5010 Health Care Eligibility Benefit Inquiry [M0]


Loop Qualifiers
xx - Loop Iteration Prefix
xxyy - Outer Loop Iteration and Inner Loop Iteration
yy / yyy - Loop Value Qualifier
xxyy / xxyyy - Loop Iteration and Value Qualifier
Segment Modifiers:
X - Distinguishing Identifier Suffix
nn - Segment Iteration (only after first iterartion)
nn - Element Repeat Iteration (only after first iterartion)

GSHDR - GROUP HEADER
GSHDRGSFunctional Group Header
02GSHDR_GS02_APP_SNDR_CDStringApplication Senders Code
03GSHDR_GS03_APP_RCV_CDStringApplication Receivers Code
04GSHDR_GS04_D8Date/TimeDate
05GSHDR_GS05_TMTimeTime
06GSHDR_GS06_GCNIntegerGroup Control Number
STHDR - TRANSACTION SET HEADER
STHDRSTTransaction Set Header
02STHDR_ST02_TCNStringTransaction Set Control Number
03STHDR_ST03_IMP_CONV_REFStringImplementation Convention Reference
STHDRBHTBeginning of Hierarchical Transaction
01STHDR_BHT01_HIER_STRUC_CDStringHierarchical Structure Code
02STHDR_BHT02_TS_PURP_CDStringTransaction Set Purpose Code
03STHDR_BHT03_SBM_TRANS_IDStringSubmitter Transaction Identifier
04STHDR_BHT04_TS_CRTN_D8Date/TimeTransaction Set Creation Date
05STHDR_BHT05_TS_CRTN_TMTimeTransaction Set Creation Time
06STHDR_BHT06_TRANS_TYP_CDStringTransaction Type Code
L2000A - INFORMATION SOURCE LEVEL
L2000AHLInformation Source Level
01L2000A_HL01_HIER_ID_NRStringHierarchical ID Number
L2100A - INFORMATION SOURCE NAME (Value Qualified)
Mapping Prefix: L2100A_2B - Third-Party Administrator
Mapping Prefix: L2100A_36 - Employer
Mapping Prefix: L2100A_GP - Gateway Provider
Mapping Prefix: L2100A_P5 - Plan Sponsor
Mapping Prefix: L2100A_PR - Payer
L2100ANM1Information Source Name
03L2100A_yy_NM103_PERSN_LNMStringPerson Last Name
03L2100A_yy_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2100A_yy_NM104_NFO_SRC_FNMStringInformation Source First Name
05L2100A_yy_NM105_NFO_SRC_MNMStringInformation Source Middle Name
07L2100A_yy_NM107_NFO_SRC_SFXStringInformation Source Name Suffix
09L2100A_yy_NM109_EMPLYR_IDStringEmployer?s Identification Number
09L2100A_yy_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
09L2100A_yy_NM109_TAX_IDStringFederal Taxpayer?s Identification Number
09L2100A_yy_NM109_NAIC_IDStringNational Association of Insurance Commissioners (NAIC) Identification
09L2100A_yy_NM109_PAYR_IDStringPayor Identification
09L2100A_yy_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
09L2100A_yy_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
L2000B - INFORMATION RECEIVER LEVEL
L2000BHLInformation Receiver Level
01L2000B_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000B_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
L2100B - INFORMATION RECEIVER NAME (Value Qualified)
Mapping Prefix: L2100B_1P - Provider
Mapping Prefix: L2100B_2B - Third-Party Administrator
Mapping Prefix: L2100B_36 - Employer
Mapping Prefix: L2100B_80 - Hospital
Mapping Prefix: L2100B_FA - Facility
Mapping Prefix: L2100B_GP - Gateway Provider
Mapping Prefix: L2100B_P5 - Plan Sponsor
Mapping Prefix: L2100B_PR - Payer
L2100BNM1Information Receiver Name
03L2100B_yy_NM103_PERSN_LNMStringPerson Last Name
03L2100B_yy_NM103_NONPSNENT_NMStringNon-Person Entity Name
04L2100B_yy_NM104_NFO_REC_FNMStringInformation Receiver First Name
05L2100B_yy_NM105_NFO_REC_MNMStringInformation Receiver Middle Name
07L2100B_yy_NM107_NFO_RCV_SFXStringInformation Receiver Name Suffix
09L2100B_yy_NM109_EMPLYR_IDStringEmployer?s Identification Number
09L2100B_yy_NM109_SSNStringSocial Security Number
09L2100B_yy_NM109_TAX_IDStringFederal Taxpayer?s Identification Number
09L2100B_yy_NM109_PAYR_IDStringPayor Identification
09L2100B_yy_NM109_PHM_PRCSR_NRStringPharmacy Processor Number
09L2100B_yy_NM109_SVC_PROV_NRStringService Provider Number
09L2100B_yy_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
09L2100B_yy_NM109_NPIStringCenters for Medicare and Medicaid Services
L2100BREFInformation Receiver Additional Identification
02L2100B_yy_REF_DUN_BRDSTStringDun and Brandstreet
02L2100B_yy_REF_DUN_BRDST_SFXStringDuns Plus Suffix
02L2100B_yy_REF_HINStringHealth Industry Number
02L2100B_yy_REF_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
02L2100B_yy_REF_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
02L2100B_yy_REF_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
02L2100B_yy_REF_TAX_IDStringUS Federal Tax Identification Number
02L2100B_yy_REF_NAIC_CDStringNational Association of Insurance Commissioners Company Code
02L2100B_yy_REF_MUTLY_DEFStringMutually Defined
03L2100B_yy_REF03_NFORCV_AD_IDStringInformation Receiver Additional Identifier State
L2100BN3Information Receiver Address
01L2100B_yy_N301_NFO_RCVR_ADDRStringInformation Receiver Address Line
02L2100B_yy_N302_NFO_RCV_ADDRStringInformation Receiver Additional Address Line
L2100BN4Information Receiver City, State, ZIP Code
01L2100B_yy_N401_NFO_RCV_CITY_NMStringInformation Receiver City Name
02L2100B_yy_N402_NFO_RCV_STATStringInformation Receiver State Code
03L2100B_yy_N403_NFO_RCV_ZIPStringInformation Receiver Postal Zone or ZIP Code
04L2100B_yy_N404_CNTRY_CDStringCountry Code
07L2100B_yy_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100BPRVInformation Receiver Provider Information
01L2100B_yy_PRV01_PVD_CDStringProvider Code
03L2100B_yy_PRV03_RCV_PVR_TAX_CDStringReceiver Provider Taxonomy Code
L2000C - SUBSCRIBER LEVEL
L2000CHLSubscriber Level
01L2000C_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000C_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
04L2000C_HL04_HL_CHLD_CDStringHierarchical Child Code
L2000CTRNSubscriber Trace Number Iterated: [01-02]
02L2000C_nnTRN02_TRAC_NRStringTrace Number
03L2000C_nnTRN03_TRAC_ASS_IDStringTrace Assigning Entity Identifier
04L2000C_nnTRN04_TRC_ASS_ADDL_IDStringTrace Assigning Entity Additional Identifier
L2100C - SUBSCRIBER NAME
L2100CNM1Subscriber Name
03L2100C_NM103_SBR_LNMStringSubscriber Last Name
04L2100C_NM104_SBR_FNMStringSubscriber First Name
05L2100C_NM105_SBR_MNMStringSubscriber Middle Name or Initial
07L2100C_NM107_SBR_SFXStringSubscriber Name Suffix
09L2100C_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2100C_NM109_MEM_ID_NRStringMember Identification Number
L2100CREFSubscriber Additional Identification Iterated: [01-09]
02L2100C_nnREF_PLAN_NRStringPlan Number
02L2100C_nnREF_GRP_POLCY_NRStringGroup or Policy Number
02L2100C_nnREF_MEM_IDStringMember Identification Number
02L2100C_nnREF_CASE_NRStringCase Number
02L2100C_nnREF_GRP_NRStringGroup Number
02L2100C_nnREF_CNTRCT_NRStringContract Number
02L2100C_nnREF_MED_REC_IDStringMedical Record Identification Number
02L2100C_nnREF_PATNT_ACCT_NRStringPatient Account Number
02L2100C_nnREF_HIC_NRStringHealth Insurance Claim (HIC) Number
02L2100C_nnREF_ID_SERL_NRStringIdentification Card Serial Number
02L2100C_nnREF_ID_CRD_NRStringIdentity Card Number
02L2100C_nnREF_INS_PLCY_NRStringInsurance Policy Number
02L2100C_nnREF_PLN_NET_IDStringPlan Network Identification Number
02L2100C_nnREF_MDCD_ID_NRStringMedicaid Recipient Identification Number
02L2100C_nnREF_SSNStringSocial Security Number
02L2100C_nnREF_AGNCY_CLM_NRStringAgency Claim Number
L2100CN3Subscriber Address
01L2100C_N301_SBR_ADDRStringSubscriber Address Line
02L2100C_N302_SBR_ADDRStringSubscriber Address Line
L2100CN4Subscriber City, State, ZIP Code
01L2100C_N401_SBR_CITYStringSubscriber City Name
02L2100C_N402_SBR_STATStringSubscriber State Code
03L2100C_N403_SBR_ZIPStringSubscriber Postal Zone or ZIP Code
04L2100C_N404_CNTRY_CDStringCountry Code
07L2100C_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100CPRVProvider Information
01L2100C_PRV01_PVD_CDStringProvider Code
03L2100C_PRV03_SERVCRStringServicer
03L2100C_PRV03_NCPDP_PHARM_NRStringNational Council for Prescription Drug Programs Pharmacy Number
03L2100C_PRV03_EMP_ID_NRStringEmployer?s Identification Number
03L2100C_PRV03_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
03L2100C_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
03L2100C_PRV03_SSNStringSocial Security Number
03L2100C_PRV03_TAX_IDStringFederal Taxpayer?s Identification Number
L2100CDMGSubscriber Demographic Information
02L2100C_DMG02_SBR_DOB_D8Date/TimeSubscriber Birth Date
03L2100C_DMG03_SUB_GENDR_CDStringSubscriber Gender Code
L2100CINSMultiple Birth Sequence Number
17L2100C_INS17_BRTH_SEQ_NRStringBirth Sequence Number
L2100CHISubscriber Health Care Diagnosis Code
0102L2100C_HI0102_ICD10_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
0102L2100C_HI0102_ICD9_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
0202L2100C_HI0202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0202L2100C_HI0202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0302L2100C_HI0302_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0302L2100C_HI0302_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0402L2100C_HI0402_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0402L2100C_HI0402_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0502L2100C_HI0502_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0502L2100C_HI0502_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0602L2100C_HI0602_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0602L2100C_HI0602_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0702L2100C_HI0702_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0702L2100C_HI0702_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0802L2100C_HI0802_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0802L2100C_HI0802_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
L2100CDTPSubscriber Date
03L2100C_DTP_ISSU_D8Start DateIssue (D8)
03L2100C_DTP_ISSU_RD8_1Start DateIssue (D8)
03L2100C_DTP_ISSU_RD8_2End DateIssue (D8)
03L2100C_DTP_PLAN_D8Start DatePlan (D8)
03L2100C_DTP_PLAN_RD8_1Start DatePlan (D8)
03L2100C_DTP_PLAN_RD8_2End DatePlan (D8)
L2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY
L2110CEQSubscriber Eligibility or Benefit Inquiry
01L2110C_EQ01_Enn_SVC_TYP_CDStringService Type Code
0202L2110C_EQ0202_ADA_CDStringAmerican Dental Association Codes
0202L2110C_EQ0202_CPT_CDStringCurrent Procedural Terminology (CPT) Codes
0202L2110C_EQ0202_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0202L2110C_EQ0202_ICD9_PROCStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure
0202L2110C_EQ0202_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
0202L2110C_EQ0202_NDC542StringNational Drug Code in 5-4-2 Format
0202L2110C_EQ0202_MUTLY_DEFStringMutually Defined
0203L2110C_EQ0203_PROC_MODStringProcedure Modifier
0204L2110C_EQ0204_PROC_MODStringProcedure Modifier
0205L2110C_EQ0205_PROC_MODStringProcedure Modifier
0206L2110C_EQ0206_PROC_MODStringProcedure Modifier
03L2110C_EQ03_COVG_LVL_CDStringCoverage Level Code
0501L2110C_EQ0501_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0502L2110C_EQ0502_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0503L2110C_EQ0503_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0504L2110C_EQ0504_DIAG_CD_PTRIntegerDiagnosis Code Pointer
L2110CAMTSubscriber Spend Down Amount
02L2110C_AMT02_SPENDOWNDate TimestampSpend Down
L2110CAMTSubscriber Spend Down Total Billed Amount
02L2110C_AMT02_BILL_AMTDate TimestampBilled Amount
L2110CIIISubscriber Eligibility or Benefit Additional Inquiry Information
02L2110C_III02_INDSTY_CDStringIndustry Code
L2110CREFSubscriber Additional Information
02L2110C_REF_REFRL_NRStringReferral Number
02L2110C_REF_PRIOR_AUTHStringPrior Authorization Number
L2110CDTPSubscriber Eligibility/Benefit Date
03L2110C_DTP_PLAN_D8Start DatePlan (D8)
03L2110C_DTP_PLAN_RD8_1Start DatePlan (D8)
03L2110C_DTP_PLAN_RD8_2End DatePlan (D8)
L2000D - DEPENDENT LEVEL
L2000DHLDependent Level
01L2000D_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000D_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
L2000DTRNDependent Trace Number Iterated: [01-02]
02L2000D_nnTRN02_TRAC_NRStringTrace Number
03L2000D_nnTRN03_TRAC_ASS_IDStringTrace Assigning Entity Identifier
04L2000D_nnTRN04_TRC_ASS_ADDL_IDStringTrace Assigning Entity Additional Identifier
L2100D - DEPENDENT NAME
L2100DNM1Dependent Name
03L2100D_NM103_DEP_LNMStringDependent Last Name
04L2100D_NM104_DEP_FNMStringDependent First Name
05L2100D_NM105_DEP_MNMStringDependent Middle Name
07L2100D_NM107_DEP_SFXStringDependent Name Suffix
L2100DREFDependent Additional Identification Iterated: [01-09]
02L2100D_nnREF_PLAN_NRStringPlan Number
02L2100D_nnREF_GRP_POLCY_NRStringGroup or Policy Number
02L2100D_nnREF_GRP_NRStringGroup Number
02L2100D_nnREF_CNTRCT_NRStringContract Number
02L2100D_nnREF_MED_REC_IDStringMedical Record Identification Number
02L2100D_nnREF_PATNT_ACCT_NRStringPatient Account Number
02L2100D_nnREF_HIC_NRStringHealth Insurance Claim (HIC) Number
02L2100D_nnREF_ID_SERL_NRStringIdentification Card Serial Number
02L2100D_nnREF_ID_CRD_NRStringIdentity Card Number
02L2100D_nnREF_ISSU_NRStringIssue Number
02L2100D_nnREF_INS_PLCY_NRStringInsurance Policy Number
02L2100D_nnREF_ELIG_CATStringEligibility Category
02L2100D_nnREF_PLN_NET_IDStringPlan Network Identification Number
02L2100D_nnREF_SSNStringSocial Security Number
02L2100D_nnREF_AGNCY_CLM_NRStringAgency Claim Number
L2100DN3Dependent Address
01L2100D_N301_DEP_ADDRStringDependent Address Line
02L2100D_N302_DEP_ADDRStringDependent Address Line
L2100DN4Dependent City, State, ZIP Code
01L2100D_N401_DEP_CITYStringDependent City Name
02L2100D_N402_DEP_STATStringDependent State Code
03L2100D_N403_DEP_POSTL_ZIPStringDependent Postal Zone or ZIP Code
04L2100D_N404_CNTRY_CDStringCountry Code
07L2100D_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100DPRVProvider Information
01L2100D_PRV01_PVD_CDStringProvider Code
03L2100D_PRV03_SERVCRStringServicer
03L2100D_PRV03_NCPDP_PHARM_NRStringNational Council for Prescription Drug Programs Pharmacy Number
03L2100D_PRV03_EMP_ID_NRStringEmployer?s Identification Number
03L2100D_PRV03_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
03L2100D_PRV03_PVD_TAXNMY_CDStringHealth Care Provider Taxonomy Code
03L2100D_PRV03_SSNStringSocial Security Number
03L2100D_PRV03_TAX_IDStringFederal Taxpayer?s Identification Number
L2100DDMGDependent Demographic Information
02L2100D_DMG02_DEP_DOB_D8Date/TimeDependent Birth Date
03L2100D_DMG03_DEP_GNDR_CDStringDependent Gender Code
L2100DINSDependent Relationship
02L2100D_INS02_IND_RELAT_CDStringIndividual Relationship Code
17L2100D_INS17_BRTH_SEQ_NRStringBirth Sequence Number
L2100DHIDependent Health Care Diagnosis Code
0102L2100D_HI0102_ICD10_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
0102L2100D_HI0102_ICD9_PRIN_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
0202L2100D_HI0202_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0202L2100D_HI0202_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0302L2100D_HI0302_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0302L2100D_HI0302_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0402L2100D_HI0402_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0402L2100D_HI0402_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0502L2100D_HI0502_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0502L2100D_HI0502_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0602L2100D_HI0602_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0602L2100D_HI0602_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0702L2100D_HI0702_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0702L2100D_HI0702_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
0802L2100D_HI0802_ICD10_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
0802L2100D_HI0802_ICD9_DIAGStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
L2100DDTPDependent Date
03L2100D_DTP_ISSU_D8Start DateIssue (D8)
03L2100D_DTP_ISSU_RD8_1Start DateIssue (D8)
03L2100D_DTP_ISSU_RD8_2End DateIssue (D8)
03L2100D_DTP_PLAN_D8Start DatePlan (D8)
03L2100D_DTP_PLAN_RD8_1Start DatePlan (D8)
03L2100D_DTP_PLAN_RD8_2End DatePlan (D8)
L2110D - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY
L2110DEQDependent Eligibility or Benefit Inquiry
01L2110D_EQ01_Enn_SVC_TYP_CDStringService Type Code
0202L2110D_EQ0202_ADA_CDStringAmerican Dental Association Codes
0202L2110D_EQ0202_CPT_CDStringCurrent Procedural Terminology (CPT) Codes
0202L2110D_EQ0202_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
0202L2110D_EQ0202_ICD9_PROCStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure
0202L2110D_EQ0202_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
0202L2110D_EQ0202_NDC542StringNational Drug Code in 5-4-2 Format
0202L2110D_EQ0202_MUTLY_DEFStringMutually Defined
0203L2110D_EQ0203_PROC_MODStringProcedure Modifier
0204L2110D_EQ0204_PROC_MODStringProcedure Modifier
0205L2110D_EQ0205_PROC_MODStringProcedure Modifier
0206L2110D_EQ0206_PROC_MODStringProcedure Modifier
0501L2110D_EQ0501_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0502L2110D_EQ0502_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0503L2110D_EQ0503_DIAG_CD_PTRIntegerDiagnosis Code Pointer
0504L2110D_EQ0504_DIAG_CD_PTRIntegerDiagnosis Code Pointer
L2110DIIIDependent Eligibility or Benefit Additional Inquiry Information
02L2110D_III02_INDSTY_CDStringIndustry Code
L2110DREFDependent Additional Information
02L2110D_REF_REFRL_NRStringReferral Number
02L2110D_REF_PRIOR_AUTHStringPrior Authorization Number
L2110DDTPDependent Eligibility/Benefit Date
03L2110D_DTP_PLAN_D8Start DatePlan (D8)
03L2110D_DTP_PLAN_RD8_1Start DatePlan (D8)
03L2110D_DTP_PLAN_RD8_2End DatePlan (D8)

STHDRSETransaction Set Trailer
01STHDR_SE01_TS_SEG_CTIntegerTransaction Segment Count
02STHDR_SE02_TCNStringTransaction Set Control Number

GSHDRGEFunctional Group Trailer
01GSHDR_GE01_NR_TS_INCLUDEDIntegerNumber of Transaction Sets Included
02GSHDR_GE02_GCNIntegerGroup Control Number