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Eligibility 4010A1 to 5010

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DESCRIPTION

EDI Version Changes between 4010A1 and 5010

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  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    ISA

    INTERCHANGE

    CONTROL HEADER ISA

    INTERCHANGE

    CONTROL HEADER 1 R

    ISA01

    Authorization

    Information Qualifier ID 2-2 R

    00, 03

    ISA01

    Authorization

    Information Qualifier ID 2-2 R

    00, 03

    ISA02

    Authorization

    Information AN 10-10 R ISA02

    Authorization

    Information AN 10-10 R

    ISA03

    Security Information

    Qualifier ID 2-2 R

    00, 01

    ISA03

    Security Information

    Qualifier ID 2-2 R

    00, 01

    ISA04 Security Information AN 10-10 R ISA04 Security Information AN 10-10 R

    ISA05 Interchange ID Qualifier ID 2-2 R

    01, 14, 20, 27, 28, 29, 30, 33,

    ZZ ISA05 Interchange ID Qualifier ID 2-2 R

    01, 14, 20, 27, 28, 29, 30, 33,

    ZZ

    ISA06 Interchange Sender ID AN 15-15 R ISA06 Interchange Sender ID AN 15-15 R

    ISA07 Interchange ID Qualifier ID 2-2 R

    01, 14, 20, 27, 28, 29, 30, 33,

    ZZ ISA07 Interchange ID Qualifier ID 2-2 R

    01, 14, 20, 27, 28, 29, 30, 33,

    ZZ

    ISA08 Interchange Receiver ID AN 15-15 R ISA08

    Interchange Receiver

    ID AN 15-15 R

    ISA09 Interchange Date DT 6-6 R YYMMDD ISA09 Interchange Date DT 6-6 R YYMMDD

    ISA10 Interchange Time TM 4-4 R HHMM ISA10 Interchange Time TM 4-4 R HHMM

    ISA11

    Interchange Control

    Standards ID ID 1-1 R

    U

    ISA11 Repetition Separator 1-1 R

    New Element

    ISA12

    Interchange Control

    Version Number ID 5-5 R

    00401

    ISA12

    Interchange Control

    Version Number ID 5-5 R

    00501

    ISA13

    Interchange Control

    Number N0 9-9 R ISA13

    Interchange Control

    Number N0 9-9 R

    ISA14

    Acknowledgement

    Requested ID 1-1 R

    0, 1

    ISA14

    Acknowledgement

    Requested ID 1-1 R

    0, 1

    ISA15 Usage Indicator ID 1-1 R

    P, T

    ISA15

    Interchange Usage

    Indicator ID 1-1 R

    P, T

    ISA16

    Component Element

    Separator 1-1 R ISA16

    Component Element

    Separator 1-1 R

    GS

    FUNCTIONAL GROUP

    HEADER 1 R GS

    FUNCTIONAL GROUP

    HEADER 1 R

    GS01

    Functional Identifier

    Code ID 2-2 R

    HB, HS

    GS01

    Functional Identifier

    Code ID 2-2 R

    GS02

    Application Sender's

    Code AN 2-15 R GS02

    Application Sender's

    Code AN 2-15 R

    GS03

    Application Receiver's

    Code AN 2-15 R GS03

    Application Receiver's

    Code AN 2-15 R

    GS04 Date DT 8-8 R CCYYMMDD GS04 Date DT 8-8 R CCYYMMDD

    GS05 Time TM 4-8 R HHMM GS05 Time TM 4-8 R HHMM

    GS06 Group Control Number N0 1-9 R GS06 Group Control Number N0 1-9 R

    GS07

    Responsible Agency

    Code ID 1-2 R

    X

    GS07

    Responsible Agency

    Code ID 1-2 R

    X

    GS08

    Version/ Release/

    Industry Identifier Code AN 1-12 R

    004010X092

    GS08

    Version/Release/

    Industry Identifier Code AN 1-12 R

    005010X279

    ST

    TRANSACTION SET

    HEADER 1 R ST

    TRANSACTION SET

    HEADER 1 R

    ST01

    Transaction Set

    Identifier Code ID 3-3 R

    270

    ST01

    Transaction Set

    Identifier Code ID 3-3 R

    270

    270 4010A1 270 5010

    4010A1 5010

    Page 1 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

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    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    ST02

    Transaction Set Control

    Number AN 4-9 R ST02

    Transaction Set Control

    Number AN 4-9 R

    ST03

    Implementation

    Convention Reference AN 1-35 R

    005010X279 New Element

    BHT

    BEGINNING OF

    HIERARCHICAL

    TRANSACTION 1 R BHT

    BEGINNING OF

    HIERARCHICAL

    TRANSACTION 1 R

    BHT01

    Hierarchical Structure

    Code ID 4-4 R

    0022

    BHT01

    Hierarchical Structure

    Code ID 4-4 R

    0022

    BHT02

    Transaction Set Purpose

    Code ID 2-2 R

    01,13,36

    BHT02

    Transaction Set

    Purpose Code ID 2-2 R

    01,13 Code Removed

    BHT03 Reference Identification AN 1-30 S BHT03 Reference Identification AN 1-50 S

    Increase

    BHT04 Date DT 8-8 R

    CCYYMMDD

    BHT04

    Transaction Set

    Creation Date DT 8-8 R

    CCYYMMDD

    BHT05 Time TM 4-8 R BHT05 Time TM 4-8 R

    BHT06 Transaction Type Code ID 2-2 S

    RT, RU

    BHT06 Transaction Type Code ID 2-2 S

    RT Code Removed

    New Situational Rule

    HL

    INFORMATION

    SOURCE LEVEL 1 R 2000A >1 HL

    INFORMATION

    SOURCE LEVEL 1 R 2000A >1

    HL01 Hierarchical ID Number AN 1-12 R HL01 Hierarchical ID Number AN 1-12 R

    HL02

    Hierarchical Parent ID

    Number AN 1-12 N/U HL02

    Hierarchical Parent ID

    Number AN 1-12 N/U

    HL03 Hierarchical Level Code ID 1-2 R

    20

    HL03 Hierarchical Level Code ID 1-2 R

    20

    HL04 Hierarchical Child Code ID 1-1 R

    1

    HL04 Hierarchical Child Code ID 1-1 R

    1

    NM1

    INFORMATION

    SOURCE NAME 1 R 2100A 1 NM1

    INFORMATION

    SOURCE NAME 1 R 2100A 1

    NM101 Entity Identifier Code ID 2-3 R 2B,36,GP,P5,PR NM101 Entity Identifier Code ID 2-3 R 2B,36,GP,P5,PR

    NM102 Entity Type Qualifier ID 1-1 R 1,2 NM102 Entity Type Qualifier ID 1-1 R 1,2 New Note

    NM103

    Name Last or

    Organization Name AN 1-35 S NM103

    Name Last or

    Organization Name AN 1-60 R

    Increase

    Usage Change

    NM104 Name First AN 1-25 S NM104 Name First AN 1-35 S

    Increase;

    New Situational Rule

    NM105 Name Middle AN 1-25 S NM105 Name Middle AN 1-25 S New Situational Rule

    NM106 Name Prefix AN 1-10 N/U NM106 Name Prefix AN 1-10 N/U

    NM107 Name Suffix AN 1-10 S NM107 Name Suffix AN 1-10 S New Situational Rule

    NM108

    Identification Code

    Qualifier ID 1-2 R

    24,46,FI,NI,PI,XV,XX

    NM108

    Identification Code

    Qualifier ID 1-2 R

    24,46,FI, NI,PI,XV,XX New Code Descriptions

    NM109 Identification Code AN 2-80 R NM109 Identification Code AN 2-80 R

    NM110 Entity Relationship Code ID 2-2 N/U NM110

    Entity Relationship

    Code ID 2-2 N/U

    NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U

    NM112

    Name Last or

    Organization Name AN 1-60 N/U

    HL

    INFORMATION

    RECEIVER LEVEL 1 R 2000B >1 HL

    INFORMATION

    RECEIVER LEVEL 1 R 2000B >1

    Page 2 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

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    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    HL01 Hierarchical ID Number AN 1/12 R HL01 Hierarchical ID Number AN 1-12 R

    HL02

    Hierarchical Parent ID

    Number AN 1/12 R HL02

    Hierarchical Parent ID

    Number AN 1-12 R

    HL03 Hierarchical Level Code ID 1/2 R

    21

    HL03 Hierarchical Level Code ID 1-2 R

    21

    HL04 Hierarchical Child Code ID 1/1 R

    1

    HL04 Hierarchical Child Code ID 1-1 R

    1

    NM1

    INFORMATION

    RECEIVER NAME 1 R 2100B 1 NM1

    INFORMATION

    RECEIVER NAME 1 R 2100B 1

    NM101 Entity Identifier Code ID 2/3 R 1P,2B,36,80,FA,GP,P5,PR NM101 Entity Identifier Code ID 2-3 R 1P,2B,36,80,FA, GP, P5, PR

    NM102 Entity Type Qualifier ID 1/1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1, 2

    NM103

    Name Last or

    Organization Name AN 1/35 S NM103

    Name Last or

    Organization Name AN 1-60 R

    Increase

    Usage Change

    NM104 Name First AN 1/25 S NM104 Name First AN 1-35 S

    New Situational Rule;

    Increase

    NM105 Name Middle AN 1/25 S NM105 Name Middle AN 1-25 S New Situational Rule

    NM106 Name Prefix AN 1-10 N/U NM106 Name Prefix AN 1-10 N/U

    NM107 Name Suffix AN 1-10 S NM107 Name Suffix AN 1-10 S New Situational Rule

    NM108

    Identification Code

    Qualifier ID 1-2 R

    24,34,FI,PI,PP,

    SV,XV, XX NM108

    Identification Code

    Qualifier ID 1-2 R

    24,34,FI, PI,PP, SV, XV, XX New Code Descriptions

    NM109 Identification Code AN 2-80 R NM109 Identification Code AN 2-80 R

    NM110 Entity Relationship Code ID 2-2 N/U NM110

    Entity Relationship

    Code ID 2-2 N/U

    NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U

    NM112

    Name Last or

    Organization Name AN 1-60 N/U

    REF

    INFORMATION

    RECEIVER

    ADDITIONAL

    IDENTIFICATION 9 S 2100B REF

    INFORMATION

    RECEIVER

    ADDITIONAL

    IDENTIFICATION 9 S 2100B

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    0B, 1C, 1D, 1J, 4A, CT,EL,

    EO, HPI, JD, N5, N7,

    Q4,SY,TJ REF01

    Reference Identification

    Qualifier ID 2-3 R

    0B, 1C, 1D, 1J, 4A, CT, EL,

    EO, HPI, JD, N5, N7, Q4, SY,

    TJ

    New Note;

    New Code Description

    REF02 Reference Identification AN 1-30 R REF02 Reference Identification AN 1-50 R

    REF03 Description AN 1-80 S REF03 Description AN 1-80 S New Situational rule

    REF04

    REFERENCE

    IDENTIFIER N/U REF04

    REFERENCE

    IDENTIFIER N/U

    N3

    INFORMATION

    RECEIVER ADDRESS 1 S 2100B N3

    INFORMATION

    RECEIVER ADDRESS 1 S 2100B

    N301 Address Information AN 1-55 R N301 Address Information AN 1-55 R

    N302 Address Information AN 1-55 S N302 Address Information AN 1-55 S

    N4

    INFORMATION

    RECEIVER CITY/

    STATE/ ZIPCODE 1 S 2100B N4

    INFORMATION

    RECEIVER

    CITY/STATE/ ZIP

    CODE 1 S 2100B

    N401 City Name AN 2-30 R N401 City Name AN 2-30 R

    N402 State or Province Code ID 2-2 R N402 State or Province Code ID 2-2 S

    New Situational rule

    N403 Postal Code ID 3-15 R N403 Postal Code ID 3-15 S New Situational rule

    Page 3 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S New Situational rule

    N405 Location Qualifier ID 1-2 N/U N405 Location Qualifier ID 1-2 N/U

    N406 Location Qualifier AN 1-30 N/U N406 Location Qualifier AN 1-30 N/U

    N407

    Country Subdivision

    Code ID 1-3 S

    New Situational rule;

    New Element

    PER

    INFORMATION

    RECEIVER CONTACT

    INFORMATION 3 S 2100B PER

    INFORMATION

    RECEIVER CONTACT

    INFORMATION

    Segment Deleted

    PER01 Contact Function Code ID 2-2 R IC

    PER02 Name AN 1-60 S

    PER03

    Communication Number

    Qualifier ID 2-2 S

    ED, EM, FX, TE

    PER04 Communication Number AN 1-80 S

    PER05

    Communication Number

    Qualifier ID 2-2 S

    ED, EM, EX, FX, TE

    PER06 Communication Number AN 1-80 S

    AAABBBCCCC

    PER07

    Communication Number

    Qualifier ID 2-2 S

    ED, EM, EX, FX, TE

    PER08 Communication Number AN 1-80 S

    AAABBBCCCC

    PER09

    Contact Inquiry

    Reference AN 1-20 N/U

    PRV

    INFORMATION

    RECEIVER PROVIDER

    INFORMATION 1 S 2100B PRV

    INFORMATION

    RECEIVER PROVIDER

    INFORMATION 1 S 2100B

    PRV01 Provider Code ID 1-3 R

    AD, AT, BI, CO, CV, H, HH,

    LA, OT, P1, P2, PC, PE, R,

    RF, SB, SK, SU PRV01 Provider Code ID 1-3 R

    AD, AT, BI, CO, CV, H, HH,

    LA, OT, P1, P2, PC, PE, R,

    RF, SB, SK, SU

    PRV02

    Reference Identification

    Qualifier ID 2-3 R ZZ PRV02

    Reference Identification

    Qualifier ID 2-3 S

    PXC New Situational Rule;

    Code Removed/Added

    PRV03 Reference Identification AN 1-30 R PRV03 Reference Identification AN 1-50 S

    New Situational Rule;

    Increase

    PRV04 State or Province Code ID 2-2 N/U PRV04 State or Province Code ID 2-2 N/U

    PRV05

    PROVIDER SPECIALTY

    INFORMATION N/U PRV05

    PROVIDER

    SPECIALTY

    INFORMATION N/U

    PRV06

    Provider Organization

    Code ID 3-3 N/U PRV06

    Provider Organization

    Code ID 3-3 N/U

    HL SUBSCRIBER LEVEL 1 R 2000C >1 HL SUBSCRIBER LEVEL 1 R 2000C >1

    HL01 Hierarchical ID Number AN 1-12 R HL01 Hierarchical ID Number AN 1-12 R

    HL02

    Hierarchical Parent ID

    Number AN 1-12 R HL02

    Hierarchical Parent ID

    Number AN 1-12 R

    HL03 Hierarchical Level Code ID 1-2 R

    22

    HL03 Hierarchical Level Code ID 1-2 R

    22

    HL04 Hierarchical Child Code ID 1-1 R

    0, 1

    HL04 Hierarchical Child Code ID 1-1 R

    0, 1

    Page 4 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    TRN

    SUBSCRIBER TRACE

    NUMBER 2 S 2000C TRN

    SUBSCRIBER TRACE

    NUMBER 2 S 2000C

    TRN01 Trace Type Code ID 1-2 R 1 TRN01 Trace Type Code ID 1-2 R 1

    TRN02 Reference Identification AN 1-30 R TRN02 Reference Identifier AN 1-50 R

    Increase

    TRN03

    Originating Company

    Identifier AN 10-10 R TRN03

    Originating Company

    Identifier AN 10-10 R

    TRN04 Reference Identification AN 1-30 S TRN04 Reference Identification AN 1-50 S

    New Situational Rule;

    Increase

    NM1 SUBSCRIBER NAME 1 R 2100C 1 NM1 SUBSCRIBER NAME 1 R 2100C 1

    NM101 Entity Identifier Code ID 2-3 R IL NM101 Entity Identifier Code ID 2-3 R IL

    NM102 Entity Type Qualifier ID 1-1 R 1 NM102 Entity Type Qualifier ID 1-1 R 1

    NM103

    Name Last or

    Organization Name AN 1-35 S NM103

    Name Last or

    Organization Name AN 1-60 S

    New Situational Rule;

    Increase

    NM104 Name First AN 1-25 S NM104 Name First AN 1-35 S

    New Situational Rule;

    Increase

    NM105 Name Middle AN 1-25 S NM105 Name Middle AN 1-25 S New Situational Rule

    NM106 Name Prefix AN 1-10 N/U NM106 Name Prefix AN 1-10 N/U

    NM107 Name Suffix AN 1-10 S NM107 Name Suffix AN 1-10 S New Situational Rule

    NM108

    Identification Code

    Qualifier ID 1-2 S

    MI, ZZ

    NM108

    Identification Code

    Qualifier ID 1-2 S

    II, MI New Situational Rule;

    Code Removed/Added

    NM109 Identification Code AN 2-80 S NM109 Identification Code AN 2-80 S

    NM110 Entity Relationship Code ID 2-2 N/U NM110

    Entity Relationship

    Code ID 2-2 N/U

    NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U

    NM112

    Name Last or

    Organization Name AN 1-60 N/U

    REF

    SUBSCRIBER

    ADDITIONAL

    IDENTIFICATION 9 S 2100C REF

    SUBSCRIBER

    ADDITIONAL

    IDENTIFICATION 9 S 2100C

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    18, 1L, 1W, 3H, 49, 6P, A6,

    CT, EA, EJ

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    18, 1L, 1W, 3H, 6P, CT, EA,

    EJ, F6, GH, HJ, IG, N6, NQ,

    SY, Y4

    Codes Removed: 49, A6

    Codes Added: 3H, Y4

    REF02 Reference Identification AN 1-30 R REF02 Reference Identification AN 1-50 R

    Increase

    REF03 Description AN 1-80 N/U REF03 Description AN 1-80 N/U

    REF04

    REFERENCE

    IDENTIFIER N/U REF04

    REFERENCE

    IDENTIFIER N/U

    N3

    SUBSCRIBER

    ADDRESS 1 S 2100C N3

    SUBSCRIBER

    ADDRESS 1 S 2100C

    N301 Address Information AN 1-55 R N301 Address Information AN 1-55 R

    N302 Address Information AN 1-55 S N302 Address Information AN 1-55 S New Situational Rule

    N4

    SUBSCRIBER CITY/

    STATE/ ZIPE CODE 1 S 2100C N4

    SUBSCRIBER

    CITY/STATE/ZIP

    CODE 1 S 2100C

    N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage Change

    N402 State or Province Name ID 2-2 S

    N402 State or Province Name ID 2-2 S

    New Situational Rule

    N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S New Situational Rule

    N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S New Situational Rule

    Page 5 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    N405 Location Qualifier ID 1-2 N/U N405 Location Qualifier ID 1-2 N/U

    N406 Location Qualifier AN 1-30 N/U N406 Location Qualifier AN 1-30 N/U

    N407

    Country Subdivision

    Code ID 1-3 S

    New Element

    New Situational Rule

    PRV

    PROVIDER

    INFORMATION 1 S 2100C PRV

    PROVIDER

    INFORMATION 1 S 2100C

    PRV01 Provider Code ID 1-3 R

    AD, AT, BI, CO, CV, H, HH,

    LA, OT, P1, P2, PC, PE, R,

    RF, SB, SK, SU PRV01 Provider Code ID 1-3 R

    AD, AT, BI, CO, CV, H, HH,

    LA, OT, P1, P2, PC, PE, R,

    RF, SK, SU

    Code Removed: SB

    PRV02

    Reference Identification

    Qualifier ID 2-3 R

    9K, D3, EI, HPI, SY, TJ, ZZ

    PRV02

    Reference Identification

    Qualifier ID 2-3 S

    9K, D3, EI, HPI, PXC, SY, TJ New Situational Rule;

    Code Removed: ZZ

    Code Added: PXC

    New Code Description: HPI

    PRV03 Reference Identification AN 1-30 R

    PRV03 Reference Identification AN 1-50 S

    New Situational Rule;

    Increase

    PRV04 State or Province Code ID 2-2 N/U

    PRV04 State or Province Code ID 2-2 N/U

    PRV05

    PROVIDER SPECIALTY

    INFORMATION N/U PRV05

    PROVIDER

    SPECIALTY

    INFORMATION N/U

    PRV06

    Provider Organization

    Code ID 3-3 N/U PRV06

    Provider Organization

    Code ID 3-3 N/U

    DMG

    SUBSCRIBER

    DEMOGRAPHIC

    INFORMATION 1 S 2100C DMG

    SUBSCRIBER

    DEMOGRAPHIC

    INFORMATION 1 S 2100C

    DMG01

    Date Time Period

    Format Qualifier ID 2-3 S

    D8

    DMG01

    Date Time Period

    Format Qualifier ID 2-3 S

    D8 New Situational Rule

    DMG02 Date Time Period AN 1-35 S DMG02 Date Time Period AN 1-35 S New Situational Rule

    DMG03 Gender Code ID 1-1 S F, M DMG03 Gender Code ID 1-1 S F, M New Situational Rule

    DMG04 Marital Status Code ID 1-1 N/U DMG04 Marital Status Code ID 1-1 N/U

    DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05

    Composite Race or

    Ethnicity Information N/U

    DMG06 Citizenship Status Code ID 1-2 N/U DMG06

    Citizenship Status

    Code ID 1-2 N/U

    DMG07 Country Code ID 2-3 N/U DMG07 Country Code ID 2-3 N/U

    DMG08

    Basis of Verification

    Code ID 1-2 N/U DMG08

    Basis of Verification

    Code ID 1-2 N/U

    DMG09 Quantity R 1-15 N/U DMG09 Quantity R 1-15 N/U

    DMG10

    Code List Qualifier

    Code ID 1-3 N/U

    DMG11 Industry Code AN 1-30 N/U

    INS

    SUBSCRIBER

    RELATIONSHIP 1 S 2100C INS

    MULTIPLE BIRTH

    SEQUENCE NUMBER 1 S 2100C

    INS01

    Yes/No Condition or

    Response Code ID 1-1 R

    Y

    INS01

    Yes/No Condition or

    Response Code ID 1-1 R

    Y New Note

    INS02

    Individual Relationship

    Code ID 2-2 R

    18

    INS02

    Individual Relationship

    Code ID 2-2 R

    18 New Note

    INS03 Maintenance Type Code ID 3-3 N/U INS03

    Maintenance Type

    Code ID 3-3 N/U

    INS04

    Maintenance Reason

    Code ID 2-3 N/U INS04

    Maintenance Reason

    Code ID 2-3 N/U

    INS05 Benefit Status Code ID 1-1 N/U INS05 Benefit Status Code ID 1-1 N/U

    Page 6 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    INS06 Medicare Plan Code ID 1-1 N/U INS06

    MEDICARE STATUS

    CODE N/U

    INS07

    Consolidated Omnibus

    Budget Reconciliation

    Act (COBRA) Qualifying ID 1-2 N/U INS07

    Consolidated Omnibus

    Budget Reconciliation

    Act (COBRA)

    Qualifying ID 1-2 N/U

    INS08

    Employment Status

    Code ID 2-2 N/U INS08

    Employment Status

    Code ID 2-2 N/U

    INS09 Student Status Code ID 1-1 N/U INS09 Student Status Code ID 1-1 N/U

    INS10

    Yes/No Condition or

    Response Code ID 1-1 N/U INS10

    Yes/No Condition or

    Response Code ID 1-1 N/U

    INS11

    Date Time Period

    Format Qualifier ID 2-3 N/U INS11

    Date Time Period

    Format Qualifier ID 2-3 N/U

    INS12 Date Time Period AN 1-35 N/U INS12 Date Time Period AN 1-35 N/U

    INS13 Confidentiality Code ID 1-1 N/U INS13 Confidentiality Code ID 1-1 N/U

    INS14 City Name AN 2-30 N/U INS14 City Name AN 2-30 N/U

    INS15 State or Province Code ID 2-2 N/U INS15 State or Province Code ID 2-2 N/U

    INS16 Country Code ID 2-3 N/U INS16 Country Code ID 2-3 N/U

    INS17 Number N0 1-9 R INS17 Number N0 1-9 R

    HI

    SUBSCRIBER

    HEALTH CARE

    DIAGNOSIS CODE 1 S 2100C

    New Segment

    HI01

    HEALTH CARE CODE

    INFORMATION R

    HI01 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABK, BK

    HI01 - 2 Industry Code AN 1-30 R

    HI01 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI01 - 4 Date Time Period AN 1-35 N/U

    HI01 - 5 Monetary Amount R 1-18 N/U

    HI01 - 6 Quantity R 1-15 N/U

    HI01 - 7 Version Identifier AN 1-30 N/U

    HI01 - 8 Industry Code AN 1-30 N/U

    HI01 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI02

    HEALTH CARE CODE

    INFORMATION S

    HI02 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI02 - 2 Industry Code AN 1-30 R

    HI02 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI02 - 4 Date Time Period AN 1-35 N/U

    HI02 - 5 Monetary Amount R 1-18 N/U

    HI02 - 6 Quantity R 1-15 N/U

    HI02 - 7 Version Identifier AN 1-30 N/U

    HI02 - 8 Industry Code AN 1-30 N/U

    HI02 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI03

    HEALTH CARE CODE

    INFORMATION S

    Page 7 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    HI03 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI03 - 2 Industry Code AN 1-30 R

    HI03 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI03 - 4 Date Time Period AN 1-35 N/U

    HI03 - 5 Monetary Amount R 1-18 N/U

    HI03 - 6 Quantity R 1-15 N/U

    HI03 - 7 Version Identifier AN 1-30 N/U

    HI03 - 8 Industry Code AN 1-30 N/U

    HI03 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI04

    HEALTH CARE CODE

    INFORMATION S

    HI04 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI04 - 2 Industry Code AN 1-30 R

    HI04 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI04 - 4 Date Time Period AN 1-35 N/U

    HI04 - 5 Monetary Amount R 1-18 N/U

    HI04 - 6 Quantity R 1-15 N/U

    HI04 - 7 Version Identifier AN 1-30 N/U

    HI04 - 8 Industry Code AN 1-30 N/U

    HI04 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI05

    HEALTH CARE CODE

    INFORMATION S

    HI05 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI05 - 2 Industry Code AN 1-30 R

    HI05 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI05 - 4 Date Time Period AN 1-35 N/U

    HI05 - 5 Monetary Amount R 1-18 N/U

    HI05 - 6 Quantity R 1-15 N/U

    HI05 - 7 Version Identifier AN 1-30 N/U

    HI05 - 8 Industry Code AN 1-30 N/U

    HI05 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI06

    HEALTH CARE CODE

    INFORMATION S

    HI06 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI06 - 2 Industry Code AN 1-30 R

    HI06 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI06 - 4 Date Time Period AN 1-35 N/U

    HI06 - 5 Monetary Amount R 1-18 N/U

    HI06 - 6 Quantity R 1-15 N/U

    HI06 - 7 Version Identifier AN 1-30 N/U

    HI06 - 8 Industry Code AN 1-30 N/U

    HI06 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    Page 8 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    HI07

    HEALTH CARE CODE

    INFORMATION S

    HI07 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI07 - 2 Industry Code AN 1-30 R

    HI07 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI07 - 4 Date Time Period AN 1-35 N/U

    HI07 - 5 Monetary Amount R 1-18 N/U

    HI07 - 6 Quantity R 1-15 N/U

    HI07 - 7 Version Identifier AN 1-30 N/U

    HI07 - 8 Industry Code AN 1-30 N/U

    HI07 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI08

    HEALTH CARE CODE

    INFORMATION S

    HI08 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI08 - 2 Industry Code AN 1-30 R

    HI08 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI08 - 4 Date Time Period AN 1-35 N/U

    HI08 - 5 Monetary Amount R 1-18 N/U

    HI08 - 6 Quantity R 1-15 N/U

    HI08 - 7 Version Identifier AN 1-30 N/U

    HI08 - 8 Industry Code AN 1-30 N/U

    HI08 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI09

    HEALTH CARE CODE

    INFORMATION N/U

    HI10

    HEALTH CARE CODE

    INFORMATION N/U

    HI11

    HEALTH CARE CODE

    INFORMATION N/U

    HI12

    HEALTH CARE CODE

    INFORMATION N/U

    DTP SUBSCRIBER DATE 2 S 2100C DTP SUBSCRIBER DATE 2 S 2100C

    DTP01 Date/Time Qualifier ID 3-3 R

    102, 307, 435, 472

    DTP01 Date Time Qualifier ID 3-3 R

    102, 291 Code Added

    Codes Removed

    DTP02

    Date Time Period

    Format Qualifier ID 2-3 R

    D8, RD8

    DTP02

    Date Time Period

    Format Qualifier ID 2-3 R

    D8, RD8

    DTP03 Date Time Period AN 1-35 R

    CCYYMMDD, CCYYMMDD-

    CCYYMMDD DTP03 Date Time Period AN 1-35 R

    CCYYMMDD, CCYYMMDD-

    CCYYMMDD

    EQ

    SUBSCRIBER

    ELIGIBILITY/ BENEFIT

    INQUIRY

    INFORMATION 1 S 2110C 99 EQ

    SUBSCIBER

    ELIGIBILITY/BENEFIT

    INQUIRY

    INFORMATION 1 S 2110C 99

    Page 9 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    EQ01 Service Type Code ID 1-2 S

    1, 2, 3, 4, 5, 6, 7, 8, 9,10,

    11,12,13, 14, 15, 16, 17, 18,

    19, 20, 21, 22, 23, 24, 25, 26,

    27, 28, 30, 32, 33, 34, 35, 36,

    37, 38, 39, 40, 41, 42, 43, 44,

    45, 46, 47, 48, 49, 50, 51, 52,

    53, 54, 55, 56, 57, 58, 59, 60,

    61, 62, 63, 64, 65, 66, 67, 68,

    69, 70, 71, 72, 73, 74, 75, 76,

    77, 78, 79, 80, 81, 82, 83, 84,

    85, 86, 87, 88, 89, 90, 91, 92,

    93, 94, 95, 96, 97, 98, 99, A0,

    A1, A2, A3, A4, A5, A6, A7,

    A8, A9, AA, AB, AC, AD, AE,

    AF, AG, AH, AI , AJ, AK, AL,

    AM, AN ,AO, AQ, AR, BA,BB,

    BC, BD, BE, BF, BG, BH, BI,

    BJ, BK, BL, BM, BN, BP, BQ,

    BR, BS

    EQ01 Service Type Code ID 1-2 S

    1, 2, 3, 4, 5, 6, 7, 8, 9,10,

    11,12,13, 14, 15, 16, 17, 18,

    19, 20, 21, 22, 23, 24, 25, 26,

    27, 28, 30, 32, 33, 34, 35, 36,

    37, 38, 39, 40, 41, 42, 43, 44,

    45, 46, 47, 48, 49, 50, 51, 52,

    53, 54, 55, 56, 57, 58, 59, 60,

    61, 62, 63, 64, 65, 66, 67, 68,

    69, 70, 71, 72, 73, 74, 75, 76,

    77, 78, 79, 80, 81, 82, 83, 84,

    85, 86, 87, 88, 89, 90, 91, 92,

    93, 94, 95, 96, 97, 98, 99, A0,

    A1, A2, A3, A4, A5, A6, A7,

    A8, A9, AA, AB, AC, AD, AE,

    AF, AG, AH, AI , AJ, AK, AL,

    AM, AN ,AO, AQ, AR, B1, B2,

    B3, BA,BB, BC, BD, BE, BF,

    BG, BH, BI, BJ, BK, BL, BM,

    BN, BP, BQ, BR, BS, BT, BU,

    BV, BW, BX, BY, BZ, C1, CA,

    CB, CC, CD, CE, CF, CG, CH,

    CI, CJ, CK, CL, CM, CN, CO,

    CP, CQ, DG, DM, DS, GF, GN,

    GY, IC, MH, NI, ON, PT, PU,

    RN, RT, TC, TN, UC

    New Situational Rule;

    Many New Codes Added;

    New Notes

    EQ02

    COMPOSITE MEDICAL

    PROCEDURE

    IDENTIFIER S EQ02

    COMPOSITE MEDICAL

    PROCEDURE

    IDENTIFIER S

    New Situational Rule

    EQ02 - 1

    Product/Service ID

    Qualifier ID 2-2 R

    AD, CJ, HC, ID, IV, N4, ZZ

    EQ02 - 1

    Product/Service ID

    Qualifier ID 2-2 R

    AD, CJ, HC, ID, IV, N4, ZZ New Situational Rule;

    New Note

    EQ02 - 2 Product/Service ID AN 1-48 R EQ02 - 2 Product/Service ID AN 1-48 R

    EQ02 - 3 Procedure Modifier AN 2-2 S EQ02 - 3 Procedure Modifier AN 2-2 S New Situational Rule

    EQ02 - 4 Procedure Modifier AN 2-2 S EQ02 - 4 Procedure Modifier AN 2-2 S New Situational Rule

    EQ02 - 5 Procedure Modifier AN 2-2 S EQ02 - 5 Procedure Modifier AN 2-2 S New Situational Rule

    EQ02 - 6 Procedure Modifier AN 2-2 S EQ02 - 6 Procedure Modifier AN 2-2 S New Situational Rule

    EQ02 - 7 Description AN 1-80 N/U EQ02 - 7 Description AN 1-80 N/U

    EQ02 - 8 Product/Service ID AN 1-48 N/U

    EQ03 Coverage Level Code ID 3-3 S

    CHD, DEP, ECH, EMP, ESP,

    FAM, IND, SPC, SPO EQ03 Coverage Level Code ID 3-3 S

    FAM New Situational Rule;

    Codes Removed

    EQ04 Insurance Type Code ID 1-3 S

    AP, C1, CO, GP, HM, HN, IP,

    MA, MB, MC, PR, PS, SP, WC

    EQ04 Insurance Type Code ID 1-3 N/U

    EQ05

    COMPOSITE

    DIAGNOSIS CODE

    POINTER S

    New Element

    EQ05 - 1 Diagnosis Code Pointer N0 1-2 R

    New Element

    Page 10 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    EQ05 - 2 Diagnosis Code Pointer N0 1-2 S

    New Element

    EQ05 - 3 Diagnosis Code Pointer N0 1-2 S

    New Element

    EQ05 - 4 Diagnosis Code Pointer N0 1-2 S

    New Element

    AMT

    SUBSCRIBER SPEND

    DOWN AMOUNT 1 S 2110C AMT

    SUBSCRIBER SPEND

    DOWN AMOUNT 1 S 2110C

    AMT01 Amount Qualifier Code ID 1-3 R

    R

    AMT01 Amount Qualifier Code ID 1-3 R

    R

    AMT02 Monetary Amount R 1-18 N/U AMT02 Monetary Amount R 1-18 R Usage Change

    AMT03 Credit/Debit Flag Code ID 1-1 N/U AMT03 Credit/Debit Flag Code ID 1-1 N/U

    AMT

    SUBSCRIBER SPEND

    DOWN TOTAL BILLED

    AMOUNT 1 S 2110C

    New Segment

    AMT01 Amount Qualifier Code ID 1-3 R

    PB

    AMT02 Monetary Amount R 1-18 R

    AMT03 Credit/Debit Flag Code ID 1-1 N/U

    III

    SUBSCRIBER

    ELIGIBILITY/ BENEFIT

    ADDITIONAL INQUIRY

    INFORMATION 10 S 2110C III

    SUBSCRIBER

    ELIGIBILITY/BENEFIT

    ADDITIONAL INQUIRY

    INFORMATION 10 S 2110C

    III01 Code List Qualifier Code ID 1-3 R BF, BK, ZZ III01

    Code List Qualifier

    Code ID 1-3 R ZZ

    Codes Removed

    III02 Industry Code AN 1-30 R

    If Ill01 = BK or BF: use

    diagnosis code from code

    source 131;

    If III01 = ZZ: 11, 12, 21, 22,

    23, 24, 25, 26, 31, 32, 33, 34,

    41, 42, 50, 51, 52, 53, 54, 55,

    56, 60, 61, 62, 65, 71, 72, 81,

    99 III02 Industry Code AN 1-30 R

    01, 03, 04, 05, 06, 07, 08, 11,

    12, 13, 14, 15, 20, 21, 22, 23,

    24, 25, 26, 31, 32, 33, 34, 41,

    42, 49, 50, 51, 52, 53, 54, 55,

    56, 57, 60, 61, 62, 65, 71, 72,

    81, 99

    Codes Added;

    New Code Descriptions

    III03 Code Category ID 2-2 N/U III03 Code Category ID 2-2 N/U

    III04

    Free-Form Message

    Text AN 1-264 N/U III04

    Free-Form Message

    Text AN 1-264 N/U

    III05 Quantity R 1-15 N/U III05 Quantity R 1-15 N/U

    III06

    COMPOSITE UNIT OF

    MEASURE N/U III06

    COMPOSITE UNIT OF

    MEASURE N/U

    III07

    Surface/Layer/Position

    Code ID 2-2 N/U III07

    Surface/Layer/Position

    Code ID 2-2 N/U

    III08

    Surface/Layer/Position

    Code ID 2-2 N/U III08

    Surface/Layer/Position

    Code ID 2-2 N/U

    III09

    Surface/Layer/Position

    Code ID 2-2 N/U III09

    Surface/Layer/Position

    Code ID 2-2 N/U

    REF

    SUBSRIBER

    ADDITIONAL

    INFORMATION 1 S 2110C REF

    SUBSCRIBER

    ADDITIONAL

    INFORMATION 1 S 2110C

    Page 11 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    9F,G1

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    9F, G1

    REF02 Reference Identification AN 1-30 R REF02 Reference Identification AN 1-50 R

    Increase

    REF03 Description AN 1-80 N/U REF03 Description AN 1-80 N/U

    REF04

    REFERENCE

    IDENTIFIER N/U REF04

    REFERENCE

    IDENTIFIER N/U

    DTP

    SUBSCRIBER/ELIGIBIL

    ITY BENEFIT DATE 1 S 2110C DTP

    SUBSCRIBER

    ELIGIBILITY/ BENEFIT

    DATE 1 S 2110C

    DTP01 Date/Time Qualifier ID 3-3 R

    307, 435, 472

    DTP01 Date Time Qualifier ID 3-3 R

    291 Code Added

    Codes Removed

    DTP02

    Date Time Period

    Format Qualifier ID 2-3 R

    D8, RD8

    DTP02

    Date Time Period

    Format Qualifier ID 2-3 R

    D8, RD8

    DTP03 Date Time Period AN 1-35 R DTP03

    Date Time Period

    Format Qualifier AN 1-35 R

    CCYYMMDD, CCYYMMDD-

    CCYYMMDD

    HL DEPENDENT LEVEL 1 S 2000D >1 HL DEPENDENT LEVEL 1 S 2000D >1

    HL01 Hierarchical ID Number AN 1-12 R HL01 Hierarchical ID Number AN 1-12 R

    HL02

    Hierarchical Parent ID

    Number AN 1-12 R HL02

    Hierarchical Parent ID

    Number AN 1-12 R

    HL03 Hierarchical Level Code ID 1-2 R

    23

    HL03 Hierarchical Level Code ID 1-2 R

    23

    HL04 Hierarchical Child Code ID 1-1 R

    0

    HL04 Hierarchical Child Code ID 1-1 R

    0

    TRN

    DEPENDENT TRACE

    NUMBER 2 S 2000D TRN

    DEPENDENT TRACE

    NUMBER 2 S 2000D

    TRN01 Trace Type Code ID 1-2 R 1 TRN01 Trace Type Code ID 1-2 R 1

    TRN02 Reference Identification AN 1-30 R TRN02 Reference Identification AN 1-50 R

    Increase

    TRN03

    Originating Company

    Identifier AN 10-10 R TRN03

    Originating Company

    Identifier AN 10-10 R

    TRN04 Reference Identification AN 1-30 S TRN04 Reference Identification AN 1-50 S

    Increase;

    New Situational Rule

    NM1 DEPENDENT NAME 1 R 2100D 1 NM1 DEPENDENT NAME 1 R 2100D 1

    NM101 Entity Identifier Code ID 2-3 R 03 NM101 Entity Identifier Code ID 2-3 R 03

    NM102 Entity Type Qualifier ID 1-1 R 1 NM102 Entity Type Qualifier ID 1-1 R 1

    NM103

    Name Last or

    Organization Name AN 1-35 S NM103

    Name Last or

    Organization Name AN 1-60 S

    Increase;

    New Situational Rule

    NM104 Name First AN 1-25 S NM104 Name First AN 1-35 S

    Increase;

    New Situational Rule

    NM105 Name Middle AN 1-25 S NM105 Name Middle AN 1-25 S New Situational Rule

    NM106 Name Prefix AN 1-10 N/U NM106 Name Prefix AN 1-10 N/U

    NM107 Name Suffix AN 1-10 S NM107 Name Suffix AN 1-10 S New Situational Rule

    NM108

    Identification Code

    Qualifier ID 1-2 N/U NM108

    Identification Code

    Qualifier ID 1-2 N/U

    NM109 Identification Code AN 2-80 N/U NM109 Identification Code AN 2-80 N/U

    NM110 Entity Relationship Code ID 2-2 N/U NM110

    Entity Relationship

    Code ID 2-2 N/U

    NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U

    Page 12 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    NM112

    Name Last or

    Organization Name AN 1-60 N/U

    REF

    DEPENDENT

    ADDITIONAL

    IDENTIFICATION 9 S 2100D

    REF

    DEPENDENT

    ADDITIONAL

    IDENTIFICATION 9 S 2100D

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    18,1L,1W,49,6P,A6,CT,EA,EJ

    ,F6,CJ,HC,ID,IV,N4,ZZ

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    18, 1L, 6P, CT, EA, EJ, F6,

    GH, HJ, IF, IG, MRC, N6, SY,

    Y4

    Code Removed: A6

    Codes Added: MRC, Y4

    REF02 Reference Identification AN 1-30 R REF02 Reference Identification AN 1-50 R

    Increase

    REF03 Description AN 1-80 N/U REF03 Description AN 1-80 N/U

    REF04

    REFERENCE

    IDENTIFIER N/U REF04

    REFERENCE

    IDENTIFIER N/U

    N3

    DEPENDENT

    ADDRESS 1 S 2100D N3

    DEPENDENT

    ADDRESS 1 S 2100D

    N301 Address Information AN 1-55 R N301 Address Information AN 1-55 R

    N302 Address Information AN 1-55 S N302 Address Information AN 1-55 S New Situational Rule

    N4

    DEPENDENT CITY/

    STATE/ ZIP CODE 1 S 2100D N4

    DEPENDENT

    CITY/STATE/ZIP

    CODE 1 S 2100D

    N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage Change

    N402 State or Province Code ID 2-2 S N402 State or Province Code ID 2-2 S

    New Situational Rule

    N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S New Situational Rule

    N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S New Situational Rule

    N405 Location Qualifier ID 1-2 N/U N405 Location Qualifier ID 1-2 N/U

    N406 Location Qualifier AN 1-30 N/U N406 Location Qualifier AN 1-30 N/U

    N407

    Country Subdivision

    Code ID 1-3 S

    New Element

    PRV

    PROVIDER

    INFORMATION 1 S 2100D PRV

    PROVIDER

    INFORMATION 1 S 2100D

    PRV01 Provider Code ID 1-3 R

    AD, AT, BI, CO, CV, H, HH,

    LA, OT, P1, P2, PC, PE, R,

    RF, SB, SK, SU PRV01 Provider Code ID 1-3 R

    AD, AT, BI, CO, CV, H, HH,

    LA, OT, P1, P2, PC, PE, R,

    RF, SK, SU

    New Situational Rule;

    Code Removed: SB

    PRV02

    Reference Identification

    Qualifier ID 2-3 R 9K, D3, EI, HPI, SY, TJ, ZZ PRV02

    Reference Identification

    Qualifier ID 2-3 S 9K, D3, EI, HPI,PXC, SY, TJ

    New Situational Rule;

    Code Removed: ZZ

    Code Added: PXC;

    New Code Descriptions

    PRV03 Reference Identification AN 1-30 R PRV03 Reference Identification AN 1-50 S

    New Situational Rule;

    Increase

    PRV04 State or Province Code ID 2-2 N/U PRV04 State or Province Code ID 2-2 N/U

    PRV05

    PROVIDER

    SPECIALITY

    INFORMATION N/U PRV05

    PROVIDER

    SPECIALITY

    INFORMATION N/U

    PRV06

    Provider Organization

    Code ID 3-3 N/U PRV06

    Provider Organization

    Code ID 3-3 N/U

    DMG

    DEPENDENT

    DEMOGRAPHIC

    INFORMATION 1 S 2100D DMG

    DEPENDENT

    DEMOGRAPHIC

    INFORMATION 1 S 2100D

    Page 13 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    DMG01

    Date Time Period

    Format Qualifier ID 2-3 S

    D8

    DMG01

    Date Time Period

    Format Qualifier ID 2-3 S

    D8 New Situational Rule

    DMG02 Date Time Period AN 1-35 S CCYYMMDD DMG02 Date Time Period AN 1-35 S CCYYMMDD New Situational Rule

    DMG03 Gender Code ID 1-1 S F, M DMG03 Gender Code ID 1-1 S F, M New Situational Rule

    DMG04 Marital Status Code ID 1-1 N/U DMG04 Marital Status Code ID 1-1 N/U

    DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05

    Composite Race or

    Ethnicity Code N/U

    DMG06 Citizenship Status Code ID 1-2 N/U DMG06

    Citizenship Status

    Code ID 1-2 N/U

    DMG07 Country Code ID 2-3 N/U DMG07 Country Code ID 2-3 N/U

    DMG08

    Basis of Verification

    Code ID 1-2 N/U DMG08

    Basis of Verification

    Code ID 1-2 N/U

    DMG09 Quantity R 1-15 N/U DMG09 Quantity R 1-15 N/U

    DMG10

    Code List Qualifier

    Code ID 1-3 N/U

    DMG11 Industry Code AN 1-30 N/U

    INS

    DEPENDENT

    RELATIONSHIP 1 S 2100D INS

    DEPENDENT

    RELATIONSHIP 1 S 2100D

    INS01

    Yes/No Condition or

    Response Code ID 1-1 R

    N

    INS01

    Yes/No Condition or

    Response Code ID 1-1 R

    N

    INS02

    Individual Relationship

    Code ID 2-2 R

    01, 19, 34

    INS02

    Individual Relationship

    Code ID 2-2 R

    01, 19, 34

    INS03 Maintenance Type Code ID 3-3 N/U INS03

    Maintenance Type

    Code ID 3-3 N/U

    INS04

    Maintenance Reason

    Code ID 2-3 N/U INS04

    Maintenance Reason

    Code ID 2-3 N/U

    INS05 Benefit Status Code ID 1-1 N/U INS05 Benefit Status Code ID 1-1 N/U

    INS06 Medicare Plan Code ID 1-1 N/U INS06

    MEDICARE STATUS

    CODE N/U

    INS07

    Consolidated Omnibus

    Budget Reconciliation

    Act (COBRA) Qualifying ID 1-2 N/U INS07

    Consolidated Omnibus

    Budget Reconciliation

    Act (COBRA)

    Qualifying ID 1-2 N/U

    INS08

    Employment Status

    Code ID 2-2 N/U INS08

    Employment Status

    Code ID 2-2 N/U

    INS09 Student Status Code ID 1-1 N/U INS09 Student Status Code ID 1-1 N/U

    INS10

    Yes/No Condition or

    Response Code ID 1-1 N/U INS10

    Yes/No Condition or

    Response Code ID 1-1 N/U

    INS11

    Date Time Period

    Format Qualifier ID 2-3 N/U INS11

    Date Time Period

    Format Qualifier ID 2-3 N/U

    INS12 Date Time Period AN 1-35 N/U INS12 Date Time Period AN 1-35 N/U

    INS13 Confidentiality Code ID 1-1 N/U INS13 Confidentiality Code ID 1-1 N/U

    INS14 City Name AN 2-30 N/U INS14 City Name AN 2-30 N/U

    INS15 State or Province Code ID 2-2 N/U INS15 State or Province Code ID 2-2 N/U

    INS16 Country Code ID 2-3 N/U INS16 Country Code ID 2-3 N/U

    INS17 Number N0 1-9 S INS17 Number N0 1-9 S New Situational Rule

    HI

    DEPENDENT HEALTH

    CARE DIAGNOSIS

    CODE 1 S 2100D

    New Segment

    HI01

    HEALTH CARE CODE

    INFORMATION R

    Page 14 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    HI01 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABK, BK

    HI01 - 2 Industry Code AN 1-30 R

    HI01 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI01 - 4 Date Time Period AN 1-35 N/U

    HI01 - 5 Monetary Amount R 1-18 N/U

    HI01 - 6 Quantity R 1-15 N/U

    HI01 - 7 Version Identifier AN 1-30 N/U

    HI01 - 8 Industry Code AN 1-30 N/U

    HI01 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI02

    HEALTH CARE CODE

    INFORMATION S

    HI02 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI02 - 2 Industry Code AN 1-30 R

    HI02 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI02 - 4 Date Time Period AN 1-35 N/U

    HI02 - 5 Monetary Amount R 1-18 N/U

    HI02 - 6 Quantity R 1-15 N/U

    HI02 - 7 Version Identifier AN 1-30 N/U

    HI02 - 8 Industry Code AN 1-30 N/U

    HI02 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI03

    HEALTH CARE CODE

    INFORMATION S

    HI03 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI03 - 2 Industry Code AN 1-30 R

    HI03 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI03 - 4 Date Time Period AN 1-35 N/U

    HI03 - 5 Monetary Amount R 1-18 N/U

    HI03 - 6 Quantity R 1-15 N/U

    HI03 - 7 Version Identifier AN 1-30 N/U

    HI03 - 8 Industry Code AN 1-30 N/U

    HI03 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI04

    HEALTH CARE CODE

    INFORMATION S

    HI04 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI04 - 2 Industry Code AN 1-30 R

    HI04 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI04 - 4 Date Time Period AN 1-35 N/U

    HI04 - 5 Monetary Amount R 1-18 N/U

    HI04 - 6 Quantity R 1-15 N/U

    HI04 - 7 Version Identifier AN 1-30 N/U

    HI04 - 8 Industry Code AN 1-30 N/U

    HI04 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    Page 15 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    HI05

    HEALTH CARE CODE

    INFORMATION S

    HI05 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI05 - 2 Industry Code AN 1-30 R

    HI05 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI05 - 4 Date Time Period AN 1-35 N/U

    HI05 - 5 Monetary Amount R 1-18 N/U

    HI05 - 6 Quantity R 1-15 N/U

    HI05 - 7 Version Identifier AN 1-30 N/U

    HI05 - 8 Industry Code AN 1-30 N/U

    HI05 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI06

    HEALTH CARE CODE

    INFORMATION S

    HI06 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI06 - 2 Industry Code AN 1-30 R

    HI06 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI06 - 4 Date Time Period AN 1-35 N/U

    HI06 - 5 Monetary Amount R 1-18 N/U

    HI06 - 6 Quantity R 1-15 N/U

    HI06 - 7 Version Identifier AN 1-30 N/U

    HI06 - 8 Industry Code AN 1-30 N/U

    HI06 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI07

    HEALTH CARE CODE

    INFORMATION S

    HI07 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI07 - 2 Industry Code AN 1-30 R

    HI07 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI07 - 4 Date Time Period AN 1-35 N/U

    HI07 - 5 Monetary Amount R 1-18 N/U

    HI07 - 6 Quantity R 1-15 N/U

    HI07 - 7 Version Identifier AN 1-30 N/U

    HI07 - 8 Industry Code AN 1-30 N/U

    HI07 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI08

    HEALTH CARE CODE

    INFORMATION S

    HI08 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI08 - 2 Industry Code AN 1-30 R

    HI08 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI08 - 4 Date Time Period AN 1-35 N/U

    HI08 - 5 Monetary Amount R 1-18 N/U

    HI08 - 6 Quantity R 1-15 N/U

    HI08 - 7 Version Identifier AN 1-30 N/U

    HI08 - 8 Industry Code AN 1-30 N/U

    Page 16 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    HI08 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI09

    HEALTH CARE CODE

    INFORMATION N/U

    HI10

    HEALTH CARE CODE

    INFORMATION N/U

    HI11

    HEALTH CARE CODE

    INFORMATION N/U

    HI12

    HEALTH CARE CODE

    INFORMATION N/U

    DTP DEPENDENT DATE 2 S 2100D DTP DEPENDENT DATE 2 S 2100D

    DTP01 Date/Time Qualifier ID 3-3 R

    102,307,435,472

    DTP01 Date Time Qualifier ID 3-3 R

    102, 291 Codes Removed;

    Code Added;

    Note Added

    DTP02

    Date Time Period

    Format Qualifier ID 2-3 R

    D8, RD8

    DTP02

    Date Time Period

    Format Qualifier ID 2-3 R

    D8, RD8

    DTP03 Date Time Period AN 1-35 R

    CCYYMMDD, CCYYMMDD-

    CCYYMMDD DTP03 Date Time Period AN 1-35 R

    CCYYMMDD, CCYYMMDD-

    CCYYMMDD

    EQ

    DEPENDENT

    ELIGIBILITY/ BENEFIT

    INQUIRY

    INFORMATION 1 R 2110D 99 EQ

    DEPENDENT

    ELIGIBILITY/BENEFIT

    INQUIRY 1 R 2110D 99

    Page 17 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    EQ01 Service Type Code ID 1-2 S

    1, 2, 3, 4, 5, 6, 7, 8, 9,10,

    11,12, 13, 14, 15, 16, 17, 18,

    19, 20, 21, 22, 23, 24, 25, 26,

    27, 28, 30, 32, 33, 34, 35, 36,

    37, 38, 39, 40, 41, 42, 43, 44,

    45, 46, 47, 48, 49, 50, 51, 52,

    53, 54, 55, 56, 57, 58, 59, 60,

    61, 62, 63, 64, 65, 66, 67, 68,

    69, 70, 71, 72, 73, 74, 75, 76,

    77, 78, 79, 80, 81, 82, 83, 84,

    85, 86, 87, 88, 89, 90, 91, 92,

    93, 94, 95, 96, 97, 98, 99, A0,

    A1, A2, A3, A4, A5, A6, A7,

    A8, A9, AA, AB, AC, AD, AE,

    AF, AG, AH, AI , AJ, AK, AL,

    AM, AN ,AO, AQ, AR, BA,BB,

    BC, BD, BE, BF, BG, BH, BI,

    BJ, BK, BL, BM, BN, BP, BQ,

    BR, BS

    EQ01 Service Type Code ID 1-2 S

    1, 2, 3, 4, 5, 6, 7, 8, 9,10,

    11,12,13, 14, 15, 16, 17, 18,

    19, 20,

    21,22,23,24,25,26,27,28,30,32

    ,33,34,35,36,37,38,39,40,41,

    42, 43, 44, 45, 46, 47, 48, 49,

    50, 51, 52, 53, 54, 55, 56, 57,

    58, 59, 60, 61, 62, 63, 64, 65,

    66, 67, 68, 69, 70, 71, 72, 73,

    74, 75, 76, 77, 78, 79, 80, 81,

    82, 83, 84, 85, 86, 87, 88, 89,

    90, 91, 92, 93, 94, 95, 96, 97,

    98, 99, A0, A1, A2, A3, A4,

    A5, A6, A7, A8, A9, AA, AB,

    AC, AD, AE, AF, AG, AH, AI ,

    AJ, AK, AL, AM, AN ,AO, AQ,

    AR, B1, B2, B3, BA,BB, BC,

    BD, BE, BF, BG, BH, BI, BJ,

    BK, BL, BM, BN, BP, BQ, BR,

    BS, BT, BU, BV, BW, BX, BY,

    BZ, C1, CA, CB, CC, CD, CE,

    CF, CG, CH, CI, CJ, CK, CL,

    CM, CN ,CO, CP, CQ, DG,

    DM, DS, GF, GN, GY, IC, MH,

    NI, ON, PY, PU, RN, RT, TC,

    TN, UC

    New Situational Rule;

    New Code;

    New Note

    EQ02

    COMPOSITE MEDICAL

    PROCEDURE

    IDENTIFIER S EQ02

    COMPOSITE MEDICAL

    PROCEDURE

    IDENTIFIER S

    New Situational Rule

    EQ02 - 1

    Product/Service ID

    Qualifier ID 2-2 R

    AD, CJ, HC, ID, IV, N4, ZZ

    EQ02 - 1

    Product/Service ID

    Qualifier ID 2-2 R

    AD, CJ, HC, ID, IV, N4, ZZ New Note

    EQ02 - 2 Product/Service ID AN 1-48 R EQ02 - 2 Product/Service ID AN 1-48 R

    EQ02 - 3 Procedure Modifier AN 2-2 S EQ02 - 3 Procedure Modifier AN 2-2 S

    EQ02 - 4 Procedure Modifier AN 2-2 S EQ02 - 4 Procedure Modifier AN 2-2 S

    EQ02 - 5 Procedure Modifier AN 2-2 S EQ02 - 5 Procedure Modifier AN 2-2 S

    EQ02 - 6 Procedure Modifier AN 2-2 S EQ02 - 6 Procedure Modifier AN 2-2 S

    EQ02 - 7 Description AN 1-80 N/U EQ02 - 7 Description AN 1-80 N/U

    EQ02 - 8 Product/Service ID AN 1-48 N/U

    EQ03 Coverage Level Code ID 3-3 S

    CHD, DEP, ECH, EMP, ESP,

    FAM, IND, SPC, SPO EQ03 Coverage Level Code ID 3-3 N/U

    EQ04 Insurance Type Code ID 1-3 S

    AP, C1, CO, GP, HM, IP, OT,

    PR, PS, SP, WC EQ04 Insurance Type Code ID 1-3 N/U

    EQ05

    COMPOSITE

    DIAGNOSIS CODE

    POINTER S

    New Element

    EQ05 - 1 Diagnosis Code Pointer N0 1-2 R

    New Element

    Page 18 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    EQ05 - 2 Diagnosis Code Pointer N0 1-2 S

    New Element

    EQ05 - 3 Diagnosis Code Pointer N0 1-2 S

    New Element

    EQ05 - 4 Diagnosis Code Pointer N0 1-2 S

    New Element

    III

    DEPENDENT

    ELIGIBILITY/ BENEFIT

    ADDITIONAL INQUIRY

    INFORMATION 10 S 2110D III

    DEPENDENT

    ELIGIBILITY/BENEFIT

    ADDITIONAL INQUIRY 10 S 2110D

    III01 Code List Qualifier Code ID 1-3 R

    BF, BK, ZZ

    III01

    Code List Qualifier

    Code ID 1-3 R

    ZZ Codes Removed

    III02 Industry Code AN 1-30 R

    If Ill01 = BK or BF, use

    diagnosis code from code

    source 131;

    If III01 = ZZ: 11, 12, 21, 22,

    23, 24, 25, 26, 31, 32, 33, 34,

    41, 42, 50, 51, 52, 53, 54, 55,

    56, 60, 61, 62, 65, 71, 72, 81,

    99III02 Industry Code AN 1-30 R

    01, 03, 04, 05, 06, 07, 08, 11,

    12, 13, 14, 15, 20, 21, 22, 23,

    24, 25, 26, 31, 32, 33, 34, 41,

    42, 49, 50, 51, 52, 53, 54, 55,

    56,57, 60, 61, 62, 65, 71, 72,

    81, 99

    Codes Added;

    New Code Descriptions

    III03 Code Category ID 2-2 N/U III03 Code Category ID 2-2 N/U

    III04

    Free-Form Message

    Text AN 1-264 N/U III04

    Free-Form Message

    Text AN 1-264 N/U

    III05 Quantity R 1-15 N/U III05 Quantity R 1-15 N/U

    III06

    COMPOSITE UNIT OF

    MEASURE N/U III06

    COMPOSITE UNIT OF

    MEASURE N/U

    III07

    Surface/Layer/Position

    Code ID 2-2 N/U III07

    Surface/Layer/Position

    Code ID 2-2 N/U

    III08

    Surface/Layer/Position

    Code ID 2-2 N/U III08

    Surface/Layer/Position

    Code ID 2-2 N/U

    III09

    Surface/Layer/Position

    Code ID 2-2 N/U III09

    Surface/Layer/Position

    Code ID 2-2 N/U

    REF

    DEPENDENT

    ADDITIONAL

    INFORMATION 1 S 2110D REF

    DEPENDENT

    ADDITIONAL

    INFORMATION 1 S 2110D

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    9F,G1

    REF01

    Reference Identification

    Qualifier ID 2-3 R

    9F, G1

    REF02 Reference Identification AN 1-30 R REF02 Reference Identification AN 1-50 R

    Increase

    REF03 Description AN 1-80 N/U REF03 Description AN 1-80 N/U

    REF04

    REFERENCE

    IDENTIFIER N/U REF04

    REFRENCE

    IDENTIFIER N/U

    DTP

    DEPENDENT

    ELIGIBILITY/ BENEFIT

    DATE 1 S 2110D DTP

    DEPENDENT

    ELIGIBILITY/ BENEFIT

    DATE 1 S 2110D

    DTP01 Date/Time Qualifier ID 3-3 R

    307,435,472

    DTP01 Date Time Qualifier ID 3-3 R

    291 Code Added;

    Codes Removed

    DTP02

    Date Time Period

    Format Qualifier ID 2-3 R

    D8, RD8

    DTP02

    Date Time Period

    Format Qualifier ID 2-3 R

    D8, RD8

    DTP03 Date Time Period AN 1-35 R

    CCYYMMDD, CCYYMMDD-

    CCYYMMDD DTP03 Date Time Period AN 1-35 R

    Page 19 of 20 8/11/200911:34 AM

  • 270 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    270 4010A1 270 5010

    4010A1 5010

    SE

    TRANSACTION SET

    TRAILER 1 R SE

    TRANSACTION SET

    TRAILER 1 R

    SE01

    Number of Included

    Segments N0 1-10 R SE01

    Number of Included

    Segments N0 1-10 R

    SE02

    Transaction Set Control

    Number AN 4-9 R SE02

    Transaction Set Control

    Number AN 4-9 R

    GE

    FUNCTIONAL GROUP

    TRAILER GE

    FUNCTIONAL GROUP

    TRAILER 1 R

    GE01

    Number of Transaction

    Sets Included N0 1-6 R GE01

    Number of Transaction

    Sets Included N0 1-6 R

    GE02 Group Control Number N0 1-9 R

    Must=GS06

    GE02 Group Control Number N0 1-9 R

    Must=GS06

    IEA

    INTERCHANGE

    CONTROL TRAILER 1 R IEA

    INTERCHANGE

    CONTROL TRAILER 1 R

    IEA01

    Number of Included

    Functional Groups N0 1-5 R IEA01

    Number of Included

    Functional Groups N0 1-5 R

    IEA02

    Interchange Control

    Number N0 9-9 R IEA02

    Interchange Control

    Number N0 9-9 R

    Page 20 of 20 8/11/200911:34 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    ISA

    INTERCHANGE

    CONTROL HEADER ISA

    INTERCHANGE

    CONTROL HEADER 1 R

    ISA01

    Authorization

    Information Qualifier ID 2/2 R

    00, 03

    ISA01

    Authorization

    Information Qualifier ID 2-2 R

    00, 03

    ISA02

    Authorization

    Information AN 10/10 R ISA02

    Authorization

    Information AN 10-10 R

    ISA03

    Security Information

    Qualifier ID 2/2 R

    00, 01

    ISA03

    Security Information

    Qualifier ID 2-2 R

    00, 01

    ISA04 Security Information AN 10/10 R ISA04 Security Information AN 10-10 R

    ISA05

    Interchange ID

    Qualifier ID 2/2 R

    01, 14, 20, 27, 28, 29, 30, 33,

    ZZ ISA05

    Interchange ID

    Qualifier ID 2-2 R

    01, 14, 20, 27, 28, 29, 30, 33,

    ZZ

    ISA06

    Interchange Sender

    ID AN 15/15 R ISA06

    Interchange Sender

    ID AN 15-15 R

    ISA07

    Interchange ID

    Qualifier ID 2/2 R

    01, 14, 20, 27, 28, 29, 30, 33,

    ZZ ISA07

    Interchange ID

    Qualifier ID 2-2 R

    01, 14, 20, 27, 28, 29, 30, 33,

    ZZ

    ISA08

    Interchange Receiver

    ID AN 15/15 R ISA08

    Interchange Receiver

    ID AN 15-15 R

    ISA09 Interchange Date DT 6/6 R YYMMDD ISA09 Interchange Date DT 6-6 R YYMMDD

    ISA10 Interchange Time TM 4/4 R HHMM ISA10 Interchange Time TM 4-4 R HHMM

    ISA11

    Interchange Control

    Standards ID ID 1/1 R

    U

    ISA11

    Repetition

    Separator 1-1 R

    New Element

    ISA12

    Interchange Control

    Version Number ID 5/5 R

    00401

    ISA12

    Interchange Control

    Version Number ID 5-5 R

    00501

    ISA13

    Interchange Control

    Number N0 9/9 R ISA13

    Interchange Control

    Number N0 9-9 R

    ISA14

    Acknowledgement

    Requested ID 1/1 R

    0, 1

    ISA14

    Acknowledgement

    Requested ID 1-1 R

    0, 1

    ISA15 Usage Indicator ID 1/1 R

    P, T

    ISA15

    Interchange Usage

    Indicator ID 1-1 R

    P, T

    ISA16

    Component Element

    Separator 1/1 R ISA16

    Component Element

    Separator 1-1 R

    GS

    FUNCTIONAL

    GROUP HEADER GS

    FUNCTIONAL

    GROUP HEADER 1 R

    GS01

    Functional Identifier

    Code ID 2/2 R

    HB, HS

    GS01

    Functional Identifier

    Code ID 2-2 R

    GS02

    Application Sender's

    Code AN 2/15 R GS02

    Application Sender's

    Code AN 2-15 R

    GS03

    Application Receiver's

    Code AN 2/15 R GS03

    Application

    Receiver's Code AN 2-15 R

    GS04 Date DT 8/8 R CCYYMMDD GS04 Date DT 8-8 R CCYYMMDD

    GS05 Time TM 4/8 R HHMM GS05 Time TM 4-8 R HHMM

    GS06

    Group Control

    Number N0 1/9 R GS06

    Group Control

    Number N0 1-9 R

    GS07

    Responsible Agency

    Code ID 1/2 R

    X

    GS07

    Responsible Agency

    Code ID 1-2 R

    X

    GS08

    Version/ Release/

    Industry Identifier

    Code AN 1/12 R

    004010X092A1

    GS08

    Version/Release/

    Industry Identifier

    Code AN 1-12 R

    005010X279

    ST

    TRANSACTION SET

    HEADER 1 R ST

    TRANSACTION SET

    HEADER 1 R

    271 4010A1 271 5010

    4010A1 5010

    Page 1 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    ST01

    Transaction Set

    Identifier Code ID 3-3 R

    271

    ST01

    Transaction Set

    Identifier Code ID 3-3 R

    271

    ST02

    Transaction Set

    Control Number AN 4-9 R ST02

    Transaction Set

    Control Number AN 4-9 R

    ST03

    Implementation

    Convention

    Reference AN 1-35 R

    005010X279 New Element

    BHT

    BEGINNING OF

    HIERARCHICAL

    TRANSACTION 1 R BHT

    BEGINNING OF

    HIERARCHICAL

    TRANSACTION 1 R

    BHT01

    Hierarchical Structure

    Code ID 4-4 R

    0022

    BHT01

    Hierarchical Structure

    Code ID 4-4 R

    0022

    BHT02

    Transaction Set

    Purpose Code ID 2-2 R

    11

    BHT02

    Transaction Set

    Purpose Code ID 2-2 R

    06, 11 Code Added

    New Note

    BHT03

    Reference

    Identification AN 1-30 S BHT03

    Reference

    Identification AN 1-50 S

    Increase

    BHT04 Date DT 8-8 R CCYYMMDD BHT04 Date DT 8-8 R CCYYMMDD

    BHT05 Time TM 4-8 R HHMM BHT05 Time TM 4-8 R HHMM

    BHT06

    Transaction Type

    Code ID 2-2 N/U BHT06

    Transaction Type

    Code ID 2-2 N/U

    HL

    INFORMATION

    SOURCE LEVEL 1 R 2000A >1 HL

    INFORMATION

    SOURCE LEVEL 1 R 2000A >1

    HL01

    Hierarchical ID

    Number AN 1-12 R HL01

    Hierarchical ID

    Number AN 1-12 R

    HL02

    Hierarchical Parent ID

    Number AN 1-12 N/U HL02

    Hierarchical Parent ID

    Number AN 1-12 N/U

    HL03

    Hierarchical Level

    Code ID 1-2 R

    20

    HL03

    Hierarchical Level

    Code ID 1-2 R

    20

    HL04

    Hierarchical Child

    Code ID 1-1 R

    0,1

    HL04

    Hierarchical Child

    Code ID 1-1 R

    0,1

    AAA

    REQUEST

    VALIDATION 9 S 2000A AAA

    REQUEST

    VALIDATION 9 S 2000A

    AAA01

    Yes/No Condition or

    Response Code ID 1-1 R

    N, Y

    AAA01

    Yes/No Condition or

    Response Code ID 1-1 R

    N, Y

    AAA02

    Agency Qualifier

    Code ID 2-2 N/U AAA02

    Agency Qualifier

    Code ID 2-2 N/U

    AAA03 Reject Reason Code ID 2-2 R

    04, 41, 42, 79

    AAA03 Reject Reason Code ID 2-2 R

    04, 41, 42, 79

    AAA04

    Follow-up Action

    Code ID 1-1 R

    C, N, P, R, S, Y

    AAA04

    Follow-up Action

    Code ID 1-1 R

    C, N, P, R, S, Y

    NM1

    INFORMATION

    SOURCE NAME 1 R 2100A 1 NM1

    INFORMATION

    SOURCE NAME 1 R 2100A 1

    NM101 Entity Identifier Code ID 2-3 R

    2B,36,GP,P5,PR

    NM101 Entity Identifier Code ID 2-3 R

    2B, 36, GP, P5, PR

    NM102 Entity Type Qualifier ID 1-1 R 1,2 NM102 Entity Type Qualifier ID 1-1 R 1, 2

    NM103

    Name Last or

    Organization Name AN 1-35 S NM103

    Name Last or

    Organization Name AN 1-60 R

    Increase

    Usage Change

    NM104 Name First AN 1-25 S NM104 Name First AN 1-35 S

    New Situational Rule

    Increase

    Page 2 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    NM105 Name Middle AN 1-25 S NM105 Name Middle AN 1-25 S New Situational Rule

    NM106 Name Prefix AN 1-10 N/U NM106 Name Prefix AN 1-10 N/U

    NM107 Name Suffix AN 1-10 S NM107 Name Suffix AN 1-10 S New Situational Rule

    NM108

    Identification Code

    Qualifier ID 1-2 R

    24,46,FI,NI,PI,XV,XX

    NM108

    Identification Code

    Qualifier ID 1-2 R

    24, 46, FI, NI, PI, XV, XX New Code Descriptions

    NM109 Identification Code AN 2-80 R NM109 Identification Code AN 2-80 R

    NM110

    Entity Relationship

    Code ID 2-2 N/U NM110

    Entity Relationship

    Code ID 2-2 N/U

    NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U

    NM112

    Name Last or

    Organization Name AN 1-60 N/U

    REF

    INFORMATION

    SOURCE

    ADDITIONAL

    IDENTIFICATION 9 S 2100A

    Deleted Segment

    REF01

    Reference

    Identification Qualifier ID 2-3 R

    18, 55

    REF02

    Reference

    Identification AN 1-30 R

    REF03 Description AN 1-80 S

    REF04

    REFERENCE

    INDENTIFIER N/U

    PER

    INFORMATION

    SOURCE CONTACT

    INFORMATION 3 S 2100A PER

    PAYER CONTACT

    INFORMATION 3 S 2100A

    PER01

    Contact Function

    Code ID 2-2 R

    IC

    PER01

    Contact Function

    Code ID 2-2 R

    IC

    PER02 Name AN 1-60 S PER02 Name AN 1-60 S New Situational Rule

    PER03

    Communication

    Number Qualifier ID 2-2 S

    ED, EM, FX, TE

    PER03

    Communication

    Number Qualifier ID 2-2 S

    ED, EM, TE, FX, UR New Situational Rule

    Code Added

    PER04

    Communication

    Number AN 1-80 S

    AAABBBCCCC

    PER04

    Communication

    Number AN 1-256 S

    AAABBBCCCC New Situational Rule

    Increase

    PER05

    Communication

    Number Qualifier ID 2-2 S

    ED, EM, EX, FX, TE

    PER05

    Communication

    Number Qualifier ID 2-2 S

    ED, EM, TE, FX, EX, UR New Situational Rule

    Code Added

    PER06

    Communication

    Number AN 1-80 S

    AAABBBCCCC

    PER06

    Communication

    Number AN 1-256 S

    AAABBBCCCC New Situational Rule

    Increase

    PER07

    Communication

    Number Qualifier ID 2-2 S

    ED, EM, EX, FX, TE

    PER07

    Communication

    Number Qualifier ID 2-2 S

    ED, EM, TE, FX, EX, UR New Situational Rule

    Code Added

    PER08

    Communication

    Number AN 1-80 S

    AAABBBCCCC

    PER08

    Communication

    Number AN 1-256 S

    AAABBBCCCC New Situational Rule

    Increase

    PER09

    Contact Inquiry

    Reference AN 1-20 N/U PER09

    Contact Inquiry

    Reference AN 1-20 N/U

    AAA

    REQUEST

    VALIDATION 9 S 2100A AAA

    REQUEST

    VALIDATION 9 S 2100A

    AAA01

    Yes/No Condition or

    Response Code ID 1-1 R

    N, Y

    AAA01

    Yes/No Condition or

    Response Code ID 1-1 R

    N, Y

    Page 3 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    AAA02

    Agency Qualifier

    Code ID 2-2 N/U AAA02

    Agency Qualifier

    Code ID 2-2 N/U

    AAA03 Reject Reason Code ID 2-2 R

    04, 41, 42, 79, 80, T4

    AAA03 Reject Reason Code ID 2-2 R

    04, 41, 42, 79, 80, T4 New Note

    AAA04

    Follow-up Action

    Code ID 1-1 R

    C, N, P, R, S, W, X, Y

    AAA04

    Follow-up Action

    Code ID 1-1 R

    C, N, P, R, S, W, X, Y

    HL

    INFORMATION

    RECEIVER LEVEL 1 S 2000B >1 HL

    INFORMATION

    RECEIVER LEVEL 1 S 2000B >1

    HL01

    Hierarchical ID

    Number AN 1-12 R HL01

    Hierarchical ID

    Number AN 1-12 R

    HL02

    Hierarchical Parent ID

    Number AN 1-12 R HL02

    Hierarchical Parent ID

    Number AN 1-12 R

    HL03

    Hierarchical Level

    Code ID 1-2 R

    21

    HL03

    Hierarchical Level

    Code ID 1-2 R

    21

    HL04

    Hierarchical Child

    Code ID 1-1 R

    0,1

    HL04

    Hierarchical Child

    Code ID 1-1 R

    0, 1

    NM1

    INFORMATION

    RECEIVER NAME 1 R 2100B 1 NM1

    INFORMATION

    RECEIVER NAME 1 R 2100B 1

    NM101 Entity Identifier Code ID 2-3 R

    1P,2B,36,80,FA,GP,P5,PR

    NM101 Entity Identifier Code ID 2-3 R

    1P, 2B, 36, 80, FA, GP, P5,

    PR

    NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1, 2

    NM103

    Name Last or

    Organization Name AN 1-35 S NM103

    Name Last or

    Organization Name AN 1-60 S

    New Situational Rule

    Increase

    NM104 Name First AN 1-25 S NM104 Name First AN 1-35 S

    New Situational Rule

    Increase

    NM105 Name Middle AN 1-25 S NM105 Name Middle AN 1-25 S New Situational Rule

    NM106 Name Prefix AN 1-10 N/U NM106 Name Prefix AN 1-10 N/U

    NM107 Name Suffix AN 1-10 S NM107 Name Suffix AN 1-10 S New Situational Rule

    NM108

    Identification Code

    Qualifier ID 1-2 R

    24,34,FI,PI,PP,SV,XV,XX

    NM108

    Identification Code

    Qualifier ID 1-2 R

    24, 34, FI, PI, PP, SV, XV, XX New Code Descriptions

    NM109 Identification Code AN 2-80 R NM109 Identification Code AN 2-80 R

    NM110

    Entity Relationship

    Code ID 2-2 N/U NM110

    Entity Relationship

    Code ID 2-2 N/U

    NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U

    NM112

    Name Last or

    Organization Name AN 1-60 N/U

    REF

    INFORMATION

    RECEIVER

    ADDITIONAL

    IDENTIFICATION 9 S 2100B REF

    INFORMATION

    RECEIVER

    ADDITIONAL

    IDENTIFICATION 9 S 2100B

    REF01

    Reference

    Identification Qualifier ID 2-3 R

    0B, 1C, 1D, 1J, 4A, CT, EL,

    EO, HPI

    REF01

    Reference

    Identification Qualifier ID 2-3 R

    0B, 1C, 1D, 1J, 4A, CT, EL,

    EO, HPI, JD, N5, N7, Q4, SY,

    TJ

    New Code Description

    New Note

    REF02

    Reference

    Identification AN 1-30 R REF02

    Reference

    Identification AN 1-50 R

    Increase

    REF03 Description AN 1-80 S REF03 Description AN 1-80 S New Situational Rule

    REF04

    REFERENCE

    IDENTIFIER N/U REF04

    REFERENCE

    IDENTIFIER N/U

    Page 4 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    AAA

    INFORMATION

    RECEIVER

    REQUEST

    VALIDATION 9 S 2100B AAA

    INFORMATION

    RECEIVER

    VALIDATION

    REQUEST 9 S 2100B

    AAA01

    Yes/ No Condition or

    Response Code ID 1-1 R

    N, Y

    AAA01

    Yes/ No Condition or

    Response Code ID 1-1 R

    N, Y

    AAA02

    Agency Qualifier

    Code ID 2-2 N/U AAA02

    Agency Qualifier

    Code ID 2-2 N/U

    AAA03 Reject Reason Code ID 2-2 R

    15, 41, 43, 44, 45, 46, 47, 48,

    50, 51, 79, 97, T4 AAA03 Reject Reason Code ID 2-2 R

    15, 41, 43, 44, 45, 46, 47, 48,

    50, 51, 79, 97, T4

    AAA04

    Follow-up Action

    Code ID 1-1 R

    C, N, R, S, W, X, Y

    AAA04

    Follow-up Action

    Code ID 1-1 R

    C, N, R, S, W, X, Y

    PRV

    INFORMATION

    RECEIVER

    PROVIDER

    INFORMATION 1 S 2100B

    New Segment

    PRV01 Provider Code ID 1-3 R

    AD, AT, BI, CO, CV, H, HH,

    LA, OT, P1, P2, PC, PE, R,

    RF, SB, SK, SU

    PRV02

    Reference

    Identification Qualifier ID 2-3 S PXC

    PRV03

    Reference

    Identification AN 1-50 S

    PRV04

    State or Province

    Code ID 2-2 N/U

    PRV05

    Provider Specialty

    Information N/U

    PRV06

    Provider Organization

    Code ID 3-3 N/U

    HL

    SUBSCRIBER

    LEVEL 1 S 2000C >1 HL

    SUBSCRIBER

    LEVEL 1 S 2000C >1

    HL01

    Hierarchical ID

    Number AN 1-12 R HL01

    Hierarchical ID

    Number AN 1-12 R

    HL02

    Hierarchical Parent ID

    Number AN 1-12 R HL02

    Hierarchical Parent ID

    Number AN 1-12 R

    HL03

    Hierarchical Level

    Code ID 1-2 R

    22

    HL03

    Hierarchical Level

    Code ID 1-2 R

    22

    HL04

    Hierarchical Child

    Code ID 1-1 R

    0, 1

    HL04

    Hierarchical Child

    Code ID 1-1 R

    0, 1

    TRN

    SUBSCRIBER

    TRACE NUMBER 3 S 2000C TRN

    SUBSCRIBER

    TRACE NUMBER 3 S 2000C

    TRN01 Trace Type Code ID 1-2 R 1,2 TRN01 Trace Type Code ID 1-2 R 1, 2

    TRN02

    Reference

    Identification AN 1-30 R TRN02

    Reference

    Identification AN 1-50 R

    New Note

    Increase

    TRN03

    Originating Company

    Identifier AN 10-10 R TRN03

    Originating Company

    Identifier AN 10-10 R

    TRN04

    Reference

    Identification AN 1-30 S TRN04

    Reference

    Identification AN 1-50 S

    New Situational Rule

    Increase

    Page 5 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    NM1 SUBSCRIBER NAME 1 R 2100C 1 NM1 SUBSCRIBER NAME 1 R 2100C 1

    NM101 Entity Identifier Code ID 2-3 R

    IL

    NM101 Entity Identifier Code ID 2-3 R

    IL

    NM102 Entity Type Qualifier ID 1-1 R 1 NM102 Entity Type Qualifier ID 1-1 R 1

    NM103

    Name Last or

    Organization Name AN 1-35 S NM103

    Name Last or

    Organization Name AN 1-60 S

    Increase

    NM104 Name First AN 1-25 S NM104 Name First AN 1-35 S Increase

    NM105 Name Middle AN 1-25 S NM105 Name Middle AN 1-25 SNew Situational Rule

    NM106 Name Prefix AN 1-10 S NM106 Name Prefix AN 1-10 N/U

    NM107 Name Suffix AN 1-10 S NM107 Name Suffix AN 1-10 S New Situational Rule

    NM108

    Identification Code

    Qualifier ID 1-2 S

    MI,ZZ

    NM108

    Identification Code

    Qualifier ID 1-2 S

    II, MI Code Removed

    Code Added

    NM109 Identification Code AN 2-80 S NM109 Identification Code AN 2-80 S

    NM110

    Entity Relationship

    Code ID 2-2 N/U NM110

    Entity Relationship

    Code ID 2-2 N/U

    NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U

    NM112

    Name Last or

    Organization Name AN 1-60 N/U

    REF

    SUBSCRIBER

    ADDITIONAL

    IDENTIFICATION 9 S 2100C REF

    SUBSCRIBER

    ADDITIONAL

    IDENTIFICATION 9 S 2100C

    REF01

    Reference

    Identification Qualifier ID 2-3 R

    18, 1L, 1W, 3H, 49, 6P, A6,

    EA, EJ, F6, GH, HJ, IF, IG,

    ML, N6, NQ, Q4, SY

    REF01

    Reference

    Identification Qualifier ID 2-3 R

    18, 1L, 1W, 3H, 49, 6P, CT,

    EA, EJ, F6, GH, HJ, IF, IG,

    N6, NQ, Q4, SY, Y4

    Codes Removed: A6, ML

    Code Added: Y4

    New Notes

    REF02

    Reference

    Identification AN 1-30 R REF02

    Reference

    Identification AN 1-50 R

    New Note

    Increase

    REF03 Description AN 1-80 S REF03 Description AN 1-80 S New Situational Rule

    REF04

    REFERENCE

    IDENTIFIER N/U REF04

    REFERENCE

    IDENTIFIER N/U

    N3

    SUBSCRIBER

    ADDRESS 1 S 2100C N3

    SUBSCRIBER

    ADDRESS 1 S 2100C

    N301 Address Information AN 1-55 R N301 Address Information AN 1-55 R

    N302 Address Information AN 1-55 S N302 Address Information AN 1-55 S

    New Situational Rule

    N4

    SUBSCRIBER CITY/

    STATE/ ZIP CODE 1 S 2100C N4

    SUBSCRIBER

    CITY/STATE/ZIP

    CODE 1 S 2100C

    N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage Change

    N402

    State or Province

    Code ID 2-2 S

    N402

    State or Province

    Code ID 2-2 S

    New Situational Rule

    N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S New Situational Rule

    Page 6 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S New Situational Rule

    N405 Location Qualifier ID 1-2 S CY, FI N405 Location Qualifier ID 1-2 N/U

    N406 Location Qualifier AN 1-30 S N406 Location Qualifier AN 1-30 N/U

    N407

    Country Subdivision

    Code ID 1-3 S

    New Element

    PER

    SUBSCRIBER

    CONTACT

    INFORMATION 3 S 2100C

    Deleted Segment

    PER01

    Contact Function

    Code ID 2-2 R

    IC

    PER02 Name AN 1-60 S

    PER03

    Communication

    Number Qualifier ID 2-2 S

    HP, TE, WP

    PER04

    Communication

    Number AN 1-80 S

    AAABBBCCCC

    PER05

    Communication

    Number Qualifier ID 2-2 S

    EX, HP, TE, WP

    PER06

    Communication

    Number AN 1-80 S

    AAABBBCCCC

    PER07

    Communication

    Number Qualifier ID 2-2 S

    EX, HP, TE, WP

    PER08

    Communication

    Number AN 1-80 S

    PER09

    Contact Inquiry

    Reference AN 1-20 N/U

    AAA

    SUBSCRIBER

    REQUEST

    VALIDATION 9 S 2100C AAA

    SUBSCRIBER

    REQUEST

    VALIDATION 9 S 2100C

    AAA01

    Yes/No Condition or

    Response Code ID 1-1 R

    N,Y

    AAA01

    Yes/No Condition or

    Response Code ID 1-1 R

    N,Y

    AAA02

    Agency Qualifier

    Code ID 2-2 N/U AAA02

    Agency Qualifier

    Code ID 2-2 N/U

    AAA03 Reject Reason Code ID 2-2 R

    15, 42, 43, 45, 47, 48, 49, 51,

    52, 56, 57, 58, 60, 61, 62, 63,

    64, 65, 66, 67, 68, 71, 72, 73,

    74, 75, 76, 77, 78AAA03 Reject Reason Code ID 2-2 R

    15, 35, 42, 43, 45, 47, 48, 49,

    51, 52, 56, 57, 58, 60, 61, 62,

    63, 71, 72, 73, 74, 75, 76, 77,

    78

    Codes Removed: 64-68, 77

    Code Added: 35

    New Notes

    AAA04

    Follow-up Action

    Code ID 1-1 R

    C, N, R, S, W, X, Y

    AAA04

    Follow-up Action

    Code ID 1-1 R

    C, N, R, S, W, X, Y

    PRV

    PROVIDER

    INFORMATION 1 S 2100C

    New Segment

    PRV01 Provider Code ID 1-3 R

    AD, AT, BI, CO, CV, H, HH,

    LA, OT, P1, P2, PC, PE, R,

    RF, SK, SU

    PRV02

    Reference

    Identification Qualifier ID 2-3 S PXC

    PRV03

    Reference

    Identification AN 1-50 S

    Page 7 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    PRV04

    State or Province

    Code ID 2-2 N/U

    PRV05

    PROVIDER

    SPECIALITY

    INFORMATION N/U

    PRV06

    Provider Organization

    Code ID 3-3 N/U

    DMG

    SUBSCRIBER

    DEMOGRAPHIC

    INFORMATION 1 S 2100C DMG

    SUBSCRIBER

    DEMOGRAPHIC

    INFORMATION 1 S 2100C

    DMG01

    Date Time Period

    Format Qualifier ID 2-3 S

    D8

    DMG01

    Date Time Period

    Format Qualifier ID 2-3 S

    D8 New Situational Rule

    DMG02 Date Time Period AN 1-35 S

    DMG02 Date Time Period AN 1-35 S

    New Situational Rule

    DMG03 Gender Code ID 1-1 S F, M, U DMG03 Gender Code ID 1-1 S F, M, U New Situational Rule

    DMG04 Marital Status Code ID 1-1 N/U DMG04 Marital Status Code ID 1-1 N/U

    DMG05

    Race or Ethnicity

    Code ID 1-1 N/U DMG05

    COMPOSITE RACE

    OR ETHNICITY

    INFORMATION N/U

    DMG06

    Citizenship Status

    Code ID 1-2 N/U DMG06

    Citizenship Status

    Code ID 1-2 N/U

    DMG07 Country Code ID 2-3 N/U DMG07 Country Code ID 2-3 N/U

    DMG08

    Basis of Verification

    Code ID 1-2 N/U DMG08

    Basis of Verification

    Code ID 1-2 N/U

    DMG09 Quantity R 1-15 N/U DMG09 Quantity R 1-15 N/U

    DMG10

    Code List Qualifier

    Code ID 1-3 N/U

    DMG11 Industry Code AN 1-30 N/U

    INS

    SUBSCRIBER

    REALTIONSHIP 1 S 2100C INS

    SUBSCRIBER

    RELATIONSHIP 1 S 2100C

    INS01

    Yes/ No Condition or

    Response Code ID 1-1 R Y INS01

    Yes/ No Condition or

    Response Code ID 1-1 R Y

    INS02

    Individual

    Relationship Code ID 2-2 R 18 INS02

    Individual

    Relationship Code ID 2-2 R 18

    INS03

    Maintenance Type

    Code ID 3-3 S 001 INS03

    Maintenance Type

    Code ID 3-3 S 001

    New Situational Rule

    INS04

    Maintenance Reason

    Code ID 2-3 S 25 INS04

    Maintenance Reason

    Code ID 2-3 S 25

    New Situational Rule

    INS05 Benefit Status Code ID 1-1 N/U INS05 Benefit Status Code ID 1-1 N/U

    INS06 Medicare Plan Code ID 1-1 N/U INS06

    MEDICARE STATUS

    CODE N/U

    INS07

    Consolidated

    Omnibus Budget

    Reconciliation Act

    (COBRA) Qualifying ID 1-2 N/U INS07

    Consolidated

    Omnibus Budget

    Reconciliation Act

    (COBRA) Qualifying ID 1-2 N/U

    INS08

    Employment Status

    Code ID 2-2 N/U INS08

    Employment Status

    Code ID 2-2 N/U

    INS09 Student Status Code ID 1-1 S F, N, P INS09 Student Status Code ID 1-1 N/U

    Page 8 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    INS10

    Yes/ No Condition or

    Response Code ID 1-1 S N,Y INS10

    Yes/ No Condition or

    Response Code ID 1-1 N/U

    INS11

    Date Time Period

    Format Qualifier ID 2-3 N/U INS11

    Date Time Period

    Format Qualifier ID 2-3 N/U

    INS12 Date Time Period AN 1-35 N/U INS12 Date Time Period AN 1-35 N/U

    INS13 Confidentiality Code ID 1-1 N/U INS13 Confidentiality Code ID 1-1 N/U

    INS14 City Name AN 2-30 N/U INS14 City Name AN 2-30 N/U

    INS15

    State or Province

    Code ID 2-2 N/U INS15

    State or Province

    Code ID 2-2 N/U

    INS16 Country Code ID 2-3 N/U INS16 Country Code ID 2-3 N/U

    INS17 Number N0 1-9 S INS17 Number N0 1-9 S New Situational Rule

    HI

    SUBSCRIBER

    HEALTH CARE

    DIAGNOSIS CODE 1 S 2100C

    New Segment

    HI01

    HEALTH CARE

    CODE

    INFORMATION R

    HI01 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABK, BK

    HI01 - 2 Industry Code AN 1-30 R

    HI01 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI01 - 4 Date Time Period AN 1-35 N/U

    HI01 - 5 Monetary Amount R 1-18 N/U

    HI01 - 6 Quantity R 1-15 N/U

    HI01 - 7 Version Identifier AN 1-30 N/U

    HI01 - 8 Industry Code AN 1-30 N/U

    HI01 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI02

    HEALTH CARE

    CODE

    INFORMATION S

    HI02 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI02 - 2 Industry Code AN 1-30 R

    HI02 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI02 - 4 Date Time Period AN 1-35 N/U

    HI02 - 5 Monetary Amount R 1-18 N/U

    HI02 - 6 Quantity R 1-15 N/U

    HI02 - 7 Version Identifier AN 1-30 N/U

    HI02 - 8 Industry Code AN 1-30 N/U

    HI02 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI03

    HEALTH CARE

    CODE

    INFORMATION S

    HI03 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    Page 9 of 32 8/11/200911:35 AM

  • 271 NotesElement

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    Element

    Identifier Description ID

    Min.

    Max.

    Usage

    Reg. Loop

    Loop

    Repeat Values

    271 4010A1 271 5010

    4010A1 5010

    HI03 - 2 Industry Code AN 1-30 R

    HI03 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI03 - 4 Date Time Period AN 1-35 N/U

    HI03 - 5 Monetary Amount R 1-18 N/U

    HI03 - 6 Quantity R 1-15 N/U

    HI03 - 7 Version Identifier AN 1-30 N/U

    HI03 - 8 Industry Code AN 1-30 N/U

    HI03 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI04

    HEALTH CARE

    CODE

    INFORMATION S

    HI04 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI04 - 2 Industry Code AN 1-30 R

    HI04 - 3

    Date Time Period

    Format Qualifier ID 2-3 N/U

    HI04 - 4 Date Time Period AN 1-35 N/U

    HI04 - 5 Monetary Amount R 1-18 N/U

    HI04 - 6 Quantity R 1-15 N/U

    HI04 - 7 Version Identifier AN 1-30 N/U

    HI04 - 8 Industry Code AN 1-30 N/U

    HI04 - 9

    Yes/No Condition or

    Response Code ID 1-1 N/U

    HI05

    HEALTH CARE

    CODE

    INFORMATION S

    HI05 - 1

    Code List Qualifier

    Code ID 1-3 R

    ABF, BF

    HI05 - 2 Industry Code AN 1-30 R

    H


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