L2100A | NM1 | Information Source Name |
| |
03 | | L2100A_yy_NM103_PERSN_LNM | String | Person Last Name |
03 | | L2100A_yy_NM103_NONPSNENT_NM | String | Non-Person Entity Name |
04 | | L2100A_yy_NM104_NFO_SRC_FNM | String | Information Source First Name |
05 | | L2100A_yy_NM105_NFO_SRC_MNM | String | Information Source Middle Name |
07 | | L2100A_yy_NM107_NFO_SRC_SFX | String | Information Source Name Suffix |
09 | | L2100A_yy_NM109_EMPLYR_ID | String | Employer?s Identification Number |
09 | | L2100A_yy_NM109_ETN_NR | String | Electronic Transmitter Identification Number (ETIN) |
09 | | L2100A_yy_NM109_TAX_ID | String | Federal Taxpayer?s Identification Number |
09 | | L2100A_yy_NM109_NAIC_ID | String | National Association of Insurance Commissioners (NAIC) Identification |
09 | | L2100A_yy_NM109_PAYR_ID | String | Payor Identification |
09 | | L2100A_yy_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
09 | | L2100A_yy_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2100A | PER | Information Source Contact Information |
Iterated: [01-03]
| |
02 | | L2100A_yy_nnPER02_NFOSRC_CN_NM | String | Information Source Contact Name |
04 | | L2100A_yy_nnPER04_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
04 | | L2100A_yy_nnPER04_EMAIL | String | Electronic Mail |
04 | | L2100A_yy_nnPER04_FAX | String | Facsimile |
04 | | L2100A_yy_nnPER04_PHN_NR | String | Telephone |
04 | | L2100A_yy_nnPER04_URL | String | Uniform Resource Locator (URL) |
06 | | L2100A_yy_nnPER06_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
06 | | L2100A_yy_nnPER06_EMAIL | String | Electronic Mail |
06 | | L2100A_yy_nnPER06_PHN_EXT | String | Telephone Extension |
06 | | L2100A_yy_nnPER06_FAX | String | Facsimile |
06 | | L2100A_yy_nnPER06_PHN_NR | String | Telephone |
06 | | L2100A_yy_nnPER06_URL | String | Uniform Resource Locator (URL) |
08 | | L2100A_yy_nnPER08_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
08 | | L2100A_yy_nnPER08_EMAIL | String | Electronic Mail |
08 | | L2100A_yy_nnPER08_PHN_EXT | String | Telephone Extension |
08 | | L2100A_yy_nnPER08_FAX | String | Facsimile |
08 | | L2100A_yy_nnPER08_PHN_NR | String | Telephone |
08 | | L2100A_yy_nnPER08_URL | String | Uniform Resource Locator (URL) |
L2100B | NM1 | Information Receiver Name |
| |
03 | | L2100B_yy_NM103_NFO_RCV_NM | String | Information Receiver Last or Organization Name |
04 | | L2100B_yy_NM104_NFO_REC_FNM | String | Information Receiver First Name |
05 | | L2100B_yy_NM105_NFO_REC_MNM | String | Information Receiver Middle Name |
07 | | L2100B_yy_NM107_NFO_RCV_SFX | String | Information Receiver Name Suffix |
09 | | L2100B_yy_NM109_EMPLYR_ID | String | Employer?s Identification Number |
09 | | L2100B_yy_NM109_SSN | String | Social Security Number |
09 | | L2100B_yy_NM109_TAX_ID | String | Federal Taxpayer?s Identification Number |
09 | | L2100B_yy_NM109_PAYR_ID | String | Payor Identification |
09 | | L2100B_yy_NM109_PHM_PRCSR_NR | String | Pharmacy Processor Number |
09 | | L2100B_yy_NM109_SVC_PROV_NR | String | Service Provider Number |
09 | | L2100B_yy_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
09 | | L2100B_yy_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2100B | REF | Information Receiver Additional Identification |
Iterated: [01-09]
| |
02 | | L2100B_yy_nnREF_STAT_LIC_NR | String | State License Number |
02 | | L2100B_yy_nnREF_MDCR_PVR_NR | String | Medicare Provider Number |
02 | | L2100B_yy_nnREF_MDCD_PVR_NR | String | Medicaid Provider Number |
02 | | L2100B_yy_nnREF_FAC_ID | String | Facility ID Number |
02 | | L2100B_yy_nnREF_PIN | String | Personal Identification Number (PIN) |
02 | | L2100B_yy_nnREF_CNTRCT_NR | String | Contract Number |
02 | | L2100B_yy_nnREF_ELEC_PIN | String | Electronic device pin number |
02 | | L2100B_yy_nnREF_SUB_ID_NR | String | Submitter Identification Number |
02 | | L2100B_yy_nnREF_MDCR_MDCD | String | Centers for Medicare and Medicaid Services National Provider Identifier |
02 | | L2100B_yy_nnREF_USER_ID | String | User Identification |
02 | | L2100B_yy_nnREF_PRV_PLN_ID | String | Provider Plan Network Identification Number |
02 | | L2100B_yy_nnREF_FAC_NET_ID | String | Facility Network Identification Number |
02 | | L2100B_yy_nnREF_PRIOR_ID | String | Prior Identifier Number |
02 | | L2100B_yy_nnREF_SSN | String | Social Security Number |
02 | | L2100B_yy_nnREF_TAX_ID | String | Federal Taxpayer?s Identification Number |
02 | | L2100B_yy_nnREF_CLSS_CONT | String | Class of Contract |
03 | | L2100B_yy_nnREF03_NFORCV_AD_ID | String | Information Receiver Additional Identifier State |
L2100B | N4 | Information Receiver City State ZIP Code |
| |
01 | | L2100B_yy_N401_NFO_RCV_CITY_NM | String | Information Receiver City Name |
02 | | L2100B_yy_N402_NFO_RCV_STAT | String | Information Receiver State Code |
03 | | L2100B_yy_N403_NFO_RCV_ZIP | String | Information Receiver Postal Zone or ZIP Code |
04 | | L2100B_yy_N404_NFORCVR_CNTY_CD | String | Information Receiver County Code |
07 | | L2100B_yy_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100C | REF | Subscriber Additional Identification |
Iterated: [01-09]
| |
02 | | L2100C_nnREF_PLAN_NR | String | Plan Number |
02 | | L2100C_nnREF_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2100C_nnREF_MEM_ID | String | Member Identification Number |
02 | | L2100C_nnREF_CASE_NR | String | Case Number |
02 | | L2100C_nnREF_FAM_UNT_NR | String | Family Unit Number |
02 | | L2100C_nnREF_GRP_NR | String | Group Number |
02 | | L2100C_nnREF_CNTRCT_NR | String | Contract Number |
02 | | L2100C_nnREF_MED_REC_ID | String | Medical Record Identification Number |
02 | | L2100C_nnREF_PATNT_ACCT_NR | String | Patient Account Number |
02 | | L2100C_nnREF_HIC_NR | String | Health Insurance Claim (HIC) Number |
02 | | L2100C_nnREF_ID_SERL_NR | String | Identification Card Serial Number |
02 | | L2100C_nnREF_ID_CRD_NR | String | Identity Card Number |
02 | | L2100C_nnREF_ISSU_NR | String | Issue Number |
02 | | L2100C_nnREF_INS_PLCY_NR | String | Insurance Policy Number |
02 | | L2100C_nnREF_PLN_NET_ID | String | Plan Network Identification Number |
02 | | L2100C_nnREF_MDCD_ID_NR | String | Medicaid Recipient Identification Number |
02 | | L2100C_nnREF_PRIOR_ID | String | Prior Identifier Number |
02 | | L2100C_nnREF_SSN | String | Social Security Number |
02 | | L2100C_nnREF_AGNCY_CLM_NR | String | Agency Claim Number |
03 | | L2100C_nnREF03_PLN_GRPNT_NM | String | Plan, Group or Plan Network Name |
L2100C | HI | Subscriber Health Care Diagnosis Code |
| |
01 | 02 | L2100C_HI0102_ICD10_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis |
01 | 02 | L2100C_HI0102_ICD9_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis |
02 | 02 | L2100C_HI0202_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
02 | 02 | L2100C_HI0202_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
03 | 02 | L2100C_HI0302_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
03 | 02 | L2100C_HI0302_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
04 | 02 | L2100C_HI0402_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
04 | 02 | L2100C_HI0402_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
05 | 02 | L2100C_HI0502_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
05 | 02 | L2100C_HI0502_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
06 | 02 | L2100C_HI0602_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
06 | 02 | L2100C_HI0602_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
07 | 02 | L2100C_HI0702_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
07 | 02 | L2100C_HI0702_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
08 | 02 | L2100C_HI0802_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
08 | 02 | L2100C_HI0802_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
L2100C | DTP | Subscriber Date |
| |
03 | | L2100C_DTP_DISCHG_D8 | Start Date | Discharge (D8) |
03 | | L2100C_DTP_DISCHG_RD8_1 | Start Date | Discharge (D8) |
03 | | L2100C_DTP_DISCHG_RD8_2 | End Date | Discharge (D8) |
03 | | L2100C_DTP_ISSU_D8 | Start Date | Issue (D8) |
03 | | L2100C_DTP_ISSU_RD8_1 | Start Date | Issue (D8) |
03 | | L2100C_DTP_ISSU_RD8_2 | End Date | Issue (D8) |
03 | | L2100C_DTP_CHG_EFF_D8 | Start Date | Effective Date of Change (D8) |
03 | | L2100C_DTP_CHG_EFF_RD8_1 | Start Date | Effective Date of Change (D8) |
03 | | L2100C_DTP_CHG_EFF_RD8_2 | End Date | Effective Date of Change (D8) |
03 | | L2100C_DTP_PLAN_D8 | Start Date | Plan (D8) |
03 | | L2100C_DTP_PLAN_RD8_1 | Start Date | Plan (D8) |
03 | | L2100C_DTP_PLAN_RD8_2 | End Date | Plan (D8) |
03 | | L2100C_DTP_ELIG_D8 | Start Date | Eligibility (D8) |
03 | | L2100C_DTP_ELIG_RD8_1 | Start Date | Eligibility (D8) |
03 | | L2100C_DTP_ELIG_RD8_2 | End Date | Eligibility (D8) |
03 | | L2100C_DTP_ADDED_D8 | Start Date | Added (D8) |
03 | | L2100C_DTP_ADDED_RD8_1 | Start Date | Added (D8) |
03 | | L2100C_DTP_ADDED_RD8_2 | End Date | Added (D8) |
03 | | L2100C_DTP_COBRA_BGN_D8 | Start Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8) |
03 | | L2100C_DTP_COBRA_BGN_RD8_1 | Start Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8) |
03 | | L2100C_DTP_COBRA_BGN_RD8_2 | End Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8) |
03 | | L2100C_DTP_COBRA_END_D8 | Start Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (D8) |
03 | | L2100C_DTP_COBRA_END_RD8_1 | Start Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (D8) |
03 | | L2100C_DTP_COBRA_END_RD8_2 | End Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (D8) |
03 | | L2100C_DTP_PRM_PD_BGN_D8 | Start Date | Premium Paid to Date Begin (D8) |
03 | | L2100C_DTP_PRM_PD_BGN_RD8_1 | Start Date | Premium Paid to Date Begin (D8) |
03 | | L2100C_DTP_PRM_PD_BGN_RD8_2 | End Date | Premium Paid to Date Begin (D8) |
03 | | L2100C_DTP_PRM_PD_END_D8 | Start Date | Premium Paid to Date End (D8) |
03 | | L2100C_DTP_PRM_PD_END_RD8_1 | Start Date | Premium Paid to Date End (D8) |
03 | | L2100C_DTP_PRM_PD_END_RD8_2 | End Date | Premium Paid to Date End (D8) |
03 | | L2100C_DTP_PLAN_BGN_D8 | Start Date | Plan Begin (D8) |
03 | | L2100C_DTP_PLAN_BGN_RD8_1 | Start Date | Plan Begin (D8) |
03 | | L2100C_DTP_PLAN_BGN_RD8_2 | End Date | Plan Begin (D8) |
03 | | L2100C_DTP_PLAN_END_D8 | Start Date | Plan End (D8) |
03 | | L2100C_DTP_PLAN_END_RD8_1 | Start Date | Plan End (D8) |
03 | | L2100C_DTP_PLAN_END_RD8_2 | End Date | Plan End (D8) |
03 | | L2100C_DTP_ELIG_BGN_D8 | Start Date | Eligibility Begin (D8) |
03 | | L2100C_DTP_ELIG_BGN_RD8_1 | Start Date | Eligibility Begin (D8) |
03 | | L2100C_DTP_ELIG_BGN_RD8_2 | End Date | Eligibility Begin (D8) |
03 | | L2100C_DTP_ELIG_END_D8 | Start Date | Eligibility End (D8) |
03 | | L2100C_DTP_ELIG_END_RD8_1 | Start Date | Eligibility End (D8) |
03 | | L2100C_DTP_ELIG_END_RD8_2 | End Date | Eligibility End (D8) |
03 | | L2100C_DTP_ENRLL_D8 | Start Date | Enrollment (D8) |
03 | | L2100C_DTP_ENRLL_RD8_1 | Start Date | Enrollment (D8) |
03 | | L2100C_DTP_ENRLL_RD8_2 | End Date | Enrollment (D8) |
03 | | L2100C_DTP_ADMSN_D8 | Start Date | Admission (D8) |
03 | | L2100C_DTP_ADMSN_RD8_1 | Start Date | Admission (D8) |
03 | | L2100C_DTP_ADMSN_RD8_2 | End Date | Admission (D8) |
03 | | L2100C_DTP_DEATH_D8 | Start Date | Date of Death (D8) |
03 | | L2100C_DTP_DEATH_RD8_1 | Start Date | Date of Death (D8) |
03 | | L2100C_DTP_DEATH_RD8_2 | End Date | Date of Death (D8) |
03 | | L2100C_DTP_CERT_D8 | Start Date | Certification (D8) |
03 | | L2100C_DTP_CERT_RD8_1 | Start Date | Certification (D8) |
03 | | L2100C_DTP_CERT_RD8_2 | End Date | Certification (D8) |
03 | | L2100C_DTP_SVC_D8 | Start Date | Service (D8) |
03 | | L2100C_DTP_SVC_RD8_1 | Start Date | Service (D8) |
03 | | L2100C_DTP_SVC_RD8_2 | End Date | Service (D8) |
03 | | L2100C_DTP_PLCY_EFF_D8 | Start Date | Policy Effective (D8) |
03 | | L2100C_DTP_PLCY_EFF_RD8_1 | Start Date | Policy Effective (D8) |
03 | | L2100C_DTP_PLCY_EFF_RD8_2 | End Date | Policy Effective (D8) |
03 | | L2100C_DTP_PLCY_EXP_D8 | Start Date | Policy Expiration (D8) |
03 | | L2100C_DTP_PLCY_EXP_RD8_1 | Start Date | Policy Expiration (D8) |
03 | | L2100C_DTP_PLCY_EXP_RD8_2 | End Date | Policy Expiration (D8) |
03 | | L2100C_DTP_LAST_UPDT_D8 | Start Date | Date of Last Update (D8) |
03 | | L2100C_DTP_LAST_UPDT_RD8_1 | Start Date | Date of Last Update (D8) |
03 | | L2100C_DTP_LAST_UPDT_RD8_2 | End Date | Date of Last Update (D8) |
03 | | L2100C_DTP_STATS_D8 | Start Date | Status (D8) |
03 | | L2100C_DTP_STATS_RD8_1 | Start Date | Status (D8) |
03 | | L2100C_DTP_STATS_RD8_2 | End Date | Status (D8) |
L2110C | EB | Subscriber Eligibility or Benefit Information |
| |
01 | | L2110C_xx_EB01_Enn_ELIG_BEN_NFO | String | Eligibility or Benefit Information |
02 | | L2110C_xx_EB02_BENE_COV_LVL_CD | String | Benefit Coverage Level Code |
03 | | L2110C_xx_EB03_Enn_SVC_TYP_CD | String | Service Type Code |
04 | | L2110C_xx_EB04_INS_TYP_CD | String | Insurance Type Code |
05 | | L2110C_xx_EB05_PLN_CVG_DSC | String | Plan Coverage Description |
07 | | L2110C_xx_EB07_HR | Decimal | Hour |
07 | | L2110C_xx_EB07_DAY | Decimal | Day |
07 | | L2110C_xx_EB07_24_HR | Decimal | 24 Hours |
07 | | L2110C_xx_EB07_YEARS | Decimal | Years |
07 | | L2110C_xx_EB07_SVC_YR | Decimal | Service Year |
07 | | L2110C_xx_EB07_CAL_YEAR | Decimal | Calendar Year |
07 | | L2110C_xx_EB07_YTD | Decimal | Year to Date |
07 | | L2110C_xx_EB07_CNTRCT | Decimal | Contract |
07 | | L2110C_xx_EB07_EPISD | Decimal | Episode |
07 | | L2110C_xx_EB07_VIST | Decimal | Visit |
07 | | L2110C_xx_EB07_OUTLIER | Decimal | Outlier |
07 | | L2110C_xx_EB07_REMNG | Decimal | Remaining |
07 | | L2110C_xx_EB07_EXCEED | Decimal | Exceeded |
07 | | L2110C_xx_EB07_NOT_XCDED | Decimal | Not Exceeded |
07 | | L2110C_xx_EB07_LFTM | Decimal | Lifetime |
07 | | L2110C_xx_EB07_LFTM_REM | Decimal | Lifetime Remaining |
07 | | L2110C_xx_EB07_MO | Decimal | Month |
07 | | L2110C_xx_EB07_WK | Decimal | Week |
07 | | L2110C_xx_EB07_ADMSN | Decimal | Admission |
08 | | L2110C_xx_EB08_BENE_PRCNT | Decimal | Benefit Percent |
10 | | L2110C_xx_EB10_MIN | Decimal | Minimum |
10 | | L2110C_xx_EB10_QTY_USED | Decimal | Quantity Used |
10 | | L2110C_xx_EB10_COVD_ACTL | Decimal | Covered - Actual |
10 | | L2110C_xx_EB10_COVD_EST | Decimal | Covered - Estimated |
10 | | L2110C_xx_EB10_NR_COINS_DYS | Decimal | Number of Co-insurance Days |
10 | | L2110C_xx_EB10_DED_BLOOD_UN | Decimal | Deductible Blood Units |
10 | | L2110C_xx_EB10_DAYS | Decimal | Days |
10 | | L2110C_xx_EB10_HR | Decimal | Hours |
10 | | L2110C_xx_EB10_LFTM_RSRV_ACTL | Decimal | Life-time Reserve - Actual |
10 | | L2110C_xx_EB10_LFTM_RSRV_EST | Decimal | Life-time Reserve - Estimated |
10 | | L2110C_xx_EB10_MAX | Decimal | Maximum |
10 | | L2110C_xx_EB10_MO | Decimal | Month |
10 | | L2110C_xx_EB10_NR_SVC_PROC | Decimal | Number of Services or Procedures |
10 | | L2110C_xx_EB10_QTY_APPR | Decimal | Quantity Approved |
10 | | L2110C_xx_EB10_AGE_HIVAL | Decimal | Age, High Value |
10 | | L2110C_xx_EB10_AGE_LOVAL | Decimal | Age, Low Value |
10 | | L2110C_xx_EB10_VIST | Decimal | Visits |
10 | | L2110C_xx_EB10_YEARS | Decimal | Years |
11 | | L2110C_xx_EB11_AUTH_CERT_IND | String | Authorization or Certification Indicator |
12 | | L2110C_xx_EB12_INPLAN_NET_IND | String | In Plan Network Indicator |
13 | 02 | L2110C_xx_EB1302_ADA_CD | String | American Dental Association Codes |
13 | 02 | L2110C_xx_EB1302_CPT_CD | String | Current Procedural Terminology (CPT) Codes |
13 | 02 | L2110C_xx_EB1302_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
13 | 02 | L2110C_xx_EB1302_ICD9_PROC | String | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure |
13 | 02 | L2110C_xx_EB1302_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
13 | 02 | L2110C_xx_EB1302_NDC542 | String | National Drug Code in 5-4-2 Format |
13 | 02 | L2110C_xx_EB1302_MUTLY_DEF | String | Mutually Defined |
13 | 03 | L2110C_xx_EB1303_PROC_MOD | String | Procedure Modifier |
13 | 04 | L2110C_xx_EB1304_PROC_MOD | String | Procedure Modifier |
13 | 05 | L2110C_xx_EB1305_PROC_MOD | String | Procedure Modifier |
13 | 06 | L2110C_xx_EB1306_PROC_MOD | String | Procedure Modifier |
13 | 08 | L2110C_xx_EB1308_PROD_SVC_ID | String | Product or Service ID |
14 | 01 | L2110C_xx_EB1401_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
14 | 02 | L2110C_xx_EB1402_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
14 | 03 | L2110C_xx_EB1403_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
14 | 04 | L2110C_xx_EB1404_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
L2110C | REF | Subscriber Additional Identification |
Iterated: [01-09]
| |
02 | | L2110C_xx_nnREF_PLAN_NR | String | Plan Number |
02 | | L2110C_xx_nnREF_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2110C_xx_nnREF_MEM_ID | String | Member Identification Number |
02 | | L2110C_xx_nnREF_FAM_UNT_NR | String | Family Unit Number |
02 | | L2110C_xx_nnREF_GRP_NR | String | Group Number |
02 | | L2110C_xx_nnREF_REFRL_NR | String | Referral Number |
02 | | L2110C_xx_nnREF_ALTN_LIST_ID | String | Alternative List ID |
02 | | L2110C_xx_nnREF_COVG_LST_ID | String | Coverage List ID |
02 | | L2110C_xx_nnREF_HIC_NR | String | Health Insurance Claim (HIC) Number |
02 | | L2110C_xx_nnREF_DRUG_FML_NR | String | Drug Formulary Number |
02 | | L2110C_xx_nnREF_PRIOR_AUTH | String | Prior Authorization Number |
02 | | L2110C_xx_nnREF_INS_PLCY_NR | String | Insurance Policy Number |
02 | | L2110C_xx_nnREF_MDCL_ASST_CAT | String | Medical Assistance Category |
02 | | L2110C_xx_nnREF_PLN_NET_ID | String | Plan Network Identification Number |
02 | | L2110C_xx_nnREF_MDCD_ID_NR | String | Medicaid Recipient Identification Number |
03 | | L2110C_xx_nnREF03_PLN_GRPNT_NM | String | Plan, Group or Plan Network Name |
L2110C | DTP | Subscriber Eligibility/Benefit Date |
| |
03 | | L2110C_xx_DTP_DISCHG_D8 | Start Date | Discharge (D8) |
03 | | L2110C_xx_DTP_DISCHG_RD8_1 | Start Date | Discharge (D8) |
03 | | L2110C_xx_DTP_DISCHG_RD8_2 | End Date | Discharge (D8) |
03 | | L2110C_xx_DTP_PRD_STRT_D8 | Start Date | Period Start (D8) |
03 | | L2110C_xx_DTP_PRD_STRT_RD8_1 | Start Date | Period Start (D8) |
03 | | L2110C_xx_DTP_PRD_STRT_RD8_2 | End Date | Period Start (D8) |
03 | | L2110C_xx_DTP_PRD_END_D8 | Start Date | Period End (D8) |
03 | | L2110C_xx_DTP_PRD_END_RD8_1 | Start Date | Period End (D8) |
03 | | L2110C_xx_DTP_PRD_END_RD8_2 | End Date | Period End (D8) |
03 | | L2110C_xx_DTP_CMPLTN_D8 | Start Date | Completion (D8) |
03 | | L2110C_xx_DTP_CMPLTN_RD8_1 | Start Date | Completion (D8) |
03 | | L2110C_xx_DTP_CMPLTN_RD8_2 | End Date | Completion (D8) |
03 | | L2110C_xx_DTP_COB_D8 | Start Date | Coordination of Benefits (D8) |
03 | | L2110C_xx_DTP_COB_RD8_1 | Start Date | Coordination of Benefits (D8) |
03 | | L2110C_xx_DTP_COB_RD8_2 | End Date | Coordination of Benefits (D8) |
03 | | L2110C_xx_DTP_PLAN_D8 | Start Date | Plan (D8) |
03 | | L2110C_xx_DTP_PLAN_RD8_1 | Start Date | Plan (D8) |
03 | | L2110C_xx_DTP_PLAN_RD8_2 | End Date | Plan (D8) |
03 | | L2110C_xx_DTP_BENFT_D8 | Start Date | Benefit (D8) |
03 | | L2110C_xx_DTP_BENFT_RD8_1 | Start Date | Benefit (D8) |
03 | | L2110C_xx_DTP_BENFT_RD8_2 | End Date | Benefit (D8) |
03 | | L2110C_xx_DTP_PCP_D8 | Start Date | Primary Care Provider (D8) |
03 | | L2110C_xx_DTP_PCP_RD8_1 | Start Date | Primary Care Provider (D8) |
03 | | L2110C_xx_DTP_PCP_RD8_2 | End Date | Primary Care Provider (D8) |
03 | | L2110C_xx_DTP_LAST_VST_D8 | Start Date | Latest Visit or Consultation (D8) |
03 | | L2110C_xx_DTP_LAST_VST_RD8_1 | Start Date | Latest Visit or Consultation (D8) |
03 | | L2110C_xx_DTP_LAST_VST_RD8_2 | End Date | Latest Visit or Consultation (D8) |
03 | | L2110C_xx_DTP_ELIG_D8 | Start Date | Eligibility (D8) |
03 | | L2110C_xx_DTP_ELIG_RD8_1 | Start Date | Eligibility (D8) |
03 | | L2110C_xx_DTP_ELIG_RD8_2 | End Date | Eligibility (D8) |
03 | | L2110C_xx_DTP_ADDED_D8 | Start Date | Added (D8) |
03 | | L2110C_xx_DTP_ADDED_RD8_1 | Start Date | Added (D8) |
03 | | L2110C_xx_DTP_ADDED_RD8_2 | End Date | Added (D8) |
03 | | L2110C_xx_DTP_PLAN_BGN_D8 | Start Date | Plan Begin (D8) |
03 | | L2110C_xx_DTP_PLAN_BGN_RD8_1 | Start Date | Plan Begin (D8) |
03 | | L2110C_xx_DTP_PLAN_BGN_RD8_2 | End Date | Plan Begin (D8) |
03 | | L2110C_xx_DTP_BNFT_BGN_D8 | Start Date | Benefit Begin (D8) |
03 | | L2110C_xx_DTP_BNFT_BGN_RD8_1 | Start Date | Benefit Begin (D8) |
03 | | L2110C_xx_DTP_BNFT_BGN_RD8_2 | End Date | Benefit Begin (D8) |
03 | | L2110C_xx_DTP_BNFT_END_D8 | Start Date | Benefit End (D8) |
03 | | L2110C_xx_DTP_BNFT_END_RD8_1 | Start Date | Benefit End (D8) |
03 | | L2110C_xx_DTP_BNFT_END_RD8_2 | End Date | Benefit End (D8) |
03 | | L2110C_xx_DTP_ELIG_BGN_D8 | Start Date | Eligibility Begin (D8) |
03 | | L2110C_xx_DTP_ELIG_BGN_RD8_1 | Start Date | Eligibility Begin (D8) |
03 | | L2110C_xx_DTP_ELIG_BGN_RD8_2 | End Date | Eligibility Begin (D8) |
03 | | L2110C_xx_DTP_ELIG_END_D8 | Start Date | Eligibility End (D8) |
03 | | L2110C_xx_DTP_ELIG_END_RD8_1 | Start Date | Eligibility End (D8) |
03 | | L2110C_xx_DTP_ELIG_END_RD8_2 | End Date | Eligibility End (D8) |
03 | | L2110C_xx_DTP_ADMSN_D8 | Start Date | Admission (D8) |
03 | | L2110C_xx_DTP_ADMSN_RD8_1 | Start Date | Admission (D8) |
03 | | L2110C_xx_DTP_ADMSN_RD8_2 | End Date | Admission (D8) |
03 | | L2110C_xx_DTP_SVC_D8 | Start Date | Service (D8) |
03 | | L2110C_xx_DTP_SVC_RD8_1 | Start Date | Service (D8) |
03 | | L2110C_xx_DTP_SVC_RD8_2 | End Date | Service (D8) |
03 | | L2110C_xx_DTP_LAST_UPDT_D8 | Start Date | Date of Last Update (D8) |
03 | | L2110C_xx_DTP_LAST_UPDT_RD8_1 | Start Date | Date of Last Update (D8) |
03 | | L2110C_xx_DTP_LAST_UPDT_RD8_2 | End Date | Date of Last Update (D8) |
03 | | L2110C_xx_DTP_STATS_D8 | Start Date | Status (D8) |
03 | | L2110C_xx_DTP_STATS_RD8_1 | Start Date | Status (D8) |
03 | | L2110C_xx_DTP_STATS_RD8_2 | End Date | Status (D8) |
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 |
L2120C | NM1 | Subscriber Benefit Related Entity Name |
| |
02 | | L2120C_xxyy_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2120C_xxyy_NM103_BNRL_LNM | String | Benefit Related Entity Last or Organization Name |
04 | | L2120C_xxyy_NM104_BNRL_ENT_FNM | String | Benefit Related Entity First Name |
05 | | L2120C_xxyy_NM105_BNRL_ENT_MNM | String | Benefit Related Entity Middle Name |
07 | | L2120C_xxyy_NM107_BNRL_ENT_SFX | String | Benefit Related Entity Name Suffix |
09 | | L2120C_xxyy_NM109_EMPLYR_ID | String | Employer?s Identification Number |
09 | | L2120C_xxyy_NM109_SSN | String | Social Security Number |
09 | | L2120C_xxyy_NM109_ETN_NR | String | Electronic Transmitter Identification Number (ETIN) |
09 | | L2120C_xxyy_NM109_FACLTY_ID | String | Facility Identification |
09 | | L2120C_xxyy_NM109_TAX_ID | String | Federal Taxpayer?s Identification Number |
09 | | L2120C_xxyy_NM109_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States |
09 | | L2120C_xxyy_NM109_MEM_ID_NR | String | Member Identification Number |
09 | | L2120C_xxyy_NM109_NAIC_ID | String | National Association of Insurance Commissioners |
09 | | L2120C_xxyy_NM109_PAYR_ID | String | Payor Identification |
09 | | L2120C_xxyy_NM109_PHM_PRCSR_NR | String | Pharmacy Processor Number |
09 | | L2120C_xxyy_NM109_SVC_PROV_NR | String | Service Provider Number |
09 | | L2120C_xxyy_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
09 | | L2120C_xxyy_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
10 | | L2120C_xxyy_NM110_BNRL_ETY_REL | String | Benefit Related Entity Relationship Code |
L2120C | N4 | Subscriber Benefit Related Entity City, State, ZIP Code |
| |
01 | | L2120C_xxyy_N401_BNRL_ENT_CITY | String | Benefit Related Entity City Name |
02 | | L2120C_xxyy_N402_BNRL_ENT_STAT | String | Benefit Related Entity State Code |
03 | | L2120C_xxyy_N403_BNRL_ENTY_ZIP | String | Benefit Related Entity Postal Zone or ZIP Code |
04 | | L2120C_xxyy_N404_BNRL_CNTRY_CD | String | Benefit Related Entity Country Code |
06 | | L2120C_xxyy_N406_BENDOD_HLTRGN | String | Benefit Related Entity DOD Health Service Region |
07 | | L2120C_xxyy_N407_BNRL_CTY_SBR | String | Benefit Related Entity Country Subdivision Code |
L2120C | PER | Subscriber Benefit Related Entity Contact Information |
Iterated: [01-03]
| |
02 | | L2120C_xxyy_nnPER02_BNRL_CON | String | Benefit Related Entity Contact Name |
04 | | L2120C_xxyy_nnPER04_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
04 | | L2120C_xxyy_nnPER04_EMAIL | String | Electronic Mail |
04 | | L2120C_xxyy_nnPER04_FAX | String | Facsimile |
04 | | L2120C_xxyy_nnPER04_PHN_NR | String | Telephone |
04 | | L2120C_xxyy_nnPER04_URL | String | Uniform Resource Locator (URL) |
04 | | L2120C_xxyy_nnPER04_WRK_PHN_NR | String | Work Phone Number |
06 | | L2120C_xxyy_nnPER06_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
06 | | L2120C_xxyy_nnPER06_EMAIL | String | Electronic Mail |
06 | | L2120C_xxyy_nnPER06_PHN_EXT | String | Telephone Extension |
06 | | L2120C_xxyy_nnPER06_FAX | String | Facsimile |
06 | | L2120C_xxyy_nnPER06_PHN_NR | String | Telephone |
06 | | L2120C_xxyy_nnPER06_URL | String | Uniform Resource Locator (URL) |
06 | | L2120C_xxyy_nnPER06_WRK_PHN_NR | String | Work Phone Number |
08 | | L2120C_xxyy_nnPER08_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
08 | | L2120C_xxyy_nnPER08_EMAIL | String | Electronic Mail |
08 | | L2120C_xxyy_nnPER08_PHN_EXT | String | Telephone Extension |
08 | | L2120C_xxyy_nnPER08_FAX | String | Facsimile |
08 | | L2120C_xxyy_nnPER08_PHN_NR | String | Telephone |
08 | | L2120C_xxyy_nnPER08_URL | String | Uniform Resource Locator (URL) |
08 | | L2120C_xxyy_nnPER08_WRK_PHN_NR | String | Work Phone Number |
L2100D | REF | Dependent Additional Identification |
Segment Suffix:
Iterated: [01-09]
| |
02 | | L2100D_nnREFB_PLAN_NR | String | Plan Number |
02 | | L2100D_nnREFB_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2100D_nnREFB_FAM_UNT_NR | String | Family Unit Number |
02 | | L2100D_nnREFB_GRP_NR | String | Group Number |
02 | | L2100D_nnREFB_CNTRCT_NR | String | Contract Number |
02 | | L2100D_nnREFB_MED_REC_ID | String | Medical Record Identification Number |
02 | | L2100D_nnREFB_PATNT_ACCT_NR | String | Patient Account Number |
02 | | L2100D_nnREFB_HIC_NR | String | Health Insurance Claim (HIC) Number |
02 | | L2100D_nnREFB_ID_SERL_NR | String | Identification Card Serial Number |
02 | | L2100D_nnREFB_ID_CRD_NR | String | Identity Card Number |
02 | | L2100D_nnREFB_ISSU_NR | String | Issue Number |
02 | | L2100D_nnREFB_INS_PLCY_NR | String | Insurance Policy Number |
02 | | L2100D_nnREFB_ELIG_CAT | String | Eligibility Category |
02 | | L2100D_nnREFB_PLN_NET_ID | String | Plan Network Identification Number |
02 | | L2100D_nnREFB_MDCD_ID_NR | String | Medicaid Recipient Identification Number |
02 | | L2100D_nnREFB_PRIOR_ID | String | Prior Identifier Number |
02 | | L2100D_nnREFB_SSN | String | Social Security Number |
02 | | L2100D_nnREFB_AGNCY_CLM_NR | String | Agency Claim Number |
03 | | L2100D_nnREFB03_PLN_GRPNT_NM | String | Plan, Group or Plan Network Name |
L2100D | HI | Dependent Health Care Diagnosis Code |
| |
01 | 02 | L2100D_HI0102_ICD10_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis |
01 | 02 | L2100D_HI0102_ICD9_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis |
02 | 02 | L2100D_HI0202_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
02 | 02 | L2100D_HI0202_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
03 | 02 | L2100D_HI0302_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
03 | 02 | L2100D_HI0302_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
04 | 02 | L2100D_HI0402_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
04 | 02 | L2100D_HI0402_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
05 | 02 | L2100D_HI0502_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
05 | 02 | L2100D_HI0502_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
06 | 02 | L2100D_HI0602_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
06 | 02 | L2100D_HI0602_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
07 | 02 | L2100D_HI0702_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
07 | 02 | L2100D_HI0702_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
08 | 02 | L2100D_HI0802_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
08 | 02 | L2100D_HI0802_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
L2100D | DTP | Dependent Date |
| |
03 | | L2100D_DTP_DISCHG_D8 | Start Date | Discharge (D8) |
03 | | L2100D_DTP_DISCHG_RD8_1 | Start Date | Discharge (D8) |
03 | | L2100D_DTP_DISCHG_RD8_2 | End Date | Discharge (D8) |
03 | | L2100D_DTP_ISSU_D8 | Start Date | Issue (D8) |
03 | | L2100D_DTP_ISSU_RD8_1 | Start Date | Issue (D8) |
03 | | L2100D_DTP_ISSU_RD8_2 | End Date | Issue (D8) |
03 | | L2100D_DTP_CHG_EFF_D8 | Start Date | Effective Date of Change (D8) |
03 | | L2100D_DTP_CHG_EFF_RD8_1 | Start Date | Effective Date of Change (D8) |
03 | | L2100D_DTP_CHG_EFF_RD8_2 | End Date | Effective Date of Change (D8) |
03 | | L2100D_DTP_PLAN_D8 | Start Date | Plan (D8) |
03 | | L2100D_DTP_PLAN_RD8_1 | Start Date | Plan (D8) |
03 | | L2100D_DTP_PLAN_RD8_2 | End Date | Plan (D8) |
03 | | L2100D_DTP_ELIG_D8 | Start Date | Eligibility (D8) |
03 | | L2100D_DTP_ELIG_RD8_1 | Start Date | Eligibility (D8) |
03 | | L2100D_DTP_ELIG_RD8_2 | End Date | Eligibility (D8) |
03 | | L2100D_DTP_ADDED_D8 | Start Date | Added (D8) |
03 | | L2100D_DTP_ADDED_RD8_1 | Start Date | Added (D8) |
03 | | L2100D_DTP_ADDED_RD8_2 | End Date | Added (D8) |
03 | | L2100D_DTP_COBRA_BGN_D8 | Start Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8) |
03 | | L2100D_DTP_COBRA_BGN_RD8_1 | Start Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8) |
03 | | L2100D_DTP_COBRA_BGN_RD8_2 | End Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8) |
03 | | L2100D_DTP_COBRA_END_D8 | Start Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (D8) |
03 | | L2100D_DTP_COBRA_END_RD8_1 | Start Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (D8) |
03 | | L2100D_DTP_COBRA_END_RD8_2 | End Date | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (D8) |
03 | | L2100D_DTP_PRM_PD_BGN_D8 | Start Date | Premium Paid to Date Begin (D8) |
03 | | L2100D_DTP_PRM_PD_BGN_RD8_1 | Start Date | Premium Paid to Date Begin (D8) |
03 | | L2100D_DTP_PRM_PD_BGN_RD8_2 | End Date | Premium Paid to Date Begin (D8) |
03 | | L2100D_DTP_PRM_PD_END_D8 | Start Date | Premium Paid to Date End (D8) |
03 | | L2100D_DTP_PRM_PD_END_RD8_1 | Start Date | Premium Paid to Date End (D8) |
03 | | L2100D_DTP_PRM_PD_END_RD8_2 | End Date | Premium Paid to Date End (D8) |
03 | | L2100D_DTP_PLAN_BGN_D8 | Start Date | Plan Begin (D8) |
03 | | L2100D_DTP_PLAN_BGN_RD8_1 | Start Date | Plan Begin (D8) |
03 | | L2100D_DTP_PLAN_BGN_RD8_2 | End Date | Plan Begin (D8) |
03 | | L2100D_DTP_PLAN_END_D8 | Start Date | Plan End (D8) |
03 | | L2100D_DTP_PLAN_END_RD8_1 | Start Date | Plan End (D8) |
03 | | L2100D_DTP_PLAN_END_RD8_2 | End Date | Plan End (D8) |
03 | | L2100D_DTP_ELIG_BGN_D8 | Start Date | Eligibility Begin (D8) |
03 | | L2100D_DTP_ELIG_BGN_RD8_1 | Start Date | Eligibility Begin (D8) |
03 | | L2100D_DTP_ELIG_BGN_RD8_2 | End Date | Eligibility Begin (D8) |
03 | | L2100D_DTP_ELIG_END_D8 | Start Date | Eligibility End (D8) |
03 | | L2100D_DTP_ELIG_END_RD8_1 | Start Date | Eligibility End (D8) |
03 | | L2100D_DTP_ELIG_END_RD8_2 | End Date | Eligibility End (D8) |
03 | | L2100D_DTP_ENRLL_D8 | Start Date | Enrollment (D8) |
03 | | L2100D_DTP_ENRLL_RD8_1 | Start Date | Enrollment (D8) |
03 | | L2100D_DTP_ENRLL_RD8_2 | End Date | Enrollment (D8) |
03 | | L2100D_DTP_ADMSN_D8 | Start Date | Admission (D8) |
03 | | L2100D_DTP_ADMSN_RD8_1 | Start Date | Admission (D8) |
03 | | L2100D_DTP_ADMSN_RD8_2 | End Date | Admission (D8) |
03 | | L2100D_DTP_DEATH_D8 | Start Date | Date of Death (D8) |
03 | | L2100D_DTP_DEATH_RD8_1 | Start Date | Date of Death (D8) |
03 | | L2100D_DTP_DEATH_RD8_2 | End Date | Date of Death (D8) |
03 | | L2100D_DTP_CERT_D8 | Start Date | Certification (D8) |
03 | | L2100D_DTP_CERT_RD8_1 | Start Date | Certification (D8) |
03 | | L2100D_DTP_CERT_RD8_2 | End Date | Certification (D8) |
03 | | L2100D_DTP_SVC_D8 | Start Date | Service (D8) |
03 | | L2100D_DTP_SVC_RD8_1 | Start Date | Service (D8) |
03 | | L2100D_DTP_SVC_RD8_2 | End Date | Service (D8) |
03 | | L2100D_DTP_PLCY_EFF_D8 | Start Date | Policy Effective (D8) |
03 | | L2100D_DTP_PLCY_EFF_RD8_1 | Start Date | Policy Effective (D8) |
03 | | L2100D_DTP_PLCY_EFF_RD8_2 | End Date | Policy Effective (D8) |
03 | | L2100D_DTP_PLCY_EXP_D8 | Start Date | Policy Expiration (D8) |
03 | | L2100D_DTP_PLCY_EXP_RD8_1 | Start Date | Policy Expiration (D8) |
03 | | L2100D_DTP_PLCY_EXP_RD8_2 | End Date | Policy Expiration (D8) |
03 | | L2100D_DTP_LAST_UPDT_D8 | Start Date | Date of Last Update (D8) |
03 | | L2100D_DTP_LAST_UPDT_RD8_1 | Start Date | Date of Last Update (D8) |
03 | | L2100D_DTP_LAST_UPDT_RD8_2 | End Date | Date of Last Update (D8) |
03 | | L2100D_DTP_STATS_D8 | Start Date | Status (D8) |
03 | | L2100D_DTP_STATS_RD8_1 | Start Date | Status (D8) |
03 | | L2100D_DTP_STATS_RD8_2 | End Date | Status (D8) |
L2110D | EB | Dependent Eligibility or Benefit Information |
| |
01 | | L2110D_EB01_Enn_ELIG_BEN_NFO | String | Eligibility or Benefit Information |
02 | | L2110D_EB02_BENE_COV_LVL_CD | String | Benefit Coverage Level Code |
03 | | L2110D_EB03_Enn_SVC_TYP_CD | String | Service Type Code |
04 | | L2110D_EB04_INS_TYP_CD | String | Insurance Type Code |
05 | | L2110D_EB05_PLN_CVG_DSC | String | Plan Coverage Description |
07 | | L2110D_EB07_HR | Decimal | Hour |
07 | | L2110D_EB07_DAY | Decimal | Day |
07 | | L2110D_EB07_24_HR | Decimal | 24 Hours |
07 | | L2110D_EB07_YEARS | Decimal | Years |
07 | | L2110D_EB07_SVC_YR | Decimal | Service Year |
07 | | L2110D_EB07_CAL_YEAR | Decimal | Calendar Year |
07 | | L2110D_EB07_YTD | Decimal | Year to Date |
07 | | L2110D_EB07_CNTRCT | Decimal | Contract |
07 | | L2110D_EB07_EPISD | Decimal | Episode |
07 | | L2110D_EB07_VIST | Decimal | Visit |
07 | | L2110D_EB07_OUTLIER | Decimal | Outlier |
07 | | L2110D_EB07_REMNG | Decimal | Remaining |
07 | | L2110D_EB07_EXCEED | Decimal | Exceeded |
07 | | L2110D_EB07_NOT_XCDED | Decimal | Not Exceeded |
07 | | L2110D_EB07_LFTM | Decimal | Lifetime |
07 | | L2110D_EB07_LFTM_REM | Decimal | Lifetime Remaining |
07 | | L2110D_EB07_MO | Decimal | Month |
07 | | L2110D_EB07_WK | Decimal | Week |
07 | | L2110D_EB07_ADMSN | Decimal | Admission |
08 | | L2110D_EB08_BENE_PRCNT | Decimal | Benefit Percent |
10 | | L2110D_EB10_MIN | Decimal | Minimum |
10 | | L2110D_EB10_QTY_USED | Decimal | Quantity Used |
10 | | L2110D_EB10_COVD_ACTL | Decimal | Covered - Actual |
10 | | L2110D_EB10_COVD_EST | Decimal | Covered - Estimated |
10 | | L2110D_EB10_NR_COINS_DYS | Decimal | Number of Co-insurance Days |
10 | | L2110D_EB10_DED_BLOOD_UN | Decimal | Deductible Blood Units |
10 | | L2110D_EB10_DAYS | Decimal | Days |
10 | | L2110D_EB10_HR | Decimal | Hours |
10 | | L2110D_EB10_LFTM_RSRV_ACTL | Decimal | Life-time Reserve - Actual |
10 | | L2110D_EB10_LFTM_RSRV_EST | Decimal | Life-time Reserve - Estimated |
10 | | L2110D_EB10_MAX | Decimal | Maximum |
10 | | L2110D_EB10_MO | Decimal | Month |
10 | | L2110D_EB10_NR_SVC_PROC | Decimal | Number of Services or Procedures |
10 | | L2110D_EB10_QTY_APPR | Decimal | Quantity Approved |
10 | | L2110D_EB10_AGE_HIVAL | Decimal | Age, High Value |
10 | | L2110D_EB10_AGE_LOVAL | Decimal | Age, Low Value |
10 | | L2110D_EB10_VIST | Decimal | Visits |
10 | | L2110D_EB10_YEARS | Decimal | Years |
11 | | L2110D_EB11_AUTH_CERT_IND | String | Authorization or Certification Indicator |
12 | | L2110D_EB12_INPLAN_NET_IND | String | In Plan Network Indicator |
13 | 02 | L2110D_EB1302_ADA_CD | String | American Dental Association Codes |
13 | 02 | L2110D_EB1302_CPT_CD | String | Current Procedural Terminology (CPT) Codes |
13 | 02 | L2110D_EB1302_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
13 | 02 | L2110D_EB1302_ICD9_PROC | String | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure |
13 | 02 | L2110D_EB1302_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
13 | 02 | L2110D_EB1302_NDC542 | String | National Drug Code in 5-4-2 Format |
13 | 02 | L2110D_EB1302_MUTLY_DEF | String | Mutually Defined |
13 | 03 | L2110D_EB1303_PROC_MOD | String | Procedure Modifier |
13 | 04 | L2110D_EB1304_PROC_MOD | String | Procedure Modifier |
13 | 05 | L2110D_EB1305_PROC_MOD | String | Procedure Modifier |
13 | 06 | L2110D_EB1306_PROC_MOD | String | Procedure Modifier |
13 | 08 | L2110D_EB1308_PROD_SVC_ID | String | Product or Service ID |
14 | 01 | L2110D_EB1401_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
14 | 02 | L2110D_EB1402_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
14 | 03 | L2110D_EB1403_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
14 | 04 | L2110D_EB1404_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
L2110D | REF | Dependent Additional Identification |
Iterated: [01-09]
| |
02 | | L2110D_nnREF_PLAN_NR | String | Plan Number |
02 | | L2110D_nnREF_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2110D_nnREF_MEM_ID | String | Member Identification Number |
02 | | L2110D_nnREF_FAM_UNT_NR | String | Family Unit Number |
02 | | L2110D_nnREF_GRP_NR | String | Group Number |
02 | | L2110D_nnREF_REFRL_NR | String | Referral Number |
02 | | L2110D_nnREF_ALTN_LIST_ID | String | Alternative List ID |
02 | | L2110D_nnREF_COVG_LST_ID | String | Coverage List ID |
02 | | L2110D_nnREF_HIC_NR | String | Health Insurance Claim (HIC) Number |
02 | | L2110D_nnREF_DRUG_FML_NR | String | Drug Formulary Number |
02 | | L2110D_nnREF_PRIOR_AUTH | String | Prior Authorization Number |
02 | | L2110D_nnREF_INS_PLCY_NR | String | Insurance Policy Number |
02 | | L2110D_nnREF_PLN_NET_ID | String | Plan Network Identification Number |
02 | | L2110D_nnREF_MDCD_ID_NR | String | Medicaid Recipient Identification Number |
03 | | L2110D_nnREF03_PLN_GRPNT_NM | String | Plan, Group or Plan Network Name |
L2110D | DTP | Dependent Eligibility/Benefit Date |
| |
03 | | L2110D_DTP_DISCHG_D8 | Start Date | Discharge (D8) |
03 | | L2110D_DTP_DISCHG_RD8_1 | Start Date | Discharge (D8) |
03 | | L2110D_DTP_DISCHG_RD8_2 | End Date | Discharge (D8) |
03 | | L2110D_DTP_PRD_STRT_D8 | Start Date | Period Start (D8) |
03 | | L2110D_DTP_PRD_STRT_RD8_1 | Start Date | Period Start (D8) |
03 | | L2110D_DTP_PRD_STRT_RD8_2 | End Date | Period Start (D8) |
03 | | L2110D_DTP_PRD_END_D8 | Start Date | Period End (D8) |
03 | | L2110D_DTP_PRD_END_RD8_1 | Start Date | Period End (D8) |
03 | | L2110D_DTP_PRD_END_RD8_2 | End Date | Period End (D8) |
03 | | L2110D_DTP_CMPLTN_D8 | Start Date | Completion (D8) |
03 | | L2110D_DTP_CMPLTN_RD8_1 | Start Date | Completion (D8) |
03 | | L2110D_DTP_CMPLTN_RD8_2 | End Date | Completion (D8) |
03 | | L2110D_DTP_COB_D8 | Start Date | Coordination of Benefits (D8) |
03 | | L2110D_DTP_COB_RD8_1 | Start Date | Coordination of Benefits (D8) |
03 | | L2110D_DTP_COB_RD8_2 | End Date | Coordination of Benefits (D8) |
03 | | L2110D_DTP_PLAN_D8 | Start Date | Plan (D8) |
03 | | L2110D_DTP_PLAN_RD8_1 | Start Date | Plan (D8) |
03 | | L2110D_DTP_PLAN_RD8_2 | End Date | Plan (D8) |
03 | | L2110D_DTP_BENFT_D8 | Start Date | Benefit (D8) |
03 | | L2110D_DTP_BENFT_RD8_1 | Start Date | Benefit (D8) |
03 | | L2110D_DTP_BENFT_RD8_2 | End Date | Benefit (D8) |
03 | | L2110D_DTP_PCP_D8 | Start Date | Primary Care Provider (D8) |
03 | | L2110D_DTP_PCP_RD8_1 | Start Date | Primary Care Provider (D8) |
03 | | L2110D_DTP_PCP_RD8_2 | End Date | Primary Care Provider (D8) |
03 | | L2110D_DTP_LAST_VST_D8 | Start Date | Latest Visit or Consultation (D8) |
03 | | L2110D_DTP_LAST_VST_RD8_1 | Start Date | Latest Visit or Consultation (D8) |
03 | | L2110D_DTP_LAST_VST_RD8_2 | End Date | Latest Visit or Consultation (D8) |
03 | | L2110D_DTP_ELIG_D8 | Start Date | Eligibility (D8) |
03 | | L2110D_DTP_ELIG_RD8_1 | Start Date | Eligibility (D8) |
03 | | L2110D_DTP_ELIG_RD8_2 | End Date | Eligibility (D8) |
03 | | L2110D_DTP_ADDED_D8 | Start Date | Added (D8) |
03 | | L2110D_DTP_ADDED_RD8_1 | Start Date | Added (D8) |
03 | | L2110D_DTP_ADDED_RD8_2 | End Date | Added (D8) |
03 | | L2110D_DTP_PLAN_BGN_D8 | Start Date | Plan Begin (D8) |
03 | | L2110D_DTP_PLAN_BGN_RD8_1 | Start Date | Plan Begin (D8) |
03 | | L2110D_DTP_PLAN_BGN_RD8_2 | End Date | Plan Begin (D8) |
03 | | L2110D_DTP_BNFT_BGN_D8 | Start Date | Benefit Begin (D8) |
03 | | L2110D_DTP_BNFT_BGN_RD8_1 | Start Date | Benefit Begin (D8) |
03 | | L2110D_DTP_BNFT_BGN_RD8_2 | End Date | Benefit Begin (D8) |
03 | | L2110D_DTP_BNFT_END_D8 | Start Date | Benefit End (D8) |
03 | | L2110D_DTP_BNFT_END_RD8_1 | Start Date | Benefit End (D8) |
03 | | L2110D_DTP_BNFT_END_RD8_2 | End Date | Benefit End (D8) |
03 | | L2110D_DTP_ELIG_BGN_D8 | Start Date | Eligibility Begin (D8) |
03 | | L2110D_DTP_ELIG_BGN_RD8_1 | Start Date | Eligibility Begin (D8) |
03 | | L2110D_DTP_ELIG_BGN_RD8_2 | End Date | Eligibility Begin (D8) |
03 | | L2110D_DTP_ELIG_END_D8 | Start Date | Eligibility End (D8) |
03 | | L2110D_DTP_ELIG_END_RD8_1 | Start Date | Eligibility End (D8) |
03 | | L2110D_DTP_ELIG_END_RD8_2 | End Date | Eligibility End (D8) |
03 | | L2110D_DTP_ADMSN_D8 | Start Date | Admission (D8) |
03 | | L2110D_DTP_ADMSN_RD8_1 | Start Date | Admission (D8) |
03 | | L2110D_DTP_ADMSN_RD8_2 | End Date | Admission (D8) |
03 | | L2110D_DTP_SVC_D8 | Start Date | Service (D8) |
03 | | L2110D_DTP_SVC_RD8_1 | Start Date | Service (D8) |
03 | | L2110D_DTP_SVC_RD8_2 | End Date | Service (D8) |
03 | | L2110D_DTP_LAST_UPDT_D8 | Start Date | Date of Last Update (D8) |
03 | | L2110D_DTP_LAST_UPDT_RD8_1 | Start Date | Date of Last Update (D8) |
03 | | L2110D_DTP_LAST_UPDT_RD8_2 | End Date | Date of Last Update (D8) |
03 | | L2110D_DTP_STATS_D8 | Start Date | Status (D8) |
03 | | L2110D_DTP_STATS_RD8_1 | Start Date | Status (D8) |
03 | | L2110D_DTP_STATS_RD8_2 | End Date | Status (D8) |
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 |
L2120D | NM1 | Dependent Benefit Related Entity Name |
| |
02 | | L2120D_yy_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2120D_yy_NM103_BNRL_LNM | String | Benefit Related Entity Last or Organization Name |
04 | | L2120D_yy_NM104_BNRL_ENT_FNM | String | Benefit Related Entity First Name |
05 | | L2120D_yy_NM105_BNRL_ENT_MNM | String | Benefit Related Entity Middle Name |
07 | | L2120D_yy_NM107_BNRL_ENT_SFX | String | Benefit Related Entity Name Suffix |
09 | | L2120D_yy_NM109_EMPLYR_ID | String | Employer?s Identification Number |
09 | | L2120D_yy_NM109_SSN | String | Social Security Number |
09 | | L2120D_yy_NM109_ETN_NR | String | Electronic Transmitter Identification Number (ETIN) |
09 | | L2120D_yy_NM109_FACLTY_ID | String | Facility Identification |
09 | | L2120D_yy_NM109_TAX_ID | String | Federal Taxpayer?s Identification Number |
09 | | L2120D_yy_NM109_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States |
09 | | L2120D_yy_NM109_MEM_ID_NR | String | Member Identification Number |
09 | | L2120D_yy_NM109_NAIC_ID | String | National Association of Insurance Commissioners |
09 | | L2120D_yy_NM109_PAYR_ID | String | Payor Identification |
09 | | L2120D_yy_NM109_PHM_PRCSR_NR | String | Pharmacy Processor Number |
09 | | L2120D_yy_NM109_SVC_PROV_NR | String | Service Provider Number |
09 | | L2120D_yy_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
09 | | L2120D_yy_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
10 | | L2120D_yy_NM110_BNRL_ETY_REL | String | Benefit Related Entity Relationship Code |
L2120D | N4 | Dependent Benefit Related Entity City, State, ZIP Code |
| |
01 | | L2120D_yy_N401_BNRL_ENT_CITY | String | Benefit Related Entity City Name |
02 | | L2120D_yy_N402_BNRL_ENT_STAT | String | Benefit Related Entity State Code |
03 | | L2120D_yy_N403_BNRL_ENTY_ZIP | String | Benefit Related Entity Postal Zone or ZIP Code |
04 | | L2120D_yy_N404_BNRL_CNTRY_CD | String | Benefit Related Entity Country Code |
06 | | L2120D_yy_N406_BENDOD_HLTRGN | String | Benefit Related Entity DOD Health Service Region |
07 | | L2120D_yy_N407_BNRL_CTY_SBR | String | Benefit Related Entity Country Subdivision Code |
L2120D | PER | Dependent Benefit Related Entity Contact Information |
Iterated: [01-03]
| |
02 | | L2120D_yy_nnPER02_BNRL_CON | String | Benefit Related Entity Contact Name |
04 | | L2120D_yy_nnPER04_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
04 | | L2120D_yy_nnPER04_EMAIL | String | Electronic Mail |
04 | | L2120D_yy_nnPER04_FAX | String | Facsimile |
04 | | L2120D_yy_nnPER04_PHN_NR | String | Telephone |
04 | | L2120D_yy_nnPER04_URL | String | Uniform Resource Locator (URL) |
04 | | L2120D_yy_nnPER04_WRK_PHN_NR | String | Work Phone Number |
06 | | L2120D_yy_nnPER06_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
06 | | L2120D_yy_nnPER06_EMAIL | String | Electronic Mail |
06 | | L2120D_yy_nnPER06_PHN_EXT | String | Telephone Extension |
06 | | L2120D_yy_nnPER06_FAX | String | Facsimile |
06 | | L2120D_yy_nnPER06_PHN_NR | String | Telephone |
06 | | L2120D_yy_nnPER06_URL | String | Uniform Resource Locator (URL) |
06 | | L2120D_yy_nnPER06_WRK_PHN_NR | String | Work Phone Number |
08 | | L2120D_yy_nnPER08_EDI_ACS_NR | String | Electronic Data Interchange Access Number |
08 | | L2120D_yy_nnPER08_EMAIL | String | Electronic Mail |
08 | | L2120D_yy_nnPER08_PHN_EXT | String | Telephone Extension |
08 | | L2120D_yy_nnPER08_FAX | String | Facsimile |
08 | | L2120D_yy_nnPER08_PHN_NR | String | Telephone |
08 | | L2120D_yy_nnPER08_URL | String | Uniform Resource Locator (URL) |
08 | | L2120D_yy_nnPER08_WRK_PHN_NR | String | Work Phone Number |