5010 Benefit Enrollment and Maintenance [T0]


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

ISA - GROUP HEADERS
ISAISAInterchange Control Header
02ISA_ISA02_NO_AUTH_NFOStringNo Authorization Information Present
02ISA_ISA02_ADDL_DATA_IDStringAdditional Data Identification
04ISA_ISA04_NO_SEC_NFOStringNo Security Information Present
04ISA_ISA04_PSSWDStringPassword
06ISA_ISA06_DUN_BRDSTStringDun and Brandstreet
06ISA_ISA06_DUN_BRDST_SFXStringDuns Plus Suffix
06ISA_ISA06_HINStringHealth Industry Number
06ISA_ISA06_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
06ISA_ISA06_TAX_IDStringUS Federal Tax Identification Number
06ISA_ISA06_NAIC_CDStringNational Association of Insurance Commissioners Company Code
06ISA_ISA06_MUTLY_DEFStringMutually Defined
08ISA_ISA08_DUN_BRDSTStringDun and Brandstreet
08ISA_ISA08_DUN_BRDST_SFXStringDuns Plus Suffix
08ISA_ISA08_HINStringHealth Industry Number
08ISA_ISA08_CARR_IDStringCarrier Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_HCFA_FIINStringFiscal Intermediary Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_HCFA_IDStringMedicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration
08ISA_ISA08_TAX_IDStringUS Federal Tax Identification Number
08ISA_ISA08_NAIC_CDStringNational Association of Insurance Commissioners Company Code
08ISA_ISA08_MUTLY_DEFStringMutually Defined
09ISA_ISA09_INTCHG_DTDate (YYMMDD)Interchange Date
10ISA_ISA10_INTCHG_TMTime (HHMM)Interchange Time
11ISA_ISA11_REPTN_SEPStringRepetition Separator
12ISA_ISA12_ICN_VERS_NRStringInterchang Control Version Number
13ISA_ISA13_ICNIntegerInterchange Control Number
14ISA_ISA14_ACK_REQStringAcknowledgment Requested
15ISA_ISA15_ICN_USG_INDStringInterchange Usage Indicator
16ISA_ISA16_COMP_ELE_SEPStringComponent Element Separator
GSHDR - GROUP HEADER
GSHDRGSFunctional Group Header
02GSHDR_GS02_APP_SNDR_CDStringApplication Senders Code
03GSHDR_GS03_APP_RCV_CDStringApplication Receivers Code
04GSHDR_GS04_D8Date (YYYYMMDD)Date
05GSHDR_GS05_TMTime (HHMM)Time
05GSHDR_GS05_TM8Time (HHMMSSCC)Time
06GSHDR_GS06_GCNIntegerGroup Control Number
STHDR - TRANSACTION SET HEADER
STHDRSTTransaction Set Header
02STHDR_ST02_TCNStringTransaction Set Control Number
03STHDR_ST03_IMP_CONV_REFStringImplementation Convention Reference
STHDRBGNBeginning Segment
01STHDR_BGN01_TS_PURP_CDStringTransaction Set Purpose Code
02STHDR_BGN02_TS_REF_NRStringTransaction Set Reference Number
03STHDR_BGN03_TS_CRTN_D8Date (YYYYMMDD)Transaction Set Creation Date
04STHDR_BGN04_TS_CRTN_TMTime (HHMM)Transaction Set Creation Time
04STHDR_BGN04_TS_CRTN_TM8Time (HHMMSSCC)Transaction Set Creation Time
05STHDR_BGN05_TIMZON_CDStringTime Zone Code
06STHDR_BGN06_ORIG_TS_REF_NRStringOriginal Transaction Set Reference Number
08STHDR_BGN08_ACTN_CDStringAction Code
STHDRREFTransaction Set Policy Number
02STHDR_REF_MSTR_PLCY_NRStringMaster Policy Number
STHDRDTPFile Effective Date
03STHDR_DTP_EFF_D8Date (YYYYMMDD)Effective Date
03STHDR_DTP_RPT_STRT_D8Date (YYYYMMDD)Report Start Date
03STHDR_DTP_RPT_END_D8Date (YYYYMMDD)Report End Date
03STHDR_DTP_MNT_EFF_D8Date (YYYYMMDD)Maintenance Effective Date
03STHDR_DTP_ENRLL_D8Date (YYYYMMDD)Enrollment Date
03STHDR_DTP_PMT_CMM_D8Date (YYYYMMDD)Payment Commencement Date
STHDRQTYTransaction Set Control Totals
02STHDR_QTY02_DEP_TOTNumberDependent Total
02STHDR_QTY02_EMPLYE_TOTNumberEmployee Total
02STHDR_QTY02_TOTNumberTotal
L1000A - SPONSOR NAME
L1000AN1Sponsor Name
02L1000A_N102_PLN_SPNSR_NMStringPlan Sponsor Name
04L1000A_N104_EMP_ID_NRStringEmployer's Identification Number
04L1000A_N104_ORG_CD_DEST_TSStringCode assigned by the organization that is the ultimate destination of the transaction set
04L1000A_N104_TAX_IDStringFederal Taxpayer's Identification Number
L1000B - PAYER
L1000BN1Payer
02L1000B_N102_INSR_NMStringInsurer Name
04L1000B_N104_ORG_CD_DEST_TSStringCode assigned by the organization that is the ultimate destination of the transaction set
04L1000B_N104_TAX_IDStringFederal Taxpayer's Identification Number
04L1000B_N104_CMS_PLANIDStringCenters for Medicare and Medicaid Services PlanID
L1000C - TPA/BROKER NAME (Value Qualified)
Mapping Prefix: L1000C_BO - Broker or Sales Office
Mapping Prefix: L1000C_TV - Third Party Administrator (TPA)
L1000CN1TPA/Broker Name
02L1000C_yy_N102_TPA_BRKR_NMStringTPA or Broker Name
04L1000C_yy_N104_ORG_CD_DEST_TSStringCode assigned by the organization that is the ultimate destination of the transaction set
04L1000C_yy_N104_TAX_IDStringFederal Taxpayer's Identification Number
04L1000C_yy_N104_CMS_PLANIDStringCenters for Medicare and Medicaid Services PlanID
L1000CACTTPA/Broker Account Information
01L1000C_yy_ACT01_TPABKR_ACCT_NRStringTPA or Broker Account Number
06L1000C_yy_ACT06_TPABKR_ACCT_NRStringTPA or Broker Account Number
L2000 - MEMBER LEVEL DETAIL
L2000INSMember Level Detail
01L2000_INS01_MEM_INDStringMember Indicator
02L2000_INS02_IND_RELAT_CDStringIndividual Relationship Code
03L2000_INS03_MAINT_TYP_CDStringMaintenance Type Code
04L2000_INS04_MAINT_RSN_CDStringMaintenance Reason Code
05L2000_INS05_BENE_STAT_CDStringBenefit Status Code
0601L2000_INS0601_MDCR_PLAN_CDStringMedicare Plan Code
0602L2000_INS0602_MDCR_ELIG_RSN_CDStringMedicare Eligibility Reason Code
07L2000_INS07_COBRA_EVNT_CDStringConsolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code
08L2000_INS08_EMPMT_STAT_CDStringEmployment Status Code
09L2000_INS09_STUD_STAT_CDStringStudent Status Code
10L2000_INS10_HANDCP_INDStringHandicap Indicator
12L2000_INS12_D8DateTimeMember Individual Death Date
13L2000_INS13_CNFDTL_CDStringConfidentiality Code
17L2000_INS17_BRTH_SEQ_NRStringBirth Sequence Number
L2000REFSubscriber Identifier
02L2000_REF_SUB_NRStringSubscriber Number
L2000REFMember Policy Number
02L2000_REF_GRP_POLCY_NRStringGroup or Policy Number
L2000REFMember Supplemental Identifier
02L2000_REF_CLT_RPT_CATStringClient Reporting Category
02L2000_REF_CLNT_NRStringClient Number
02L2000_REF_CASE_NRStringCase Number
02L2000_REF_PINStringPersonal Identification Number (PIN)
02L2000_REF_XREF_NRStringCross Reference Number
02L2000_REF_PERSL_ID_NRStringPersonal ID Number
02L2000_REF_NABP_NRStringNational Council for Prescription Drug Programs Pharmacy Number
02L2000_REF_DEPT_AGCY_NRStringDepartment/Agency Number
02L2000_REF_HIC_NRStringHealth Insurance Claim (HIC) Number
02L2000_REF_POS_CDStringPosition Code
02L2000_REF_PRIOR_IDStringPrior Identifier Number
02L2000_REF_UNIT_NRStringUnit Number
02L2000_REF_MUTLY_DEFStringMutually Defined
L2000DTPMember Level Dates
03L2000_DTP_RCVD_D8Date (YYYYMMDD)Received Date
03L2000_DTP_RETRMNT_D8Date (YYYYMMDD)Retirement Date
03L2000_DTP_DIS_RET_WRK_D8Date (YYYYMMDD)Initial Disability Period Return To Work Date
03L2000_DTP_LST_WRK_D8Date (YYYYMMDD)Initial Disability Period Last Day Worked Date
03L2000_DTP_ENRL_SIG_D8Date (YYYYMMDD)Enrollment Signature Date Date
03L2000_DTP_COBRA_EVNT_D8Date (YYYYMMDD)Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Date
03L2000_DTP_MNT_EFF_D8Date (YYYYMMDD)Maintenance Effective Date
03L2000_DTP_EMP_BGN_D8Date (YYYYMMDD)Employment Begin Date
03L2000_DTP_EMP_END_D8Date (YYYYMMDD)Employment End Date
03L2000_DTP_MDCR_BGN_D8Date (YYYYMMDD)Medicare Begin Date
03L2000_DTP_MDCR_END_D8Date (YYYYMMDD)Medicare End Date
03L2000_DTP_COBRA_BGN_D8Date (YYYYMMDD)Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin Date
03L2000_DTP_COBRA_END_D8Date (YYYYMMDD)Consolidated Omnibus Budget Reconciliation Act (COBRA) End Date
03L2000_DTP_EDU_BGN_D8Date (YYYYMMDD)Education Begin Date
03L2000_DTP_EDU_END_D8Date (YYYYMMDD)Education End Date
03L2000_DTP_ELIG_BGN_D8Date (YYYYMMDD)Eligibility Begin Date
03L2000_DTP_ELIG_END_D8Date (YYYYMMDD)Eligibility End Date
03L2000_DTP_ADJ_HIR_D8Date (YYYYMMDD)Adjusted Hire Date
03L2000_DTP_CRD_SVC_BGN_D8Date (YYYYMMDD)Credited Service Begin Date
03L2000_DTP_CRD_SVC_END_D8Date (YYYYMMDD)Credited Service End Date
03L2000_DTP_PLN_SUSP_D8Date (YYYYMMDD)Plan Participation Suspension Date
03L2000_DTP_REHR_D8Date (YYYYMMDD)Rehire Date
03L2000_DTP_MDCD_BGN_D8Date (YYYYMMDD)Medicaid Begin Date
03L2000_DTP_MDCD_END_D8Date (YYYYMMDD)Medicaid End Date
L2100A - MEMBER NAME (Value Qualified)
Mapping Prefix: L2100A_74 - Corrected Insured
Mapping Prefix: L2100A_IL - Insured or Subscriber
L2100ANM1Member Name
03L2100A_yy_NM103_PERSN_LNMStringPerson Last Name
04L2100A_yy_NM104_MBR_FNMStringMember First Name
05L2100A_yy_NM105_MBR_MNMStringMember Middle Name
06L2100A_yy_NM106_MBR_PFXStringMember Name Prefix
07L2100A_yy_NM107_MBR_SFXStringMember Name Suffix
09L2100A_yy_NM109_SSNStringSocial Security Number
09L2100A_yy_NM109_MUTLY_DEFNDStringMutually Defined
L2100APERMember Communications Numbers
04L2100A_yy_PER04_ALTRN_PHN_NRStringAlternate Telephone
04L2100A_yy_PER04_BPR_NRStringBeeper Number
04L2100A_yy_PER04_CELL_PHNStringCellular Phone
04L2100A_yy_PER04_EMAILStringElectronic Mail
04L2100A_yy_PER04_PHN_EXTStringTelephone Extension
04L2100A_yy_PER04_FAXStringFacsimile
04L2100A_yy_PER04_HM_PHN_NRStringHome Phone Number
04L2100A_yy_PER04_PHN_NRStringTelephone
04L2100A_yy_PER04_WRK_PHN_NRStringWork Phone Number
06L2100A_yy_PER06_ALTRN_PHN_NRStringAlternate Telephone
06L2100A_yy_PER06_BPR_NRStringBeeper Number
06L2100A_yy_PER06_CELL_PHNStringCellular Phone
06L2100A_yy_PER06_EMAILStringElectronic Mail
06L2100A_yy_PER06_PHN_EXTStringTelephone Extension
06L2100A_yy_PER06_FAXStringFacsimile
06L2100A_yy_PER06_HM_PHN_NRStringHome Phone Number
06L2100A_yy_PER06_PHN_NRStringTelephone
06L2100A_yy_PER06_WRK_PHN_NRStringWork Phone Number
08L2100A_yy_PER08_ALTRN_PHN_NRStringAlternate Telephone
08L2100A_yy_PER08_BPR_NRStringBeeper Number
08L2100A_yy_PER08_CELL_PHNStringCellular Phone
08L2100A_yy_PER08_EMAILStringElectronic Mail
08L2100A_yy_PER08_PHN_EXTStringTelephone Extension
08L2100A_yy_PER08_FAXStringFacsimile
08L2100A_yy_PER08_HM_PHN_NRStringHome Phone Number
08L2100A_yy_PER08_PHN_NRStringTelephone
08L2100A_yy_PER08_WRK_PHN_NRStringWork Phone Number
L2100AN3Member Residence Street Address
01L2100A_yy_N301_MBR_ADDRStringMember Address Line
02L2100A_yy_N302_MBR_ADDRStringMember Address Line
L2100AN4Member City, State, ZIP Code
01L2100A_yy_N401_MBR_CITYStringMember City Name
02L2100A_yy_N402_MBR_STATStringMember State Code
03L2100A_yy_N403_MBR_ZIPStringMember Postal Zone or Zip Code
04L2100A_yy_N404_CNTRY_CDStringCountry Code
06L2100A_yy_N406_AREAStringArea
06L2100A_yy_N406_COUNTYStringCounty/Parish
07L2100A_yy_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100ADMGMember Demographics
02L2100A_yy_DMG02_D8DateTimeMember Birth Date
03L2100A_yy_DMG03_GENDR_CDStringGender Code
04L2100A_yy_DMG04_MARTL_STATStringMarital Status Code
0501L2100A_yy_DMG0501_RC_CDStringRace or Ethnicity Code
0503L2100A_yy_DMG0503_RC_CDStringClassification of Race or Ethnicity
06L2100A_yy_DMG06_CTZN_STATS_CDStringCitizenship Status Code
11L2100A_yy_DMG11_RAC_ETH_COLL_CDStringRace or Ethnicity Collection Code
L2100AECEmployment Class
01L2100A_yy_nnEC01_EMPMT_CLSS_CDStringEmployment Class Code
02L2100A_yy_nnEC02_EMPMT_CLSS_CDStringEmployment Class Code
03L2100A_yy_nnEC03_EMPMT_CLSS_CDStringEmployment Class Code
L2100AICMMember Income
02L2100A_yy_ICM02_YTDNumberYear-to-Date
02L2100A_yy_ICM02_SINGLNumberSingle
02L2100A_yy_ICM02_HRLYNumberHourly
02L2100A_yy_ICM02_QUARTLYNumberQuarterly
02L2100A_yy_ICM02_SEMIANNLNumberSemiannual
02L2100A_yy_ICM02_UNKWNNumberUnknown
02L2100A_yy_ICM02_WKLYNumberWeekly
02L2100A_yy_ICM02_BIWKLYNumberBiweekly
02L2100A_yy_ICM02_SEMIMTHLYNumberSemimonthly
02L2100A_yy_ICM02_MNTHLYNumberMonthly
02L2100A_yy_ICM02_DAILYNumberDaily
02L2100A_yy_ICM02_ANNULNumberAnnual
02L2100A_yy_ICM02_2CAL_MOSNumberTwo Calendar Months
02L2100A_yy_ICM02_LMPSM_SEP_ALNCNumberLump-Sum Separation Allowance
03L2100A_yy_ICM03_WRK_HRS_CTNumberWork Hours Count
04L2100A_yy_ICM04_LOC_ID_CDStringLocation Identification Code
05L2100A_yy_ICM05_SALARY_GRD_CDStringSalary Grade Code
L2100AAMTMember Policy Amounts
02L2100A_yy_AMT02_COINS_ACTLNumberCo-insurance - Actual
02L2100A_yy_AMT02_COPAY_AMTNumberCo-Payment Amount
02L2100A_yy_AMT02_DED_AMTNumberDeductible Amount
02L2100A_yy_AMT02_EXP_EXP_AMTNumberExpected Expenditure Amount
02L2100A_yy_AMT02_OTH_UNLS_AMTNumberOther Unlisted Amount
02L2100A_yy_AMT02_PREM_AMTNumberPremium Amount
02L2100A_yy_AMT02_SPENDOWNNumberSpend Down
L2100AHLHMember Health Information
01L2100A_yy_HLH01_HLTH_REL_CDStringHealth Related Code
02L2100A_yy_HLH02_MBR_HGTNumberMember Height
03L2100A_yy_HLH03_MBR_WGTNumberMember Weight
L2100ALUIMember Language
02L2100A_yy_nnLUI02_ISO3953_LGCDStringNISO Z39.53 Language Codes
02L2100A_yy_nnLUI02_I639_LANG_CDStringISO 639 Language Codes
03L2100A_yy_nnLUI03_LANG_DESCStringLanguage Description
04L2100A_yy_nnLUI04_LANG_USE_INDStringLanguage Use Indicator
L2100B - INCORRECT MEMBER NAME
L2100BNM1Incorrect Member Name
03L2100B_NM103_PERSN_LNMStringPerson Last Name
04L2100B_NM104_PRI_INC_MBR_FNMStringPrior Incorrect Member First Name
05L2100B_NM105_PRI_INC_MBR_MNMStringPrior Incorrect Member Middle Name
06L2100B_NM106_PRI_INC_MBR_PFXStringPrior Incorrect Member Name Prefix
07L2100B_NM107_PRI_INC_MBR_SFXStringPrior Incorrect Member Name Suffix
09L2100B_NM109_SSNStringSocial Security Number
09L2100B_NM109_MUTLY_DEFNDStringMutually Defined
L2100BDMGIncorrect Member Demographics
02L2100B_DMG02_D8DateTimePrior Incorrect Insured Birth Date
03L2100B_DMG03_PRI_INC_GENDR_CDStringPrior Incorrect Insured Gender Code
04L2100B_DMG04_MARTL_STATStringMarital Status Code
0501L2100B_DMG0501_RAC_ETH_CDStringRace or Ethnicity Code
0502L2100B_DMG0502_CD_LST_QLStringCode List Qualifier Code
0503L2100B_DMG0503_RAC_ETH_CDStringRace or Ethnicity Code
06L2100B_DMG06_CTZN_STATS_CDStringCitizenship Status Code
10L2100B_DMG10_CD_LST_QLStringCode List Qualifier Code
11L2100B_DMG11_RACETH_COLL_CDStringRace or Ethnicity Collection Code
L2100C - MEMBER MAILING ADDRESS
L2100CNM1Member Mailing Address
L2100CN3Member Mail Street Address
01L2100C_N301_MBR_ADDRStringMember Address Line
02L2100C_N302_MBR_ADDRStringMember Address Line
L2100CN4Member Mail City, State, ZIP Code
01L2100C_N401_MBR_MAIL_CITYStringMember Mail City Name
02L2100C_N402_MBR_MAIL_STATStringMember Mail State Code
03L2100C_N403_MBR_MAIL_ZIPStringMember Mail Postal Zone or ZIP Code
04L2100C_N404_CNTRY_CDStringCountry Code
07L2100C_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100D - MEMBER EMPLOYER (Single Iteration)
L2100DNM1Member Employer
02L2100D_xx_NM102_ENT_TYP_QUALStringEntity Type Qualifier
03L2100D_xx_NM103_MBR_EMP_NMStringMember Employer Name
04L2100D_xx_NM104_MBR_EMPLR_FNMStringMember Employer First Name
05L2100D_xx_NM105_MBR_EMP_MNMStringMember Employer Middle Name
06L2100D_xx_NM106_MBR_EMPLR_PFXStringMember Employer Name Prefix
07L2100D_xx_NM107_MBR_EMP_SFXStringMember Employer Name Suffix
09L2100D_xx_NM109_EMP_ID_NRStringEmployer's Identification Number
09L2100D_xx_NM109_SSNStringSocial Security Number
L2100DPERMember Employer Communications Numbers
02L2100D_xx_PER02_MBR_EMP_CM_CONStringMember Employer Communications Contact
04L2100D_xx_PER04_ALTRN_PHN_NRStringAlternate Telephone
04L2100D_xx_PER04_BPR_NRStringBeeper Number
04L2100D_xx_PER04_CELL_PHNStringCellular Phone
04L2100D_xx_PER04_EMAILStringElectronic Mail
04L2100D_xx_PER04_PHN_EXTStringTelephone Extension
04L2100D_xx_PER04_FAXStringFacsimile
04L2100D_xx_PER04_PHN_NRStringTelephone
06L2100D_xx_PER06_ALTRN_PHN_NRStringAlternate Telephone
06L2100D_xx_PER06_BPR_NRStringBeeper Number
06L2100D_xx_PER06_CELL_PHNStringCellular Phone
06L2100D_xx_PER06_EMAILStringElectronic Mail
06L2100D_xx_PER06_PHN_EXTStringTelephone Extension
06L2100D_xx_PER06_FAXStringFacsimile
06L2100D_xx_PER06_PHN_NRStringTelephone
08L2100D_xx_PER08_ALTRN_PHN_NRStringAlternate Telephone
08L2100D_xx_PER08_BPR_NRStringBeeper Number
08L2100D_xx_PER08_CELL_PHNStringCellular Phone
08L2100D_xx_PER08_EMAILStringElectronic Mail
08L2100D_xx_PER08_PHN_EXTStringTelephone Extension
08L2100D_xx_PER08_FAXStringFacsimile
08L2100D_xx_PER08_PHN_NRStringTelephone
L2100DN3Member Employer Street Address
01L2100D_xx_N301_MBR_EMP_ADDRStringMember Employer Address Line
02L2100D_xx_N302_MBR_EMP_ADDRStringMember Employer Address Line
L2100DN4Member Employer City, State, ZIP Code
01L2100D_xx_N401_MBR_EMP_CITYStringMember Employer City Name
02L2100D_xx_N402_MBR_EMP_STATStringMember Employer State Code
03L2100D_xx_N403_MBR_EMP_ZIPStringMember Employer Postal Zone or ZIP Code
04L2100D_xx_N404_CNTRY_CDStringCountry Code
07L2100D_xx_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100E - MEMBER SCHOOL (Single Iteration)
L2100ENM1Member School
03L2100E_xx_NM103_NONPSNENT_NMStringNon-Person Entity Name
L2100EPERMember School Commmunications Numbers
02L2100E_xx_PER02_MBR_SCH_CMMCONStringMember School Communications Contact Name
04L2100E_xx_PER04_EMAILStringElectronic Mail
04L2100E_xx_PER04_PHN_EXTStringTelephone Extension
04L2100E_xx_PER04_FAXStringFacsimile
04L2100E_xx_PER04_PHN_NRStringTelephone
06L2100E_xx_PER06_EMAILStringElectronic Mail
06L2100E_xx_PER06_PHN_EXTStringTelephone Extension
06L2100E_xx_PER06_FAXStringFacsimile
06L2100E_xx_PER06_PHN_NRStringTelephone
08L2100E_xx_PER08_EMAILStringElectronic Mail
08L2100E_xx_PER08_PHN_EXTStringTelephone Extension
08L2100E_xx_PER08_FAXStringFacsimile
08L2100E_xx_PER08_PHN_NRStringTelephone
L2100EN3Member School Street Address
01L2100E_xx_N301_SCHL_ADDRStringSchool Address Line
02L2100E_xx_N302_SCHL_ADDRStringSchool Address Line
L2100EN4Member School City, State, ZIP Code
01L2100E_xx_N401_MBR_SCH_CITYStringMember School City Name
02L2100E_xx_N402_MBR_SCH_STATStringMember School State Code
03L2100E_xx_N403_MBR_SCH_ZIPStringMember School Postal Zone or ZIP Code
04L2100E_xx_N404_CNTRY_CDStringCountry Code
07L2100E_xx_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100F - CUSTODIAL PARENT
L2100FNM1Custodial Parent
03L2100F_NM103_PERSN_LNMStringPerson Last Name
04L2100F_NM104_CUST_PAR_FNMStringCustodial Parent First Name
05L2100F_NM105_CUST_PAR_MNMStringCustodial Parent Middle Name
06L2100F_NM106_CUST_PAR_PFXStringCustodial Parent Name Prefix
07L2100F_NM107_CUST_PAR_SFXStringCustodial Parent Name Suffix
09L2100F_NM109_SSNStringSocial Security Number
09L2100F_NM109_MUTLY_DEFNDStringMutually Defined
L2100FPERCustodial Parent Communications Numbers
04L2100F_PER04_ALTRN_PHN_NRStringAlternate Telephone
04L2100F_PER04_BPR_NRStringBeeper Number
04L2100F_PER04_CELL_PHNStringCellular Phone
04L2100F_PER04_EMAILStringElectronic Mail
04L2100F_PER04_PHN_EXTStringTelephone Extension
04L2100F_PER04_FAXStringFacsimile
04L2100F_PER04_HM_PHN_NRStringHome Phone Number
04L2100F_PER04_PHN_NRStringTelephone
04L2100F_PER04_WRK_PHN_NRStringWork Phone Number
06L2100F_PER06_ALTRN_PHN_NRStringAlternate Telephone
06L2100F_PER06_BPR_NRStringBeeper Number
06L2100F_PER06_CELL_PHNStringCellular Phone
06L2100F_PER06_EMAILStringElectronic Mail
06L2100F_PER06_PHN_EXTStringTelephone Extension
06L2100F_PER06_FAXStringFacsimile
06L2100F_PER06_HM_PHN_NRStringHome Phone Number
06L2100F_PER06_PHN_NRStringTelephone
06L2100F_PER06_WRK_PHN_NRStringWork Phone Number
08L2100F_PER08_ALTRN_PHN_NRStringAlternate Telephone
08L2100F_PER08_BPR_NRStringBeeper Number
08L2100F_PER08_CELL_PHNStringCellular Phone
08L2100F_PER08_EMAILStringElectronic Mail
08L2100F_PER08_PHN_EXTStringTelephone Extension
08L2100F_PER08_HM_PHN_NRStringHome Phone Number
08L2100F_PER08_PHN_NRStringTelephone
08L2100F_PER08_WRK_PHN_NRStringWork Phone Number
L2100FN3Custodial Parent Street Address
01L2100F_N301_CUST_PAR_ADDRStringCustodial Parent Address Line
02L2100F_N302_CUST_PAR_ADDRStringCustodial Parent Address Line
L2100FN4Custodial Parent City, State, ZIP Code
01L2100F_N401_CUST_PAR_CITYStringCustodial Parent City Name
02L2100F_N402_CUST_PAR_STATStringCustodial Parent State Code
03L2100F_N403_CUST_PAR_ZIPStringCustodial Parent Postal Zone or ZIP Code
04L2100F_N404_CNTRY_CDStringCountry Code
07L2100F_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100G - RESPONSIBLE PERSON (Value Qualified)
Mapping Prefix: L2100G_6Y - Case Manager
Mapping Prefix: L2100G_9K - Key Person
Mapping Prefix: L2100G_E1 - Person or Other Entity Legally Responsible for a Child
Mapping Prefix: L2100G_EI - Executor of Estate
Mapping Prefix: L2100G_EXS - Ex-spouse
Mapping Prefix: L2100G_GB - Other Insured
Mapping Prefix: L2100G_GD - Guardian
Mapping Prefix: L2100G_J6 - Power of Attorney
Mapping Prefix: L2100G_LR - Legal Representative
Mapping Prefix: L2100G_QD - Responsible Party
Mapping Prefix: L2100G_S1 - Parent
Mapping Prefix: L2100G_TZ - Significant Other
Mapping Prefix: L2100G_X4 - Spouse
L2100GNM1Responsible Person
03L2100G_yy_NM103_PERSN_LNMStringPerson Last Name
04L2100G_yy_NM104_RESP_PRTY_FNAMStringResponsible Party First Name
05L2100G_yy_NM105_RESP_MNMStringResponsible Party Middle Name
06L2100G_yy_NM106_RSP_PRTY_PFXStringResponsible Party Name Prefix
07L2100G_yy_NM107_RSP_PARTY_SFXStringResponsible Party Suffix Name
09L2100G_yy_NM109_SSNStringSocial Security Number
09L2100G_yy_NM109_MUTLY_DEFNDStringMutually Defined
L2100GPERResponsible Person Communications Numbers
04L2100G_yy_PER04_ALTRN_PHN_NRStringAlternate Telephone
04L2100G_yy_PER04_BPR_NRStringBeeper Number
04L2100G_yy_PER04_CELL_PHNStringCellular Phone
04L2100G_yy_PER04_EMAILStringElectronic Mail
04L2100G_yy_PER04_PHN_EXTStringTelephone Extension
04L2100G_yy_PER04_FAXStringFacsimile
04L2100G_yy_PER04_HM_PHN_NRStringHome Phone Number
04L2100G_yy_PER04_PHN_NRStringTelephone
04L2100G_yy_PER04_WRK_PHN_NRStringWork Phone Number
06L2100G_yy_PER06_ALTRN_PHN_NRStringAlternate Telephone
06L2100G_yy_PER06_BPR_NRStringBeeper Number
06L2100G_yy_PER06_CELL_PHNStringCellular Phone
06L2100G_yy_PER06_EMAILStringElectronic Mail
06L2100G_yy_PER06_PHN_EXTStringTelephone Extension
06L2100G_yy_PER06_FAXStringFacsimile
06L2100G_yy_PER06_HM_PHN_NRStringHome Phone Number
06L2100G_yy_PER06_PHN_NRStringTelephone
06L2100G_yy_PER06_WRK_PHN_NRStringWork Phone Number
08L2100G_yy_PER08_ALTRN_PHN_NRStringAlternate Telephone
08L2100G_yy_PER08_BPR_NRStringBeeper Number
08L2100G_yy_PER08_CELL_PHNStringCellular Phone
08L2100G_yy_PER08_EMAILStringElectronic Mail
08L2100G_yy_PER08_PHN_EXTStringTelephone Extension
08L2100G_yy_PER08_FAXStringFacsimile
08L2100G_yy_PER08_HM_PHN_NRStringHome Phone Number
08L2100G_yy_PER08_PHN_NRStringTelephone
08L2100G_yy_PER08_WRK_PHN_NRStringWork Phone Number
L2100GN3Responsible Person Street Address
01L2100G_yy_N301_RSP_PRTY_ADDRStringResponsible Party Address Line
02L2100G_yy_N302_RSP_PRTY_ADDRStringResponsible Party Address Line
L2100GN4Responsible Person City, State, ZIP Code
01L2100G_yy_N401_RSP_PERS_CITYStringResponsible Person City Name
02L2100G_yy_N402_RSP_PERS_STATStringResponsible Person State Code
03L2100G_yy_N403_RESP_PRSN_ZIPStringResponsible Person Postal Zone or ZIP Code
04L2100G_yy_N404_CNTRY_CDStringCountry Code
07L2100G_yy_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2100H - DROP OFF LOCATION
L2100HNM1Drop Off Location
03L2100H_NM103_NM_LAST_ORG_NMStringName Last or Organization Name
04L2100H_NM104_FNMStringName First
05L2100H_NM105_NM_MIDStringName Middle
06L2100H_NM106_PFXStringName Prefix
07L2100H_NM107_SFXStringName Suffix
L2100HN3Drop Off Location Street Address
01L2100H_N301_DROPOFF_LOC_ADDRStringDrop Off Location Address Line
02L2100H_N302_DROPOFF_LOC_ADDRStringDrop Off Location Address Line
L2100HN4Drop Off Location City, State, ZIP Code
01L2100H_N401_DROPOFF_LOC_CITYStringDrop Off Location City Name
02L2100H_N402_DROPOFF_LOC_STATStringDrop Off Location State Code
03L2100H_N403_DROPOFF_LOC_ZIPStringDrop Off Location Postal Zone or ZIP Code
04L2100H_N404_CNTRY_CDStringCountry Code
07L2100H_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2200 - DISABILITY INFORMATION
L2200DSBDisability Information
01L2200_DSB01_DISABTY_TYP_CDStringDisability Type Code
08L2200_DSB08_ICD9_DIAGStringInternational Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis
08L2200_DSB08_MUTLY_DEFStringMutually Defined
L2200DTPDisability Eligibility Dates
03L2200_DTP_DIS_BGN_D8Date (YYYYMMDD)Initial Disability Period Start Date
03L2200_DTP_DIS_END_D8Date (YYYYMMDD)Initial Disability Period End Date
L2300 - HEALTH COVERAGE
L2300HDHealth Coverage
01L2300_HD01_MAINT_TYP_CDStringMaintenance Type Code
03L2300_HD03_INS_LIN_CDStringInsurance Line Code
04L2300_HD04_PLN_CVG_DSCStringPlan Coverage Description
05L2300_HD05_COVG_LVL_CDStringCoverage Level Code
09L2300_HD09_LAT_ENRL_INDStringLate Enrollment Indicator
L2300DTPHealth Coverage Dates
03L2300_DTP_ENRL_SIG_D8Date (YYYYMMDD)Enrollment Signature Date Date
03L2300_DTP_ENRL_SIG_RD8_1Start Date (YYYYMMDD)Enrollment Signature Date Date
03L2300_DTP_ENRL_SIG_RD8_2End Date (YYYYMMDD)Enrollment Signature Date Date
03L2300_DTP_MNT_EFF_D8Date (YYYYMMDD)Maintenance Effective Date
03L2300_DTP_MNT_EFF_RD8_1Start Date (YYYYMMDD)Maintenance Effective Date
03L2300_DTP_MNT_EFF_RD8_2End Date (YYYYMMDD)Maintenance Effective Date
03L2300_DTP_PRM_PD_END_D8Date (YYYYMMDD)Premium Paid to Date End Date
03L2300_DTP_PRM_PD_END_RD8_1Start Date (YYYYMMDD)Premium Paid to Date End Date
03L2300_DTP_PRM_PD_END_RD8_2End Date (YYYYMMDD)Premium Paid to Date End Date
03L2300_DTP_BNFT_BGN_D8Date (YYYYMMDD)Benefit Begin Date
03L2300_DTP_BNFT_BGN_RD8_1Start Date (YYYYMMDD)Benefit Begin Date
03L2300_DTP_BNFT_BGN_RD8_2End Date (YYYYMMDD)Benefit Begin Date
03L2300_DTP_BNFT_END_D8Date (YYYYMMDD)Benefit End Date
03L2300_DTP_BNFT_END_RD8_1Start Date (YYYYMMDD)Benefit End Date
03L2300_DTP_BNFT_END_RD8_2End Date (YYYYMMDD)Benefit End Date
03L2300_DTP_PRM_PD_D8Date (YYYYMMDD)Last Premium Paid Date Date
03L2300_DTP_PRM_PD_RD8_1Start Date (YYYYMMDD)Last Premium Paid Date Date
03L2300_DTP_PRM_PD_RD8_2End Date (YYYYMMDD)Last Premium Paid Date Date
03L2300_DTP_PRV_PERD_D8Date (YYYYMMDD)Previous Period Date
03L2300_DTP_PRV_PERD_RD8_1Start Date (YYYYMMDD)Previous Period Date
03L2300_DTP_PRV_PERD_RD8_2End Date (YYYYMMDD)Previous Period Date
L2300AMTHealth Coverage Policy
02L2300_AMT02_COINS_ACTLNumberCo-insurance - Actual
02L2300_AMT02_COPAY_AMTNumberCo-Payment Amount
02L2300_AMT02_DED_AMTNumberDeductible Amount
02L2300_AMT02_EXP_EXP_AMTNumberExpected Expenditure Amount
02L2300_AMT02_OTH_UNLS_AMTNumberOther Unlisted Amount
02L2300_AMT02_PREM_AMTNumberPremium Amount
02L2300_AMT02_SPENDOWNNumberSpend Down
L2300REFHealth Coverage Policy Number
02L2300_REF_CLT_RPT_CATStringClient Reporting Category
02L2300_REF_GRP_POLCY_NRStringGroup or Policy Number
02L2300_REF_PMT_CATStringPayment Category
02L2300_REF_CLSS_CONTStringClass of Contract Code
02L2300_REF_COVG_NRStringService Contract (Coverage) Number
02L2300_REF_MDCL_ASST_CATStringMedical Assistance Category
02L2300_REF_PROG_IDStringProgram Identification Number
02L2300_REF_RAT_CD_NRStringRate code number
02L2300_REF_INT_CTL_NRStringInternal Control Number
02L2300_REF_ISSR_NRStringIssuer Number
02L2300_REF_SP_PROG_CDStringSpecial Program Code
02L2300_REF_SVC_AREA_CDStringService Area Code
02L2300_REF_CNTY_CDStringCounty Code
02L2300_REF_MUTLY_DEFStringMutually Defined
L2300REFPrior Coverage Months
02L2300_REF_UNIT_NRStringUnit Number
L2300IDCIdentification Card
01L2300_nnIDC01_PLN_CVG_DSCStringPlan Coverage Description
02L2300_nnIDC02_ID_TYP_CDStringIdentification Card Type Code
03L2300_nnIDC03_ID_CRD_CTNumberIdentification Card Count
04L2300_nnIDC04_ACTN_CDStringAction Code
L2310 - PROVIDER INFORMATION
L2310LXProvider Information
01L2310_LX01_ASSGD_NRIntegerAssigned Number
L2310NM1Provider Name
1XLaboratory
3DObstetrics and Gynecology Facility
80Hospital
FAFacility
ODDoctor of Optometry
P3Primary Care Provider
QAPharmacy
QNDentist
Y2Managed Care Organization
01L2310_NM1yy01_ENTY_ID_CDStringEntity Identifier Code
02L2310_NM1yy02_ENT_TYP_QUALStringEntity Type Qualifier
03L2310_NM1yy03_PVR_LNMStringProvider Last or Organization Name
04L2310_NM1yy04_PVR_FNMStringProvider First Name
05L2310_NM1yy05_PVR_MNMStringProvider Middle Name
06L2310_NM1yy06_PVR_PFXStringProvider Name Prefix
07L2310_NM1yy07_PVR_SFXStringProvider Name Suffix
09L2310_NM1yy09_SSNStringSocial Security Number
09L2310_NM1yy09_TAX_IDStringFederal Taxpayer's Identification Number
09L2310_NM1yy09_SVC_PROV_NRStringService Provider Number
09L2310_NM1yy09_NPIStringCenters for Medicare and Medicaid Services National Provider Identifier
10L2310_NM1yy10_ENTY_REL_CDStringEntity Relationship Code
L2310N3Provider Address
01L2310_nnN301_PVR_ADDRStringProvider Address Line
02L2310_nnN302_PVR_ADDRStringProvider Address Line
L2310N4Provider City, State, ZIP Code
01L2310_N401_PVR_CITYStringProvider City Name
02L2310_N402_PVR_STATStringProvider State Code
03L2310_N403_PVR_ZIPStringProvider Postal Zone or ZIP Code
04L2310_N404_CNTRY_CDStringCountry Code
07L2310_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2310PERProvider Communications Numbers
04L2310_nnPER04_ALTRN_PHN_NRStringAlternate Telephone
04L2310_nnPER04_BPR_NRStringBeeper Number
04L2310_nnPER04_CELL_PHNStringCellular Phone
04L2310_nnPER04_EMAILStringElectronic Mail
04L2310_nnPER04_PHN_EXTStringTelephone Extension
04L2310_nnPER04_FAXStringFacsimile
04L2310_nnPER04_HM_PHN_NRStringHome Phone Number
04L2310_nnPER04_PHN_NRStringTelephone
04L2310_nnPER04_WRK_PHN_NRStringWork Phone Number
06L2310_nnPER06_ALTRN_PHN_NRStringAlternate Telephone
06L2310_nnPER06_BPR_NRStringBeeper Number
06L2310_nnPER06_CELL_PHNStringCellular Phone
06L2310_nnPER06_EMAILStringElectronic Mail
06L2310_nnPER06_PHN_EXTStringTelephone Extension
06L2310_nnPER06_FAXStringFacsimile
06L2310_nnPER06_HM_PHN_NRStringHome Phone Number
06L2310_nnPER06_PHN_NRStringTelephone
06L2310_nnPER06_WRK_PHN_NRStringWork Phone Number
08L2310_nnPER08_ALTRN_PHN_NRStringAlternate Telephone
08L2310_nnPER08_BPR_NRStringBeeper Number
08L2310_nnPER08_CELL_PHNStringCellular Phone
08L2310_nnPER08_EMAILStringElectronic Mail
08L2310_nnPER08_PHN_EXTStringTelephone Extension
08L2310_nnPER08_FAXStringFacsimile
08L2310_nnPER08_HM_PHN_NRStringHome Phone Number
08L2310_nnPER08_PHN_NRStringTelephone
08L2310_nnPER08_WRK_PHN_NRStringWork Phone Number
L2310PLAProvider Change Reason
03L2310_PLA03_PVR_EFF_D8Date (YYYYMMDD)Provider Effective Date
05L2310_PLA05_MAINT_RSN_CDStringMaintenance Reason Code
L2320 - COORDINATION OF BENEFITS (Single Iteration)
L2320COBCoordination of Benefits
01L2320_xx_COB01_PYR_RESP_SEQ_NRStringPayer Responsibility Sequence Number Code
02L2320_xx_COB02_MBR_GRP_POL_NRStringMember Group or Policy Number
03L2320_xx_COB03_COB_CDStringCoordination of Benefits Code
04L2320_xx_COB04_Enn_SVC_TYP_CDStringService Type Code
L2320REFAdditional Coordination of Benefits Identifiers
02L2320_xx_REF_ACCT_SFXStringAccount Suffix Code
02L2320_xx_REF_GRP_NRStringGroup Number
02L2320_xx_REF_SSNStringSocial Security Number
02L2320_xx_REF_MUTLY_DEFStringMutually Defined
L2320DTPCoordination of Benefits Eligibility Dates
03L2320_xx_DTP_COBRA_BGN_D8Date (YYYYMMDD)Coordination of Benefits Begin Date
03L2320_xx_DTP_COBRA_END_D8Date (YYYYMMDD)Coordination of Benefits End Date
L2330 - COORDINATION OF BENEFITS RELATED ENTITY (Inherited Loop Iteration & Value Qualified)
Mapping Prefix: L2330_xx36 - Employer
Mapping Prefix: L2330_xxGW - Group
Mapping Prefix: L2330_xxIN - Insurer
L2330NM1Coordination of Benefits Related Entity
03L2330_xxyy_NM103_COB_INS_NMStringCoordination of Benefits Insurer Name
09L2330_xxyy_NM109_TAX_IDStringFederal Taxpayer's Identification Number
09L2330_xxyy_NM109_NAIC_IDStringNational Association of Insurance Commissioners (NAIC) Identification
09L2330_xxyy_NM109_HCFA_PLAN_IDStringCenters for Medicare and Medicaid Services PlanID
L2330N3Coordination of Benefits Related Entity Address
01L2330_xxyy_N301_ADDR_NFOStringAddress Information
02L2330_xxyy_N302_ADDR_NFOStringAddress Information
L2330N4Coordination of Benefits Other Insurance Company City, State, ZIP Code
01L2330_xxyy_N401_COB_OTH_INSStringCoordination of Benefits Other Insurance adequate to specify a location.
02L2330_xxyy_N402_COB_OINSStringCoordination of Benefits Other Insurance implementation guide, do not send.
03L2330_xxyy_N403_COB_OINSStringCoordination of Benefits Other Insurance implementation guide, do not send.
04L2330_xxyy_N404_CNTRY_CDStringCountry Code
07L2330_xxyy_N407_CNTRY_SUBDV_CDStringCountry Subdivision Code
L2330PERAdministrative Communications Contact
04L2330_xxyy_PER04_PHN_NRStringTelephone
L2710 - MEMBER REPORTING CATEGORIES
L2710LSAdditional Reporting Categories
01L2710_LS01_LOOP_ID_CDStringLoop Identifier Code
L2750 - REPORTING CATEGORY
L2750LXMember Reporting Categories
01L2750_LX01_ASSGD_NRIntegerAssigned Number
L2750N1Reporting Category
02L2750_N102_MBR_REP_CAT_NMStringMember Reporting Category Name
L2750REFReporting Category Reference
02L2750_REF_DST_NRStringContracting District Number
02L2750_REF_CLT_RPT_CATStringClient Reporting Category
02L2750_REF_PLAN_NRStringPlan Number
02L2750_REF_DIV_IDStringDivision Identifier
02L2750_REF_UNION_NRStringUnion Number
02L2750_REF_BRNCH_IDStringBranch Identifier
02L2750_REF_APP_NRStringApplication Number
02L2750_REF_PMT_CATStringPayment Category
02L2750_REF_ACCT_CATStringAccount Category
02L2750_REF_GEO_NRStringGeographic Number
02L2750_REF_LOC_NRStringLocation Number
02L2750_REF_PROG_IDStringProgram Identification Number
02L2750_REF_SP_PROG_CDStringSpecial Program Code
02L2750_REF_SVC_AREA_CDStringService Area Code
02L2750_REF_GEO_KEYStringGeographic Key
02L2750_REF_MUTLY_DEFStringMutually Defined
L2750DTPReporting Category Date
03L2750_DTP_EFF_D8Date (YYYYMMDD)Effective Date
03L2750_DTP_EFF_RD8_1Start Date (YYYYMMDD)Effective Date
03L2750_DTP_EFF_RD8_2End Date (YYYYMMDD)Effective Date
L2710LEAdditional Reporting Categories Loop Termination
01L2710_LE01_LOOP_ID_CDStringLoop Identifier Code
STHDRSETransaction Set Trailer
01STHDR_SE01_TS_SEG_CTIntegerTransaction Segment Count
02STHDR_SE02_TCNStringTransaction Set Control Number
GSHDRGEFunctional Group Trailer
01GSHDR_GE01_NR_TS_INCLUDEDIntegerNumber of Transaction Sets Included
02GSHDR_GE02_GCNIntegerGroup Control Number
ISAIEAInterchange Control Trailer
01ISA_IEA01_NR_INC_FUNC_GRPIntegerNumber of Included Functional Groups
02ISA_IEA02_ICNIntegerInterchange Control Number