Segment Modifiers:
X - Distinguishing Identifier Suffix
nn - Segment Iteration (only after first iterartion)
nn - Element Repeat Iteration (only after first iterartion)

ISA - GROUP HEADERS

ISA

ISA

Interchange Control Header

02

ISA_ISA02_NO_AUTH_NFO

String

No Authorization Information Present

02

ISA_ISA02_ADDL_DATA_ID

String

Additional Data Identification

04

ISA_ISA04_NO_SEC_NFO

String

No Security Information Present

04

ISA_ISA04_PSSWD

String

Password

06

ISA_ISA06_DUN_BRDST

String

Dun and Brandstreet

06

ISA_ISA06_DUN_BRDST_SFX

String

Duns Plus Suffix

06

ISA_ISA06_HIN

String

Health Industry Number

06

ISA_ISA06_CARR_ID

String

Carrier Identification Number as assigned by Health Care Financing Administration

06

ISA_ISA06_HCFA_FIIN

String

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration

06

ISA_ISA06_HCFA_ID

String

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

06

ISA_ISA06_TAX_ID

String

US Federal Tax Identification Number

06

ISA_ISA06_NAIC_CD

String

National Association of Insurance Commissioners Company Code

06

ISA_ISA06_MUTLY_DEF

String

Mutually Defined

08

ISA_ISA08_DUN_BRDST

String

Dun and Brandstreet

08

ISA_ISA08_DUN_BRDST_SFX

String

Duns Plus Suffix

08

ISA_ISA08_HIN

String

Health Industry Number

08

ISA_ISA08_CARR_ID

String

Carrier Identification Number as assigned by Health Care Financing Administration

08

ISA_ISA08_HCFA_FIIN

String

Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration

08

ISA_ISA08_HCFA_ID

String

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

08

ISA_ISA08_TAX_ID

String

US Federal Tax Identification Number

08

ISA_ISA08_NAIC_CD

String

National Association of Insurance Commissioners Company Code

08

ISA_ISA08_MUTLY_DEF

String

Mutually Defined

09

ISA_ISA09_INTCHG_DT

Date (YYMMDD)

Interchange Date

10

ISA_ISA10_INTCHG_TM

Time (HHMM)

Interchange Time

11

ISA_ISA11_REPTN_SEP

String

Repetition Separator

12

ISA_ISA12_ICN_VERS_NR

String

Interchang Control Version Number

13

ISA_ISA13_ICN

Integer

Interchange Control Number

14

ISA_ISA14_ACK_REQ

String

Acknowledgment Requested

15

ISA_ISA15_ICN_USG_IND

String

Interchange Usage Indicator

16

ISA_ISA16_COMP_ELE_SEP

String

Component Element Separator

GSHDR - GROUP HEADER

GSHDR

GS

Functional Group Header

02

GSHDR_GS02_APP_SNDR_CD

String

Application Senders Code

03

GSHDR_GS03_APP_RCV_CD

String

Application Receivers Code

04

GSHDR_GS04_D8

Date (YYYYMMDD)

Date

05

GSHDR_GS05_TM

Time (HHMM)

Time

05

GSHDR_GS05_TM8

Time (HHMMSSCC)

Time

06

GSHDR_GS06_GCN

Integer

Group Control Number

STHDR - TRANSACTION SET HEADER

STHDR

ST

Transaction Set Header

02

STHDR_ST02_TCN

String

Transaction Set Control Number

03

STHDR_ST03_IMP_CONV_REF

String

Implementation Convention Reference

STHDR

BHT

Beginning of Hierarchical Transaction

01

STHDR_BHT01_HIER_STRUC_CD

String

Hierarchical Structure Code

02

STHDR_BHT02_TS_PURP_CD

String

Transaction Set Purpose Code

03

STHDR_BHT03_SBM_TRANS_ID

String

Submitter Transaction Identifier

04

STHDR_BHT04_TS_CRTN_D8

Date (YYYYMMDD)

Transaction Set Creation Date

05

STHDR_BHT05_TS_CRTN_TM

Time (HHMM)

Transaction Set Creation Time

05

STHDR_BHT05_TS_CRTN_TM8

Time (HHMMSSCC)

Transaction Set Creation Time

L2000A - INFORMATION SOURCE LEVEL

L2000A

HL

Information Source Level

01

L2000A_HL01_HIER_ID_NR

String

Hierarchical ID Number

04

L2000A_HL04_HL_CHLD_CD

String

Hierarchical Child Code

L2000A

AAA

Request Validation

01

L2000A_nnAAA01_VLDREQ_IND

String

Valid Request Indicator

03

L2000A_nnAAA03_REJ_RSN_CD

String

Reject Reason Code

04

L2000A_nnAAA04_FWUP_ACTCD

String

Follow-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

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

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)

L2100A

AAA

Request Validation

01

L2100A_yy_nnAAA01_VLDREQ_IND

String

Valid Request Indicator

03

L2100A_yy_nnAAA03_REJ_RSN_CD

String

Reject Reason Code

04

L2100A_yy_nnAAA04_FWUP_ACTCD

String

Follow-up Action Code

L2000B - INFORMATION RECEIVER LEVEL

L2000B

HL

Information Receiver Level

01

L2000B_HL01_HIER_ID_NR

String

Hierarchical ID Number

02

L2000B_HL02_HIER_PARNT_ID_NR

String

Hierarchical Parent ID Number

04

L2000B_HL04_HL_CHLD_CD

String

Hierarchical 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

L2100B

NM1

Information Receiver Name

02

L2100B_yy_NM102_ENT_TYP_QUAL

String

Entity Type Qualifier

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

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

03

L2100B_yy_nnREF03_NFORCV_AD_ID

String

L2100B

AAA

Information Receiver Request Validation

01

L2100B_yy_nnAAA01_VLDREQ_IND

String

Valid Request Indicator

03

L2100B_yy_nnAAA03_REJ_RSN_CD

String

Reject Reason Code

04

L2100B_yy_nnAAA04_FWUP_ACTCD

String

Follow-up Action Code

L2100B

PRV

Information Receiver Provider Information

01

L2100B_yy_PRV01_PVD_CD

String

Provider Code

03

L2100B_yy_PRV03_PVD_TAXNMY_CD

String

Health Care Provider Taxonomy Code

L2000C - SUBSCRIBER LEVEL

L2000C

HL

Subscriber Level

01

L2000C_HL01_HIER_ID_NR

String

Hierarchical ID Number

02

L2000C_HL02_HIER_PARNT_ID_NR

String

Hierarchical Parent ID Number

04

L2000C_HL04_HL_CHLD_CD

String

Hierarchical Child Code

L2000C

TRN

Subscriber Trace Number

01

L2000C_nnTRN01_TRAC_TYP_CD

String

Trace Type Code

02

L2000C_nnTRN02_TRAC_NR

String

Trace Number

03

L2000C_nnTRN03_TRAC_ASS_ID

String

Trace Assigning Entity Identifier

04

L2000C_nnTRN04_TRC_ASS_ADDL_ID

String

Trace Assigning Entity Additional Identifier

L2100C - SUBSCRIBER NAME

L2100C

NM1

Subscriber Name

03

L2100C_NM103_SBR_LNM

String

Subscriber Last Name

04

L2100C_NM104_SBR_FNM

String

Subscriber First Name

05

L2100C_NM105_SBR_MNM

String

Subscriber Middle Name or Initial

07

L2100C_NM107_SBR_SFX

String

Subscriber Name Suffix

09

L2100C_NM109_UNQ_HLTH_ID

String

Standard Unique Health Identifier for each Individual in the United States

09

L2100C_NM109_MEM_ID_NR

String

Member Identification Number

L2100C

REF

Subscriber Additional Identification

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

L2100C

N3

Subscriber Address

01

L2100C_N301_SBR_ADDR

String

Subscriber Address Line

02

L2100C_N302_SBR_ADDR

String

Subscriber Address Line

L2100C

N4

Subscriber City, State, ZIP Code

01

L2100C_N401_SBR_CITY

String

Subscriber City Name

02

L2100C_N402_SBR_STAT

String

Subscriber State Code

03

L2100C_N403_SBR_ZIP

String

Subscriber Postal Zone or ZIP Code

04

L2100C_N404_SBR_CNTRY_CD

String

Subscriber Country Code

07

L2100C_N407_SBR_CNTRY_SBR_CD

String

Subscriber Country Subdivision Code

L2100C

AAA

Subscriber Request Validation

01

L2100C_nnAAA01_VLDREQ_IND

String

Valid Request Indicator

03

L2100C_nnAAA03_REJ_RSN_CD

String

Reject Reason Code

04

L2100C_nnAAA04_FWUP_ACTCD

String

Follow-up Action Code

L2100C

PRV

Provider Information

01

L2100C_PRV01_PVD_CD

String

Provider Code

03

L2100C_PRV03_PVD_TAXNMY_CD

String

Health Care Provider Taxonomy Code

L2100C

DMG

Subscriber Demographic Information

02

L2100C_DMG02_D8

DateTime

Subscriber Birth Date

03

L2100C_DMG03_SUB_GENDR_CD

String

Subscriber Gender Code

L2100C

INS

Subscriber Relationship

03

L2100C_INS03_MAINT_TYP_CD

String

Maintenance Type Code

04

L2100C_INS04_MAINT_RSN_CD

String

Maintenance Reason Code

17

L2100C_INS17_BRTH_SEQ_NR

String

Birth Sequence Number

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

Date (YYYYMMDD)

Discharge Date

03

L2100C_DTP_DISCHG_RD8_1

Start Date (YYYYMMDD)

Discharge Date

03

L2100C_DTP_DISCHG_RD8_2

End Date (YYYYMMDD)

Discharge Date

03

L2100C_DTP_ISSU_D8

Date (YYYYMMDD)

Issue Date

03

L2100C_DTP_ISSU_RD8_1

Start Date (YYYYMMDD)

Issue Date

03

L2100C_DTP_ISSU_RD8_2

End Date (YYYYMMDD)

Issue Date

03

L2100C_DTP_CHG_EFF_D8

Date (YYYYMMDD)

Effective Date of Change Date

03

L2100C_DTP_CHG_EFF_RD8_1

Start Date (YYYYMMDD)

Effective Date of Change Date

03

L2100C_DTP_CHG_EFF_RD8_2

End Date (YYYYMMDD)

Effective Date of Change Date

03

L2100C_DTP_PLAN_D8

Date (YYYYMMDD)

Plan Date

03

L2100C_DTP_PLAN_RD8_1

Start Date (YYYYMMDD)

Plan Date

03

L2100C_DTP_PLAN_RD8_2

End Date (YYYYMMDD)

Plan Date

03

L2100C_DTP_ELIG_D8

Date (YYYYMMDD)

Eligibility Date

03

L2100C_DTP_ELIG_RD8_1

Start Date (YYYYMMDD)

Eligibility Date

03

L2100C_DTP_ELIG_RD8_2

End Date (YYYYMMDD)

Eligibility Date

03

L2100C_DTP_ADDED_D8

Date (YYYYMMDD)

Added Date

03

L2100C_DTP_ADDED_RD8_1

Start Date (YYYYMMDD)

Added Date

03

L2100C_DTP_ADDED_RD8_2

End Date (YYYYMMDD)

Added Date

03

L2100C_DTP_COBRA_BGN_D8

Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin Date

03

L2100C_DTP_COBRA_BGN_RD8_1

Start Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin Date

03

L2100C_DTP_COBRA_BGN_RD8_2

End Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin Date

03

L2100C_DTP_COBRA_END_D8

Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) End Date

03

L2100C_DTP_COBRA_END_RD8_1

Start Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) End Date

03

L2100C_DTP_COBRA_END_RD8_2

End Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) End Date

03

L2100C_DTP_PRM_PD_BGN_D8

Date (YYYYMMDD)

Premium Paid to Date Begin Date

03

L2100C_DTP_PRM_PD_BGN_RD8_1

Start Date (YYYYMMDD)

Premium Paid to Date Begin Date

03

L2100C_DTP_PRM_PD_BGN_RD8_2

End Date (YYYYMMDD)

Premium Paid to Date Begin Date

03

L2100C_DTP_PRM_PD_END_D8

Date (YYYYMMDD)

Premium Paid to Date End Date

03

L2100C_DTP_PRM_PD_END_RD8_1

Start Date (YYYYMMDD)

Premium Paid to Date End Date

03

L2100C_DTP_PRM_PD_END_RD8_2

End Date (YYYYMMDD)

Premium Paid to Date End Date

03

L2100C_DTP_PLAN_BGN_D8

Date (YYYYMMDD)

Plan Begin Date

03

L2100C_DTP_PLAN_BGN_RD8_1

Start Date (YYYYMMDD)

Plan Begin Date

03

L2100C_DTP_PLAN_BGN_RD8_2

End Date (YYYYMMDD)

Plan Begin Date

03

L2100C_DTP_PLAN_END_D8

Date (YYYYMMDD)

Plan End Date

03

L2100C_DTP_PLAN_END_RD8_1

Start Date (YYYYMMDD)

Plan End Date

03

L2100C_DTP_PLAN_END_RD8_2

End Date (YYYYMMDD)

Plan End Date

03

L2100C_DTP_ELIG_BGN_D8

Date (YYYYMMDD)

Eligibility Begin Date

03

L2100C_DTP_ELIG_BGN_RD8_1

Start Date (YYYYMMDD)

Eligibility Begin Date

03

L2100C_DTP_ELIG_BGN_RD8_2

End Date (YYYYMMDD)

Eligibility Begin Date

03

L2100C_DTP_ELIG_END_D8

Date (YYYYMMDD)

Eligibility End Date

03

L2100C_DTP_ELIG_END_RD8_1

Start Date (YYYYMMDD)

Eligibility End Date

03

L2100C_DTP_ELIG_END_RD8_2

End Date (YYYYMMDD)

Eligibility End Date

03

L2100C_DTP_ENRLL_D8

Date (YYYYMMDD)

Enrollment Date

03

L2100C_DTP_ENRLL_RD8_1

Start Date (YYYYMMDD)

Enrollment Date

03

L2100C_DTP_ENRLL_RD8_2

End Date (YYYYMMDD)

Enrollment Date

03

L2100C_DTP_ADMSN_D8

Date (YYYYMMDD)

Admission Date

03

L2100C_DTP_ADMSN_RD8_1

Start Date (YYYYMMDD)

Admission Date

03

L2100C_DTP_ADMSN_RD8_2

End Date (YYYYMMDD)

Admission Date

03

L2100C_DTP_DEATH_D8

Date (YYYYMMDD)

Date of Death Date

03

L2100C_DTP_DEATH_RD8_1

Start Date (YYYYMMDD)

Date of Death Date

03

L2100C_DTP_DEATH_RD8_2

End Date (YYYYMMDD)

Date of Death Date

03

L2100C_DTP_CERT_D8

Date (YYYYMMDD)

Certification Date

03

L2100C_DTP_CERT_RD8_1

Start Date (YYYYMMDD)

Certification Date

03

L2100C_DTP_CERT_RD8_2

End Date (YYYYMMDD)

Certification Date

03

L2100C_DTP_SVC_D8

Date (YYYYMMDD)

Service Date

03

L2100C_DTP_SVC_RD8_1

Start Date (YYYYMMDD)

Service Date

03

L2100C_DTP_SVC_RD8_2

End Date (YYYYMMDD)

Service Date

03

L2100C_DTP_PLCY_EFF_D8

Date (YYYYMMDD)

Policy Effective Date

03

L2100C_DTP_PLCY_EFF_RD8_1

Start Date (YYYYMMDD)

Policy Effective Date

03

L2100C_DTP_PLCY_EFF_RD8_2

End Date (YYYYMMDD)

Policy Effective Date

03

L2100C_DTP_PLCY_EXP_D8

Date (YYYYMMDD)

Policy Expiration Date

03

L2100C_DTP_PLCY_EXP_RD8_1

Start Date (YYYYMMDD)

Policy Expiration Date

03

L2100C_DTP_PLCY_EXP_RD8_2

End Date (YYYYMMDD)

Policy Expiration Date

03

L2100C_DTP_LAST_UPDT_D8

Date (YYYYMMDD)

Date of Last Update Date

03

L2100C_DTP_LAST_UPDT_RD8_1

Start Date (YYYYMMDD)

Date of Last Update Date

03

L2100C_DTP_LAST_UPDT_RD8_2

End Date (YYYYMMDD)

Date of Last Update Date

03

L2100C_DTP_STATS_D8

Date (YYYYMMDD)

Status Date

03

L2100C_DTP_STATS_RD8_1

Start Date (YYYYMMDD)

Status Date

03

L2100C_DTP_STATS_RD8_2

End Date (YYYYMMDD)

Status Date

L2100C

MPI

Subscriber Military Personnel Information

01

L2100C_MPI01_NFO_STAT_CD

String

Information Status Code

02

L2100C_MPI02_EMPMT_STAT_CD

String

Employment Status Code

03

L2100C_MPI03_GOV_SVC_AFF_CD

String

Government Service Affiliation Code

04

L2100C_MPI04_DESCR

String

Description

05

L2100C_MPI05_MIL_SVC_RNK_CD

String

Military Service Rank Code

07

L2100C_MPI07_D8

String

Date Time Period

07

L2100C_MPI07_RD8

String

Date Time Period

07

L2100C_MPI07_RD8

String

Date Time Period

L2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION (Single Iteration)

L2110C

EB

Subscriber Eligibility or Benefit Information

01

L2110C_xx_EB01_ELG_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

Number

Hour

07

L2110C_xx_EB07_DAY

Number

Day

07

L2110C_xx_EB07_24_HR

Number

24 Hours

07

L2110C_xx_EB07_YEARS

Number

Years

07

L2110C_xx_EB07_SVC_YR

Number

Service Year

07

L2110C_xx_EB07_CAL_YEAR

Number

Calendar Year

07

L2110C_xx_EB07_YTD

Number

Year to Date

07

L2110C_xx_EB07_CNTRCT

Number

Contract

07

L2110C_xx_EB07_EPISD

Number

Episode

07

L2110C_xx_EB07_VIST

Number

Visit

07

L2110C_xx_EB07_OUTLIER

Number

Outlier

07

L2110C_xx_EB07_REMNG

Number

Remaining

07

L2110C_xx_EB07_EXCEED

Number

Exceeded

07

L2110C_xx_EB07_NOT_XCDED

Number

Not Exceeded

07

L2110C_xx_EB07_LFTM

Number

Lifetime

07

L2110C_xx_EB07_LFTM_REM

Number

Lifetime Remaining

07

L2110C_xx_EB07_MO

Number

Month

07

L2110C_xx_EB07_WK

Number

Week

07

L2110C_xx_EB07_ADMSN

Number

Admission

08

L2110C_xx_EB08_BENE_PRCNT

Number

Benefit Percent

10

L2110C_xx_EB10_MIN

Number

Minimum

10

L2110C_xx_EB10_QTY_USED

Number

Quantity Used

10

L2110C_xx_EB10_COVD_ACTL

Number

Covered - Actual

10

L2110C_xx_EB10_COVD_EST

Number

Covered - Estimated

10

L2110C_xx_EB10_NR_COINS_DYS

Number

Number of Co-insurance Days

10

L2110C_xx_EB10_DED_BLOOD_UN

Number

Deductible Blood Units

10

L2110C_xx_EB10_DAYS

Number

Days

10

L2110C_xx_EB10_HR

Number

Hours

10

L2110C_xx_EB10_LFTM_RSRV_ACTL

Number

Life-time Reserve - Actual

10

L2110C_xx_EB10_LFTM_RSRV_EST

Number

Life-time Reserve - Estimated

10

L2110C_xx_EB10_MAX

Number

Maximum

10

L2110C_xx_EB10_MO

Number

Month

10

L2110C_xx_EB10_NR_SVC_PROC

Number

Number of Services or Procedures

10

L2110C_xx_EB10_QTY_APPR

Number

Quantity Approved

10

L2110C_xx_EB10_AGE_HIVAL

Number

Age, High Value

10

L2110C_xx_EB10_AGE_LOVAL

Number

Age, Low Value

10

L2110C_xx_EB10_VIST

Number

Visits

10

L2110C_xx_EB10_YEARS

Number

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

HSD

Health Care Services Delivery

02

L2110C_xx_nnHSD02_DAYS

Number

Days

02

L2110C_xx_nnHSD02_UN

Number

Units

02

L2110C_xx_nnHSD02_HR

Number

Hours

02

L2110C_xx_nnHSD02_MO

Number

Month

02

L2110C_xx_nnHSD02_VIST

Number

Visits

04

L2110C_xx_nnHSD04_DAYS

Number

Days

04

L2110C_xx_nnHSD04_MOS

Number

Months

04

L2110C_xx_nnHSD04_VIST

Number

Visit

04

L2110C_xx_nnHSD04_WK

Number

Week

04

L2110C_xx_nnHSD04_YEARS

Number

Years

06

L2110C_xx_nnHSD06_HR

Integer

Hour

06

L2110C_xx_nnHSD06_DAY

Integer

Day

06

L2110C_xx_nnHSD06_YEARS

Integer

Years

06

L2110C_xx_nnHSD06_SVC_YR

Integer

Service Year

06

L2110C_xx_nnHSD06_CAL_YEAR

Integer

Calendar Year

06

L2110C_xx_nnHSD06_YTD

Integer

Year to Date

06

L2110C_xx_nnHSD06_CNTRCT

Integer

Contract

06

L2110C_xx_nnHSD06_EPISD

Integer

Episode

06

L2110C_xx_nnHSD06_VIST

Integer

Visit

06

L2110C_xx_nnHSD06_OUTLIER

Integer

Outlier

06

L2110C_xx_nnHSD06_REMNG

Integer

Remaining

06

L2110C_xx_nnHSD06_EXCEED

Integer

Exceeded

06

L2110C_xx_nnHSD06_NOT_XCDED

Integer

Not Exceeded

06

L2110C_xx_nnHSD06_LFTM

Integer

Lifetime

06

L2110C_xx_nnHSD06_LFTM_REM

Integer

Lifetime Remaining

06

L2110C_xx_nnHSD06_MO

Integer

Month

06

L2110C_xx_nnHSD06_WK

Integer

Week

07

L2110C_xx_nnHSD07_DLVY_FREQ_CD

String

Delivery Frequency Code

08

L2110C_xx_nnHSD08_DVY_PT_TM_CD

String

Delivery Pattern Time Code

L2110C

REF

Subscriber Additional Identification

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

L2110C

DTP

Subscriber Eligibility/Benefit Date

03

L2110C_xx_DTP_DISCHG_D8

Date (YYYYMMDD)

Discharge Date

03

L2110C_xx_DTP_DISCHG_RD8_1

Start Date (YYYYMMDD)

Discharge Date

03

L2110C_xx_DTP_DISCHG_RD8_2

End Date (YYYYMMDD)

Discharge Date

03

L2110C_xx_DTP_PRD_STRT_D8

Date (YYYYMMDD)

Period Start Date

03

L2110C_xx_DTP_PRD_STRT_RD8_1

Start Date (YYYYMMDD)

Period Start Date

03

L2110C_xx_DTP_PRD_STRT_RD8_2

End Date (YYYYMMDD)

Period Start Date

03

L2110C_xx_DTP_PRD_END_D8

Date (YYYYMMDD)

Period End Date

03

L2110C_xx_DTP_PRD_END_RD8_1

Start Date (YYYYMMDD)

Period End Date

03

L2110C_xx_DTP_PRD_END_RD8_2

End Date (YYYYMMDD)

Period End Date

03

L2110C_xx_DTP_CMPLTN_D8

Date (YYYYMMDD)

Completion Date

03

L2110C_xx_DTP_CMPLTN_RD8_1

Start Date (YYYYMMDD)

Completion Date

03

L2110C_xx_DTP_CMPLTN_RD8_2

End Date (YYYYMMDD)

Completion Date

03

L2110C_xx_DTP_COB_D8

Date (YYYYMMDD)

Coordination of Benefits Date

03

L2110C_xx_DTP_COB_RD8_1

Start Date (YYYYMMDD)

Coordination of Benefits Date

03

L2110C_xx_DTP_COB_RD8_2

End Date (YYYYMMDD)

Coordination of Benefits Date

03

L2110C_xx_DTP_PLAN_D8

Date (YYYYMMDD)

Plan Date

03

L2110C_xx_DTP_PLAN_RD8_1

Start Date (YYYYMMDD)

Plan Date

03

L2110C_xx_DTP_PLAN_RD8_2

End Date (YYYYMMDD)

Plan Date

03

L2110C_xx_DTP_BENFT_D8

Date (YYYYMMDD)

Benefit Date

03

L2110C_xx_DTP_BENFT_RD8_1

Start Date (YYYYMMDD)

Benefit Date

03

L2110C_xx_DTP_BENFT_RD8_2

End Date (YYYYMMDD)

Benefit Date

03

L2110C_xx_DTP_PCP_D8

Date (YYYYMMDD)

Primary Care Provider Date

03

L2110C_xx_DTP_PCP_RD8_1

Start Date (YYYYMMDD)

Primary Care Provider Date

03

L2110C_xx_DTP_PCP_RD8_2

End Date (YYYYMMDD)

Primary Care Provider Date

03

L2110C_xx_DTP_LAST_VST_D8

Date (YYYYMMDD)

Latest Visit or Consultation Date

03

L2110C_xx_DTP_LAST_VST_RD8_1

Start Date (YYYYMMDD)

Latest Visit or Consultation Date

03

L2110C_xx_DTP_LAST_VST_RD8_2

End Date (YYYYMMDD)

Latest Visit or Consultation Date

03

L2110C_xx_DTP_ELIG_D8

Date (YYYYMMDD)

Eligibility Date

03

L2110C_xx_DTP_ELIG_RD8_1

Start Date (YYYYMMDD)

Eligibility Date

03

L2110C_xx_DTP_ELIG_RD8_2

End Date (YYYYMMDD)

Eligibility Date

03

L2110C_xx_DTP_ADDED_D8

Date (YYYYMMDD)

Added Date

03

L2110C_xx_DTP_ADDED_RD8_1

Start Date (YYYYMMDD)

Added Date

03

L2110C_xx_DTP_ADDED_RD8_2

End Date (YYYYMMDD)

Added Date

03

L2110C_xx_DTP_PLAN_BGN_D8

Date (YYYYMMDD)

Plan Begin Date

03

L2110C_xx_DTP_PLAN_BGN_RD8_1

Start Date (YYYYMMDD)

Plan Begin Date

03

L2110C_xx_DTP_PLAN_BGN_RD8_2

End Date (YYYYMMDD)

Plan Begin Date

03

L2110C_xx_DTP_BNFT_BGN_D8

Date (YYYYMMDD)

Benefit Begin Date

03

L2110C_xx_DTP_BNFT_BGN_RD8_1

Start Date (YYYYMMDD)

Benefit Begin Date

03

L2110C_xx_DTP_BNFT_BGN_RD8_2

End Date (YYYYMMDD)

Benefit Begin Date

03

L2110C_xx_DTP_BNFT_END_D8

Date (YYYYMMDD)

Benefit End Date

03

L2110C_xx_DTP_BNFT_END_RD8_1

Start Date (YYYYMMDD)

Benefit End Date

03

L2110C_xx_DTP_BNFT_END_RD8_2

End Date (YYYYMMDD)

Benefit End Date

03

L2110C_xx_DTP_ELIG_BGN_D8

Date (YYYYMMDD)

Eligibility Begin Date

03

L2110C_xx_DTP_ELIG_BGN_RD8_1

Start Date (YYYYMMDD)

Eligibility Begin Date

03

L2110C_xx_DTP_ELIG_BGN_RD8_2

End Date (YYYYMMDD)

Eligibility Begin Date

03

L2110C_xx_DTP_ELIG_END_D8

Date (YYYYMMDD)

Eligibility End Date

03

L2110C_xx_DTP_ELIG_END_RD8_1

Start Date (YYYYMMDD)

Eligibility End Date

03

L2110C_xx_DTP_ELIG_END_RD8_2

End Date (YYYYMMDD)

Eligibility End Date

03

L2110C_xx_DTP_ADMSN_D8

Date (YYYYMMDD)

Admission Date

03

L2110C_xx_DTP_ADMSN_RD8_1

Start Date (YYYYMMDD)

Admission Date

03

L2110C_xx_DTP_ADMSN_RD8_2

End Date (YYYYMMDD)

Admission Date

03

L2110C_xx_DTP_SVC_D8

Date (YYYYMMDD)

Service Date

03

L2110C_xx_DTP_SVC_RD8_1

Start Date (YYYYMMDD)

Service Date

03

L2110C_xx_DTP_SVC_RD8_2

End Date (YYYYMMDD)

Service Date

03

L2110C_xx_DTP_LAST_UPDT_D8

Date (YYYYMMDD)

Date of Last Update Date

03

L2110C_xx_DTP_LAST_UPDT_RD8_1

Start Date (YYYYMMDD)

Date of Last Update Date

03

L2110C_xx_DTP_LAST_UPDT_RD8_2

End Date (YYYYMMDD)

Date of Last Update Date

03

L2110C_xx_DTP_STATS_D8

Date (YYYYMMDD)

Status Date

03

L2110C_xx_DTP_STATS_RD8_1

Start Date (YYYYMMDD)

Status Date

03

L2110C_xx_DTP_STATS_RD8_2

End Date (YYYYMMDD)

Status Date

L2110C

AAA

Subscriber Request Validation

01

L2110C_xx_nnAAA01_VLDREQ_IND

String

Valid Request Indicator

03

L2110C_xx_nnAAA03_REJ_RSN_CD

String

Reject Reason Code

04

L2110C_xx_nnAAA04_FWUP_ACTCD

String

Follow-up Action Code

L2110C

MSG

Message Text

01

L2110C_xx_nnMSG01_FRFM_MSG_TXT

String

Free Form Message Text

L2110C

III

Subscriber Eligibility or Benefit Additional Information

02

L2110C_xx_nnIII02_NCCI_INJ_CD

String

National Council on Compensation Insurance (NCCI) Nature of Injury Code

02

L2110C_xx_nnIII02_NTR_INJRY_CD

String

Nature of Injury Code

02

L2110C_xx_nnIII02_MUTLY_DEF

String

Mutually Defined

03

L2110C_xx_nnIII03_CD_CAT

String

Code Category

04

L2110C_xx_nnIII04_INJR_BDY_PRT

String

Injured Body Part Name

L2110C

LS

Loop Header

01

L2110C_xx_LS01_LOOP_ID_CD

String

Loop 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

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

N3

Subscriber Benefit Related Entity Address

01

L2120C_xxyy_N301_BNRL_ENT_ADDR

String

Benefit Related Entity Address Line

02

L2120C_xxyy_N302_BNRL_ENT_ADDR

String

Benefit Related Entity Address Line

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_REGN

String

Region

07

L2120C_xxyy_N407_BNRL_CTY_SBR

String

Benefit Related Entity Country Subdivision Code

L2120C

PER

Subscriber Benefit Related Entity Contact Information

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

L2120C

PRV

Subscriber Benefit Related Provider Information

01

L2120C_xxyy_PRV01_PVD_CD

String

Provider Code

03

L2120C_xxyy_PRV03_PVD_TAXNMY_CD

String

Health Care Provider Taxonomy Code

L2110C

LE

Loop Trailer

01

L2110C_xx_LE01_LOOP_ID_CD

String

Loop Identifier Code

L2000D - DEPENDENT LEVEL

L2000D

HL

Dependent Level

01

L2000D_HL01_HIER_ID_NR

String

Hierarchical ID Number

02

L2000D_HL02_HIER_PARNT_ID_NR

String

Hierarchical Parent ID Number

L2000D

TRN

Dependent Trace Number

01

L2000D_nnTRN01_TRAC_TYP_CD

String

Trace Type Code

02

L2000D_nnTRN02_TRAC_NR

String

Trace Number

03

L2000D_nnTRN03_TRAC_ASS_ID

String

Trace Assigning Entity Identifier

04

L2000D_nnTRN04_TRC_ASS_ADDL_ID

String

Trace Assigning Entity Additional Identifier

L2100D - DEPENDENT NAME

L2100D

NM1

Dependent Name

03

L2100D_NM103_DEP_LNM

String

Dependent Last Name

04

L2100D_NM104_DEP_FNM

String

Dependent First Name

05

L2100D_NM105_DEP_MNM

String

Dependent Middle Name

07

L2100D_NM107_DEP_SFX

String

Dependent Name Suffix

L2100D

REF

Dependent Additional Identification

Segment Suffix: B

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

L2100D

N3

Dependent Address

01

L2100D_N301_DEP_ADDR

String

Dependent Address Line

02

L2100D_N302_DEP_ADDR

String

Dependent Address Line

L2100D

N4

Dependent City, State, ZIP Code

01

L2100D_N401_DEP_CITY

String

Dependent City Name

02

L2100D_N402_DEP_STAT

String

Dependent State Code

03

L2100D_N403_DEP_POSTL_ZIP

String

Dependent Postal Zone or ZIP Code

04

L2100D_N404_DEP_CNTRY_CD

String

Dependent Country Code

07

L2100D_N407_DEP_CNTRY_SBR_CD

String

Dependent Country Subdivision Code

L2100D

AAA

Dependent Request Validation

01

L2100D_nnAAA01_VLDREQ_IND

String

Valid Request Indicator

03

L2100D_nnAAA03_REJ_RSN_CD

String

Reject Reason Code

04

L2100D_nnAAA04_FWUP_ACTCD

String

Follow-up Action Code

L2100D

PRV

Provider Information

01

L2100D_PRV01_PVD_CD

String

Provider Code

03

L2100D_PRV03_PVD_TAXNMY_CD

String

Health Care Provider Taxonomy Code

L2100D

DMG

Dependent Demographic Information

02

L2100D_DMG02_D8

DateTime

Dependent Birth Date

03

L2100D_DMG03_DEP_GNDR_CD

String

Dependent Gender Code

L2100D

INS

Dependent Relationship

02

L2100D_INS02_IND_RELAT_CD

String

Individual Relationship Code

03

L2100D_INS03_MAINT_TYP_CD

String

Maintenance Type Code

04

L2100D_INS04_MAINT_RSN_CD

String

Maintenance Reason Code

17

L2100D_INS17_BRTH_SEQ_NR

String

Birth Sequence Number

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

Date (YYYYMMDD)

Discharge Date

03

L2100D_DTP_DISCHG_RD8_1

Start Date (YYYYMMDD)

Discharge Date

03

L2100D_DTP_DISCHG_RD8_2

End Date (YYYYMMDD)

Discharge Date

03

L2100D_DTP_ISSU_D8

Date (YYYYMMDD)

Issue Date

03

L2100D_DTP_ISSU_RD8_1

Start Date (YYYYMMDD)

Issue Date

03

L2100D_DTP_ISSU_RD8_2

End Date (YYYYMMDD)

Issue Date

03

L2100D_DTP_CHG_EFF_D8

Date (YYYYMMDD)

Effective Date of Change Date

03

L2100D_DTP_CHG_EFF_RD8_1

Start Date (YYYYMMDD)

Effective Date of Change Date

03

L2100D_DTP_CHG_EFF_RD8_2

End Date (YYYYMMDD)

Effective Date of Change Date

03

L2100D_DTP_PLAN_D8

Date (YYYYMMDD)

Plan Date

03

L2100D_DTP_PLAN_RD8_1

Start Date (YYYYMMDD)

Plan Date

03

L2100D_DTP_PLAN_RD8_2

End Date (YYYYMMDD)

Plan Date

03

L2100D_DTP_ELIG_D8

Date (YYYYMMDD)

Eligibility Date

03

L2100D_DTP_ELIG_RD8_1

Start Date (YYYYMMDD)

Eligibility Date

03

L2100D_DTP_ELIG_RD8_2

End Date (YYYYMMDD)

Eligibility Date

03

L2100D_DTP_ADDED_D8

Date (YYYYMMDD)

Added Date

03

L2100D_DTP_ADDED_RD8_1

Start Date (YYYYMMDD)

Added Date

03

L2100D_DTP_ADDED_RD8_2

End Date (YYYYMMDD)

Added Date

03

L2100D_DTP_COBRA_BGN_D8

Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin Date

03

L2100D_DTP_COBRA_BGN_RD8_1

Start Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin Date

03

L2100D_DTP_COBRA_BGN_RD8_2

End Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin Date

03

L2100D_DTP_COBRA_END_D8

Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) End Date

03

L2100D_DTP_COBRA_END_RD8_1

Start Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) End Date

03

L2100D_DTP_COBRA_END_RD8_2

End Date (YYYYMMDD)

Consolidated Omnibus Budget Reconciliation Act (COBRA) End Date

03

L2100D_DTP_PRM_PD_BGN_D8

Date (YYYYMMDD)

Premium Paid to Date Begin Date

03

L2100D_DTP_PRM_PD_BGN_RD8_1

Start Date (YYYYMMDD)

Premium Paid to Date Begin Date

03

L2100D_DTP_PRM_PD_BGN_RD8_2

End Date (YYYYMMDD)

Premium Paid to Date Begin Date

03

L2100D_DTP_PRM_PD_END_D8

Date (YYYYMMDD)

Premium Paid to Date End Date

03

L2100D_DTP_PRM_PD_END_RD8_1

Start Date (YYYYMMDD)

Premium Paid to Date End Date

03

L2100D_DTP_PRM_PD_END_RD8_2

End Date (YYYYMMDD)

Premium Paid to Date End Date

03

L2100D_DTP_PLAN_BGN_D8

Date (YYYYMMDD)

Plan Begin Date

03

L2100D_DTP_PLAN_BGN_RD8_1

Start Date (YYYYMMDD)

Plan Begin Date

03

L2100D_DTP_PLAN_BGN_RD8_2

End Date (YYYYMMDD)

Plan Begin Date

03

L2100D_DTP_PLAN_END_D8

Date (YYYYMMDD)

Plan End Date

03

L2100D_DTP_PLAN_END_RD8_1

Start Date (YYYYMMDD)

Plan End Date

03

L2100D_DTP_PLAN_END_RD8_2

End Date (YYYYMMDD)

Plan End Date

03

L2100D_DTP_ELIG_BGN_D8

Date (YYYYMMDD)

Eligibility Begin Date

03

L2100D_DTP_ELIG_BGN_RD8_1

Start Date (YYYYMMDD)

Eligibility Begin Date

03

L2100D_DTP_ELIG_BGN_RD8_2

End Date (YYYYMMDD)

Eligibility Begin Date

03

L2100D_DTP_ELIG_END_D8

Date (YYYYMMDD)

Eligibility End Date

03

L2100D_DTP_ELIG_END_RD8_1

Start Date (YYYYMMDD)

Eligibility End Date

03

L2100D_DTP_ELIG_END_RD8_2

End Date (YYYYMMDD)

Eligibility End Date

03

L2100D_DTP_ENRLL_D8

Date (YYYYMMDD)

Enrollment Date

03

L2100D_DTP_ENRLL_RD8_1

Start Date (YYYYMMDD)

Enrollment Date

03

L2100D_DTP_ENRLL_RD8_2

End Date (YYYYMMDD)

Enrollment Date

03

L2100D_DTP_ADMSN_D8

Date (YYYYMMDD)

Admission Date

03

L2100D_DTP_ADMSN_RD8_1

Start Date (YYYYMMDD)

Admission Date

03

L2100D_DTP_ADMSN_RD8_2

End Date (YYYYMMDD)

Admission Date

03

L2100D_DTP_DEATH_D8

Date (YYYYMMDD)

Date of Death Date

03

L2100D_DTP_DEATH_RD8_1

Start Date (YYYYMMDD)

Date of Death Date

03

L2100D_DTP_DEATH_RD8_2

End Date (YYYYMMDD)

Date of Death Date

03

L2100D_DTP_CERT_D8

Date (YYYYMMDD)

Certification Date

03

L2100D_DTP_CERT_RD8_1

Start Date (YYYYMMDD)

Certification Date

03

L2100D_DTP_CERT_RD8_2

End Date (YYYYMMDD)

Certification Date

03

L2100D_DTP_SVC_D8

Date (YYYYMMDD)

Service Date

03

L2100D_DTP_SVC_RD8_1

Start Date (YYYYMMDD)

Service Date

03

L2100D_DTP_SVC_RD8_2

End Date (YYYYMMDD)

Service Date

03

L2100D_DTP_PLCY_EFF_D8

Date (YYYYMMDD)

Policy Effective Date

03

L2100D_DTP_PLCY_EFF_RD8_1

Start Date (YYYYMMDD)

Policy Effective Date

03

L2100D_DTP_PLCY_EFF_RD8_2

End Date (YYYYMMDD)

Policy Effective Date

03

L2100D_DTP_PLCY_EXP_D8

Date (YYYYMMDD)

Policy Expiration Date

03

L2100D_DTP_PLCY_EXP_RD8_1

Start Date (YYYYMMDD)

Policy Expiration Date

03

L2100D_DTP_PLCY_EXP_RD8_2

End Date (YYYYMMDD)

Policy Expiration Date

03

L2100D_DTP_LAST_UPDT_D8

Date (YYYYMMDD)

Date of Last Update Date

03

L2100D_DTP_LAST_UPDT_RD8_1

Start Date (YYYYMMDD)

Date of Last Update Date

03

L2100D_DTP_LAST_UPDT_RD8_2

End Date (YYYYMMDD)

Date of Last Update Date

03

L2100D_DTP_STATS_D8

Date (YYYYMMDD)

Status Date

03

L2100D_DTP_STATS_RD8_1

Start Date (YYYYMMDD)

Status Date

03

L2100D_DTP_STATS_RD8_2

End Date (YYYYMMDD)

Status Date

L2100D

MPI

Dependent Military Personnel Information

01

L2100D_MPI01_NFO_STAT_CD

String

Information Status Code

02

L2100D_MPI02_EMPMT_STAT_CD

String

Employment Status Code

03

L2100D_MPI03_GOV_SVC_AFF_CD

String

Government Service Affiliation Code

04

L2100D_MPI04_DESCR

String

Description

05

L2100D_MPI05_MIL_SVC_RNK_CD

String

Military Service Rank Code

07

L2100D_MPI07_D8

String

Date Time Period

07

L2100D_MPI07_RD8

String

Date Time Period

07

L2100D_MPI07_RD8

String

Date Time Period

L2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION

L2110D

EB

Dependent Eligibility or Benefit Information

01

L2110D_EB01_Enn_ELG_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

Number

Hour

07

L2110D_EB07_DAY

Number

Day

07

L2110D_EB07_24_HR

Number

24 Hours

07

L2110D_EB07_YEARS

Number

Years

07

L2110D_EB07_SVC_YR

Number

Service Year

07

L2110D_EB07_CAL_YEAR

Number

Calendar Year

07

L2110D_EB07_YTD

Number

Year to Date

07

L2110D_EB07_CNTRCT

Number

Contract

07

L2110D_EB07_EPISD

Number

Episode

07

L2110D_EB07_VIST

Number

Visit

07

L2110D_EB07_OUTLIER

Number

Outlier

07

L2110D_EB07_REMNG

Number

Remaining

07

L2110D_EB07_EXCEED

Number

Exceeded

07

L2110D_EB07_NOT_XCDED

Number

Not Exceeded

07

L2110D_EB07_LFTM

Number

Lifetime

07

L2110D_EB07_LFTM_REM

Number

Lifetime Remaining

07

L2110D_EB07_MO

Number

Month

07

L2110D_EB07_WK

Number

Week

07

L2110D_EB07_ADMSN

Number

Admission

08

L2110D_EB08_BENE_PRCNT

Number

Benefit Percent

10

L2110D_EB10_MIN

Number

Minimum

10

L2110D_EB10_QTY_USED

Number

Quantity Used

10

L2110D_EB10_COVD_ACTL

Number

Covered - Actual

10

L2110D_EB10_COVD_EST

Number

Covered - Estimated

10

L2110D_EB10_NR_COINS_DYS

Number

Number of Co-insurance Days

10

L2110D_EB10_DED_BLOOD_UN

Number

Deductible Blood Units

10

L2110D_EB10_DAYS

Number

Days

10

L2110D_EB10_HR

Number

Hours

10

L2110D_EB10_LFTM_RSRV_ACTL

Number

Life-time Reserve - Actual

10

L2110D_EB10_LFTM_RSRV_EST

Number

Life-time Reserve - Estimated

10

L2110D_EB10_MAX

Number

Maximum

10

L2110D_EB10_MO

Number

Month

10

L2110D_EB10_NR_SVC_PROC

Number

Number of Services or Procedures

10

L2110D_EB10_QTY_APPR

Number

Quantity Approved

10

L2110D_EB10_AGE_HIVAL

Number

Age, High Value

10

L2110D_EB10_AGE_LOVAL

Number

Age, Low Value

10

L2110D_EB10_VIST

Number

Visits

10

L2110D_EB10_YEARS

Number

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

HSD

Health Care Services Delivery

02

L2110D_nnHSD02_DAYS

Number

Days

02

L2110D_nnHSD02_UN

Number

Units

02

L2110D_nnHSD02_HR

Number

Hours

02

L2110D_nnHSD02_MO

Number

Month

02

L2110D_nnHSD02_VIST

Number

Visits

04

L2110D_nnHSD04_DAYS

Number

Days

04

L2110D_nnHSD04_MOS

Number

Months

04

L2110D_nnHSD04_VIST

Number

Visit

04

L2110D_nnHSD04_WK

Number

Week

04

L2110D_nnHSD04_YEARS

Number

Years

06

L2110D_nnHSD06_HR

Integer

Hour

06

L2110D_nnHSD06_DAY

Integer

Day

06

L2110D_nnHSD06_YEARS

Integer

Years

06

L2110D_nnHSD06_SVC_YR

Integer

Service Year

06

L2110D_nnHSD06_CAL_YEAR

Integer

Calendar Year

06

L2110D_nnHSD06_YTD

Integer

Year to Date

06

L2110D_nnHSD06_CNTRCT

Integer

Contract

06

L2110D_nnHSD06_EPISD

Integer

Episode

06

L2110D_nnHSD06_VIST

Integer

Visit

06

L2110D_nnHSD06_OUTLIER

Integer

Outlier

06

L2110D_nnHSD06_REMNG

Integer

Remaining

06

L2110D_nnHSD06_EXCEED

Integer

Exceeded

06

L2110D_nnHSD06_NOT_XCDED

Integer

Not Exceeded

06

L2110D_nnHSD06_LFTM

Integer

Lifetime

06

L2110D_nnHSD06_LFTM_REM

Integer

Lifetime Remaining

06

L2110D_nnHSD06_MO

Integer

Month

06

L2110D_nnHSD06_WK

Integer

Week

07

L2110D_nnHSD07_DLVY_FREQ_CD

String

Delivery Frequency Code

08

L2110D_nnHSD08_DVY_PT_TM_CD

String

Delivery Pattern Time Code

L2110D

REF

Dependent Additional Identification

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

L2110D

DTP

Dependent Eligibility/Benefit Date

03

L2110D_DTP_DISCHG_D8

Date (YYYYMMDD)

Discharge Date

03

L2110D_DTP_DISCHG_RD8_1

Start Date (YYYYMMDD)

Discharge Date

03

L2110D_DTP_DISCHG_RD8_2

End Date (YYYYMMDD)

Discharge Date

03

L2110D_DTP_PRD_STRT_D8

Date (YYYYMMDD)

Period Start Date

03

L2110D_DTP_PRD_STRT_RD8_1

Start Date (YYYYMMDD)

Period Start Date

03

L2110D_DTP_PRD_STRT_RD8_2

End Date (YYYYMMDD)

Period Start Date

03

L2110D_DTP_PRD_END_D8

Date (YYYYMMDD)

Period End Date

03

L2110D_DTP_PRD_END_RD8_1

Start Date (YYYYMMDD)

Period End Date

03

L2110D_DTP_PRD_END_RD8_2

End Date (YYYYMMDD)

Period End Date

03

L2110D_DTP_CMPLTN_D8

Date (YYYYMMDD)

Completion Date

03

L2110D_DTP_CMPLTN_RD8_1

Start Date (YYYYMMDD)

Completion Date

03

L2110D_DTP_CMPLTN_RD8_2

End Date (YYYYMMDD)

Completion Date

03

L2110D_DTP_COB_D8

Date (YYYYMMDD)

Coordination of Benefits Date

03

L2110D_DTP_COB_RD8_1

Start Date (YYYYMMDD)

Coordination of Benefits Date

03

L2110D_DTP_COB_RD8_2

End Date (YYYYMMDD)

Coordination of Benefits Date

03

L2110D_DTP_PLAN_D8

Date (YYYYMMDD)

Plan Date

03

L2110D_DTP_PLAN_RD8_1

Start Date (YYYYMMDD)

Plan Date

03

L2110D_DTP_PLAN_RD8_2

End Date (YYYYMMDD)

Plan Date

03

L2110D_DTP_BENFT_D8

Date (YYYYMMDD)

Benefit Date

03

L2110D_DTP_BENFT_RD8_1

Start Date (YYYYMMDD)

Benefit Date

03

L2110D_DTP_BENFT_RD8_2

End Date (YYYYMMDD)

Benefit Date

03

L2110D_DTP_PCP_D8

Date (YYYYMMDD)

Primary Care Provider Date

03

L2110D_DTP_PCP_RD8_1

Start Date (YYYYMMDD)

Primary Care Provider Date

03

L2110D_DTP_PCP_RD8_2

End Date (YYYYMMDD)

Primary Care Provider Date

03

L2110D_DTP_LAST_VST_D8

Date (YYYYMMDD)

Latest Visit or Consultation Date

03

L2110D_DTP_LAST_VST_RD8_1

Start Date (YYYYMMDD)

Latest Visit or Consultation Date

03

L2110D_DTP_LAST_VST_RD8_2

End Date (YYYYMMDD)

Latest Visit or Consultation Date

03

L2110D_DTP_ELIG_D8

Date (YYYYMMDD)

Eligibility Date

03

L2110D_DTP_ELIG_RD8_1

Start Date (YYYYMMDD)

Eligibility Date

03

L2110D_DTP_ELIG_RD8_2

End Date (YYYYMMDD)

Eligibility Date

03

L2110D_DTP_ADDED_D8

Date (YYYYMMDD)

Added Date

03

L2110D_DTP_ADDED_RD8_1

Start Date (YYYYMMDD)

Added Date

03

L2110D_DTP_ADDED_RD8_2

End Date (YYYYMMDD)

Added Date

03

L2110D_DTP_PLAN_BGN_D8

Date (YYYYMMDD)

Plan Begin Date

03

L2110D_DTP_PLAN_BGN_RD8_1

Start Date (YYYYMMDD)

Plan Begin Date

03

L2110D_DTP_PLAN_BGN_RD8_2

End Date (YYYYMMDD)

Plan Begin Date

03

L2110D_DTP_BNFT_BGN_D8

Date (YYYYMMDD)

Benefit Begin Date

03

L2110D_DTP_BNFT_BGN_RD8_1

Start Date (YYYYMMDD)

Benefit Begin Date

03

L2110D_DTP_BNFT_BGN_RD8_2

End Date (YYYYMMDD)

Benefit Begin Date

03

L2110D_DTP_BNFT_END_D8

Date (YYYYMMDD)

Benefit End Date

03

L2110D_DTP_BNFT_END_RD8_1

Start Date (YYYYMMDD)

Benefit End Date

03

L2110D_DTP_BNFT_END_RD8_2

End Date (YYYYMMDD)

Benefit End Date

03

L2110D_DTP_ELIG_BGN_D8

Date (YYYYMMDD)

Eligibility Begin Date

03

L2110D_DTP_ELIG_BGN_RD8_1

Start Date (YYYYMMDD)

Eligibility Begin Date

03

L2110D_DTP_ELIG_BGN_RD8_2

End Date (YYYYMMDD)

Eligibility Begin Date

03

L2110D_DTP_ELIG_END_D8

Date (YYYYMMDD)

Eligibility End Date

03

L2110D_DTP_ELIG_END_RD8_1

Start Date (YYYYMMDD)

Eligibility End Date

03

L2110D_DTP_ELIG_END_RD8_2

End Date (YYYYMMDD)

Eligibility End Date

03

L2110D_DTP_ADMSN_D8

Date (YYYYMMDD)

Admission Date

03

L2110D_DTP_ADMSN_RD8_1

Start Date (YYYYMMDD)

Admission Date

03

L2110D_DTP_ADMSN_RD8_2

End Date (YYYYMMDD)

Admission Date

03

L2110D_DTP_SVC_D8

Date (YYYYMMDD)

Service Date

03

L2110D_DTP_SVC_RD8_1

Start Date (YYYYMMDD)

Service Date

03

L2110D_DTP_SVC_RD8_2

End Date (YYYYMMDD)

Service Date

03

L2110D_DTP_LAST_UPDT_D8

Date (YYYYMMDD)

Date of Last Update Date

03

L2110D_DTP_LAST_UPDT_RD8_1

Start Date (YYYYMMDD)

Date of Last Update Date

03

L2110D_DTP_LAST_UPDT_RD8_2

End Date (YYYYMMDD)

Date of Last Update Date

03

L2110D_DTP_STATS_D8

Date (YYYYMMDD)

Status Date

03

L2110D_DTP_STATS_RD8_1

Start Date (YYYYMMDD)

Status Date

03

L2110D_DTP_STATS_RD8_2

End Date (YYYYMMDD)

Status Date

L2110D

AAA

Dependent Request Validation

01

L2110D_nnAAA01_VLDREQ_IND

String

Valid Request Indicator

03

L2110D_nnAAA03_REJ_RSN_CD

String

Reject Reason Code

04

L2110D_nnAAA04_FWUP_ACTCD

String

Follow-up Action Code

L2110D

MSG

Message Text

01

L2110D_nnMSG01_FRFM_MSG_TXT

String

Free Form Message Text

L2115D - DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION (Single Iteration)

L2115D

III

Dependent Eligibility or Benefit Additional Information

02

L2115D_xx_III02_NCCI_INJ_CD

String

National Council on Compensation Insurance (NCCI) Nature of Injury Code

02

L2115D_xx_III02_NTR_INJRY_CD

String

Nature of Injury Code

02

L2115D_xx_III02_MUTLY_DEF

String

Mutually Defined

03

L2115D_xx_III03_CD_CAT

String

Code Category

04

L2115D_xx_III04_INJR_BDY_PRT

String

Injured Body Part Name

L2110D

LS

Loop Header

01

L2110D_LS01_LOOP_ID_CD

String

Loop 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

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

N3

Dependent Benefit Related Entity Address

01

L2120D_yy_N301_BNRL_ENT_ADDR

String

Benefit Related Entity Address Line

02

L2120D_yy_N302_BNRL_ENT_ADDR

String

Benefit Related Entity Address Line

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_REGN

String

Region

07

L2120D_yy_N407_BNRL_CTY_SBR

String

Benefit Related Entity Country Subdivision Code

L2120D

PER

Dependent Benefit Related Entity Contact Information

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

L2120D

PRV

Dependent Benefit Related Provider Information

01

L2120D_yy_PRV01_PVD_CD

String

Provider Code

03

L2120D_yy_PRV03_PVD_TAXNMY_CD

String

Health Care Provider Taxonomy Code

L2110D

LE

Loop Trailer

01

L2110D_LE01_LOOP_ID_CD

String

Loop Identifier Code

STHDR

SE

Transaction Set Trailer

01

STHDR_SE01_TS_SEG_CT

Integer

Transaction Segment Count

02

STHDR_SE02_TCN

String

Transaction Set Control Number

GSHDR

GE

Functional Group Trailer

01

GSHDR_GE01_NR_TS_INCLUDED

Integer

Number of Transaction Sets Included

02

GSHDR_GE02_GCN

Integer

Group Control Number

ISA

IEA

Interchange Control Trailer

01

ISA_IEA01_NR_INC_FUNC_GRP

Integer

Number of Included Functional Groups

02

ISA_IEA02_ICN

Integer

Interchange Control Number