166

Address Information

O 1

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: Billing Address Line

N4 - PRIMARY BILLING 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:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Billing City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Billing State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

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

SEGMENT SYNTAX: E0308

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

INDUSTRY NAME: Billing Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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.

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PER*AJ - PRIMARY 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:

Required

Segment Repeat:

TR3 Notes:

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

TR3 Example:

PER✱AJ✱HUMAN✱TE✱8001234567✱EM✱HUMAN@JOB.COM~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Primary Contact

Required

Name

O 1

1/60

Free-form name

INDUSTRY NAME: Enrollee Employer Communications Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Facsimile

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

PER*AL - ALTERNATE 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:

Situational Rule:

Required when there is an alternate contact for the Employer Group/ Sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱AL✱SMALLS✱TE✱8001234567~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Alternate Contact

Required

Name

O 1

1/60

Free-form name

INDUSTRY NAME: Enrollee Employer Communications Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Facsimile

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

ACT - SPONSOR/EMPLOYER GROUP 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:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

ACT✱1~

ACT

✱

✱

✱

✱

✱

Acct Number
Qualifier

✱

✱

✱

✱

Required

508

Account Number

M 1

1/35

Account number assigned

Populate this element with a '1'.

Not Used

Name

O 1

1/60

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

569

Account Number Qualifier

X 1

1/3

Not Used

508

Account Number

X 1

1/35

Not Used

352

Description

O 1

1/80

Not Used

107

Payment Method Type Code

O 1

1/2

Not Used

1216

Benefit Status Code

O 1

REF*18 - EXCHANGE ASSIGNED EMPLOYER GROUP IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱18✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Plan Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned Employer Group Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*QQ - EMPLOYER SIZE

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱QQ✱43~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Unit Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Employee Count

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
Report the total number of full-time employees.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - EMPLOYER CLASSIFICATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱IJ✱7349~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Standard Industry Classification (SIC) Code

Mutually Defined

Use to identify the North American Industry Classification System

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Employer Classification Code

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*DU - EMPLOYER DEPENDENT INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when dependent coverage is offered by this Sponsor/Employer Group. If not required by this implementation guide, do not send.

TR3 Example:

REF✱DU✱YES~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Dependents Information

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Employer Dependent Coverage Indication

Populate with 'YES' to denote that dependent coverage is offered.
Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

N3 - ALTERNATE BILLING ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there is an alternate billing address. If not required by this implementation guide, do not send.

TR3 Example:

N3✱P.O. Box 1234~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Alternate Billing Address Line

Situational

166

Address Information

O 1

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: Alternate Billing Address Line

N4 - ALTERNATE BILLING CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there is an alternate billing address. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Alternate Billing City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Alternate Billing State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Alternate Billing Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PER*BI - ALTERNATE BILLING 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:

Situational Rule:

Required when there is an alternate billing contact. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱EP✱BILL✱TE✱8001234567~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Bill Inquiry Contact

Required

Name

O 1

1/60

Free-form name

INDUSTRY NAME: Enrollee Employer Communications Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Facsimile

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

DTP*AB4 - EMPLOYER WAITING PERIOD

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

DTP✱AB4✱UN✱30~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

AB4

Time Period

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Unstructured

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Waiting Period Days

Enter the number of days in the waiting period. For example, '0' indicates there is no waiting period, '15' indicates the waiting period is 15 days. '30' = 30 days, etc.

AMT - EMPLOYER CONTRIBUTION

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop 1100EB - SPONSOR/EMPLOYER GROUP OTHER LOCATION INFORMATION

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

AMT✱JN✱100~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code specifying the amount qualifier

CODE

DEFINITION

Contribution

Use code 93 when the number reported in AMT02 is a percentage.

Employer Contribution

Use code JN when the number reported in AMT02 is a dollar amount.

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Employer Contribution

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

478

Credit/Debit Flag Code

O 1

ACT - SPONSOR/EMPLOYER GROUP OTHER LOCATION 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:

Situational Rule:

Required when there are additional locations for this Sponsor/Employer Group. If not required by this implementation guide, do not send.

TR3 Example:

ACT✱2~

ACT

✱

✱

✱

✱

✱

Acct Number
Qualifier

✱

✱

✱

✱

Required

508

Account Number

M 1

1/35

Account number assigned

Populate the first iteration of this loop with '2' and increment by 1 for each additional iteration of this loop.

Not Used

Name

O 1

1/60

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

569

Account Number Qualifier

X 1

1/3

Not Used

508

Account Number

X 1

1/35

Not Used

352

Description

O 1

1/80

Not Used

107

Payment Method Type Code

O 1

1/2

Not Used

1216

Benefit Status Code

O 1

N3 - SPONSOR/EMPLOYER GROUP OTHER LOCATION STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop 1100EB - SPONSOR/EMPLOYER GROUP OTHER LOCATION INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱P.O. Box 1234~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Sponsor/Employer Group Other Location Address Line

Situational

166

Address Information

O 1

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: Sponsor/Employer Group Other Location Address Line

N4 - SPONSOR/EMPLOYER GROUP OTHER 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 1100EB - SPONSOR/EMPLOYER GROUP OTHER LOCATION INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Loop 1100EB - SPONSOR/EMPLOYER GROUP OTHER LOCATION INFORMATION

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Sponsor/Employer Group Other Location City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Sponsor/Employer Group Other Location State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Sponsor/Employer Group Other Location Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PER*1I - SPONSOR/EMPLOYER GROUP OTHER LOCATION 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:

Situational Rule:

Required when there is contact information specific to this other location. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱1I✱✱TE✱8001234567~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Local Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the enrollee's employer communication contact name is supplied by the enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollee Employer Communications Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Facsimile

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

INS - ENROLLEE LEVEL DETAIL

X12 Name:

Insured Benefit

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

Subscriber information must precede 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

✱

1073

✱

1069

Individual
Relat Code

✱

875

Maintenance
Type Code

✱

✱

✱

✱

COBRA Qual
Event Code

1/2

✱

584

Employment
Status Code

✱

✱

✱

1250

✱

✱

✱

✱

✱

✱

✱

Chge Identi
Info Code

O 20

1/2

✱

1793

Prov Netwrk
Info Code

1/2

Required

1073

Yes/No Condition or Response Code

M 1

Code indicating a Yes or No condition or response

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

INDUSTRY NAME: Enrollee Indicator

CODE

DEFINITION

Yes

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

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

CODE

DEFINITION

Spouse

Father or Mother

Grandfather or Grandmother

Grandson or Granddaughter

Uncle or Aunt

Nephew or Niece

Cousin

Adopted Child

Foster Child

Son-in-law or Daughter-in-law

Brother-in-law or Sister-in-law

Mother-in-law or Father-in-law

Brother or Sister

Ward

Stepparent

Stepson or Stepdaughter

Self

Child

REF*38 - EXCHANGE ASSIGNED QUALIFIED HEALTH PLAN IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Exchange Assigned QHP segment in the header is not used.

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

TR3 Notes:

The QHP identified by this segment may be overwritten by a coverage specific identifier when necessary.

TR3 Example:

REF✱38✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Master Policy Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned Qualified Health Plan Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*TV - ISSUER ASSIGNED QUALIFIED HEALTH PLAN IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the Issuer Assigned QHP segment in the header is not used, and the Issuer Assigned QHP Identifier is known by the submitter.

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

TR3 Notes:

The QHP identified by this segment may be overwritten by a coverage specific identifier when necessary.

TR3 Example:

REF✱TV✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Line of Business

CODE SOURCE: 244: Line of Business

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Issuer Assigned Qualified Health Plan Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*38 - COVERAGE SPECIFIC EXCHANGE ASSIGNED QUALIFIED HEALTH PLAN IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when one or more of the specific coverages identified in Loop ID 2300 belong to a different QHP than reported as the enrollee or header level QHP. If not required by this implementation guide, do not send.

TR3 Notes:

The identifier applicable to a specific coverage is reported in REF02. Populate REF03 with the counter (HD06) of the appropriate coverage information.

TR3 Example:

REF✱38✱12565496✱3~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Master Policy Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Coverage Specific Exchange Assigned Qualified Health Plan Identifier

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

Required

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

Populate this field with the value reported in HD06 of the coverage being identified.

Not Used

C040

Reference Identifier

O 1

REF*TV - COVERAGE SPECIFIC ISSUER ASSIGNED QUALIFIED HEALTH PLAN IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when one or more of the specific coverages identified in Loop ID 2300 belong to a different QHP than reported as the enrollee or header level QHP and the Issuer Assigned QHP identifier is known to the submitter. If not required by this implementation guide, do not send.

TR3 Notes:

The identifier applicable to a specific coverage is reported in REF02. Populate REF03 with the counter (HD06) of the appropriate coverage information.

TR3 Example:

REF✱TV✱12565496✱3~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Line of Business

CODE SOURCE: 244: Line of Business

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Coverage Specific Issuer Assigned Qualified Health Plan Identifier

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

Required

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

Populate this field with the value reported in HD06 of the coverage being identified.

Not Used

C040

Reference Identifier

O 1

REF*18 - EXCHANGE ASSIGNED EMPLOYER GROUP IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the enrollment is from a SHOP exchange and the header exchange assigned employer group segment is not used. If not required by this implementation guide, do not send.

TR3 Notes:

The Employer Group identified by this segment may be overwritten by a coverage specific identifier when necessary.

TR3 Example:

REF✱18✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Plan Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned Employer Group Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*1L - ISSUER ASSIGNED EMPLOYER GROUP IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the enrollment is from a SHOP exchange, the header issuer assigned employer group segment is not used, the issuer has assigned an identifier to that employer group, and the identifier is known to the submitter. If not required by this implementation guide, do not send.

TR3 Notes:

The Employer Group identified by this segment may be overwritten by a coverage specific identifier when necessary.

TR3 Example:

REF✱1L✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Issuer Assigned Employer Group Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*18 - COVERAGE SPECIFIC EXCHANGE ASSIGNED EMPLOYER GROUP IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the enrollment is from a SHOP exchange and one or more of the specific coverages identified in Loop ID 2300 belong to a different employer group than reported as either the enrollee or header level employer group. If not required by this implementation guide, do not send.

TR3 Notes:

The identifier applicable to a specific coverage is reported in REF02. Populate REF03 with the counter (HD06) of the appropriate coverage information.

TR3 Example:

REF✱18✱12565496✱3~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Plan Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Coverage Specific Exchange Assigned Employer Group 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.

Required

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

Populate this field with the value reported in HD06 of the coverage being identified.

Not Used

C040

Reference Identifier

O 1

REF*1L - COVERAGE SPECIFIC ISSUER ASSIGNED EMPLOYER GROUP IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the enrollment is from a SHOP exchange,
and one or more of the specific coverages identified in Loop ID 2300 belong to a different employer group than reported as either the enrollee or header level employer group,
and the issuer assigned identifier is known by the submitter.

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

TR3 Notes:

The identifier applicable to a specific coverage is reported in REF02. Populate REF03 with the counter (HD06) of the appropriate coverage information.

TR3 Example:

REF✱1L✱12565496✱3~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Coverage Specific Issuer Assigned Employer Group 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.

Required

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

Populate this field with the value reported in HD06 of the coverage being identified.

Not Used

C040

Reference Identifier

O 1

REF*POL - EXCHANGE ASSIGNED POLICY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

For the purposes of this implementation, policy is defined as the collective of enrollees constituting a family unit or household.

TR3 Example:

REF✱POL✱1232456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

POL

Policy Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned Policy Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*AZ - ISSUER ASSIGNED POLICY IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when known by the submitter. If not required by this implementation guide, do not send.

TR3 Example:

REF✱AZ✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Health Insurance Policy Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Issuer Assigned Policy Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*WH - EXCHANGE ASSIGNED SUBSCRIBER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment must contain the unique subscriber identification number assigned by the Health Insurance Exchange. This identifier may be used to link the dependent to the subscriber.

TR3 Example:

REF✱WH✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Master Reference (Link) Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned Subscriber Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*0F - ISSUER ASSIGNED SUBSCRIBER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the issuer has assigned an identifier to the subscriber and that identifier has been made known to the submitter. If not required by this implementation guide, do not send.

TR3 Notes:

This segment must contain the unique SUBSCRIBER identification number assigned by the issuer. This identifier may be used to link the subscriber to the dependents.

TR3 Example:

REF✱0F✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Subscriber Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Issuer Assigned Subscriber 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*6O - EXCHANGE ASSIGNED DEPENDENT IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when:
an exchange has assigned an identifier to the dependent named in Loop 2100A,
and that identifier is known to the submitter,
and the identifier is permitted for use under applicable regulation.

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

TR3 Notes:

This segment must contain the unique identifier assigned by the Health Insurance Exchange.

TR3 Example:

REF✱6O✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Cross Reference Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned Dependent Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*1W - ISSUER ASSIGNED DEPENDENT IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the issuer has assigned an identifier to the dependent and that identifier has been made known to the submitter. If not required by this implementation guide, do not send.

TR3 Notes:

This segment must contain the unique identifier assigned by the Issuer.

TR3 Example:

REF✱1W✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Member Identification Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Issuer Assigned Dependent Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*4A - EXCHANGE ASSIGNED APTC CONTRIBUTOR/TAX PAYER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when:

• an exchange has assigned an identifier to the ATPC contributor named in Loop 2100I,
• and the identifier is known to the submitter,
• and the identifier is permitted for use under applicable regulation.

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

TR3 Example:

REF✱4A✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Personal Identification Number (PIN)

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Exchange Assigned APTC Contributor/Tax Payer Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*23 - ISSUER ASSIGNED APTC CONTRIBUTOR/TAX PAYER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the issuer has assigned an identifier to the individual named in Loop 2100I and that identifier is known to the submitter.
If not required by this implementation guide, do not send.

TR3 Example:

REF✱23✱12565496~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Client Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Issuer Assigned APTC Contributor/Tax Payer Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - ENROLLEE SUPPLEMENTAL IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱Q4✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Prior Identifier Number

Use to pass the prior issuer assigned identifier when the member had previous coverage with the same issuer.

Mutually Defined

Use when an exchange has defined another form of enrollee identifier not otherwise accounted for in this transaction.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Enrollee Supplemental Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*01 - ACH BANK INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an exchange has collected bank information for the purposes of premium payment. If not required by this implementation guide, do not send.

TR3 Example:

REF✱01✱12565496✱JOHN DOE✱PB:00123456789~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

American Bankers Assoc. (ABA) Transit/Routing Number (Including Check Digit, 9 Digits)

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Routing 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.

Required

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Account Holder Name

Required

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Payer's Financial Institution Account Number for Check, Draft, or Wire Payments; Originating Company Account Number for ACH Transfers

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Bank Account 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

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

REF*PSM - CREDIT/DEBIT CARD INFORMATION

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an exchange has collected credit/debit card information for the purposes of premium payment. If not required by this implementation guide, do not send.

TR3 Example:

REF✱PSM✱1234432112344321✱JOHN DOE✱8U:123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

PSM

Credit Card

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Credit/Debit Card 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.

Required

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Card Holder Name

Required

C040

Reference Identifier

O 1

To identify one or more reference numbers or identification numbers as specified by the Reference Qualifier

SEMANTIC: REF04 contains data relating to the value cited in REF02.

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C04003 or C04004 is present, then the other is required.
P0506
If either C04005 or C04006 is present, then the other is required.

Required

4-1

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Bank Assigned Security Identifier

Required

4-2

127

Reference Identification

M 1

1/80

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

INDUSTRY NAME: Card Security Code

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

Not Used

4-3

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-4

127

Reference Identification

X 1

1/80

Not Used

4-5

128

Reference Identification Qualifier

X 1

2/3

Not Used

4-6

127

Reference Identification

X 1

1/80

DTP - ENROLLEE LEVEL DATES

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when any of the dates defined by the date qualifiers and code notes available in DTP01 apply to the enrollee initial enrollment and/or enrollment reconciliation process.

OR

Required when this transaction is reporting a change to an enrollee's record, and one of the dates defined by the date qualifiers and code notes available in DTP01 have changed.

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

TR3 Notes:

While many of the dates listed for DTP01 are related to termination, the only code that is used to actually terminate an Enrollee is 357 (Eligibility End). Similarly, the Eligibility Begin Date (code 356) is the date the individual is eligible for coverage, not the date coverage is effective.
For new enrollments or reconciliation, all dates that apply to the particular insurance contract are to be sent.
For updates, all dates that apply to the particular insurance contract which have changed are to be sent.

TR3 Example:

DTP✱356✱D8✱20220101~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

286

Retirement

300

Enrollment Signature Date

301

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event

303

Maintenance Effective

This code is used to send the effective date of a change to an existing enrollee'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

356

Eligibility Begin

The date when an enrollee could elect to enroll or begin benefits in any health care plan through the employer. This is not the actual begin date of coverage, which is conveyed in the DTP segment at position 2700.

357

Eligibility End

The eligibility end date represents the last date of coverage for which claims will be paid for the individual being terminated. For example, if a date of 02/28/2014 is passed then claims for this individual will be paid through 11:59 p.m. on 02/28/2014.

382

Enrollment

388

Payment Commencement

393

Plan Participation Suspension

473

Medicaid Begin

474

Medicaid End

754

Next Payment Due

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

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: 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:

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

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

903

Application Entry

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

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

1251

Date Time Period

M 1

1/35

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

DTP*196 - INDIAN TRIBAL STATUS EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when collected by an exchange. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱196✱D8✱20220601~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

196

Start

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Indian Tribal Status Effective Date

DTP*771 - TOBACCO STATUS EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when collected by an exchange. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱771✱D8✱20220201~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

771

Status

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Tobacco Status Effective Date

DTP*ABW - CREDIT CARD EXPIRATION DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an exchange has collected credit/debit card information for the purposes of premium payment. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱ABW✱YM✱2107~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

ABW

Credit Documentation Expiration

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Year and Month Expressed in Format YYMM

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Credit Card Expiration Date

NM1 - ENROLLEE NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱IL✱1✱SMITH✱JOHN✱M✱✱SR~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

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 transaction, or if it is a new or update enrollment transaction.

CODE

DEFINITION

Corrected Insured

Use this code if this transmission is correcting the identifier information on an enrollee already enrolled. Usage of this code requires the sending of an NM1 with code '70' in loop 2100B.

Insured or Subscriber

Use this code for enrolling a new enrollee or updating an enrollee with no change in identifying information.

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Enrollee Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Enrollee First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollee Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollee Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollee Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

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.

Mutually Defined

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when an Enrollee Identifier is known and allowed under confidentiality regulations. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollee Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*IP - ENROLLEE COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required ((when enrolling new subscribers) or (when enrolling new dependents with contact information different than the subscriber) or (when changing the member's contact information)) and the information is available to the submitter.

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

TR3 Notes:

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

TR3 Example:

PER✱IP✱✱HP✱8015554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Insured Party

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

Select the appropriate PER03 qualifier necessary to represent the individual's preferred contact method as indicated on the application.

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Telemail

Use when the enrollee designates a telephone number at which to receive text message communications.

Text Message Address

Work Cellular

Work Phone Number

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Populate this element with the individual's preferred contact information as provided on the application.

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Telemail

Use when the enrollee designates a telephone number at which to receive text message communications.

Text Message Address

Work Cellular

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Telemail

Use when the enrollee designates a telephone number at which to receive text message communications.

Text Message Address

Work Cellular

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - ENROLLEE RESIDENCE STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when enrolling new subscribers, when enrolling new dependents with address different than the subscriber, or when changing a member's address. If not required by this implementation guide, do not send.

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Enrollee Address Line

Situational

166

Address Information

O 1

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: Enrollee Address Line

N4 - ENROLLEE CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Enrollee City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Enrollee State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Enrollee Postal Zone or Zip Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Situational

309

Location Qualifier

X 1

1/2

Code identifying type of location

SEGMENT SYNTAX: C0605

SITUATIONAL RULE: Required when this data is required by the trading partner agreement between the exchange and the issuer and allowed by federal and state regulations. If not required by this implementation guide, do not send.

CODE

DEFINITION

Area

County/Parish

Situational

310

Location Identifier

O 1

1/30

Code which identifies a specific location

SEGMENT SYNTAX: C0605

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

DMG*D8 - ENROLLEE DEMOGRAPHICS

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when enrolling a new enrollee, changing an enrollee's demographic information, or terminating an enrollee. If not required by this implementation guide, do not send.

TR3 Example:

DMG✱D8✱19620915✱F✱M✱^RET^2054-5~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Enrollee Birth Date

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

CODE

DEFINITION

Not Provided

Use when the gender cannot be sent due to reporting restrictions.

Not Applicable

Use when member self-reports as transgender.

Female

Male

Unknown

Use when the gender is unknown.

Situational

1067

Marital Status Code

O 1

Code specifying the marital status of a person

SITUATIONAL RULE: Required when collected by the Exchange and the enrollee identified in the related INS segment is the subscriber.If not required by this implementation guide, do not send.

CODE

DEFINITION

Registered Domestic Partner

Divorced

Single

Married

Unreported

Separated

Unmarried (Single or Divorced or Widowed)

Widowed

Legally Separated

Situational

C056

Composite Race or Ethnicity Information

X 25

To send general and detailed information on race or ethnicity

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

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

SITUATIONAL RULE: Required when collected by the Exchange.If not required by this implementation guide, do not send.

Not Used

5-1

1109

Race or Ethnicity Code

O 1

Required

5-2

1270

Code List Qualifier Code

X 1

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

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203

INDUSTRY NAME: Race or Ethnicity Code

CODE SOURCE 859: Classification of Race or Ethnicity

Situational

1066

Citizenship Status Code

O 1

1/2

Code indicating citizenship status

SITUATIONAL RULE: Required when deemed necessary by the trading partner agreement between an exchange and issuer, Andtransmission of the data is allowed by federal and state regulations.If not required by this implementation guide, do not send.

CODE

DEFINITION

U.S. Citizen

Non-Resident Alien

Resident Alien

Illegal Alien

Alien

U.S. Citizen - Non-Resident

U.S. Citizen - Resident

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Situational

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P1011

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

REC

Race or Ethnicity Collection Code

CODE SOURCE: 860: Race or Ethnicity Collection Code

Situational

1271

Industry Code

X 1

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 there is a need 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

Not Used

Country Code

O 1

2/3

EC - EMPLOYMENT CLASS

X12 Name:

Employment Class

X12 Purpose:

To provide class of employment information

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when sending additional employment class information on the enrollee. If not required by this implementation guide, do not send.

TR3 Example:

EC✱04✱06✱07~

✱

1176

Employment
Class Code

2/3

✱

1176

Employment
Class Code

2/3

✱

1176

Employment
Class Code

✱

✱

Information
Status Code

✱

Required

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Situational

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

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

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Situational

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

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

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Not Used

954

Percentage as Decimal

O 1

1/10

Not Used

1201

Information Status Code

O 1

Not Used

1149

Occupation Code

O 1

4/6

HLH - ENROLLEE HEALTH INFORMATION

X12 Name:

Health Information

X12 Purpose:

To provide health information

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on initial enrollment of an enrollee when appropriate medical information about the enrollee is available

Or

Required on an enrollment update when an enrollee'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

✱

C061

Membr Healt
Treat Info

✱

✱

✱

✱

✱

✱

Situational

C061

Member Health and Treatment Information

O 10

To identify member health and treatment information

X12 COMPOSITE SYNTAX NOTES:

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

X12 COMPOSITE SEMANTIC NOTES:

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

SITUATIONAL RULE: Required on initial enrollment to report tobacco use, substance abuse or pregnancy status when the enrollee's information is available.ORRequired on an enrollment update to report tobacco use, substance abuse or pregnancy status when an enrollee's information is available.If not required by this implementation guide, do not send.

Situational

1-1

1212

Health-Related Code

O 1

Code indicating a specific health situation

INDUSTRY NAME: Health Related Code

CODE

DEFINITION

None

Pregnancy

Substance Abuse

Tobacco Use

Unknown

Situational

1-2

1073

Yes/No Condition or Response Code

O 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

Unknown

Yes

Situational

1-3

374

Date/Time Qualifier

X 1

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

COMPOSITE SYNTAX: L030405, C0403, C0503

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

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

COMPOSITE SYNTAX: L030405, C0403

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

Situational

Height

O 1

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: Enrollee Height

The height must be reported in inches.

Situational

Weight

O 1

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: Enrollee Weight

Not Used

Weight

O 1

1/10

Not Used

352

Description

O 1

1/80

Not Used

1213

Current Health Condition Code

O 1

Not Used

352

Description

O 1

1/80

HI - ENROLLMENT AMOUNT INFORMATION

X12 Name:

Health Care Information Codes

X12 Purpose:

To supply information related to the delivery of health care

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when there are amounts that apply to the individual identified in this loop.

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

TR3 Notes:

Examples of amounts to be reported include: APTCs, CSRs, APTC Amount Paid, Total Premium Amount (APTC + Enrollee Premium Liability), State Mandated Benefit Amount, and others.

TR3 Example:

HI✱ZZ:1:RD8:20220101-20220131:427.35:1✱ZZ:1:RD8:20220101- 20220131:127:2✱ZZ:2:RD8:20220101-20220131:225.5::3~

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

C022

Health Care Code Information

M 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

1-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

1-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

1-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

1-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

1-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

1-6

380

Quantity

O 1

1/15

Numeric value of quantity

SITUATIONAL RULE: Required when there are multiple Health Coverages in Loop 2300 and the amount represented in this composite applies to the one specific Health Coverage identified by HD06. If not required by this implementation guide, do not send.

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

1-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

1-8

1271

Industry Code

X 1

1/30

Not Used

1-9

1271

Industry Code

X 1

1/30

Not Used

1-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

SITUATIONAL RULE: Required when it is necessary to report an additional enrollment amount and the preceding HI data elements have been used to report other enrollment amounts. If not required by this implementation guide, do not send.

Required

2-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

2-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

2-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

2-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

2-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

2-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

2-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

2-8

1271

Industry Code

X 1

1/30

Not Used

2-9

1271

Industry Code

X 1

1/30

Not Used

2-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

3-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

3-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

3-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

3-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

3-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

3-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

3-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

3-8

1271

Industry Code

X 1

1/30

Not Used

3-9

1271

Industry Code

X 1

1/30

Not Used

3-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

4-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

4-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

4-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

4-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

4-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

4-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

4-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

4-8

1271

Industry Code

X 1

1/30

Not Used

4-9

1271

Industry Code

X 1

1/30

Not Used

4-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

5-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

5-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

5-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

5-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

5-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

5-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

5-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

5-8

1271

Industry Code

X 1

1/30

Not Used

5-9

1271

Industry Code

X 1

1/30

Not Used

5-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

6-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

6-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

6-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

6-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

6-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

6-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

6-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

6-8

1271

Industry Code

X 1

1/30

Not Used

6-9

1271

Industry Code

X 1

1/30

Not Used

6-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

7-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

7-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

7-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

7-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

7-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

7-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

7-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

7-8

1271

Industry Code

X 1

1/30

Not Used

7-9

1271

Industry Code

X 1

1/30

Not Used

7-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

8-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

8-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

8-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

8-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

8-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

8-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

8-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

8-8

1271

Industry Code

X 1

1/30

Not Used

8-9

1271

Industry Code

X 1

1/30

Not Used

8-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

9-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

9-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

9-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

9-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

9-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

9-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

9-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

9-8

1271

Industry Code

X 1

1/30

Not Used

9-9

1271

Industry Code

X 1

1/30

Not Used

9-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

10-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

10-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

10-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

10-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

10-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

10-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

10-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

10-8

1271

Industry Code

X 1

1/30

Not Used

10-9

1271

Industry Code

X 1

1/30

Not Used

10-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

11-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

11-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

11-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

11-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

11-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

11-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

11-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

11-8

1271

Industry Code

X 1

1/30

Not Used

11-9

1271

Industry Code

X 1

1/30

Not Used

11-10

1271

Industry Code

O 1

1/30

Situational

C022

Health Care Code Information

O 1

To send health care codes and their associated dates, amounts and quantities

X12 COMPOSITE SYNTAX NOTES:

P0304
If either C02203 or C02204 is present, then the other is required.
E0809
Only one of C02208 or C02209 may be present.

X12 COMPOSITE SEMANTIC NOTES:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06, C022-08 and C022-10.
If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
C022-03 is the date format that will appear in C022-04.
C022-07 qualifies C022-01.
C022-08 represents the ending value in a range of codes.
C022-09 is a value from Code Source 959 for the Present on Admission Indicator.
C022-10 is the attribute of the code in C022-02 from the same code list.

X12 COMPOSITE COMMENTS: C022-09 would only need to be reported when C022-02 is a Diagnosis Code and range of diagnosis codes were NOT given in C022-08.

Required

12-1

1270

Code List Qualifier Code

M 1

1/3

Code identifying a specific industry code list

CODE

DEFINITION

Mutually Defined

CMS/CCIIO Enrollment Amounts Code Set

Required

12-2

1271

Industry Code

M 1

1/30

Code indicating a code from a specific industry code list

INDUSTRY NAME: Enrollment Amount Code

This element defines the type of amount being reported. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Situational

12-3

1250

Date Time Period Format Qualifier

X 1

2/3

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amount represented in this composite. If not required by this implementation guide, do not send.

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Situational

12-4

1251

Date Time Period

X 1

1/35

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

COMPOSITE SYNTAX: P0304

SITUATIONAL RULE: Required when specific dates apply to the amounts represented in this composite. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollment Amount Related Date or Date Range

Required

12-5

782

Monetary Amount

O 1

1/18

Monetary amount

INDUSTRY NAME: Enrollment 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

12-6

380

Quantity

O 1

1/15

Numeric value of quantity

INDUSTRY NAME: Health Coverage Sequence Number

Populate this field with the value reported in HD06 of the coverage loop this amount is related to.

Situational

12-7

799

Version Identifier

O 1

1/30

Revision level of a particular format, program, technique or algorithm

SITUATIONAL RULE: Required when the amount represented in this composite is identifying an advance cost share amount. If not required by this implementation guide, do not send.

This element identifies the applicable CSR plan variation in which the member is enrolled. Codification and Definitions can be found on the CMS Health Insurance Exchange website.

Not Used

12-8

1271

Industry Code

X 1

1/30

Not Used

12-9

1271

Industry Code

X 1

1/30

Not Used

12-10

1271

Industry Code

O 1

1/30

LUI - ENROLLEE LANGUAGE

X12 Name:

Language Use

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop 2100B - INCORRECT ENROLLEE NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected this information and is legally allowed to share it. If not required by this implementation guide, do not send.

TR3 Example:

LUI✱LD✱123✱✱8~

LUI

✱

✱

✱

✱

✱

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0102

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

CODE

DEFINITION

NISO Z39.53 Language Codes

CODE SOURCE: 457: NISO Z39.53 Language Code List

ISO 639 Language Codes

CODE SOURCE: 102: Languages

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEMANTIC: LUI02 is the language code.

SEGMENT SYNTAX: P0102, L040203

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

INDUSTRY NAME: Language Code

Situational

352

Description

X 1

1/80

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

SEMANTIC: LUI03 is the name of the language.

SEGMENT SYNTAX: L040203

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

INDUSTRY NAME: Language Description

Situational

1303

Use of Language Indicator Code

O 1

1/2

Code indicating the use of a language

SEGMENT SYNTAX: L040203

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Language Use Indicator

CODE

DEFINITION

Language Reading

Language Writing

Language Speaking

Native Language

Not Used

1476

Language Proficiency Indicator Code

O 1

NM1*70 - INCORRECT ENROLLEE NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when 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 Example:

NM1✱70✱1✱SMYTH✱JON~

NM1

✱

✱

Loop 2100B - INCORRECT ENROLLEE NAME

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

This code identifies that the information that follows is previously reported enrollment information that is being corrected.

CODE

DEFINITION

Prior Incorrect Insured

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Prior Incorrect Enrollee Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Prior Incorrect Enrollee First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prior Incorrect Enrollee Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prior Incorrect Enrollee Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prior Incorrect Enrollee Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Social Security Number

Standard Unique Health Identifier for each Individual in the United States

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

Individual Taxpayer's Identification Number (ITIN)

Situational

Identification Code

X 1

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 Insured Identifier

NM109 is the identifier that was previously sent in error. This allows matching with data on receiver's system.

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

DMG*D8 - INCORRECT ENROLLEE DEMOGRAPHICS

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the 2100A loop DMG segment contains corrected demographic information.

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

TR3 Example:

DMG✱D8✱19740915✱M~

DMG

✱

1250

Loop 2100C - ENROLLEE MAILING ADDRESS

✱

✱

✱

✱

Comp Race
or Ethn Inf

X 25

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

✱

Situational

1250

Date Time Period Format Qualifier

X 1

2/3

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

SEGMENT SYNTAX: P0102

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Situational

1251

Date Time Period

X 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

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

INDUSTRY NAME: Prior Incorrect Insured Birth Date

Situational

1068

Gender Code

O 1

Code indicating the sex of the individual

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

INDUSTRY NAME: Prior Incorrect Insured Gender Code

CODE

DEFINITION

Not Provided

Use when the gender cannot be sent due to reporting restrictions.

Not Applicable

Use when member self-reports as transgender.

Female

Male

Unknown

Use when the gender is unknown.

Situational

1067

Marital Status Code

O 1

Code specifying the marital status of a person

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

CODE

DEFINITION

Registered Domestic Partner

Divorced

Single

Married

Unreported

Separated

Unmarried (Single or Divorced or Widowed)

Widowed

Legally Separated

Situational

C056

Composite Race or Ethnicity Information

X 25

To send general and detailed information on race or ethnicity

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

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

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

Not Used

5-1

1109

Race or Ethnicity Code

O 1

Required

5-2

1270

Code List Qualifier Code

X 1

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

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203

INDUSTRY NAME: Prior Race or Ethnicity Code

Situational

1066

Citizenship Status Code

O 1

1/2

Code indicating citizenship status

SITUATIONAL RULE: Required when the enrollee's Citizenship status code is being corrected. If not required this implementation guide, do not send.

CODE

DEFINITION

U.S. Citizen

Non-Resident Alien

Resident Alien

Illegal Alien

Alien

U.S. Citizen - Non-Resident

U.S. Citizen - Resident

Not Used

Country Code

O 1

2/3

Not Used

659

Basis of Verification Code

O 1

1/2

Not Used

380

Quantity

O 1

1/15

Situational

1270

Code List Qualifier Code

X 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P1011

SITUATIONAL RULE: Required when the 2100A loop DMG11 contains corrected information. 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

1271

Industry Code

X 1

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 enrollee's Race or Ethnicity is being corrected. If not required this implementation guide, do not send.

INDUSTRY NAME: Race or Ethnicity Collection Code

Not Used

Country Code

O 1

2/3

NM1*31 - ENROLLEE MAILING ADDRESS

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Example:

NM1✱31✱1~

NM1

✱

✱

Loop 2100C - ENROLLEE MAILING ADDRESS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Postal Mailing Address

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Not Used

1035

Name Last or Organization Name

X 1

1/80

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - ENROLLEE MAIL STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱P.O. Box 1234~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Enrollee Address Line

Situational

166

Address Information

O 1

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: Enrollee Address Line

N4 - ENROLLEE 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 2100C - ENROLLEE MAILING ADDRESS

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Enrollee Mail City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Enrollee Mail State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Enrollee Postal Zone or Zip Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

NM1*36 - ENROLLEE EMPLOYER

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the enrollee is employed by someone other than the sponsor and the employer is known to the submitter.
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

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Employer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Enrollee Employer Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Enrollee Employer First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Enrollee Employer Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

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

INDUSTRY NAME: Enrollee Employer Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Enrollee Employer Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Employer's Identification Number

Use when reporting the Employer Identification Number (EIN) issued by the IRS.

Social Security Number

Situational

Identification Code

X 1

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: Enrollee Employer Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*EP - ENROLLEE EMPLOYER COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information, the enrollee is employed by someone other than the sponsor, and the Exchange can legally share the information.

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

TR3 Notes:

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

TR3 Example:

PER✱EP✱✱TE✱8001234567~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Employer Contact

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required when the enrollee's employer communication contact name is supplied by the enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollee Employer Communications Contact

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Facsimile

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - ENROLLEE EMPLOYER STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Enrollee Employer Address Line

Situational

166

Address Information

O 1

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: Enrollee Employer Address Line

N4 - ENROLLEE 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:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Enrollee Employer City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Enrollee Employer State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Enrollee Employer Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

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:

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

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Custodial Parent

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Custodial Parent Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Custodial Parent First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Custodial Parent Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Custodial Parent Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Custodial Parent Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Social Security Number

Standard Unique Health Identifier for each Individual in the United States

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

Individual Taxpayer's Identification Number (ITIN)

Situational

Identification Code

X 1

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

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*PQ - CUSTODIAL PARENT COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the Exchange.

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

TR3 Notes:

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

TR3 Example:

PER✱PQ✱✱TE✱8001234567~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Parent or Guardian

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Telephone Extension

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - CUSTODIAL PARENT STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Custodial Parent Address Line

Situational

166

Address Information

O 1

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:

Situational Rule:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Custodial Parent City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Custodial Parent State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Custodial Parent Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

NM1 - RESPONSIBLE PERSON

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Notes:

This segment does not identify the individual with fiscal responsibility for premium payment. That person or entity is identified as the sponsor.

TR3 Example:

NM1✱QD✱1✱CASE✱JOHN✱✱✱✱34✱111223333✱01~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Case Manager

Key Person

Person or Other Entity Legally Responsible for a Child

Used to identify a legal indemnity situation.

This code is used when a Qualified Medical Child Support Order (QMSCO) is present.

Executor of Estate

This is used when the subscriber is deceased and the executor/responsible person is other than a surviving spouse.

EXS

Ex-spouse

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

Other Insured

Guardian

Power of Attorney

Legal Representative

Responsible Party

Parent

Primary Taxpayer

Significant Other

Spouse

Mutually Defined

Sponsoring Indian Health Entity

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Responsible Person Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Responsible Person First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Person Suffix Name

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when available and allowed under confidentiality regulations.If not required by this implementation guide, do not send.

CODE

DEFINITION

Social Security Number

Standard Unique Health Identifier for each Individual in the United States

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

Individual Taxpayer's Identification Number (ITIN)

Situational

Identification Code

X 1

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 Person Identifier

Required

706

Entity Relationship Code

X 1

Code specifying entity relationship

COMMENT: NM110 and NM111 further define the type of entity in NM101.

SEGMENT SYNTAX: C1110

INDUSTRY NAME: Responsible Person Relationship Code

CODE

DEFINITION

Parent

Child

Sibling

Domestic Partner

Power of Attorney Delegee

Significant Other

Spouse

Foster Parent

Friend

Grand Child

Grand Parent

Guardian

Other

Unknown

Aunt

Nephew

Niece

Uncle

Former Spouse

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*RP - RESPONSIBLE PERSON COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Notes:

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

TR3 Example:

PER✱RP✱✱HP✱8015554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Responsible Person

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - RESPONSIBLE PERSON STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Responsible Person Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Responsible Person Address Line

N4 - RESPONSIBLE PERSON CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2100G - DROP OFF LOCATION

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Responsible Person City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Responsible Person State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Responsible Person Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

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:

Situational Rule:

Required when enrollee has requested shipments to be sent to an address other then their residence or mailing. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱45✱1✱CASE✱JOHN~

NM1

✱

✱

Loop 2100G - DROP OFF LOCATION

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Drop-off Location

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required if supplied by the enrollee. If not required by this implementation guide, do not send.

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required if supplied by the enrollee. If not required by this implementation guide, do not send.

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required if supplied by the enrollee. If not required by this implementation guide, do not send.

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required if supplied by the enrollee. If not required by this implementation guide, do not send.

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required if supplied by the enrollee. If not required by this implementation guide, do not send.

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - DROP OFF LOCATION STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Drop Off Location Address Line

Situational

166

Address Information

O 1

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 2100G - DROP OFF LOCATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2100H - SPONSOR NAME

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Drop Off Location City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Drop Off Location State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Drop Off Location Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

NM1 - SPONSOR NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when Loop 1000D Sponsor is not used AND:

this enrollment is from a SHOP exchange.

OR

the enrollment is from an Individual Market Exchange, and the exchange is able to determine the entity responsible for payment.

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

TR3 Notes:

This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.
When the exchange cannot determine a sponsor (the entity responsible for premium payment) in the individual market, the contact person must be reported in the subscriber PER.

TR3 Example:

NM1✱2J✱1✱SMITH✱JOHN✱M✱✱SR✱FI✱123456789~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Individual

Use when this enrollment is from the Individual Market.

Plan Sponsor

Use when this enrollment is from the SHOP Market.

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Sponsor Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Sponsor First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Sponsor Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

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

INDUSTRY NAME: Sponsor Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Sponsor Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when N101 = P5.ORRequired when N101 = 2J and a Tax Identification Number was collected.If not required by this implementation guide, do not send.

CODE

DEFINITION

Employer's Identification Number

The identifier is the Employer Identification Number (EIN) issued by the IRS. The EIN has been adopted as the HIPAA Standard Unique Employer Identifier.

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

Federal Taxpayer's Identification Number

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required when N101 = P5.ORRequired when N101 = 2J and a Tax Identification Number was collected.If not required by this implementation guide, do not send.

INDUSTRY NAME: Sponsor Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

NM1*2C - APTC CONTRIBUTOR/TAX PAYER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when an APTC amount designated for this policy is attributed to a tax payer who is not an enrollee in this policy and the exchange provides APTC tax payer detail. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱2C✱1✱JONES✱MARY~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Co-Participant

Used to represent the APTC contributor/Tax Payer.

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: APTC Contributor/Tax Payer Last Name

Required

1036

Name First

O 1

1/35

Individual first name

INDUSTRY NAME: APTC Contributor/Tax Payer First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: APTC Contributor/Tax Payer Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: APTC Contributor/Tax Payer Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

SITUATIONAL RULE: Required if supplied by enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: APTC Contributor/Tax Payer Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE.

Mutually Defined

Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used.

Situational

Identification Code

X 1

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: APTC Contributor/Tax Payer Identifier

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*IC - APTC CONTRIBUTOR/TAX PAYER COMMUNICATION NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is provided to the Exchange. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

PER✱IC✱✱TE✱8001234567~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Alternate Telephone

Use when reporting the phone number for the individual's closest relative.

Beeper Number

Cellular Phone

Use when the cellular phone ownership is unknown.

Internet Email Address

Use when reporting a secondary or alternate email address.

Electronic Mail

Telephone Extension

Home Phone Number

Night Telephone

Other Residential Telephone Number

Use when reporting a TTY communication number.

Personal Cellular

Personal Phone

Telephone

Use when identifying the primary phone number.

Text Message Address

Work Cellular

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - APTC CONTRIBUTOR/TAX PAYER STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is provided to the Exchange. If not required by this implementation guide, do not send.

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: APTC Contributor/Tax Payer Address Line

Situational

166

Address Information

O 1

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: APTC Contributor/Tax Payer Address Line

N4 - APTC CONTRIBUTOR/TAX PAYER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when this information is provided to the Exchange. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Loop 2200 - DISABILITY INFORMATION

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: APTC Contributor/Tax Payer City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: APTC Contributor/Tax Payer State or Province Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: APTC Contributor/Tax Payer Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

DSB - DISABILITY INFORMATION

X12 Name:

Disability Information

X12 Purpose:

To supply disability information

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Example:

DSB✱2✱✱✱✱✱✱DX✱585~

DSB

✱

✱

✱

✱

✱

✱

✱

✱

Required

1146

Disability Type Code

M 1

Code identifying the disability status of the individual

CODE

DEFINITION

Short Term Disability

Long Term Disability

Permanent or Total Disability

No Disability

Not Used

380

Quantity

O 1

1/15

Not Used

1149

Occupation Code

O 1

4/6

Not Used

1154

Work Intensity Code

O 1

Not Used

1161

Product Option Code

O 1

1/2

Not Used

782

Monetary Amount

O 1

1/18

Situational

235

Product/Service ID Qualifier

X 1

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

SEGMENT SYNTAX: P0708

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

INDUSTRY NAME: Product or Service ID Qualifier

CODE

DEFINITION

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

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

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

1137

Medical Code Value

X 1

1/15

Code value for describing a medical condition or procedure

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

SEGMENT SYNTAX: P0708

SITUATIONAL RULE: Required when an Exchange has collected the information and the Exchange can legally share the information.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 2200 - DISABILITY INFORMATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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✱20220101~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

360

Initial Disability Period Start

361

Initial Disability Period End

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

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:

Situational Rule:

Required when enrolling a new enrollee or when adding, updating, removing coverage or auditing an existing enrollee. If not required by this implementation guide, do not send.

TR3 Example:

HD✱021✱✱HLT✱✱FAM✱1~

✱

875

Maintenance
Type Code

✱

✱

✱

Plan Cvrg
Description

✱

✱

✱

✱

Underwrite
Decide Code

✱

1073

✱

✱

Required

875

Maintenance Type Code

M 1

Code identifying the specific type of item maintenance

Required to identify the specific type of item maintenance.

CODE

DEFINITION

001

Change

002

Delete

Use this code for deleting an incorrect coverage record.

021

Addition

024

Cancellation or Termination

Use this code for cancelling/terminating a coverage.

025

Reinstatement

026

Correction

This code is used to correct an incorrect record.

030

Audit or Compare

032

Employee Information Not Applicable

Certain situations, such as military duty and CHAMPUS/TRICARE, classify the subscriber as ineligible for coverage or benefits. However, dependents of the subscribers are still eligible for coverage or benefits under the subscriber. Subscriber identifying elements are needed to accurately identify dependents.

Not Used

1203

Maintenance Reason Code

O 1

2/3

Required

1205

Insurance Line Code

O 1

2/3

Code identifying a group of insurance products

CODE

DEFINITION

Preventative Care/Wellness

24 Hour Care

Medicare Risk

Mental Health

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

This identifies a dental managed care organization (DMO).

DEN

Dental

EPO

Exclusive Provider Organization

FAC

Facility

Hearing

HLT

Health

Includes both hospital and professional coverage.

HMO

Health Maintenance Organization

LTC

Long-Term Care

LTD

Long-Term Disability

Major Medical

MOD

Mail Order Drug

PDG

Prescription Drug

POS

Point of Service

PPO

Preferred Provider Organization

PRA

Practitioners

STD

Short-Term Disability

Utilization Review

VIS

Vision

Not Used

1204

Plan Coverage Description

O 1

1/50

Situational

1207

Coverage Level Code

O 1

Code indicating the level of coverage being provided for this insured

SITUATIONAL RULE: Required when an Exchange has collected the information and the Exchange can legally share the information.If not required by this implementation guide, do not send.

CODE

DEFINITION

CHD

Children Only

DEP

Dependents Only

E1D

Employee and One Dependent

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

E2D

Employee and Two Dependents

E3D

Employee and Three Dependents

E5D

Employee and One or More Dependents

E6D

Employee and Two or More Dependents

E7D

Employee and Three or More Dependents

E8D

Employee and Four or More Dependents

E9D

Employee and Five or More Dependents

ECH

Employee and Children

EMP

Employee Only

ESP

Employee and Spouse

FAM

Family

IND

Individual

SPC

Spouse and Children

SPO

Spouse Only

TWO

Two Party

Required

609

Count

O 1

1/9

Occurrence counter

SEMANTIC: HD06 is the number of collateral dependents for the primary insured. A collateral dependent is a relative related by blood or marriage who resides in the home and is dependent on the employee for support.

INDUSTRY NAME: Health Coverage Sequence Number

The first HD06 within each enrollee (2100A) must be '1'. Each subsequent occurrence of HD06 within the enrollee is incremented by one.

Not Used

609

Count

O 1

1/9

Not Used

1209

Underwriting Decision Code

O 1

Situational

1073

Yes/No Condition or Response Code

O 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 there is a need to designate an enrollee as a late enrollee. If not required by this implementation guide, do not send.

INDUSTRY NAME: Late Enrollment Indicator

CODE

DEFINITION

Yes

Not Used

1211

Drug House Code

O 1

2/3

Not Used

1073

Yes/No Condition or Response Code

O 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:

TR3 Example:

DTP✱348✱D8✱20221001~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

300

Enrollment Signature Date

303

Maintenance Effective

This is the effective date of a change where an enrollee's coverage is not being added or removed.

343

Premium Paid to Date End

348

Benefit Begin

This is the effective date of coverage. This code must always be sent when adding or reinstating coverage.

349

Benefit End

The termination date represents the last date of coverage in which claims will be paid for the individual being terminated. For example, if a date of 02/28/2014 is passed then claims for this individual will be paid through 11:59 p.m. on 2/28/14.

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

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

This value is only to be used when reporting Previous Coverage Months.

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: 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:

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 Example:

DTP✱903✱UN✱08012021132732001~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

903

Application Entry

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Unstructured

Required

1251

Date Time Period

M 1

1/35

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

REF - HEALTH COVERAGE POLICY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Example:

REF✱PID✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Medical Assistance Category

PID

Program Identification Number

Rate code number

XX1

Special Program Code

XX2

Service Area Code

Mutually Defined

Use this code for the Payment Plan Type Code (Annual or Quarterly) until a standard code is assigned.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Enrollee Group or 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

352

Description

X 1

1/80

Not Used

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.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the portability provisions of the Health Insurance Portability and Accountability Act require reporting of the number of months of prior health coverage that meet the certification requirements of the Act. If not required by this implementation guide, do not send.

TR3 Example:

REF✱QQ✱0~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Unit Number

This code is used in this implementation guide to indicate that the value in REF02 is the response required under the portability provisions of HIPAA.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Prior Coverage Month Count

Refer to Appendix B.1.1.2.1 Maximum Length of Data Element 127 Reference Identification for more information about this data element length.
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.
Report as a left-justified integer with no leading zeroes.

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

LX - PROVIDER INFORMATION

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

X12 Set Notes:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Notes:

Use one iteration of the loop to identify each applicable health care service provider.
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.

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/9

Number assigned for differentiation within a transaction set

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

NM1 - PROVIDER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱P3✱1✱JOHNSON✱RICHARD✱✱✱✱XX✱1253412345✱25~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Laboratory

Obstetrics and Gynecology Facility

Hospital

Facility

Doctor of Optometry

Primary Care Provider

Pharmacy

Dentist

Managed Care Organization

Mutually Defined

Indian Health Entity

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

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

1036

Name First

O 1

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

1037

Name Middle

O 1

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

1038

Name Prefix

O 1

1/10

Prefix to individual name

INDUSTRY NAME: Provider Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

INDUSTRY NAME: Provider Name Suffix

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required for providers in the United States or its territories when the provider has received an NPI. If not required by this implementation guide, do not send.

CODE

DEFINITION

Standard Unique Health Identifier for Health Care Providers (NPI)

CODE SOURCE: 537: National Provider Identifier (NPI)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

SITUATIONAL RULE: Required for providers in the United States or its territories when the provider has received an NPI. If not required by this implementation guide, do not send.

INDUSTRY NAME: Provider Identifier

Required

706

Entity Relationship Code

X 1

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 enrollee is an existing patient of the provider.

CODE

DEFINITION

Established Patient

Not Established Patient

Unknown

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

N3 - PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Provider Address Line

Situational

166

Address Information

O 1

1/55

Address information

SITUATIONAL RULE: Required 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:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Provider City Name

Situational

156

State or Province Code

X 1

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

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Provider State Code

CODE SOURCE 22: States and Provinces

Situational

116

Postal Code

X 1

3/15

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

SEGMENT SYNTAX: E0308

INDUSTRY NAME: Provider Postal Zone or ZIP Code

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

Situational

Country Code

X 1

2/3

Code identifying the country

SEGMENT SYNTAX: C0704

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

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

309

Location Qualifier

X 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

X 1

1/3

Code identifying the country subdivision

SEGMENT SYNTAX: E0207, C0704

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

CODE SOURCE 5: Countries, Currencies and Funds

Not Used

1702

Postal Code-Formatted

X 1

3/20

PER*IC - PROVIDER COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Notes:

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

TR3 Example:

PER✱IC✱✱HP✱8015554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

Information Contact

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Facsimile

Home Phone Number

Telephone

Work Phone Number

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0506

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

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Telephone

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0506

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

Situational

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Telephone

Work Phone Number

Situational

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

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:

Situational Rule:

Required when it is necessary to report the reason and the effective date of the provider changes.

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

TR3 Example:

PLA✱2✱1P✱20210628✱✱AI~

PLA

✱

✱

✱

✱

✱

Required

306

Action Code

M 1

1/2

Code indicating type of action

CODE

DEFINITION

Change (Update)

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Provider

Required

373

Date

M 1

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

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

INDUSTRY NAME: Provider Effective Date

This is the effective date of the change of PCP.

Not Used

337

Time

O 1

4/8

Required

1203

Maintenance Reason Code

O 1

2/3

Code identifying the reason for the maintenance change

If none of the specific Maintenance Reasons apply, send 'AI', No Reason Given.

CODE

DEFINITION

Voluntary Withdrawal

Plan Change

Current Customer Information File in Error

Dissatisfaction with Office Staff

Dissatisfaction with Medical Care/Services Rendered

Inconvenient Office Location

Dissatisfaction with Office Hours

Unable to Schedule Appointments in a Timely Manner

Dissatisfaction with Physician's Referral Policy

Less Respect and Attention Time Given than to Other Patients

Patient Moved to a New Location

No Reason Given

Appointment Times not Met in a Timely Manner

Mutually Defined

Use this code to indicate the change is due to Personal Preference.

COB - COORDINATION OF BENEFITS

X12 Name:

Coordination of Benefits

X12 Purpose:

To supply information on coordination of benefits

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when an enrollee has another insurance plan with benefits similar to those covered by the insurance product specified in the HD segment for this occurrence of Loop ID-2300. If not required by this implementation guide, do not send.

TR3 Example:

COB✱P✱XYZ123✱1~

COB

✱

1138

Payer Resp
Seq No Code

✱

✱

✱

Required

1138

Payer Responsibility Sequence Number Code

O 1

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

CODE

DEFINITION

Primary

Secondary

Tertiary

Unknown

Situational

127

Reference Identification

O 1

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 policy number is available. If not required by this implementation guide, do not send.

INDUSTRY NAME: Enrollee Group or 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.

Required

1143

Coordination of Benefits Code

O 1

Code identifying whether there is a coordination of benefits

CODE

DEFINITION

Coordination of Benefits

Unknown

No Coordination of Benefits

This code is sent when it has been determined that there is no COB.

Situational

1365

Service Type Code

O 9

1/2

Code identifying the classification of service

SITUATIONAL RULE: Required when an exchange has collected this information. If not required by this implementation guide, do not send.

CODE

DEFINITION

Medical Care

Dental Care

Hospital - Inpatient

Hospital - Outpatient

Long Term Care

Free Standing Prescription Drug

Mail Order Prescription Drug

Psychiatric

Skilled Nursing Care

Vision (Optometry)

Partial Hospitalization (Psychiatric)

REF*1W - COORDINATION OF BENEFITS ENROLLEE IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required if additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.

TR3 Notes:

Use the Social Security Number until the National ID Number for individuals is available.

TR3 Example:

REF✱1W✱468523Z~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Member Identification Number

Code 1W is intended to be the enrollee's identification number as assigned by the COB payer. (For example, Insured's ID, Subscriber's ID, Health Insurance Claim Number (HIC), etc.)

When sending the Social Security Number as the enrollee ID, it 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.

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Plan's Enrollee Group or 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

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*6P - COORDINATION OF BENEFITS PAYER GROUP IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the group number assigned by this COB payer is known. If not required by this implementation guide, do not send.

TR3 Example:

REF✱6P✱468523Z~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Group Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Other Plan's Enrollee Coordination of Benefits Group Identifier

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

Not Used

352

Description

X 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*344 - COORDINATION OF BENEFITS ELIGIBILITY BEGIN DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the begin date for coordination of benefits has been collected. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱344✱D8✱20220101~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

344

Coordination of Benefits Begin

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Coordination of Benefits Begin Date

DTP*345 - COORDINATION OF BENEFITS ELIGIBILITY END DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the end date for coordination of benefits has been collected. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱345✱D8✱20220831~

DTP

✱

✱

Loop 2330 - COORDINATION OF BENEFITS RELATED ENTITY

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

345

Coordination of Benefits End

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Coordination of Benefits End Date

NM1*IN - 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:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Example:

NM1✱IN✱2✱ABC INSURANCE CO~

NM1

✱

✱

Loop 2330 - COORDINATION OF BENEFITS RELATED ENTITY

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Insurer

Required

1065

Entity Type Qualifier

M 1

Code identifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Situational

1035

Name Last or Organization Name

X 1

1/80

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when NM109 is not used. If not required by this implementation guide, may be sent at the sender's discretion, but cannot be required by the receiver.

INDUSTRY NAME: Coordination of Benefits Insurer Name

Not Used

1036

Name First

O 1

1/35

Not Used

1037

Name Middle

O 1

1/25

Not Used

1038

Name Prefix

O 1

1/10

Not Used

1039

Name Suffix

O 1

1/10

Situational

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: P0809

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

CODE

DEFINITION

Federal Taxpayer's Identification Number

National Association of Insurance Commissioners (NAIC) Identification

Standard Unique Health Plan Identifier (HPID)

CODE SOURCE: 540: Health Plan Identifier (HPID)

Situational

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Coordination of Benefits Insurer Identification Code

Not Used

706

Entity Relationship Code

X 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/80

PER*CN - ADMINISTRATIVE COMMUNICATIONS CONTACT

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange has collected the information and the Exchange can legally share the information.

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

TR3 Example:

PER✱CN✱✱TE✱8015554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

366

Contact Function Code

M 1

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

CODE

DEFINITION

General Contact

Not Used

Name

O 1

1/60

Required

365

Communication Number Qualifier

X 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

X 1

1/2048

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Not Used

365

Communication Number Qualifier

X 1

Not Used

364

Communication Number

X 1

1/2048

Not Used

365

Communication Number Qualifier

X 1

Not Used

364

Communication Number

X 1

1/2048

Not Used

443

Contact Inquiry Reference

O 1

1/20

LS - ADDITIONAL REPORTING CATEGORIES

X12 Name:

Loop Header

X12 Purpose:

To indicate that the next segment begins a loop

X12 Comments:

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

Loop:

Loop 2700A - AGENT/BROKER REPORTING

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when an Exchange realizes a data need that cannot be accommodated within the other defined data elements in this transaction.

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

TR3 Example:

LS✱2700~

✱

Required

447

Loop Identifier Code

M 1

1/6

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

Use the value 2700.

LX - AGENT/BROKER REPORTING

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when an Agent/Broker is involved in this enrollment. If not required by this implementation guide, do not send.

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/9

Number assigned for differentiation within a transaction set

The first LX01 within each enrollee (2100A) must be '1'. Each subsequent occurrence of LX01 within the enrollee is incremented by one.

N1*AG - AGENT/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.

Loop:

Loop 2750A - AGENT/BROKER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱AG✱MONEY TALKS AGENCY✱FI✱123356799~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Agent/Agency

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Agent/Broker Name

Required

Identification Code Qualifier

X 1

1/2

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

SEGMENT SYNTAX: R0203, P0304, C0703

CODE

DEFINITION

Federal Taxpayer's Identification Number

Primary Agent Identification

This is the identifier assigned to the Agent/Broker by the Exchange.

Required

Identification Code

X 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: Agent/Broker Identification Code

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

REF*0B - AGENT/BROKER LICENSE NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2750A - AGENT/BROKER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱0B✱123456✱PA~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

State License Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Agent/Broker License 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.

Required

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

This element represents the issuing state code.

Use code source 22.

Not Used

C040

Reference Identifier

O 1

DTP*007 - AGENT/BROKER RELATIONSHIP 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 2750A - AGENT/BROKER NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

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

✱

✱

Loop 2700B - NAVIGATOR REPORTING

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Agent/Broker Relationship Date(s)

LX - NAVIGATOR REPORTING

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when a Navigator is involved in this enrollment. If not required by this implementation guide, do not send.

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/9

Number assigned for differentiation within a transaction set

The first LX01 within each enrollee (2100A) must be '1'. Each subsequent occurrence of LX01 within the enrollee is incremented by one.

N1*ZZ - NAVIGATOR 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.

Loop:

Loop 2750B - NAVIGATOR NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱ZZ✱JOE NAVIGATOR~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Mutually Defined

Use when the entity identified is a Navigator.

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Navigator Name

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

REF - NAVIGATOR IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2750B - NAVIGATOR NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱0B✱123456✱PA~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

When the navigator has a license, code '0B' is the required value. Use code 'AAL' to report the exchange assigned identifier when the navigator does not have a license.

CODE

DEFINITION

State License Number

AAL

Agent Number

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Navigator 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.

Situational

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when REF01 = 0B. If not required by this implementation guide, do not send.

This element represents the issuing state code.

Use code source 22.

Not Used

C040

Reference Identifier

O 1

DTP*007 - NAVIGATOR RELATIONSHIP 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 2750B - NAVIGATOR NAME

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

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✱007✱RD8✱20220101-20220531~

DTP

✱

✱

Loop 2700C - ENROLLEE REPORTING CATEGORIES

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Navigator Relationship Date(s)

LX - ENROLLEE REPORTING CATEGORIES

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when an Exchange realizes a data need that cannot be accommodated within the other defined data elements in this transaction.

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

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/9

Number assigned for differentiation within a transaction set

The first LX01 within each enrollee (2100A) must be '1'. Each subsequent occurrence of LX01 within the enrollee is incremented by one.

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 2750C - REPORTING CATEGORY

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N1✱75✱SOUTHEASTERN UNION~

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Participant

Required

Name

X 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Enrollee Reporting Category Name

Not Used

Identification Code Qualifier

X 1

1/2

Not Used

Identification Code

X 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

C076

Composite Identification Codes

O 1

REF*ZZ - REPORTING CATEGORY REFERENCE

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2750C - REPORTING CATEGORY

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

REF✱ZZ✱MEDICALIDCARD✱XYH974023121~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code identifying the Reference Identification

CODE

DEFINITION

Mutually Defined

Required

127

Reference Identification

X 1

1/80

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Enrollee Reporting Category Reference ID

This element defines the data to be reported in REF03 and, when applicable, related dates in the DTP segment. Codification and Definitions can be found on the CMS Health Insurance Exchange website.
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

352

Description

X 1

1/80

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

SEGMENT SYNTAX: R0203

This element carries the value defined by the code reported in REF02.

Not Used

C040

Reference Identifier

O 1

DTP*007 - REPORTING CATEGORY DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop 2750C - REPORTING CATEGORY

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when it is necessary to report effective dates associated with the data reported in REF03 of this loop. 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

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Enrollee 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: