834 Benefit and Enrollment Maintenance (005010X220, 005010X220E1, 005010X220E2, 005010X220A1)

Required

I01

Authorization Information Qualifier

M 1

Code identifying the type of information in the Authorization Information

CODE

DEFINITION

No Authorization Information Present (No Meaningful Information in I02)

Additional Data Identification

Required

I02

Authorization Information

M 1

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

This element is fixed in length with identical minimum and maximum lengths. Spaces are inserted to meet the minimum length in an AN data element. With the associated code 00 in ISA01 or ISA03, an all space value indicates no information.

Required

I03

Security Information Qualifier

M 1

Code identifying the type of information in the Security Information

CODE

DEFINITION

No Security Information Present (No Meaningful Information in I04)

Password

Required

I04

Security Information

M 1

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

Required

I05

Interchange ID Qualifier

M 1

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the Sender in ISA06.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I06

Interchange Sender ID

M 1

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

Required

I05

Interchange ID Qualifier

M 1

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

This ID qualifies the Receiver in ISA08.

CODE

DEFINITION

Duns (Dun & Bradstreet)

Duns Plus Suffix

Health Industry Number (HIN)

Carrier Identification Number as assigned by Health Care Financing Administration (HCFA)

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration (HCFA)

Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration (HCFA)

U.S. Federal Tax Identification Number

National Association of Insurance Commissioners Company Code (NAIC)

Mutually Defined

Required

I07

Interchange Receiver ID

M 1

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

Required

I08

Interchange Date

M 1

Date of the interchange

The date format is YYMMDD.

Required

I09

Interchange Time

M 1

Time of the interchange

The time format is HHMM.

Required

I65

Repetition Separator

M 1

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

Required

I11

Interchange Control Version Number

M 1

Code specifying the version number of the interchange control segments

CODE

DEFINITION

00501

Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003

Required

I12

Interchange Control Number

M 1

A control number assigned by the interchange sender

The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.
Must be a positive unsigned number and must be identical to the value in IEA02.

Required

I13

Acknowledgment Requested

M 1

Code indicating sender's request for an interchange acknowledgment

See Section B.1.1.5.1 for interchange acknowledgment information.

CODE

DEFINITION

No Interchange Acknowledgment Requested

Interchange Acknowledgment Requested (TA1)

Required

I14

Interchange Usage Indicator

M 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

CODE

DEFINITION

Production Data

Test Data

Required

I15

Component Element Separator

M 1

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

GS*BE - FUNCTIONAL GROUP HEADER

X12 Name:

Functional Group Header

X12 Purpose:

To indicate the beginning of a functional group and to provide control information

X12 Comments:

A functional group of related transaction sets, within the scope of X12 standards, consists of a collection of similar transaction sets enclosed by a functional group header and a functional group trailer.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

GS✱BE✱SENDER CODE✱RECEIVER CODE✱19991231✱0802✱1✱X✱005010X220A1~

✱

✱

Application
Send's Code

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

005010X220A1

Benefit and Enrollment Maintenance

ST*834 - TRANSACTION SET HEADER

X12 Name:

Transaction Set Header

X12 Purpose:

To indicate the start of a transaction set and to assign a control number

Segment Usage:

Required

Segment Repeat:

TR3 Example:

ST✱834✱0001✱005010X220A1~

✱

✱

✱

Required

143

Transaction Set Identifier Code

M 1

Code uniquely 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 Number in ST02 and SE02 must be identical. The number must be unique within a specific interchange (ISA-IEA), but can repeat in other interchanges.

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

005010X220A1

Benefit and Enrollment Maintenance

BGN - BEGINNING SEGMENT

X12 Name:

Beginning Segment

X12 Purpose:

To indicate the beginning of a transaction set

X12 Syntax:

C0504
If BGN05 is present, then BGN04 is required.

Segment Usage:

Required

Segment Repeat:

TR3 Example:

BGN✱00✱11227✱19970920✱1200✱ES✱✱✱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

1/50

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

SEMANTIC: BGN02 is the transaction set reference number.

INDUSTRY NAME: Transaction Set Reference Number

This element is the transaction set reference number assigned by the sender's application. It uniquely identifies this occurrence of the transaction for future reference.

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

O 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

Equivalent to ISO P01

Equivalent to ISO P02

Equivalent to ISO P03

Equivalent to ISO P04

Equivalent to ISO P05

Equivalent to ISO P06

Equivalent to ISO P07

Equivalent to ISO P08

Equivalent to ISO P09

Equivalent to ISO P10

Equivalent to ISO P11

Equivalent to ISO P12

Equivalent to ISO M12

Equivalent to ISO M11

Equivalent to ISO M10

Equivalent to ISO M09

Equivalent to ISO M08

Equivalent to ISO M07

Equivalent to ISO M06

Equivalent to ISO M05

Equivalent to ISO M04

Equivalent to ISO M03

Equivalent to ISO M02

Equivalent to ISO M01

Alaska Daylight Time

Alaska Standard Time

Alaska Time

Central Daylight Time

Central Standard Time

Central Time

Eastern Daylight Time

Eastern Standard Time

Eastern Time

Greenwich Mean Time

Hawaii-Aleutian Daylight Time

Hawaii-Aleutian Standard Time

Hawaii-Aleutian Time

Local Time

Mountain Daylight Time

Mountain Standard Time

Mountain Time

Newfoundland Daylight Time

Newfoundland Standard Time

Newfoundland Time

Pacific Daylight Time

Pacific Standard Time

Pacific Time

Atlantic Daylight Time

Atlantic Standard Time

Atlantic Time

Universal Time Coordinate

Situational

127

Reference Identification

O 1

1/50

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

SEMANTIC: BGN06 is the transaction set reference number of a previously sent transaction affected by the current transaction.

SITUATIONAL RULE: Required when there is a previously sent transaction to cross-reference. If not required by this implementation guide, do not send.

INDUSTRY NAME: Original Transaction Set Reference Number

Not Used

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 sponsor's and payer'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 - TRANSACTION SET POLICY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the insurance contract or trading partner agreement identifies a Master Policy Number for use with electronic enrollment. If not required may be provided at the sender's discretion if a unique ID Number for a group applies to the entire transaction set.

TR3 Notes:

The definition of the Master Policy Number is determined by the issuer of the policy, the Payer/Plan Administrator. The Master Policy Number may be used to meet various business needs such as indicating the line of business under which the policy is defined.

TR3 Example:

REF✱38✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Master Policy Number

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Master Policy Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP - FILE EFFECTIVE DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when specified in the contract. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱007✱D8✱19961001~

DTP

✱

✱

Loop 1000A - SPONSOR 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

090

Report Start

091

Report End

303

Maintenance Effective

382

Enrollment

388

Payment Commencement

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

QTY - TRANSACTION SET CONTROL TOTALS

X12 Name:

Quantity Information

X12 Purpose:

To specify quantity information

X12 Syntax:

R0204
At least one of QTY02 or QTY04 is required.
E0204
Only one of QTY02 or QTY04 may be present.

X12 Set Notes:

NOTE: The QTY segment is used to record the total number of subscribers and dependents in the transaction set.

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the contract or trading partner agreement specifies that this information be included in the transaction set. If not required by this implementation guide, do not send.

TR3 Example:

QTY✱TO✱10000~

QTY

✱

✱

✱

Composite
Unit of Mea

✱

Required

673

Quantity Qualifier

M 1

Code specifying the type of quantity

CODE

DEFINITION

Dependent Total

Employee Total

Total

Required

380

Quantity

O 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

O 1

1/30

N1*P5 - SPONSOR NAME

X12 Name:

Party Identification

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This loop identifies the sponsor. See section 1.5 for the definition of Sponsor.

TR3 Example:

N1✱P5✱✱FI✱12356799~

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Plan Sponsor

Situational

Name

O 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when the receiver needs the sponsor name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Plan Sponsor Name

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: R0203, P0304

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

Required

Identification Code

O 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: Sponsor Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

N1*IN - PAYER

X12 Name:

Party Identification

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop 1000B - PAYER

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This loop identifies the payer. See section 1.5 for the definition of payer.

TR3 Example:

N1✱IN✱✱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

Situational

Name

O 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

SITUATIONAL RULE: Required when the receiver needs the payer name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Insurer Name

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: R0203, P0304

CODE

DEFINITION

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

Federal Taxpayer's Identification Number

Centers for Medicare and Medicaid Services PlanID

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

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 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

N1 - TPA/BROKER NAME

X12 Name:

Party Identification

X12 Purpose:

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

X12 Syntax:

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

X12 Set Notes:

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

Loop:

Loop 1000C - TPA/BROKER NAME

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when a TPA or a Broker is involved in this enrollment. See section 1.5 for definitions. If not required by this implementation guide, do not send.

TR3 Example:

N1✱TV✱MONEY TALKS BROKERAGE✱FI✱123356799~

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Broker or Sales Office

Third Party Administrator (TPA)

Required

Name

O 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: TPA or Broker Name

Required

Identification Code Qualifier

O 1

1/2

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

SEGMENT SYNTAX: R0203, P0304

CODE

DEFINITION

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

Federal Taxpayer's Identification Number

Centers for Medicare and Medicaid Services PlanID

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

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Required

Identification Code

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0304

INDUSTRY NAME: TPA or Broker Identification Code

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

ACT - TPA/BROKER ACCOUNT INFORMATION

X12 Name:

Account Identification

X12 Purpose:

To specify account information

X12 Syntax:

P0304
If either ACT03 or ACT04 is present, then the other is required.
C0506
If ACT05 is present, then ACT06 is required.
C0705
If ACT07 is present, then ACT05 is required.

Loop:

Loop 1100C - TPA/BROKER ACCOUNT INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the account number of the TPA or Broker is different than the account number for the sponsor. If not required by this implementation guide, do not send.

TR3 Example:

ACT✱1234✱✱✱✱✱23498765~

ACT

✱

✱

✱

✱

✱

Acct Number
Qualifier

✱

✱

✱

✱

Required

508

Account Number

M 1

1/35

Account number assigned

INDUSTRY NAME: TPA or Broker Account Number

Not Used

Name

O 1

1/60

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

569

Account Number Qualifier

O 1

1/3

Situational

508

Account Number

O 1

1/35

Account number assigned

COMMENT: ACT06 is an account associated with the account in ACT01.

SEGMENT SYNTAX: C0506

SITUATIONAL RULE: Required when more than 1 TPA or Broker Account Number applies to this transaction. If not required by this implementation guide, do not send.

INDUSTRY NAME: TPA or Broker Account Number

Not Used

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

INS - MEMBER LEVEL DETAIL

X12 Name:

Insured Benefit

X12 Purpose:

To provide benefit 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 preceed 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

✱

✱

✱

✱

✱

✱

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: Member Indicator

Subscriber Indicator

CODE

DEFINITION

Yes

Required

1069

Individual Relationship Code

M 1

Code indicating the relationship between two individuals or entities

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

CODE

DEFINITION

Spouse

Father or Mother

Grandfather or Grandmother

Grandson or Granddaughter

Uncle or Aunt

Nephew or Niece

Cousin

Adopted Child

Foster Child

Son-in-law or Daughter-in-law

Brother-in-law or Sister-in-law

Mother-in-law or Father-in-law

Brother or Sister

Ward

Stepparent

Stepson or Stepdaughter

Self

Child

REF*0F - SUBSCRIBER IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Notes:

This segment must contain a unique SUBSCRIBER identification number (SSN or other). This occurrence is identified by the 0F qualifier (REF01). This identifier is used for linking the subscriber with dependents as required under many policies.
The developers recommend using the identifier developed under the HIPAA legislation, when that becomes available.

TR3 Example:

REF✱0F✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Subscriber Number

The assignment of the Subscriber Number is designated within the Insurance Contract.

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Subscriber Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF*1L - MEMBER POLICY NUMBER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

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 policy or group number applies to all coverage data (all 2300 loops for this member). If not required by this implementation guide, do not send.

TR3 Notes:

The policy number passed in this segment is an attribute of the contract relationship between the plan sponsor (sender) and the payer (receiver) and not an attribute of an individual's participation in any coverage passed in an HD loop.

TR3 Example:

REF✱1L✱9CC4123~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Group or Policy Number

The submitter sends the payer's pre-assigned Group or Policy Number.

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Group or Policy Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

REF - MEMBER SUPPLEMENTAL IDENTIFIER

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

X12 Set Notes:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

REF✱17✱920399398~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Client Reporting Category

Used when further identification of a member is required under the insurance contract between the sponsor and the payer and allowed by federal and state regulations.

Client Number

To be used to pass a payer specific identifier for a member. Not to be used after the HIPAA standard National Identifier for Individuals is implemented.

Case Number

Personal Identification Number (PIN)

Use this code to transmit a password that is associated with the member's record.

Cross Reference Number

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

ABB

Personal ID Number

National Council for Prescription Drug Programs Pharmacy Number

CODE SOURCE 307: National Council for Prescription Drug Programs Pharmacy Number

Department/Agency Number

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

Health Insurance Claim (HIC) Number

Use when reporting Medicare eligibility for a member until the National Identifier is mandated for use.

Position Code

Use this code to transmit the title of the member's employment position.

Prior Identifier Number

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

Unit Number

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

Mutually Defined

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Supplemental Identifier

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP - MEMBER LEVEL DATES

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when enrolling a member or when the sponsor is informed of a change to any applicable date listed in DTP01. Only those dates that apply to the particular insurance contract need to be sent. 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 a Member 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.

TR3 Example:

DTP✱356✱D8✱19960705~

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

050

Received

Used to identify the date an enrollment application is received.

286

Retirement

296

Initial Disability Period Return To Work

297

Initial Disability Period Last Day Worked

300

Enrollment Signature Date

301

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event

303

Maintenance Effective

This code is used to send the effective date of a change to an existing member's information, excluding changes made in Loop 2300.

336

Employment Begin

337

Employment End

338

Medicare Begin

339

Medicare End

340

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin

341

Consolidated Omnibus Budget Reconciliation Act (COBRA) End

350

Education Begin

This is the start date for the student at the current educational institution.

351

Education End

This is the expected graduation date the student at the current educational institution.

356

Eligibility Begin

The date when a member 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 02/28/2001 is passed then claims for this individual will be paid through 11:59 p.m. on 02/28/2001.

383

Adjusted Hire

385

Credited Service Begin

The start date from which an employee's length of service, as defined in the plan document, will be calculated.

386

Credited Service End

The end date to be used in the calculation of an employee's length of service, as defined in the plan document.

393

Plan Participation Suspension

394

Rehire

473

Medicaid Begin

474

Medicaid End

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

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

NM1 - MEMBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Required

Segment Repeat:

TR3 Example:

NM1✱IL✱1✱SMITH✱JOHN✱M✱✱SR~

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 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 a member 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 member or updating a member with no change in identifying information. The identifying information for a member is specified under the insurance contract between the sponsor and payer.

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Member Last Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Member First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Member Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

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

INDUSTRY NAME: Member Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Member Name Suffix

Situational

Identification Code Qualifier

O 1

1/2

Code designating 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

O 1

2/80

Code identifying a party or other code

SEGMENT SYNTAX: P0809

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

INDUSTRY NAME: Member Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PER*IP - MEMBER COMMUNICATIONS NUMBERS

X12 Name:

Administrative Communications Contact

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when enrolling subscribers, dependents with different contact information, or when changing a member's contact information and the information is provided to the sponsor for the member. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

PER✱IP✱✱HP✱8015554321~

PER

✱

✱

✱

✱

✱

✱

✱

✱

✱

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

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Telephone

Work Phone Number

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 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

O 1

1/256

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

O 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

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - MEMBER RESIDENCE STREET ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when enrolling subscribers, dependents with different address information, 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: Member Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Member Address Line

N4 - MEMBER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

E0207
Only one of N402 or N407 may be present.
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 enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Member City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Member State Code

CODE SOURCE 22:States and Provinces

Situational

116

Postal Code

O 1

3/15

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

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

INDUSTRY NAME: Member Postal Zone or Zip Code

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

Situational

Country Code

O 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

O 1

1/2

Code identifying type of location

SEGMENT SYNTAX: C0605

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 SOURCE 206:Government Bill of Lading Office Code

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

O 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

DMG*D8 - MEMBER DEMOGRAPHICS

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

DMG✱D8✱19450915✱F✱M~

DMG

✱

1250

✱

✱

✱

✱

Comp Race
or Ethn Inf

O 10

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

Required

1250

Date Time Period Format Qualifier

O 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

O 1

1/35

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

SEMANTIC: DMG02 is the date of birth.

SEGMENT SYNTAX: P0102

INDUSTRY NAME: Member Birth Date

Required

1068

Gender Code

O 1

Code indicating the sex of the individual

CODE

DEFINITION

Female

Male

Unknown

This code is to be used only when the gender is unknown or when it can not be sent due to reporting restrictions.

Situational

1067

Marital Status Code

O 1

Code defining the marital status of a person

SITUATIONAL RULE: Required when such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. This element is NOT USED when the member identified in the related INS segment is not 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)

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

Widowed

Legally Separated

Situational

C056

Composite Race or Ethnicity Information

O 10

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.

Race or Ethnicity information is reported in either DMG05-1 or DMG05-2 and DMG05-3.

Situational

5-1

1109

Race or Ethnicity Code

O 1

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

SITUATIONAL RULE: Required when reporting the Race or Ethnicity code from the DMG05-1 list of code values. If not required by this implementation guide, do not send.

CODE

DEFINITION

Not Provided

Not Applicable

Asian or Pacific Islander

Black

Caucasian

Subcontinent Asian American

Other Race or Ethnicity

Asian Pacific American

Native American

Hispanic

American Indian or Alaskan Native

Native Hawaiian

Black (Non-Hispanic)

White (Non-Hispanic)

Pacific Islander

Mutually Defined

Situational

5-2

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

COMPOSITE SYNTAX: P0203

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

CODE

DEFINITION

RET

Classification of Race or Ethnicity

CODE SOURCE 859: Classification of Race or Ethnicity

Situational

5-3

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203

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

INDUSTRY NAME: Race or Ethnicity Code

CODE SOURCE 859: Classification of Race or Ethnicity

Situational

1066

Citizenship Status Code

O 1

1/2

Code indicating citizenship status

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

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P1011

CODE

DEFINITION

REC

Race or Ethnicity Collection Code

CODE SOURCE 860: Race or Ethnicity Collection Code

Situational

1271

Industry Code

O 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

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

TR3 Example:

EC✱04✱06✱07~

✱

1176

Employment
Class Code

2/3

✱

1176

Employment
Class Code

2/3

✱

1176

Employment
Class Code

✱

✱

Information
Status Code

✱

Required

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Situational

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

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

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Situational

1176

Employment Class Code

O 1

2/3

Code indicating category of employee

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

CODE

DEFINITION

Union

Non-Union

Executive

Non-Executive

Management

Non-Management

Hourly

Salaried

Administrative

Non-Administrative

Exempt

Non-Exempt

Highly Compensated

Key-Employee

Bargaining

Non-Bargaining

Owner

President

Vice President

Not Used

954

Percentage as Decimal

O 1

1/10

Not Used

1201

Information Status Code

O 1

Not Used

1149

Occupation Code

O 1

4/6

ICM - MEMBER INCOME

X12 Name:

Individual Income

X12 Purpose:

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

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.

TR3 Example:

ICM✱1✱425.25✱40~

ICM

✱

✱

✱

✱

✱

✱

Required

594

Frequency Code

M 1

Code indicating frequency or type of activities or actions being reported

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

CODE

DEFINITION

Weekly

Biweekly

Semimonthly

Monthly

Daily

Annual

Two Calendar Months

Lump-Sum Separation Allowance

Year-to-Date

Single

Hourly

Quarterly

Semiannual

Unknown

Required

782

Monetary Amount

M 1

1/18

Monetary amount

SEMANTIC: ICM02 is the yearly wages amount.

INDUSTRY NAME: Wage Amount

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: ICM03 is the weekly hours.

SITUATIONAL RULE: Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.

INDUSTRY NAME: Work Hours Count

Situational

310

Location Identifier

O 1

1/30

Code which identifies a specific location

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

SITUATIONAL RULE: Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.

INDUSTRY NAME: Location Identification Code

Situational

1214

Salary Grade

O 1

1/5

The salary grade code assigned by the employer

SITUATIONAL RULE: Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.

INDUSTRY NAME: Salary Grade Code

Not Used

100

Currency Code

O 1

AMT - MEMBER POLICY AMOUNTS

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.

TR3 Example:

AMT✱D2✱100~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Co-insurance - Actual

This will contain any co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract.

Co-Payment Amount

Deductible Amount

EBA

Expected Expenditure Amount

Other Unlisted Amount

Premium Amount

Spend Down

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Contract Amount

Not Used

478

Credit/Debit Flag Code

O 1

HLH - MEMBER HEALTH INFORMATION

X12 Name:

Health Information

X12 Purpose:

To provide health information

Loop:

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required on initial enrollment of a member when appropriate medical information about the member is available. If not required by this implementation guide, do not send.

TR3 Example:

HLH✱X✱74✱210~

HLH

✱

✱

✱

✱

✱

✱

✱

Required

1212

Health-Related Code

O 1

Code indicating a specific health situation

INDUSTRY NAME: Health Related Code

CODE

DEFINITION

None

Substance Abuse

Tobacco Use

Unknown

Tobacco Use and Substance Abuse

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: Member 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: Member 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

LUI - MEMBER LANGUAGE

X12 Name:

Language Use

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop 2100B - INCORRECT MEMBER NAME

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required if the sponsor knows that the member's primary language is not English, and 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.

TR3 Notes:

Any need to send/collect this information will need to be contained in the trading partner agreement.

TR3 Example:

LUI✱LD✱123✱✱8~

LUI

✱

✱

✱

✱

✱

Situational

Identification Code Qualifier

O 1

1/2

Code designating 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

O 1

2/80

Code identifying a party or other code

SEMANTIC: LUI02 is the language code.

SEGMENT SYNTAX: P0102, L040203

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

INDUSTRY NAME: Language Code

Situational

352

Description

O 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

O 1

1/2

Code indicating the use of a language

SEGMENT SYNTAX: L040203

SITUATIONAL RULE: Required if supplied by member. 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

O 1

NM1*70 - INCORRECT MEMBER NAME

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required if a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70. If not required by this implementation guide, do not send.

TR3 Notes:

If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70.

TR3 Example:

NM1✱70✱1✱SMYTH✱JON~

NM1

✱

✱

Loop 2100B - INCORRECT MEMBER 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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Prior Incorrect Member 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 Member First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Prior Incorrect Member Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

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

INDUSTRY NAME: Prior Incorrect Member Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Prior Incorrect Member Name Suffix

Situational

Identification Code Qualifier

O 1

1/2

Code designating 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

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

O 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

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

DMG*D8 - INCORRECT MEMBER DEMOGRAPHICS

X12 Name:

Demographic Information

X12 Purpose:

To supply demographic information

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

DMG✱D8✱19450915✱M~

DMG

✱

1250

Loop 2100C - MEMBER MAILING ADDRESS

✱

✱

✱

✱

Comp Race
or Ethn Inf

O 10

✱

1066

Citizenship
Status Code

✱

✱

✱

✱

✱

Situational

1250

Date Time Period Format Qualifier

O 1

2/3

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

SEGMENT SYNTAX: P0102

SITUATIONAL RULE: Required when the members 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

O 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 members 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 members gender is being corrected. If not required by this implementation guide, do not send.

INDUSTRY NAME: Prior Incorrect Insured Gender Code

CODE

DEFINITION

Female

Male

Unknown

Situational

1067

Marital Status Code

O 1

Code defining the marital status of a person

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

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

O 10

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

Situational

5-1

1109

Race or Ethnicity Code

O 1

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

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

CODE

DEFINITION

Not Provided

Not Applicable

Asian or Pacific Islander

Black

Caucasian

Subcontinent Asian American

Other Race or Ethnicity

Asian Pacific American

Native American

Hispanic

American Indian or Alaskan Native

Native Hawaiian

Black (Non-Hispanic)

White (Non-Hispanic)

Pacific Islander

Mutually Defined

Situational

5-2

1270

Code List Qualifier Code

O 1

1/3

Code identifying a specific industry code list

COMPOSITE SYNTAX: P0203

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

CODE

DEFINITION

RET

Classification of Race or Ethnicity

CODE SOURCE 859: Classification of Race or Ethnicity

Situational

5-3

1271

Industry Code

O 1

1/30

Code indicating a code from a specific industry code list

COMPOSITE SYNTAX: P0203

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

INDUSTRY NAME: Race or Ethnicity Code

Situational

1066

Citizenship Status Code

O 1

1/2

Code indicating citizenship status

SITUATIONAL RULE: Required when the members Race or Ethnicity 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

O 1

1/3

Code identifying a specific industry code list

SEGMENT SYNTAX: P1011

SITUATIONAL RULE: Required when the members Race or Ethnicity is being corrected. If not required 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

O 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 members Race or Ethnicity is being corrected. If not required this implementation guide, do not send.

INDUSTRY NAME: Race or Ethnicity Collection Code

NM1*31 - MEMBER MAILING ADDRESS

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Example:

NM1✱31✱1~

NM1

✱

✱

Loop 2100C - MEMBER MAILING ADDRESS

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Postal Mailing Address

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Not Used

1035

Name Last or Organization Name

O 1

1/60

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

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - MEMBER 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: Member Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Member Address Line

N4 - MEMBER 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.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop 2100C - MEMBER MAILING ADDRESS

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Member Mail City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Member Mail State Code

CODE SOURCE 22:States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Member Mail Postal Zone or ZIP Code

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

Situational

Country Code

O 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

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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

NM1*36 - MEMBER EMPLOYER

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the member is employed by someone other than the sponsor and the insurance contract requires the payer to be notified of such employment. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

NM1✱36✱2✱ABC CORP.~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required until the National Identifier for employer is implemented. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Employer Name

Situational

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Member Employer First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Member Employer Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

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

INDUSTRY NAME: Member Employer Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Member Employer Name Suffix

Situational

Identification Code Qualifier

O 1

1/2

Code designating 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

This is the "HIPAA Employer Identifier".

Social Security Number

Situational

Identification Code

O 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: Member Employer Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PER*EP - MEMBER 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 the Member Employers contact information is provided to the sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

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 if member employer communication contact name is supplied by the member. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member Employer Communications Contact Name

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 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

O 1

1/256

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

O 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

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - MEMBER 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:

Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Member Employer Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Member Employer Address Line

N4 - MEMBER EMPLOYER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Member Employer City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Member Employer State Code

CODE SOURCE 22:States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Member Employer Postal Zone or ZIP Code

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

Situational

Country Code

O 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

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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

NM1*M8 - MEMBER SCHOOL

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required when the member is enrolled in school and the payer is required to be notified under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.

TR3 Example:

NM1✱M8✱2✱University of Utah~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Educational Institution

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: School 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

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

PER*SK - MEMBER SCHOOL COMMMUNICATIONS 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 Member School contact information is provided to the sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

TR3 Example:

PER✱SK✱✱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

School Clerk

Situational

Name

O 1

1/60

Free-form name

SITUATIONAL RULE: Required if member school communication contact name is supplied by the member. If not required by this implementation guide, do not send.

INDUSTRY NAME: Member School Communications Contact Name

Required

365

Communication Number Qualifier

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 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

Telephone

Situational

364

Communication Number

O 1

1/256

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

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0708

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

CODE

DEFINITION

Electronic Mail

Telephone Extension

Facsimile

Telephone

Situational

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0708

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

Not Used

443

Contact Inquiry Reference

O 1

1/20

N3 - MEMBER SCHOOL 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 the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.

TR3 Example:

N3✱P.O. Box 1234~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: School Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: School Address Line

N4 - MEMBER SCHOOL CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send.

TR3 Example:

N4✱KANSAS CITY✱MO✱64108~

✱

✱

✱

✱

✱

✱

✱

Required

City Name

O 1

2/30

Free-form text for city name

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

INDUSTRY NAME: Member School City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Member School State Code

CODE SOURCE 22:States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Member School Postal Zone or ZIP Code

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

Situational

Country Code

O 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

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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

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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Custodial Parent Last Name

Required

1036

Name First

O 1

1/35

Individual first name

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

INDUSTRY NAME: Custodial Parent Name Suffix

Situational

Identification Code Qualifier

O 1

1/2

Code designating 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

O 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

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 contact information is provided to the sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

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

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Telephone

Work Phone Number

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 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

O 1

1/256

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

O 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

Home Phone Number

Telephone

Work Phone Number

Situational

364

Communication Number

O 1

1/256

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:

Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. 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: Custodial Parent Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: 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.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. 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: Custodial Parent City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

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

O 1

3/15

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

INDUSTRY NAME: Custodial Parent Postal Zone or ZIP Code

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

Situational

Country Code

O 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

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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

NM1 - RESPONSIBLE PERSON

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Example:

NM1✱QD✱1✱CASE✱JOHN~

NM1

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

✱

Required

Entity Identifier Code

M 1

2/3

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

CODE

DEFINITION

Case Manager

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 party is other than a surviving spouse.

EXS

Ex-spouse

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

Other Insured

Guardian

Power of Attorney

Legal Representative

Responsible Party

Parent

Significant Other

Spouse

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Required

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

INDUSTRY NAME: Responsible Party Last or Organization Name

Situational

1036

Name First

O 1

1/35

Individual first name

SITUATIONAL RULE: Required when NM102 is equal to <169>1<170> (person) and the person has a first name. If not required by this implementation guide, do not send.

INDUSTRY NAME: Responsible Party First Name

Situational

1037

Name Middle

O 1

1/25

Individual middle name or initial

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

INDUSTRY NAME: Responsible Party Middle Name

Situational

1038

Name Prefix

O 1

1/10

Prefix to individual name

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

INDUSTRY NAME: Responsible Party Name Prefix

Situational

1039

Name Suffix

O 1

1/10

Suffix to individual name

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

INDUSTRY NAME: Responsible Party Suffix Name

Situational

Identification Code Qualifier

O 1

1/2

Code designating 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

O 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 Party Identifier

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

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 the Responsible Person contact information is provided to the sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

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

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Telephone

Work Phone Number

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 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

O 1

1/256

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

O 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

O 1

1/256

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 there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. 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 Party Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Responsible Party Address Line

N4 - RESPONSIBLE PERSON CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop 2100H - DROP OFF LOCATION

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: Responsible Person City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

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

O 1

3/15

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

INDUSTRY NAME: Responsible Person Postal Zone or ZIP Code

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

Situational

Country Code

O 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

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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

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 member 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 2100H - 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 qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

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

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

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:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

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 if 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.
C0605
If N406 is present, then N405 is required.
C0704
If N407 is present, then N404 is required.

Loop:

Loop 2100H - DROP OFF LOCATION

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

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: Drop Off Location City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

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

O 1

3/15

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

INDUSTRY NAME: Drop Off Location Postal Zone or ZIP Code

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

Situational

Country Code

O 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

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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

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 2200 - DISABILITY INFORMATION

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 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

O 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, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis

CODE SOURCE 131: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

Mutually Defined

To be used for the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) - Diagnosis.

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

Situational

1137

Medical Code Value

O 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 called for in 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.

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 enrolling a disabled member or when disability dates change for an existing member, and the disability dates are known by the sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

This segment is used to send the first and last date of disability.

TR3 Example:

DTP✱360✱D8✱19961001~

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 member or when adding, updating, removing coverage or auditing an existing member. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

HD✱021✱✱HLT✱PLAN A BCD✱FAM~

✱

875

Maintenance
Type Code

✱

✱

✱

Plan Cvrg
Description

✱

✱

✱

✱

Underwrite
Decide Code

✱

1073

✱

✱

Required

875

Maintenance Type Code

M 1

Code identifying the specific type of item maintenance

Required to identify the specific type of item maintenance.

CODE

DEFINITION

001

Change

002

Delete

Use 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

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

Situational

1204

Plan Coverage Description

O 1

1/50

A description or number that identifies the plan or coverage

SITUATIONAL RULE: Required when additional information is needed to describe the exact type of coverage being provided. If not required by this implementation guide, do not send.

Situational

1207

Coverage Level Code

O 1

Code indicating the level of coverage being provided for this insured

See section 1.4.6, Coverage Levels and Dependents, for additional information.

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

Not Used

609

Count

O 1

1/9

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 a member 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✱19961001~

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 a member'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 02/28/2001 is passed then claims for this individual will be paid through 11:59 p.m. on 2/28/01.

543

Last Premium Paid Date

695

Previous Period

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

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

AMT - HEALTH COVERAGE POLICY

X12 Name:

Monetary Amount Information

X12 Purpose:

To indicate the total monetary amount

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when such transmission is required under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send.

TR3 Example:

AMT✱C1✱20~

AMT

✱

✱

✱

Required

522

Amount Qualifier Code

M 1

1/3

Code to qualify amount

CODE

DEFINITION

Co-insurance - Actual

This will contain any co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract.

Co-Payment Amount

Deductible Amount

EBA

Expected Expenditure Amount

Other Unlisted Amount

Premium Amount

Spend Down

Required

782

Monetary Amount

M 1

1/18

Monetary amount

INDUSTRY NAME: Contract Amount

Not Used

478

Credit/Debit Flag Code

O 1

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 such transmission is required under the Trading Partner Agreement between the sponsor and the payer. If not required by this implementation guide, do not send.

TR3 Example:

REF✱1L✱123456~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Client Reporting Category

Group or Policy Number

Required when a group number that applies to this individual's participation in the coverage passed in this HD loop is required by the terms of the contract between the sponsor (sender) and payer (receiver); if not required may be sent at the sender's discretion.

Payment Category

Class of Contract Code

Service Contract (Coverage) Number

Medical Assistance Category

PID

Program Identification Number

Rate code number

Internal Control Number

Issuer Number

XX1

Special Program Code

XX2

Service Area Code

County Code

Mutually Defined

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

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Group or Policy Number

Not Used

352

Description

O 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.

TR3 Example:

REF✱QQ✱0~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying 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

O 1

1/50

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

Indicator identifying the number of prior months insurance coverage that may apply under the portability provisions of the Health Insurance Portability and Accountability Act.
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.

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

IDC - IDENTIFICATION CARD

X12 Name:

Identification Card

X12 Purpose:

To provide notification to produce replacement identification card(s)

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when requesting the production of an identification card as the result of an enrollment add, change, or statement. If not required by this implementation guide, do not send.

TR3 Notes:

An enrollment statement refers to a situation where no change is being made to the enrollment except to request a replacement ID card.

TR3 Example:

IDC✱12345✱H~

IDC

✱

1204

Plan Cvrg
Description

✱

✱

✱

Required

1204

Plan Coverage Description

M 1

1/50

A description or number that identifies the plan or coverage

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

Required

1215

Identification Card Type Code

M 1

Code identifying the type of identification card

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

CODE

DEFINITION

Dental Insurance

Health Insurance

Prescription Drug Service Drug Insurance

Situational

380

Quantity

O 1

1/15

Numeric value of quantity

SEMANTIC: IDC03 is the number of cards being requested.

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

INDUSTRY NAME: Identification Card Count

Only non-negative integer values are to be sent.

Situational

306

Action Code

O 1

1/2

Code indicating type of action

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

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

CODE

DEFINITION

Add

Change (Update)

Replace

Use when requesting replacement cards with no change to data.

LX - PROVIDER INFORMATION

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

X12 Set Notes:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required to provide information about the primary care or capitated physicians and pharmacies chosen by the enrollee in a managed care plan when that selection is made through the sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

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

1/6

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 Notes:

The National Provider ID must be passed in NM109. Until that ID is available, the Federal Taxpayer's Identification Number or another identification number that is necessary to identify the entity must be sent if available. If the identification number is not available then the Provider's Name must be passed using elements NM103 through NM107 as outlined in segment note 2.

TR3 Example:

NM1✱P3✱1✱✱✱✱✱✱SV✱25341234567✱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

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Person

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required when NM102 is equal to '1' or '2' 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 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

O 1

1/2

Code designating 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

Social Security Number

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

Federal Taxpayer's Identification Number

Service Provider Number

This is a number assigned by the payer used to identify a provider.

Centers for Medicare and Medicaid Services National Provider Identifier

CODE SOURCE 537: Centers for Medicare and Medicaid Services National Provider Identifier

Situational

Identification Code

O 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

O 1

Code describing entity relationship

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

SEGMENT SYNTAX: C1110

This element indicates whether or not the member is an existing patient of the provider.

CODE

DEFINITION

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

1/60

N3 - PROVIDER ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

INDUSTRY NAME: Provider Address Line

Situational

166

Address Information

O 1

1/55

Address information

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

INDUSTRY NAME: Provider Address Line

N4 - PROVIDER CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the location of the named provider needs to be reported. 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

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

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

O 1

3/15

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

INDUSTRY NAME: Provider Postal Zone or ZIP Code

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

Situational

Country Code

O 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

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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

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 the Provider contact information is provided to the sponsor. If not required by this implementation guide, do not send.

TR3 Notes:

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

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Alternate Telephone

Beeper Number

Cellular Phone

Electronic Mail

Telephone Extension

Facsimile

Home Phone Number

Telephone

Work Phone Number

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Situational

365

Communication Number Qualifier

O 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

O 1

1/256

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

O 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

O 1

1/256

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 2320 - COORDINATION OF BENEFITS

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required to report the reason and the effective date that a member changes providers as described by the NM1 segment in Loop 2310. If not required by this implementation guide, do not send.

TR3 Example:

PLA✱2✱1P✱19970628✱✱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

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 whenever an individual 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

1/50

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: Member Group or Policy Number

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 detailed COB coverage information is agreed to be exchanged. 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 - ADDITIONAL COORDINATION OF BENEFITS IDENTIFIERS

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2320 - COORDINATION OF BENEFITS

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✱6P✱AZ12345~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Account Suffix Code

Group Number

Social Security Number

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

Mutually Defined

Mutually Defined, will be used in this REF01 for National Individual Identifier until a standard code is defined.

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Group or Policy Number

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP - COORDINATION OF BENEFITS ELIGIBILITY DATES

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop 2320 - COORDINATION OF BENEFITS

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when the submitter needs to send effective dates for coordination of benefits. If not required by this implementation guide, do not send.

TR3 Example:

DTP✱344✱D8✱19960401~

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

344

Coordination of Benefits Begin

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 Date

NM1 - COORDINATION OF BENEFITS RELATED ENTITY

X12 Name:

Individual or Organizational Name

X12 Purpose:

To supply the full name of an individual or organizational entity

X12 Syntax:

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

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required to send the name of the insurance company when provided to the sponsor. 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

Employer

Group

Insurer

Required

1065

Entity Type Qualifier

M 1

Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE

DEFINITION

Non-Person Entity

Situational

1035

Name Last or Organization Name

O 1

1/60

Individual last name or organizational name

SEGMENT SYNTAX: C1203

SITUATIONAL RULE: Required to send the insurance company name if no standard identifier is available to pass in NM109. If not required by this implementation guide, do not send.

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

O 1

1/2

Code designating 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

Centers for Medicare and Medicaid Services PlanID

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

CODE SOURCE 540: Centers for Medicare and Medicaid Services PlanID

Situational

Identification Code

O 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

O 1

Not Used

Entity Identifier Code

O 1

2/3

Not Used

1035

Name Last or Organization Name

O 1

1/60

N3 - COORDINATION OF BENEFITS RELATED ENTITY ADDRESS

X12 Name:

Party Location

X12 Purpose:

To specify the location of the named party

Loop:

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send.

TR3 Example:

N3✱50 ORCHARD STREET~

✱

✱

Required

166

Address Information

M 1

1/55

Address information

Situational

166

Address Information

O 1

1/55

Address information

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

N4 - COORDINATION OF BENEFITS OTHER INSURANCE COMPANY CITY, STATE, ZIP CODE

X12 Name:

Geographic Location

X12 Purpose:

To specify the geographic place of the named party

X12 Syntax:

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

Loop:

Loop 2330 - COORDINATION OF BENEFITS RELATED ENTITY

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when detailed COB coverage information is agreed to be exchanged. 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: Coordination of Benefits Other Insurance Company City Name

Situational

156

State or Province Code

O 1

Code (Standard State/Province) as defined by appropriate government agency

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

SEGMENT SYNTAX: E0207

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

INDUSTRY NAME: Coordination of Benefits Other Insurance Company State Code

CODE SOURCE 22:States and Provinces

Situational

116

Postal Code

O 1

3/15

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

INDUSTRY NAME: Coordination of Benefits Other Insurance Company Postal Zone or ZIP Code

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

Situational

Country Code

O 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

O 1

1/2

Not Used

310

Location Identifier

O 1

1/30

Situational

1715

Country Subdivision Code

O 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

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 2330 - COORDINATION OF BENEFITS RELATED ENTITY

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when detailed COB coverage information is agreed to be exchanged. 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

O 1

Code identifying the type of communication number

SEGMENT SYNTAX: P0304

CODE

DEFINITION

Telephone

Required

364

Communication Number

O 1

1/256

Complete communications number including country or area code when applicable

SEGMENT SYNTAX: P0304

Not Used

365

Communication Number Qualifier

O 1

Not Used

364

Communication Number

O 1

1/256

Not Used

365

Communication Number Qualifier

O 1

Not Used

364

Communication Number

O 1

1/256

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 2700 - MEMBER REPORTING CATEGORIES

Loop Usage:

Required

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

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

TR3 Example:

LS✱2700~

✱

Required

447

Loop Identifier Code

M 1

1/4

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

Use the value 2700.

LX - MEMBER REPORTING CATEGORIES

X12 Name:

Transaction Set Line Number

X12 Purpose:

To reference a line number in a transaction set

Loop:

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

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

TR3 Example:

LX✱1~

✱

Required

554

Assigned Number

M 1

1/6

Number assigned for differentiation within a transaction set

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

N1*75 - REPORTING CATEGORY

X12 Name:

Party Identification

X12 Purpose:

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

X12 Syntax:

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

Loop:

Loop 2750 - REPORTING CATEGORY

Loop Usage:

Situational

Segment Usage:

Required

Segment Repeat:

Situational Rule:

Required to specify the name of the reporting category of the member's participating entity.

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

O 1

1/60

Free-form name

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Reporting Category Name

Not Used

Identification Code Qualifier

O 1

1/2

Not Used

Identification Code

O 1

2/80

Not Used

706

Entity Relationship Code

O 1

Not Used

Entity Identifier Code

O 1

2/3

REF - REPORTING CATEGORY REFERENCE

X12 Name:

Reference Information

X12 Purpose:

To specify identifying information

X12 Syntax:

R0203
At least one of REF02 or REF03 is required.

Loop:

Loop 2750 - REPORTING CATEGORY

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required to specify the reference identifier associated with the reporting category of the member's participating entity.

TR3 Example:

REF✱26✱442~

REF

✱

✱

✱

✱

Required

128

Reference Identification Qualifier

M 1

2/3

Code qualifying the Reference Identification

CODE

DEFINITION

Contracting District Number

Client Reporting Category

Plan Number

Division Identifier

Union Number

Branch Identifier

Application Number

Payment Category

Account Category

Geographic Number

Location Number

PID

Program Identification Number

XX1

Special Program Code

XX2

Service Area Code

Geographic Key

Mutually Defined

Required

127

Reference Identification

O 1

1/50

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

SEGMENT SYNTAX: R0203

INDUSTRY NAME: Member Reporting Category Reference ID

Not Used

352

Description

O 1

1/80

Not Used

C040

Reference Identifier

O 1

DTP*007 - REPORTING CATEGORY DATE

X12 Name:

Date or Time or Period

X12 Purpose:

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

Loop:

Loop 2750 - REPORTING CATEGORY

Loop Usage:

Situational

Segment Usage:

Situational

Segment Repeat:

Situational Rule:

Required when called for in the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.

TR3 Notes:

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

TR3 Example:

DTP✱007✱RD8✱20040101-20040531~

DTP

✱

✱

✱

Required

374

Date/Time Qualifier

M 1

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

INDUSTRY NAME: Date Time Qualifier

CODE

DEFINITION

007

Effective

Required

1250

Date Time Period Format Qualifier

M 1

2/3

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

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

CODE

DEFINITION

Date Expressed in Format CCYYMMDD

RD8

Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

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

Required

1251

Date Time Period

M 1

1/35

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

INDUSTRY NAME: Member Reporting Category Effective Date(s)

LE - ADDITIONAL REPORTING CATEGORIES LOOP TERMINATION

X12 Name:

Loop Trailer

X12 Purpose:

To indicate that the loop immediately preceding this segment is complete

X12 Comments:

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

Loop: