5010 Health Care Eligibility Benefit Response [N1]


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
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
L2000A - INFORMATION SOURCE LEVEL
L2000AHLInformation Source Level
01L2000A_HL01_HIER_ID_NRStringHierarchical ID Number
04L2000A_HL04_HL_CHLD_CDStringHierarchical Child Code
L2000AAAARequest Validation Iterated: [01-09]
01L2000A_nnAAA01_VLDREQ_INDStringValid Request Indicator
03L2000A_nnAAA03_REJ_RSN_CDStringReject Reason Code
04L2000A_nnAAA04_FWUP_ACTCDStringFollow-up Action Code
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
L2100APERInformation Source Contact Information Iterated: [01-03]
02L2100A_yy_nnPER02_NFOSRC_CN_NMStringInformation Source Contact Name
04L2100A_yy_nnPER04_EDI_ACS_NRStringElectronic Data Interchange Access Number
04L2100A_yy_nnPER04_EMAILStringElectronic Mail
04L2100A_yy_nnPER04_FAXStringFacsimile
04L2100A_yy_nnPER04_PHN_NRStringTelephone
04L2100A_yy_nnPER04_URLStringUniform Resource Locator (URL)
06L2100A_yy_nnPER06_EDI_ACS_NRStringElectronic Data Interchange Access Number
06L2100A_yy_nnPER06_EMAILStringElectronic Mail
06L2100A_yy_nnPER06_PHN_EXTStringTelephone Extension
06L2100A_yy_nnPER06_FAXStringFacsimile
06L2100A_yy_nnPER06_PHN_NRStringTelephone
06L2100A_yy_nnPER06_URLStringUniform Resource Locator (URL)
08L2100A_yy_nnPER08_EDI_ACS_NRStringElectronic Data Interchange Access Number
08L2100A_yy_nnPER08_EMAILStringElectronic Mail
08L2100A_yy_nnPER08_PHN_EXTStringTelephone Extension
08L2100A_yy_nnPER08_FAXStringFacsimile
08L2100A_yy_nnPER08_PHN_NRStringTelephone
08L2100A_yy_nnPER08_URLStringUniform Resource Locator (URL)
L2100AAAARequest Validation Iterated: [01-09]
01L2100A_yy_nnAAA01_VLDREQ_INDStringValid Request Indicator
03L2100A_yy_nnAAA03_REJ_RSN_CDStringReject Reason Code
04L2100A_yy_nnAAA04_FWUP_ACTCDStringFollow-up Action Code
L2000B - INFORMATION RECEIVER LEVEL
L2000BHLInformation Receiver Level
01L2000B_HL01_HIER_ID_NRStringHierarchical ID Number
02L2000B_HL02_HIER_PARNT_ID_NRStringHierarchical Parent ID Number
04L2000B_HL04_HL_CHLD_CDStringHierarchical Child Code
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_NFO_RCV_NMStringInformation Receiver Last or Organization 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 National Provider Identifier
L2100BREFInformation Receiver Additional Identification Iterated: [01-09]
02L2100B_yy_nnREF_STAT_LIC_NRStringState License Number
02L2100B_yy_nnREF_MDCR_PVR_NRStringMedicare Provider Number
02L2100B_yy_nnREF_MDCD_PVR_NRStringMedicaid Provider Number
02L2100B_yy_nnREF_FAC_IDStringFacility ID Number
02L2100B_yy_nnREF_PINStringPersonal Identification Number (PIN)
02L2100B_yy_nnREF_CNTRCT_NRStringContract Number
02L2100B_yy_nnREF_ELEC_PINStringElectronic device pin number
02L2100B_yy_nnREF_SUB_ID_NRStringSubmitter Identification Number
02L2100B_yy_nnREF_MDCR_MDCDStringCenters for Medicare and Medicaid Services National Provider Identifier
02L2100B_yy_nnREF_USER_IDStringUser Identification
02L2100B_yy_nnREF_PRV_PLN_IDStringProvider Plan Network Identification Number
02L2100B_yy_nnREF_FAC_NET_IDStringFacility Network Identification Number
02L2100B_yy_nnREF_PRIOR_IDStringPrior Identifier Number
02L2100B_yy_nnREF_SSNStringSocial Security Number
02L2100B_yy_nnREF_TAX_IDStringFederal Taxpayer?s Identification Number
02L2100B_yy_nnREF_CLSS_CONTStringClass of Contract
03L2100B_yy_nnREF03_NFORCV_AD_IDStringInformation Receiver Additional Identifier State
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_NFORCVR_CNTY_CDStringInformation Receiver County Code
07L2100B_yy_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100BN3Information Receiver Address
01L2100B_yy_N301_NFO_RCVR_ADDRStringInformation Receiver Address Line
02L2100B_yy_N302_NFO_RCVR_ADDRStringInformation Receiver Address Line
L2100BAAAInformation Receiver Request Validation Iterated: [01-09]
01L2100B_yy_nnAAA01_VLDREQ_INDStringValid Request Indicator
03L2100B_yy_nnAAA03_REJ_RSN_CDStringReject Reason Code
04L2100B_yy_nnAAA04_FWUP_ACTCDStringFollow-up Action Code
L2100BPRVInformation Receiver Provider Information
01L2100B_yy_PRV01_PVD_CDStringProvider Code
02L2100B_yy_PRV02_REF_ID_QUALStringReference Identification Qualifier
03L2100B_yy_PRV03_NFORCVPVR_TXCDStringInformation Receiver 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: [01-03]
01L2000C_nnTRN01_TRAC_TYP_CDStringTrace Type Code
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_FAM_UNT_NRStringFamily Unit 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_ISSU_NRStringIssue 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_PRIOR_IDStringPrior Identifier Number
02L2100C_nnREF_SSNStringSocial Security Number
02L2100C_nnREF_AGNCY_CLM_NRStringAgency Claim Number
03L2100C_nnREF03_PLN_GRPNT_NMStringPlan, Group or Plan Network Name
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_SBR_CNTRY_CDStringSubscriber Country Code
07L2100C_N407_SBR_CNTRY_SBR_CDStringSubscriber Country Subdivision Code
L2100CAAASubscriber Request Validation Iterated: [01-09]
01L2100C_nnAAA01_VLDREQ_INDStringValid Request Indicator
03L2100C_nnAAA03_REJ_RSN_CDStringReject Reason Code
04L2100C_nnAAA04_FWUP_ACTCDStringFollow-up Action Code
L2100CPRVProvider Information
01L2100C_PRV01_PVD_CDStringProvider Code
03L2100C_PRV03_PVR_IDStringProvider Identifier
L2100CDMGSubscriber Demographic Information
02L2100C_DMG02_SBR_DOB_D8Date/TimeSubscriber Birth Date
03L2100C_DMG03_SUB_GENDR_CDStringSubscriber Gender Code
L2100CINSSubscriber Relationship
03L2100C_INS03_MAINT_TYP_CDStringMaintenance Type Code
04L2100C_INS04_MAINT_RSN_CDStringMaintenance Reason Code
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_DISCHG_D8Start DateDischarge (D8)
03L2100C_DTP_DISCHG_RD8_1Start DateDischarge (D8)
03L2100C_DTP_DISCHG_RD8_2End DateDischarge (D8)
03L2100C_DTP_ISSU_D8Start DateIssue (D8)
03L2100C_DTP_ISSU_RD8_1Start DateIssue (D8)
03L2100C_DTP_ISSU_RD8_2End DateIssue (D8)
03L2100C_DTP_CHG_EFF_D8Start DateEffective Date of Change (D8)
03L2100C_DTP_CHG_EFF_RD8_1Start DateEffective Date of Change (D8)
03L2100C_DTP_CHG_EFF_RD8_2End DateEffective Date of Change (D8)
03L2100C_DTP_PLAN_D8Start DatePlan (D8)
03L2100C_DTP_PLAN_RD8_1Start DatePlan (D8)
03L2100C_DTP_PLAN_RD8_2End DatePlan (D8)
03L2100C_DTP_ELIG_D8Start DateEligibility (D8)
03L2100C_DTP_ELIG_RD8_1Start DateEligibility (D8)
03L2100C_DTP_ELIG_RD8_2End DateEligibility (D8)
03L2100C_DTP_ADDED_D8Start DateAdded (D8)
03L2100C_DTP_ADDED_RD8_1Start DateAdded (D8)
03L2100C_DTP_ADDED_RD8_2End DateAdded (D8)
03L2100C_DTP_COBRA_BGN_D8Start DateConsolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8)
03L2100C_DTP_COBRA_BGN_RD8_1Start DateConsolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8)
03L2100C_DTP_COBRA_BGN_RD8_2End DateConsolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8)
03L2100C_DTP_COBRA_END_D8Start DateConsolidated Omnibus Budget Reconciliation Act (COBRA) End (D8)
03L2100C_DTP_COBRA_END_RD8_1Start DateConsolidated Omnibus Budget Reconciliation Act (COBRA) End (D8)
03L2100C_DTP_COBRA_END_RD8_2End DateConsolidated Omnibus Budget Reconciliation Act (COBRA) End (D8)
03L2100C_DTP_PRM_PD_BGN_D8Start DatePremium Paid to Date Begin (D8)
03L2100C_DTP_PRM_PD_BGN_RD8_1Start DatePremium Paid to Date Begin (D8)
03L2100C_DTP_PRM_PD_BGN_RD8_2End DatePremium Paid to Date Begin (D8)
03L2100C_DTP_PRM_PD_END_D8Start DatePremium Paid to Date End (D8)
03L2100C_DTP_PRM_PD_END_RD8_1Start DatePremium Paid to Date End (D8)
03L2100C_DTP_PRM_PD_END_RD8_2End DatePremium Paid to Date End (D8)
03L2100C_DTP_PLAN_BGN_D8Start DatePlan Begin (D8)
03L2100C_DTP_PLAN_BGN_RD8_1Start DatePlan Begin (D8)
03L2100C_DTP_PLAN_BGN_RD8_2End DatePlan Begin (D8)
03L2100C_DTP_PLAN_END_D8Start DatePlan End (D8)
03L2100C_DTP_PLAN_END_RD8_1Start DatePlan End (D8)
03L2100C_DTP_PLAN_END_RD8_2End DatePlan End (D8)
03L2100C_DTP_ELIG_BGN_D8Start DateEligibility Begin (D8)
03L2100C_DTP_ELIG_BGN_RD8_1Start DateEligibility Begin (D8)
03L2100C_DTP_ELIG_BGN_RD8_2End DateEligibility Begin (D8)
03L2100C_DTP_ELIG_END_D8Start DateEligibility End (D8)
03L2100C_DTP_ELIG_END_RD8_1Start DateEligibility End (D8)
03L2100C_DTP_ELIG_END_RD8_2End DateEligibility End (D8)
03L2100C_DTP_ENRLL_D8Start DateEnrollment (D8)
03L2100C_DTP_ENRLL_RD8_1Start DateEnrollment (D8)
03L2100C_DTP_ENRLL_RD8_2End DateEnrollment (D8)
03L2100C_DTP_ADMSN_D8Start DateAdmission (D8)
03L2100C_DTP_ADMSN_RD8_1Start DateAdmission (D8)
03L2100C_DTP_ADMSN_RD8_2End DateAdmission (D8)
03L2100C_DTP_DEATH_D8Start DateDate of Death (D8)
03L2100C_DTP_DEATH_RD8_1Start DateDate of Death (D8)
03L2100C_DTP_DEATH_RD8_2End DateDate of Death (D8)
03L2100C_DTP_CERT_D8Start DateCertification (D8)
03L2100C_DTP_CERT_RD8_1Start DateCertification (D8)
03L2100C_DTP_CERT_RD8_2End DateCertification (D8)
03L2100C_DTP_SVC_D8Start DateService (D8)
03L2100C_DTP_SVC_RD8_1Start DateService (D8)
03L2100C_DTP_SVC_RD8_2End DateService (D8)
03L2100C_DTP_PLCY_EFF_D8Start DatePolicy Effective (D8)
03L2100C_DTP_PLCY_EFF_RD8_1Start DatePolicy Effective (D8)
03L2100C_DTP_PLCY_EFF_RD8_2End DatePolicy Effective (D8)
03L2100C_DTP_PLCY_EXP_D8Start DatePolicy Expiration (D8)
03L2100C_DTP_PLCY_EXP_RD8_1Start DatePolicy Expiration (D8)
03L2100C_DTP_PLCY_EXP_RD8_2End DatePolicy Expiration (D8)
03L2100C_DTP_LAST_UPDT_D8Start DateDate of Last Update (D8)
03L2100C_DTP_LAST_UPDT_RD8_1Start DateDate of Last Update (D8)
03L2100C_DTP_LAST_UPDT_RD8_2End DateDate of Last Update (D8)
03L2100C_DTP_STATS_D8Start DateStatus (D8)
03L2100C_DTP_STATS_RD8_1Start DateStatus (D8)
03L2100C_DTP_STATS_RD8_2End DateStatus (D8)
L2100CMPISubscriber Military Personnel Information
01L2100C_MPI01_NFO_STAT_CDStringInformation Status Code
02L2100C_MPI02_EMPMT_STAT_CDStringEmployment Status Code
03L2100C_MPI03_GOV_SVC_AFF_CDStringGovernment Service Affiliation Code
04L2100C_MPI04_DESCRStringDescription
05L2100C_MPI05_MIL_SVC_RNK_CDStringMilitary Service Rank Code
07L2100C_MPI07_D8StringDate Expressed in Format CCYYMMDD
07L2100C_MPI07_RD8StringRange of Dates Expressed in Format CCYYMMDD- CCYYMMDD
L2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION (Single Iteration)
L2110CEBSubscriber Eligibility or Benefit Information
01L2110C_xx_EB01_Enn_ELIG_BEN_NFOStringEligibility or Benefit Information
02L2110C_xx_EB02_BENE_COV_LVL_CDStringBenefit Coverage Level Code
03L2110C_xx_EB03_Enn_SVC_TYP_CDStringService Type Code
04L2110C_xx_EB04_INS_TYP_CDStringInsurance Type Code
05L2110C_xx_EB05_PLN_CVG_DSCStringPlan Coverage Description
07L2110C_xx_EB07_HRDecimalHour
07L2110C_xx_EB07_DAYDecimalDay
07L2110C_xx_EB07_24_HRDecimal24 Hours
07L2110C_xx_EB07_YEARSDecimalYears
07L2110C_xx_EB07_SVC_YRDecimalService Year
07L2110C_xx_EB07_CAL_YEARDecimalCalendar Year
07L2110C_xx_EB07_YTDDecimalYear to Date
07L2110C_xx_EB07_CNTRCTDecimalContract
07L2110C_xx_EB07_EPISDDecimalEpisode
07L2110C_xx_EB07_VISTDecimalVisit
07L2110C_xx_EB07_OUTLIERDecimalOutlier
07L2110C_xx_EB07_REMNGDecimalRemaining
07L2110C_xx_EB07_EXCEEDDecimalExceeded
07L2110C_xx_EB07_NOT_XCDEDDecimalNot Exceeded
07L2110C_xx_EB07_LFTMDecimalLifetime
07L2110C_xx_EB07_LFTM_REMDecimalLifetime Remaining
07L2110C_xx_EB07_MODecimalMonth
07L2110C_xx_EB07_WKDecimalWeek
07L2110C_xx_EB07_ADMSNDecimalAdmission
08L2110C_xx_EB08_BENE_PRCNTDecimalBenefit Percent
10L2110C_xx_EB10_MINDecimalMinimum
10L2110C_xx_EB10_QTY_USEDDecimalQuantity Used
10L2110C_xx_EB10_COVD_ACTLDecimalCovered - Actual
10L2110C_xx_EB10_COVD_ESTDecimalCovered - Estimated
10L2110C_xx_EB10_NR_COINS_DYSDecimalNumber of Co-insurance Days
10L2110C_xx_EB10_DED_BLOOD_UNDecimalDeductible Blood Units
10L2110C_xx_EB10_DAYSDecimalDays
10L2110C_xx_EB10_HRDecimalHours
10L2110C_xx_EB10_LFTM_RSRV_ACTLDecimalLife-time Reserve - Actual
10L2110C_xx_EB10_LFTM_RSRV_ESTDecimalLife-time Reserve - Estimated
10L2110C_xx_EB10_MAXDecimalMaximum
10L2110C_xx_EB10_MODecimalMonth
10L2110C_xx_EB10_NR_SVC_PROCDecimalNumber of Services or Procedures
10L2110C_xx_EB10_QTY_APPRDecimalQuantity Approved
10L2110C_xx_EB10_AGE_HIVALDecimalAge, High Value
10L2110C_xx_EB10_AGE_LOVALDecimalAge, Low Value
10L2110C_xx_EB10_VISTDecimalVisits
10L2110C_xx_EB10_YEARSDecimalYears
11L2110C_xx_EB11_AUTH_CERT_INDStringAuthorization or Certification Indicator
12L2110C_xx_EB12_INPLAN_NET_INDStringIn Plan Network Indicator
1302L2110C_xx_EB1302_ADA_CDStringAmerican Dental Association Codes
1302L2110C_xx_EB1302_CPT_CDStringCurrent Procedural Terminology (CPT) Codes
1302L2110C_xx_EB1302_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
1302L2110C_xx_EB1302_ICD9_PROCStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure
1302L2110C_xx_EB1302_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
1302L2110C_xx_EB1302_NDC542StringNational Drug Code in 5-4-2 Format
1302L2110C_xx_EB1302_MUTLY_DEFStringMutually Defined
1303L2110C_xx_EB1303_PROC_MODStringProcedure Modifier
1304L2110C_xx_EB1304_PROC_MODStringProcedure Modifier
1305L2110C_xx_EB1305_PROC_MODStringProcedure Modifier
1306L2110C_xx_EB1306_PROC_MODStringProcedure Modifier
1308L2110C_xx_EB1308_PROD_SVC_IDStringProduct or Service ID
1401L2110C_xx_EB1401_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1402L2110C_xx_EB1402_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1403L2110C_xx_EB1403_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1404L2110C_xx_EB1404_DIAG_CD_PTRIntegerDiagnosis Code Pointer
L2110CHSDHealth Care Services Delivery Iterated: [01-09]
02L2110C_xx_nnHSD02_DAYSDecimalDays
02L2110C_xx_nnHSD02_UNDecimalUnits
02L2110C_xx_nnHSD02_HRDecimalHours
02L2110C_xx_nnHSD02_MODecimalMonth
02L2110C_xx_nnHSD02_VISTDecimalVisits
04L2110C_xx_nnHSD04_DAYSDecimalDays
04L2110C_xx_nnHSD04_MOSDecimalMonths
04L2110C_xx_nnHSD04_VISTDecimalVisit
04L2110C_xx_nnHSD04_WKDecimalWeek
04L2110C_xx_nnHSD04_YEARSDecimalYears
06L2110C_xx_nnHSD06_HRIntegerHour
06L2110C_xx_nnHSD06_DAYIntegerDay
06L2110C_xx_nnHSD06_YEARSIntegerYears
06L2110C_xx_nnHSD06_SVC_YRIntegerService Year
06L2110C_xx_nnHSD06_CAL_YEARIntegerCalendar Year
06L2110C_xx_nnHSD06_YTDIntegerYear to Date
06L2110C_xx_nnHSD06_CNTRCTIntegerContract
06L2110C_xx_nnHSD06_EPISDIntegerEpisode
06L2110C_xx_nnHSD06_VISTIntegerVisit
06L2110C_xx_nnHSD06_OUTLIERIntegerOutlier
06L2110C_xx_nnHSD06_REMNGIntegerRemaining
06L2110C_xx_nnHSD06_EXCEEDIntegerExceeded
06L2110C_xx_nnHSD06_NOT_XCDEDIntegerNot Exceeded
06L2110C_xx_nnHSD06_LFTMIntegerLifetime
06L2110C_xx_nnHSD06_LFTM_REMIntegerLifetime Remaining
06L2110C_xx_nnHSD06_MOIntegerMonth
06L2110C_xx_nnHSD06_WKIntegerWeek
07L2110C_xx_nnHSD07_DLVY_FREQ_CDStringDelivery Frequency Code
08L2110C_xx_nnHSD08_DVY_PT_TM_CDStringDelivery Pattern Time Code
L2110CREFSubscriber Additional Identification Iterated: [01-09]
02L2110C_xx_nnREF_PLAN_NRStringPlan Number
02L2110C_xx_nnREF_GRP_POLCY_NRStringGroup or Policy Number
02L2110C_xx_nnREF_MEM_IDStringMember Identification Number
02L2110C_xx_nnREF_FAM_UNT_NRStringFamily Unit Number
02L2110C_xx_nnREF_GRP_NRStringGroup Number
02L2110C_xx_nnREF_REFRL_NRStringReferral Number
02L2110C_xx_nnREF_ALTN_LIST_IDStringAlternative List ID
02L2110C_xx_nnREF_COVG_LST_IDStringCoverage List ID
02L2110C_xx_nnREF_HIC_NRStringHealth Insurance Claim (HIC) Number
02L2110C_xx_nnREF_DRUG_FML_NRStringDrug Formulary Number
02L2110C_xx_nnREF_PRIOR_AUTHStringPrior Authorization Number
02L2110C_xx_nnREF_INS_PLCY_NRStringInsurance Policy Number
02L2110C_xx_nnREF_MDCL_ASST_CATStringMedical Assistance Category
02L2110C_xx_nnREF_PLN_NET_IDStringPlan Network Identification Number
02L2110C_xx_nnREF_MDCD_ID_NRStringMedicaid Recipient Identification Number
03L2110C_xx_nnREF03_PLN_GRPNT_NMStringPlan, Group or Plan Network Name
L2110CDTPSubscriber Eligibility/Benefit Date
03L2110C_xx_DTP_DISCHG_D8Start DateDischarge (D8)
03L2110C_xx_DTP_DISCHG_RD8_1Start DateDischarge (D8)
03L2110C_xx_DTP_DISCHG_RD8_2End DateDischarge (D8)
03L2110C_xx_DTP_PRD_STRT_D8Start DatePeriod Start (D8)
03L2110C_xx_DTP_PRD_STRT_RD8_1Start DatePeriod Start (D8)
03L2110C_xx_DTP_PRD_STRT_RD8_2End DatePeriod Start (D8)
03L2110C_xx_DTP_PRD_END_D8Start DatePeriod End (D8)
03L2110C_xx_DTP_PRD_END_RD8_1Start DatePeriod End (D8)
03L2110C_xx_DTP_PRD_END_RD8_2End DatePeriod End (D8)
03L2110C_xx_DTP_CMPLTN_D8Start DateCompletion (D8)
03L2110C_xx_DTP_CMPLTN_RD8_1Start DateCompletion (D8)
03L2110C_xx_DTP_CMPLTN_RD8_2End DateCompletion (D8)
03L2110C_xx_DTP_COB_D8Start DateCoordination of Benefits (D8)
03L2110C_xx_DTP_COB_RD8_1Start DateCoordination of Benefits (D8)
03L2110C_xx_DTP_COB_RD8_2End DateCoordination of Benefits (D8)
03L2110C_xx_DTP_PLAN_D8Start DatePlan (D8)
03L2110C_xx_DTP_PLAN_RD8_1Start DatePlan (D8)
03L2110C_xx_DTP_PLAN_RD8_2End DatePlan (D8)
03L2110C_xx_DTP_BENFT_D8Start DateBenefit (D8)
03L2110C_xx_DTP_BENFT_RD8_1Start DateBenefit (D8)
03L2110C_xx_DTP_BENFT_RD8_2End DateBenefit (D8)
03L2110C_xx_DTP_PCP_D8Start DatePrimary Care Provider (D8)
03L2110C_xx_DTP_PCP_RD8_1Start DatePrimary Care Provider (D8)
03L2110C_xx_DTP_PCP_RD8_2End DatePrimary Care Provider (D8)
03L2110C_xx_DTP_LAST_VST_D8Start DateLatest Visit or Consultation (D8)
03L2110C_xx_DTP_LAST_VST_RD8_1Start DateLatest Visit or Consultation (D8)
03L2110C_xx_DTP_LAST_VST_RD8_2End DateLatest Visit or Consultation (D8)
03L2110C_xx_DTP_ELIG_D8Start DateEligibility (D8)
03L2110C_xx_DTP_ELIG_RD8_1Start DateEligibility (D8)
03L2110C_xx_DTP_ELIG_RD8_2End DateEligibility (D8)
03L2110C_xx_DTP_ADDED_D8Start DateAdded (D8)
03L2110C_xx_DTP_ADDED_RD8_1Start DateAdded (D8)
03L2110C_xx_DTP_ADDED_RD8_2End DateAdded (D8)
03L2110C_xx_DTP_PLAN_BGN_D8Start DatePlan Begin (D8)
03L2110C_xx_DTP_PLAN_BGN_RD8_1Start DatePlan Begin (D8)
03L2110C_xx_DTP_PLAN_BGN_RD8_2End DatePlan Begin (D8)
03L2110C_xx_DTP_BNFT_BGN_D8Start DateBenefit Begin (D8)
03L2110C_xx_DTP_BNFT_BGN_RD8_1Start DateBenefit Begin (D8)
03L2110C_xx_DTP_BNFT_BGN_RD8_2End DateBenefit Begin (D8)
03L2110C_xx_DTP_BNFT_END_D8Start DateBenefit End (D8)
03L2110C_xx_DTP_BNFT_END_RD8_1Start DateBenefit End (D8)
03L2110C_xx_DTP_BNFT_END_RD8_2End DateBenefit End (D8)
03L2110C_xx_DTP_ELIG_BGN_D8Start DateEligibility Begin (D8)
03L2110C_xx_DTP_ELIG_BGN_RD8_1Start DateEligibility Begin (D8)
03L2110C_xx_DTP_ELIG_BGN_RD8_2End DateEligibility Begin (D8)
03L2110C_xx_DTP_ELIG_END_D8Start DateEligibility End (D8)
03L2110C_xx_DTP_ELIG_END_RD8_1Start DateEligibility End (D8)
03L2110C_xx_DTP_ELIG_END_RD8_2End DateEligibility End (D8)
03L2110C_xx_DTP_ADMSN_D8Start DateAdmission (D8)
03L2110C_xx_DTP_ADMSN_RD8_1Start DateAdmission (D8)
03L2110C_xx_DTP_ADMSN_RD8_2End DateAdmission (D8)
03L2110C_xx_DTP_SVC_D8Start DateService (D8)
03L2110C_xx_DTP_SVC_RD8_1Start DateService (D8)
03L2110C_xx_DTP_SVC_RD8_2End DateService (D8)
03L2110C_xx_DTP_LAST_UPDT_D8Start DateDate of Last Update (D8)
03L2110C_xx_DTP_LAST_UPDT_RD8_1Start DateDate of Last Update (D8)
03L2110C_xx_DTP_LAST_UPDT_RD8_2End DateDate of Last Update (D8)
03L2110C_xx_DTP_STATS_D8Start DateStatus (D8)
03L2110C_xx_DTP_STATS_RD8_1Start DateStatus (D8)
03L2110C_xx_DTP_STATS_RD8_2End DateStatus (D8)
L2110CAAASubscriber Request Validation Iterated: [01-09]
01L2110C_xx_nnAAA01_VLDREQ_INDStringValid Request Indicator
03L2110C_xx_nnAAA03_REJ_RSN_CDStringReject Reason Code
04L2110C_xx_nnAAA04_FWUP_ACTCDStringFollow-up Action Code
L2110CMSGMessage Text Iterated: [01-10]
01L2110C_xx_nnMSG01_FRFM_MSG_TXTStringFree Form Message Text
L2110CIIISubscriber Eligibility or Benefit Additional Information Iterated: [01-10]
L2110CLSLoop Header
01L2110C_xx_LS01_LOOP_ID_CDStringLoop Identifier Code
L2120C - SUBSCRIBER BENEFIT RELATED ENTITY NAME (Inherited Loop Iteration & Value Qualified)
Mapping Prefix: L2120C_xx13 - Contracted Service Provider
Mapping Prefix: L2120C_xx1I - Preferred Provider Organization (PPO)
Mapping Prefix: L2120C_xx1P - Provider
Mapping Prefix: L2120C_xx2B - Third-Party Administrator
Mapping Prefix: L2120C_xx36 - Employer
Mapping Prefix: L2120C_xx73 - Other Physician
Mapping Prefix: L2120C_xxFA - Facility
Mapping Prefix: L2120C_xxGP - Gateway Provider
Mapping Prefix: L2120C_xxGW - Group
Mapping Prefix: L2120C_xxI3 - Independent Physicians Association (IPA)
Mapping Prefix: L2120C_xxIL - Insured or Subscriber
Mapping Prefix: L2120C_xxLR - Legal Representative
Mapping Prefix: L2120C_xxOC - Origin Carrier
Mapping Prefix: L2120C_xxP3 - Primary Care Provider
Mapping Prefix: L2120C_xxP4 - Prior Insurance Carrier
Mapping Prefix: L2120C_xxP5 - Plan Sponsor
Mapping Prefix: L2120C_xxPR - Payer
Mapping Prefix: L2120C_xxPRP - Primary Payer
Mapping Prefix: L2120C_xxSEP - Secondary Payer
Mapping Prefix: L2120C_xxTTP - Tertiary Payer
Mapping Prefix: L2120C_xxVN - Vendor
Mapping Prefix: L2120C_xxVY - Organization Completing Configuration Change
Mapping Prefix: L2120C_xxX3 - Utilization Management Organization
Mapping Prefix: L2120C_xxVER - Party Performing Verification
Mapping Prefix: L2120C_xxY2 - Managed Care Organization
L2120CNM1Subscriber Benefit Related Entity Name
02L2120C_xxyy_NM102_ENT_TYP_QUALStringEntity Type Qualifier
03L2120C_xxyy_NM103_BNRL_LNMStringBenefit Related Entity Last or Organization Name
04L2120C_xxyy_NM104_BNRL_ENT_FNMStringBenefit Related Entity First Name
05L2120C_xxyy_NM105_BNRL_ENT_MNMStringBenefit Related Entity Middle Name
07L2120C_xxyy_NM107_BNRL_ENT_SFXStringBenefit Related Entity Name Suffix
09L2120C_xxyy_NM109_EMPLYR_IDStringEmployer?s Identification Number
09L2120C_xxyy_NM109_SSNStringSocial Security Number
09L2120C_xxyy_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
09L2120C_xxyy_NM109_FACLTY_IDStringFacility Identification
09L2120C_xxyy_NM109_TAX_IDStringFederal Taxpayer?s Identification Number
09L2120C_xxyy_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2120C_xxyy_NM109_MEM_ID_NRStringMember Identification Number
09L2120C_xxyy_NM109_NAIC_IDStringNational Association of Insurance Commissioners
09L2120C_xxyy_NM109_PAYR_IDStringPayor Identification
09L2120C_xxyy_NM109_PHM_PRCSR_NRStringPharmacy Processor Number
09L2120C_xxyy_NM109_SVC_PROV_NRStringService Provider Number
09L2120C_xxyy_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
09L2120C_xxyy_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
10L2120C_xxyy_NM110_BNRL_ETY_RELStringBenefit Related Entity Relationship Code
L2120CN3Subscriber Benefit Related Entity Address
01L2120C_xxyy_N301_BNRL_ENT_ADDRStringBenefit Related Entity Address Line
02L2120C_xxyy_N302_BNRL_ENT_ADDRStringBenefit Related Entity Address Line
L2120CN4Subscriber Benefit Related Entity City, State, ZIP Code
01L2120C_xxyy_N401_BNRL_ENT_CITYStringBenefit Related Entity City Name
02L2120C_xxyy_N402_BNRL_ENT_STATStringBenefit Related Entity State Code
03L2120C_xxyy_N403_BNRL_ENTY_ZIPStringBenefit Related Entity Postal Zone or ZIP Code
04L2120C_xxyy_N404_BNRL_CNTRY_CDStringBenefit Related Entity Country Code
06L2120C_xxyy_N406_BENDOD_HLTRGNStringBenefit Related Entity DOD Health Service Region
07L2120C_xxyy_N407_BNRL_CTY_SBRStringBenefit Related Entity Country Subdivision Code
L2120CPERSubscriber Benefit Related Entity Contact Information Iterated: [01-03]
02L2120C_xxyy_nnPER02_BNRL_CONStringBenefit Related Entity Contact Name
04L2120C_xxyy_nnPER04_EDI_ACS_NRStringElectronic Data Interchange Access Number
04L2120C_xxyy_nnPER04_EMAILStringElectronic Mail
04L2120C_xxyy_nnPER04_FAXStringFacsimile
04L2120C_xxyy_nnPER04_PHN_NRStringTelephone
04L2120C_xxyy_nnPER04_URLStringUniform Resource Locator (URL)
04L2120C_xxyy_nnPER04_WRK_PHN_NRStringWork Phone Number
06L2120C_xxyy_nnPER06_EDI_ACS_NRStringElectronic Data Interchange Access Number
06L2120C_xxyy_nnPER06_EMAILStringElectronic Mail
06L2120C_xxyy_nnPER06_PHN_EXTStringTelephone Extension
06L2120C_xxyy_nnPER06_FAXStringFacsimile
06L2120C_xxyy_nnPER06_PHN_NRStringTelephone
06L2120C_xxyy_nnPER06_URLStringUniform Resource Locator (URL)
06L2120C_xxyy_nnPER06_WRK_PHN_NRStringWork Phone Number
08L2120C_xxyy_nnPER08_EDI_ACS_NRStringElectronic Data Interchange Access Number
08L2120C_xxyy_nnPER08_EMAILStringElectronic Mail
08L2120C_xxyy_nnPER08_PHN_EXTStringTelephone Extension
08L2120C_xxyy_nnPER08_FAXStringFacsimile
08L2120C_xxyy_nnPER08_PHN_NRStringTelephone
08L2120C_xxyy_nnPER08_URLStringUniform Resource Locator (URL)
08L2120C_xxyy_nnPER08_WRK_PHN_NRStringWork Phone Number
L2120CPRVSubscriber Benefit Related Provider Information
01L2120C_xxyy_PRV01_PVD_CDStringProvider Code
03L2120C_xxyy_PRV03_BNRL_PVR_TAXStringBenefit Related Entity Provider Taxnonomy Code

L2110CLELoop Trailer
01L2110C_xx_LE01_LOOP_ID_CDStringLoop Identifier Code
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: [01-03]
01L2000D_nnTRN01_TRAC_TYP_CDStringTrace Type Code
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 Segment Suffix:
Iterated: [01-09]
02L2100D_nnREFB_PLAN_NRStringPlan Number
02L2100D_nnREFB_GRP_POLCY_NRStringGroup or Policy Number
02L2100D_nnREFB_FAM_UNT_NRStringFamily Unit Number
02L2100D_nnREFB_GRP_NRStringGroup Number
02L2100D_nnREFB_CNTRCT_NRStringContract Number
02L2100D_nnREFB_MED_REC_IDStringMedical Record Identification Number
02L2100D_nnREFB_PATNT_ACCT_NRStringPatient Account Number
02L2100D_nnREFB_HIC_NRStringHealth Insurance Claim (HIC) Number
02L2100D_nnREFB_ID_SERL_NRStringIdentification Card Serial Number
02L2100D_nnREFB_ID_CRD_NRStringIdentity Card Number
02L2100D_nnREFB_ISSU_NRStringIssue Number
02L2100D_nnREFB_INS_PLCY_NRStringInsurance Policy Number
02L2100D_nnREFB_ELIG_CATStringEligibility Category
02L2100D_nnREFB_PLN_NET_IDStringPlan Network Identification Number
02L2100D_nnREFB_MDCD_ID_NRStringMedicaid Recipient Identification Number
02L2100D_nnREFB_PRIOR_IDStringPrior Identifier Number
02L2100D_nnREFB_SSNStringSocial Security Number
02L2100D_nnREFB_AGNCY_CLM_NRStringAgency Claim Number
03L2100D_nnREFB03_PLN_GRPNT_NMStringPlan, Group or Plan Network Name
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_DEP_CNTRY_CDStringDependent Country Code
07L2100D_N407_DEP_CNTRY_SBR_CDStringDependent Country Subdivision Code
L2100DAAADependent Request Validation Iterated: [01-09]
01L2100D_nnAAA01_VLDREQ_INDStringValid Request Indicator
03L2100D_nnAAA03_REJ_RSN_CDStringReject Reason Code
04L2100D_nnAAA04_FWUP_ACTCDStringFollow-up Action Code
L2100DPRVProvider Information
01L2100D_PRV01_PVD_CDStringProvider Code
03L2100D_PRV03_PVR_IDStringProvider Identifier
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
03L2100D_INS03_MAINT_TYP_CDStringMaintenance Type Code
04L2100D_INS04_MAINT_RSN_CDStringMaintenance Reason 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_DISCHG_D8Start DateDischarge (D8)
03L2100D_DTP_DISCHG_RD8_1Start DateDischarge (D8)
03L2100D_DTP_DISCHG_RD8_2End DateDischarge (D8)
03L2100D_DTP_ISSU_D8Start DateIssue (D8)
03L2100D_DTP_ISSU_RD8_1Start DateIssue (D8)
03L2100D_DTP_ISSU_RD8_2End DateIssue (D8)
03L2100D_DTP_CHG_EFF_D8Start DateEffective Date of Change (D8)
03L2100D_DTP_CHG_EFF_RD8_1Start DateEffective Date of Change (D8)
03L2100D_DTP_CHG_EFF_RD8_2End DateEffective Date of Change (D8)
03L2100D_DTP_PLAN_D8Start DatePlan (D8)
03L2100D_DTP_PLAN_RD8_1Start DatePlan (D8)
03L2100D_DTP_PLAN_RD8_2End DatePlan (D8)
03L2100D_DTP_ELIG_D8Start DateEligibility (D8)
03L2100D_DTP_ELIG_RD8_1Start DateEligibility (D8)
03L2100D_DTP_ELIG_RD8_2End DateEligibility (D8)
03L2100D_DTP_ADDED_D8Start DateAdded (D8)
03L2100D_DTP_ADDED_RD8_1Start DateAdded (D8)
03L2100D_DTP_ADDED_RD8_2End DateAdded (D8)
03L2100D_DTP_COBRA_BGN_D8Start DateConsolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8)
03L2100D_DTP_COBRA_BGN_RD8_1Start DateConsolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8)
03L2100D_DTP_COBRA_BGN_RD8_2End DateConsolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8)
03L2100D_DTP_COBRA_END_D8Start DateConsolidated Omnibus Budget Reconciliation Act (COBRA) End (D8)
03L2100D_DTP_COBRA_END_RD8_1Start DateConsolidated Omnibus Budget Reconciliation Act (COBRA) End (D8)
03L2100D_DTP_COBRA_END_RD8_2End DateConsolidated Omnibus Budget Reconciliation Act (COBRA) End (D8)
03L2100D_DTP_PRM_PD_BGN_D8Start DatePremium Paid to Date Begin (D8)
03L2100D_DTP_PRM_PD_BGN_RD8_1Start DatePremium Paid to Date Begin (D8)
03L2100D_DTP_PRM_PD_BGN_RD8_2End DatePremium Paid to Date Begin (D8)
03L2100D_DTP_PRM_PD_END_D8Start DatePremium Paid to Date End (D8)
03L2100D_DTP_PRM_PD_END_RD8_1Start DatePremium Paid to Date End (D8)
03L2100D_DTP_PRM_PD_END_RD8_2End DatePremium Paid to Date End (D8)
03L2100D_DTP_PLAN_BGN_D8Start DatePlan Begin (D8)
03L2100D_DTP_PLAN_BGN_RD8_1Start DatePlan Begin (D8)
03L2100D_DTP_PLAN_BGN_RD8_2End DatePlan Begin (D8)
03L2100D_DTP_PLAN_END_D8Start DatePlan End (D8)
03L2100D_DTP_PLAN_END_RD8_1Start DatePlan End (D8)
03L2100D_DTP_PLAN_END_RD8_2End DatePlan End (D8)
03L2100D_DTP_ELIG_BGN_D8Start DateEligibility Begin (D8)
03L2100D_DTP_ELIG_BGN_RD8_1Start DateEligibility Begin (D8)
03L2100D_DTP_ELIG_BGN_RD8_2End DateEligibility Begin (D8)
03L2100D_DTP_ELIG_END_D8Start DateEligibility End (D8)
03L2100D_DTP_ELIG_END_RD8_1Start DateEligibility End (D8)
03L2100D_DTP_ELIG_END_RD8_2End DateEligibility End (D8)
03L2100D_DTP_ENRLL_D8Start DateEnrollment (D8)
03L2100D_DTP_ENRLL_RD8_1Start DateEnrollment (D8)
03L2100D_DTP_ENRLL_RD8_2End DateEnrollment (D8)
03L2100D_DTP_ADMSN_D8Start DateAdmission (D8)
03L2100D_DTP_ADMSN_RD8_1Start DateAdmission (D8)
03L2100D_DTP_ADMSN_RD8_2End DateAdmission (D8)
03L2100D_DTP_DEATH_D8Start DateDate of Death (D8)
03L2100D_DTP_DEATH_RD8_1Start DateDate of Death (D8)
03L2100D_DTP_DEATH_RD8_2End DateDate of Death (D8)
03L2100D_DTP_CERT_D8Start DateCertification (D8)
03L2100D_DTP_CERT_RD8_1Start DateCertification (D8)
03L2100D_DTP_CERT_RD8_2End DateCertification (D8)
03L2100D_DTP_SVC_D8Start DateService (D8)
03L2100D_DTP_SVC_RD8_1Start DateService (D8)
03L2100D_DTP_SVC_RD8_2End DateService (D8)
03L2100D_DTP_PLCY_EFF_D8Start DatePolicy Effective (D8)
03L2100D_DTP_PLCY_EFF_RD8_1Start DatePolicy Effective (D8)
03L2100D_DTP_PLCY_EFF_RD8_2End DatePolicy Effective (D8)
03L2100D_DTP_PLCY_EXP_D8Start DatePolicy Expiration (D8)
03L2100D_DTP_PLCY_EXP_RD8_1Start DatePolicy Expiration (D8)
03L2100D_DTP_PLCY_EXP_RD8_2End DatePolicy Expiration (D8)
03L2100D_DTP_LAST_UPDT_D8Start DateDate of Last Update (D8)
03L2100D_DTP_LAST_UPDT_RD8_1Start DateDate of Last Update (D8)
03L2100D_DTP_LAST_UPDT_RD8_2End DateDate of Last Update (D8)
03L2100D_DTP_STATS_D8Start DateStatus (D8)
03L2100D_DTP_STATS_RD8_1Start DateStatus (D8)
03L2100D_DTP_STATS_RD8_2End DateStatus (D8)
L2100DMPIDependent Military Personnel Information
01L2100D_MPI01_NFO_STAT_CDStringInformation Status Code
02L2100D_MPI02_EMPMT_STAT_CDStringEmployment Status Code
03L2100D_MPI03_GOV_SVC_AFF_CDStringGovernment Service Affiliation Code
04L2100D_MPI04_DESCRStringDescription
05L2100D_MPI05_MIL_SVC_RNK_CDStringMilitary Service Rank Code
07L2100D_MPI07_D8StringDate Expressed in Format CCYYMMDD
07L2100D_MPI07_RD8StringRange of Dates Expressed in Format CCYYMMDD- CCYYMMDD
L2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION
L2110DEBDependent Eligibility or Benefit Information
01L2110D_EB01_Enn_ELIG_BEN_NFOStringEligibility or Benefit Information
02L2110D_EB02_BENE_COV_LVL_CDStringBenefit Coverage Level Code
03L2110D_EB03_Enn_SVC_TYP_CDStringService Type Code
04L2110D_EB04_INS_TYP_CDStringInsurance Type Code
05L2110D_EB05_PLN_CVG_DSCStringPlan Coverage Description
07L2110D_EB07_HRDecimalHour
07L2110D_EB07_DAYDecimalDay
07L2110D_EB07_24_HRDecimal24 Hours
07L2110D_EB07_YEARSDecimalYears
07L2110D_EB07_SVC_YRDecimalService Year
07L2110D_EB07_CAL_YEARDecimalCalendar Year
07L2110D_EB07_YTDDecimalYear to Date
07L2110D_EB07_CNTRCTDecimalContract
07L2110D_EB07_EPISDDecimalEpisode
07L2110D_EB07_VISTDecimalVisit
07L2110D_EB07_OUTLIERDecimalOutlier
07L2110D_EB07_REMNGDecimalRemaining
07L2110D_EB07_EXCEEDDecimalExceeded
07L2110D_EB07_NOT_XCDEDDecimalNot Exceeded
07L2110D_EB07_LFTMDecimalLifetime
07L2110D_EB07_LFTM_REMDecimalLifetime Remaining
07L2110D_EB07_MODecimalMonth
07L2110D_EB07_WKDecimalWeek
07L2110D_EB07_ADMSNDecimalAdmission
08L2110D_EB08_BENE_PRCNTDecimalBenefit Percent
10L2110D_EB10_MINDecimalMinimum
10L2110D_EB10_QTY_USEDDecimalQuantity Used
10L2110D_EB10_COVD_ACTLDecimalCovered - Actual
10L2110D_EB10_COVD_ESTDecimalCovered - Estimated
10L2110D_EB10_NR_COINS_DYSDecimalNumber of Co-insurance Days
10L2110D_EB10_DED_BLOOD_UNDecimalDeductible Blood Units
10L2110D_EB10_DAYSDecimalDays
10L2110D_EB10_HRDecimalHours
10L2110D_EB10_LFTM_RSRV_ACTLDecimalLife-time Reserve - Actual
10L2110D_EB10_LFTM_RSRV_ESTDecimalLife-time Reserve - Estimated
10L2110D_EB10_MAXDecimalMaximum
10L2110D_EB10_MODecimalMonth
10L2110D_EB10_NR_SVC_PROCDecimalNumber of Services or Procedures
10L2110D_EB10_QTY_APPRDecimalQuantity Approved
10L2110D_EB10_AGE_HIVALDecimalAge, High Value
10L2110D_EB10_AGE_LOVALDecimalAge, Low Value
10L2110D_EB10_VISTDecimalVisits
10L2110D_EB10_YEARSDecimalYears
11L2110D_EB11_AUTH_CERT_INDStringAuthorization or Certification Indicator
12L2110D_EB12_INPLAN_NET_INDStringIn Plan Network Indicator
1302L2110D_EB1302_ADA_CDStringAmerican Dental Association Codes
1302L2110D_EB1302_CPT_CDStringCurrent Procedural Terminology (CPT) Codes
1302L2110D_EB1302_HCPCS_CDStringHealth Care Financing Administration Common Procedural Coding System (HCPCS) Codes
1302L2110D_EB1302_ICD9_PROCStringInternational Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure
1302L2110D_EB1302_HIC_PRD_SVCCDStringHome Infusion EDI Coalition (HIEC) Product/Service Code
1302L2110D_EB1302_NDC542StringNational Drug Code in 5-4-2 Format
1302L2110D_EB1302_MUTLY_DEFStringMutually Defined
1303L2110D_EB1303_PROC_MODStringProcedure Modifier
1304L2110D_EB1304_PROC_MODStringProcedure Modifier
1305L2110D_EB1305_PROC_MODStringProcedure Modifier
1306L2110D_EB1306_PROC_MODStringProcedure Modifier
1308L2110D_EB1308_PROD_SVC_IDStringProduct or Service ID
1401L2110D_EB1401_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1402L2110D_EB1402_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1403L2110D_EB1403_DIAG_CD_PTRIntegerDiagnosis Code Pointer
1404L2110D_EB1404_DIAG_CD_PTRIntegerDiagnosis Code Pointer
L2110DHSDHealth Care Services Delivery Iterated: [01-09]
02L2110D_nnHSD02_DAYSDecimalDays
02L2110D_nnHSD02_UNDecimalUnits
02L2110D_nnHSD02_HRDecimalHours
02L2110D_nnHSD02_MODecimalMonth
02L2110D_nnHSD02_VISTDecimalVisits
04L2110D_nnHSD04_DAYSDecimalDays
04L2110D_nnHSD04_MOSDecimalMonths
04L2110D_nnHSD04_VISTDecimalVisit
04L2110D_nnHSD04_WKDecimalWeek
04L2110D_nnHSD04_YEARSDecimalYears
06L2110D_nnHSD06_HRIntegerHour
06L2110D_nnHSD06_DAYIntegerDay
06L2110D_nnHSD06_YEARSIntegerYears
06L2110D_nnHSD06_SVC_YRIntegerService Year
06L2110D_nnHSD06_CAL_YEARIntegerCalendar Year
06L2110D_nnHSD06_YTDIntegerYear to Date
06L2110D_nnHSD06_CNTRCTIntegerContract
06L2110D_nnHSD06_EPISDIntegerEpisode
06L2110D_nnHSD06_VISTIntegerVisit
06L2110D_nnHSD06_OUTLIERIntegerOutlier
06L2110D_nnHSD06_REMNGIntegerRemaining
06L2110D_nnHSD06_EXCEEDIntegerExceeded
06L2110D_nnHSD06_NOT_XCDEDIntegerNot Exceeded
06L2110D_nnHSD06_LFTMIntegerLifetime
06L2110D_nnHSD06_LFTM_REMIntegerLifetime Remaining
06L2110D_nnHSD06_MOIntegerMonth
06L2110D_nnHSD06_WKIntegerWeek
07L2110D_nnHSD07_DLVY_FREQ_CDStringDelivery Frequency Code
08L2110D_nnHSD08_DVY_PT_TM_CDStringDelivery Pattern Time Code
L2110DREFDependent Additional Identification Iterated: [01-09]
02L2110D_nnREF_PLAN_NRStringPlan Number
02L2110D_nnREF_GRP_POLCY_NRStringGroup or Policy Number
02L2110D_nnREF_MEM_IDStringMember Identification Number
02L2110D_nnREF_FAM_UNT_NRStringFamily Unit Number
02L2110D_nnREF_GRP_NRStringGroup Number
02L2110D_nnREF_REFRL_NRStringReferral Number
02L2110D_nnREF_ALTN_LIST_IDStringAlternative List ID
02L2110D_nnREF_COVG_LST_IDStringCoverage List ID
02L2110D_nnREF_HIC_NRStringHealth Insurance Claim (HIC) Number
02L2110D_nnREF_DRUG_FML_NRStringDrug Formulary Number
02L2110D_nnREF_PRIOR_AUTHStringPrior Authorization Number
02L2110D_nnREF_INS_PLCY_NRStringInsurance Policy Number
02L2110D_nnREF_PLN_NET_IDStringPlan Network Identification Number
02L2110D_nnREF_MDCD_ID_NRStringMedicaid Recipient Identification Number
03L2110D_nnREF03_PLN_GRPNT_NMStringPlan, Group or Plan Network Name
L2110DDTPDependent Eligibility/Benefit Date
03L2110D_DTP_DISCHG_D8Start DateDischarge (D8)
03L2110D_DTP_DISCHG_RD8_1Start DateDischarge (D8)
03L2110D_DTP_DISCHG_RD8_2End DateDischarge (D8)
03L2110D_DTP_PRD_STRT_D8Start DatePeriod Start (D8)
03L2110D_DTP_PRD_STRT_RD8_1Start DatePeriod Start (D8)
03L2110D_DTP_PRD_STRT_RD8_2End DatePeriod Start (D8)
03L2110D_DTP_PRD_END_D8Start DatePeriod End (D8)
03L2110D_DTP_PRD_END_RD8_1Start DatePeriod End (D8)
03L2110D_DTP_PRD_END_RD8_2End DatePeriod End (D8)
03L2110D_DTP_CMPLTN_D8Start DateCompletion (D8)
03L2110D_DTP_CMPLTN_RD8_1Start DateCompletion (D8)
03L2110D_DTP_CMPLTN_RD8_2End DateCompletion (D8)
03L2110D_DTP_COB_D8Start DateCoordination of Benefits (D8)
03L2110D_DTP_COB_RD8_1Start DateCoordination of Benefits (D8)
03L2110D_DTP_COB_RD8_2End DateCoordination of Benefits (D8)
03L2110D_DTP_PLAN_D8Start DatePlan (D8)
03L2110D_DTP_PLAN_RD8_1Start DatePlan (D8)
03L2110D_DTP_PLAN_RD8_2End DatePlan (D8)
03L2110D_DTP_BENFT_D8Start DateBenefit (D8)
03L2110D_DTP_BENFT_RD8_1Start DateBenefit (D8)
03L2110D_DTP_BENFT_RD8_2End DateBenefit (D8)
03L2110D_DTP_PCP_D8Start DatePrimary Care Provider (D8)
03L2110D_DTP_PCP_RD8_1Start DatePrimary Care Provider (D8)
03L2110D_DTP_PCP_RD8_2End DatePrimary Care Provider (D8)
03L2110D_DTP_LAST_VST_D8Start DateLatest Visit or Consultation (D8)
03L2110D_DTP_LAST_VST_RD8_1Start DateLatest Visit or Consultation (D8)
03L2110D_DTP_LAST_VST_RD8_2End DateLatest Visit or Consultation (D8)
03L2110D_DTP_ELIG_D8Start DateEligibility (D8)
03L2110D_DTP_ELIG_RD8_1Start DateEligibility (D8)
03L2110D_DTP_ELIG_RD8_2End DateEligibility (D8)
03L2110D_DTP_ADDED_D8Start DateAdded (D8)
03L2110D_DTP_ADDED_RD8_1Start DateAdded (D8)
03L2110D_DTP_ADDED_RD8_2End DateAdded (D8)
03L2110D_DTP_PLAN_BGN_D8Start DatePlan Begin (D8)
03L2110D_DTP_PLAN_BGN_RD8_1Start DatePlan Begin (D8)
03L2110D_DTP_PLAN_BGN_RD8_2End DatePlan Begin (D8)
03L2110D_DTP_BNFT_BGN_D8Start DateBenefit Begin (D8)
03L2110D_DTP_BNFT_BGN_RD8_1Start DateBenefit Begin (D8)
03L2110D_DTP_BNFT_BGN_RD8_2End DateBenefit Begin (D8)
03L2110D_DTP_BNFT_END_D8Start DateBenefit End (D8)
03L2110D_DTP_BNFT_END_RD8_1Start DateBenefit End (D8)
03L2110D_DTP_BNFT_END_RD8_2End DateBenefit End (D8)
03L2110D_DTP_ELIG_BGN_D8Start DateEligibility Begin (D8)
03L2110D_DTP_ELIG_BGN_RD8_1Start DateEligibility Begin (D8)
03L2110D_DTP_ELIG_BGN_RD8_2End DateEligibility Begin (D8)
03L2110D_DTP_ELIG_END_D8Start DateEligibility End (D8)
03L2110D_DTP_ELIG_END_RD8_1Start DateEligibility End (D8)
03L2110D_DTP_ELIG_END_RD8_2End DateEligibility End (D8)
03L2110D_DTP_ADMSN_D8Start DateAdmission (D8)
03L2110D_DTP_ADMSN_RD8_1Start DateAdmission (D8)
03L2110D_DTP_ADMSN_RD8_2End DateAdmission (D8)
03L2110D_DTP_SVC_D8Start DateService (D8)
03L2110D_DTP_SVC_RD8_1Start DateService (D8)
03L2110D_DTP_SVC_RD8_2End DateService (D8)
03L2110D_DTP_LAST_UPDT_D8Start DateDate of Last Update (D8)
03L2110D_DTP_LAST_UPDT_RD8_1Start DateDate of Last Update (D8)
03L2110D_DTP_LAST_UPDT_RD8_2End DateDate of Last Update (D8)
03L2110D_DTP_STATS_D8Start DateStatus (D8)
03L2110D_DTP_STATS_RD8_1Start DateStatus (D8)
03L2110D_DTP_STATS_RD8_2End DateStatus (D8)
L2110DAAADependent Request Validation Iterated: [01-09]
01L2110D_nnAAA01_VLDREQ_INDStringValid Request Indicator
03L2110D_nnAAA03_REJ_RSN_CDStringReject Reason Code
04L2110D_nnAAA04_FWUP_ACTCDStringFollow-up Action Code
L2110DMSGMessage Text Iterated: [01-10]
01L2110D_nnMSG01_FRFM_MSG_TXTStringFree Form Message Text
L2115D - DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION (Single Iteration)
L2115DIIIDependent Eligibility or Benefit Additional Information
02L2115D_xx_III02_NCCI_INJ_CDStringNational Council on Compensation Insurance (NCCI) Nature of Injury Code
02L2115D_xx_III02_NTR_INJRY_CDStringNature of Injury Code
02L2115D_xx_III02_MUTLY_DEFStringMutually Defined
03L2115D_xx_III03_CD_CATStringCode Category
04L2115D_xx_III04_INJR_BDY_PRTStringInjured Body Part Name

L2110DLSLoop Header
01L2110D_LS01_LOOP_ID_CDStringLoop Identifier Code
L2120D - DEPENDENT BENEFIT RELATED ENTITY NAME (Value Qualified)
Mapping Prefix: L2120D_13 - Contracted Service Provider
Mapping Prefix: L2120D_1I - Preferred Provider Organization (PPO)
Mapping Prefix: L2120D_1P - Provider
Mapping Prefix: L2120D_2B - Third-Party Administrator
Mapping Prefix: L2120D_36 - Employer
Mapping Prefix: L2120D_73 - Other Physician
Mapping Prefix: L2120D_FA - Facility
Mapping Prefix: L2120D_GP - Gateway Provider
Mapping Prefix: L2120D_GW - Group
Mapping Prefix: L2120D_I3 - Independent Physicians Association (IPA)
Mapping Prefix: L2120D_IL - Insured or Subscriber
Mapping Prefix: L2120D_LR - Legal Representative
Mapping Prefix: L2120D_OC - Origin Carrier
Mapping Prefix: L2120D_P3 - Primary Care Provider
Mapping Prefix: L2120D_P4 - Prior Insurance Carrier
Mapping Prefix: L2120D_P5 - Plan Sponsor
Mapping Prefix: L2120D_PR - Payer
Mapping Prefix: L2120D_PRP - Primary Payer
Mapping Prefix: L2120D_SEP - Secondary Payer
Mapping Prefix: L2120D_TTP - Tertiary Payer
Mapping Prefix: L2120D_VN - Vendor
Mapping Prefix: L2120D_VY - Organization Completing Configuration Change
Mapping Prefix: L2120D_X3 - Utilization Management Organization
L2120DNM1Dependent Benefit Related Entity Name
02L2120D_yy_NM102_ENT_TYP_QUALStringEntity Type Qualifier
03L2120D_yy_NM103_BNRL_LNMStringBenefit Related Entity Last or Organization Name
04L2120D_yy_NM104_BNRL_ENT_FNMStringBenefit Related Entity First Name
05L2120D_yy_NM105_BNRL_ENT_MNMStringBenefit Related Entity Middle Name
07L2120D_yy_NM107_BNRL_ENT_SFXStringBenefit Related Entity Name Suffix
09L2120D_yy_NM109_EMPLYR_IDStringEmployer?s Identification Number
09L2120D_yy_NM109_SSNStringSocial Security Number
09L2120D_yy_NM109_ETN_NRStringElectronic Transmitter Identification Number (ETIN)
09L2120D_yy_NM109_FACLTY_IDStringFacility Identification
09L2120D_yy_NM109_TAX_IDStringFederal Taxpayer?s Identification Number
09L2120D_yy_NM109_UNQ_HLTH_IDStringStandard Unique Health Identifier for each Individual in the United States
09L2120D_yy_NM109_MEM_ID_NRStringMember Identification Number
09L2120D_yy_NM109_NAIC_IDStringNational Association of Insurance Commissioners
09L2120D_yy_NM109_PAYR_IDStringPayor Identification
09L2120D_yy_NM109_PHM_PRCSR_NRStringPharmacy Processor Number
09L2120D_yy_NM109_SVC_PROV_NRStringService Provider Number
09L2120D_yy_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
09L2120D_yy_NM109_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
10L2120D_yy_NM110_BNRL_ETY_RELStringBenefit Related Entity Relationship Code
L2120DN3Dependent Benefit Related Entity Address
01L2120D_yy_N301_BNRL_ENT_ADDRStringBenefit Related Entity Address Line
02L2120D_yy_N302_BNRL_ENT_ADDRStringBenefit Related Entity Address Line
L2120DN4Dependent Benefit Related Entity City, State, ZIP Code
01L2120D_yy_N401_BNRL_ENT_CITYStringBenefit Related Entity City Name
02L2120D_yy_N402_BNRL_ENT_STATStringBenefit Related Entity State Code
03L2120D_yy_N403_BNRL_ENTY_ZIPStringBenefit Related Entity Postal Zone or ZIP Code
04L2120D_yy_N404_BNRL_CNTRY_CDStringBenefit Related Entity Country Code
06L2120D_yy_N406_BENDOD_HLTRGNStringBenefit Related Entity DOD Health Service Region
07L2120D_yy_N407_BNRL_CTY_SBRStringBenefit Related Entity Country Subdivision Code
L2120DPERDependent Benefit Related Entity Contact Information Iterated: [01-03]
02L2120D_yy_nnPER02_BNRL_CONStringBenefit Related Entity Contact Name
04L2120D_yy_nnPER04_EDI_ACS_NRStringElectronic Data Interchange Access Number
04L2120D_yy_nnPER04_EMAILStringElectronic Mail
04L2120D_yy_nnPER04_FAXStringFacsimile
04L2120D_yy_nnPER04_PHN_NRStringTelephone
04L2120D_yy_nnPER04_URLStringUniform Resource Locator (URL)
04L2120D_yy_nnPER04_WRK_PHN_NRStringWork Phone Number
06L2120D_yy_nnPER06_EDI_ACS_NRStringElectronic Data Interchange Access Number
06L2120D_yy_nnPER06_EMAILStringElectronic Mail
06L2120D_yy_nnPER06_PHN_EXTStringTelephone Extension
06L2120D_yy_nnPER06_FAXStringFacsimile
06L2120D_yy_nnPER06_PHN_NRStringTelephone
06L2120D_yy_nnPER06_URLStringUniform Resource Locator (URL)
06L2120D_yy_nnPER06_WRK_PHN_NRStringWork Phone Number
08L2120D_yy_nnPER08_EDI_ACS_NRStringElectronic Data Interchange Access Number
08L2120D_yy_nnPER08_EMAILStringElectronic Mail
08L2120D_yy_nnPER08_PHN_EXTStringTelephone Extension
08L2120D_yy_nnPER08_FAXStringFacsimile
08L2120D_yy_nnPER08_PHN_NRStringTelephone
08L2120D_yy_nnPER08_URLStringUniform Resource Locator (URL)
08L2120D_yy_nnPER08_WRK_PHN_NRStringWork Phone Number
L2120DPRVDependent Benefit Related Provider Information
01L2120D_yy_PRV01_PVD_CDStringProvider Code
03L2120D_yy_PRV03_PVR_IDStringProvider Identifier

L2110DLELoop Trailer
01L2110D_LE01_LOOP_ID_CDStringLoop Identifier Code

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