Loop Qualifiersxx - 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 | 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 | 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 | BGN | Beginning Segment | | |
01 | | STHDR_BGN01_TS_PURP_CD | String | Transaction Set Purpose Code |
02 | | STHDR_BGN02_TS_REF_NR | String | Transaction Set Reference Number |
03 | | STHDR_BGN03_TS_CRTN_D8 | Date (YYYYMMDD) | Transaction Set Creation Date |
04 | | STHDR_BGN04_TS_CRTN_TM | Time (HHMM) | Transaction Set Creation Time |
04 | | STHDR_BGN04_TS_CRTN_TM8 | Time (HHMMSSCC) | Transaction Set Creation Time |
05 | | STHDR_BGN05_TIMZON_CD | String | Time Zone Code |
06 | | STHDR_BGN06_ORIG_TS_REF_NR | String | Original Transaction Set Reference Number |
08 | | STHDR_BGN08_ACTN_CD | String | Action Code |
STHDR | REF | Transaction Set Policy Number | | |
02 | | STHDR_REF_MSTR_PLCY_NR | String | Master Policy Number |
STHDR | DTP | File Effective Date | | |
03 | | STHDR_DTP_EFF_D8 | Date (YYYYMMDD) | Effective Date |
03 | | STHDR_DTP_RPT_STRT_D8 | Date (YYYYMMDD) | Report Start Date |
03 | | STHDR_DTP_RPT_END_D8 | Date (YYYYMMDD) | Report End Date |
03 | | STHDR_DTP_MNT_EFF_D8 | Date (YYYYMMDD) | Maintenance Effective Date |
03 | | STHDR_DTP_ENRLL_D8 | Date (YYYYMMDD) | Enrollment Date |
03 | | STHDR_DTP_PMT_CMM_D8 | Date (YYYYMMDD) | Payment Commencement Date |
STHDR | QTY | Transaction Set Control Totals | | |
02 | | STHDR_QTY02_DEP_TOT | Number | Dependent Total |
02 | | STHDR_QTY02_EMPLYE_TOT | Number | Employee Total |
02 | | STHDR_QTY02_TOT | Number | Total |
02 | | L1000A_N102_PLN_SPNSR_NM | String | Plan Sponsor Name |
04 | | L1000A_N104_EMP_ID_NR | String | Employer's Identification Number |
04 | | L1000A_N104_ORG_CD_DEST_TS | String | Code assigned by the organization that is the ultimate destination of the transaction set |
04 | | L1000A_N104_TAX_ID | String | Federal Taxpayer's Identification Number |
02 | | L1000B_N102_INSR_NM | String | Insurer Name |
04 | | L1000B_N104_ORG_CD_DEST_TS | String | Code assigned by the organization that is the ultimate destination of the transaction set |
04 | | L1000B_N104_TAX_ID | String | Federal Taxpayer's Identification Number |
04 | | L1000B_N104_CMS_PLANID | String | Centers 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) |
02 | | L1000C_yy_N102_TPA_BRKR_NM | String | TPA or Broker Name |
04 | | L1000C_yy_N104_ORG_CD_DEST_TS | String | Code assigned by the organization that is the ultimate destination of the transaction set |
04 | | L1000C_yy_N104_TAX_ID | String | Federal Taxpayer's Identification Number |
04 | | L1000C_yy_N104_CMS_PLANID | String | Centers for Medicare and Medicaid Services PlanID |
L1000C | ACT | TPA/Broker Account Information | | |
01 | | L1000C_yy_ACT01_TPABKR_ACCT_NR | String | TPA or Broker Account Number |
06 | | L1000C_yy_ACT06_TPABKR_ACCT_NR | String | TPA or Broker Account Number |
L2000 - MEMBER LEVEL DETAIL |
L2000 | INS | Member Level Detail | | |
01 | | L2000_INS01_MEM_IND | String | Member Indicator |
02 | | L2000_INS02_IND_RELAT_CD | String | Individual Relationship Code |
03 | | L2000_INS03_MAINT_TYP_CD | String | Maintenance Type Code |
04 | | L2000_INS04_MAINT_RSN_CD | String | Maintenance Reason Code |
05 | | L2000_INS05_BENE_STAT_CD | String | Benefit Status Code |
06 | 01 | L2000_INS0601_MDCR_PLAN_CD | String | Medicare Plan Code |
06 | 02 | L2000_INS0602_MDCR_ELIG_RSN_CD | String | Medicare Eligibility Reason Code |
07 | | L2000_INS07_COBRA_EVNT_CD | String | Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code |
08 | | L2000_INS08_EMPMT_STAT_CD | String | Employment Status Code |
09 | | L2000_INS09_STUD_STAT_CD | String | Student Status Code |
10 | | L2000_INS10_HANDCP_IND | String | Handicap Indicator |
12 | | L2000_INS12_D8 | DateTime | Member Individual Death Date |
13 | | L2000_INS13_CNFDTL_CD | String | Confidentiality Code |
17 | | L2000_INS17_BRTH_SEQ_NR | String | Birth Sequence Number |
L2000 | REF | Subscriber Identifier | | |
02 | | L2000_REF_SUB_NR | String | Subscriber Number |
L2000 | REF | Member Policy Number | | |
02 | | L2000_REF_GRP_POLCY_NR | String | Group or Policy Number |
L2000 | REF | Member Supplemental Identifier | | |
02 | | L2000_REF_CLT_RPT_CAT | String | Client Reporting Category |
02 | | L2000_REF_CLNT_NR | String | Client Number |
02 | | L2000_REF_CASE_NR | String | Case Number |
02 | | L2000_REF_PIN | String | Personal Identification Number (PIN) |
02 | | L2000_REF_XREF_NR | String | Cross Reference Number |
02 | | L2000_REF_PERSL_ID_NR | String | Personal ID Number |
02 | | L2000_REF_NABP_NR | String | National Council for Prescription Drug Programs Pharmacy Number |
02 | | L2000_REF_DEPT_AGCY_NR | String | Department/Agency Number |
02 | | L2000_REF_HIC_NR | String | Health Insurance Claim (HIC) Number |
02 | | L2000_REF_POS_CD | String | Position Code |
02 | | L2000_REF_PRIOR_ID | String | Prior Identifier Number |
02 | | L2000_REF_UNIT_NR | String | Unit Number |
02 | | L2000_REF_MUTLY_DEF | String | Mutually Defined |
L2000 | DTP | Member Level Dates | | |
03 | | L2000_DTP_RCVD_D8 | Date (YYYYMMDD) | Received Date |
03 | | L2000_DTP_RETRMNT_D8 | Date (YYYYMMDD) | Retirement Date |
03 | | L2000_DTP_DIS_RET_WRK_D8 | Date (YYYYMMDD) | Initial Disability Period Return To Work Date |
03 | | L2000_DTP_LST_WRK_D8 | Date (YYYYMMDD) | Initial Disability Period Last Day Worked Date |
03 | | L2000_DTP_ENRL_SIG_D8 | Date (YYYYMMDD) | Enrollment Signature Date Date |
03 | | L2000_DTP_COBRA_EVNT_D8 | Date (YYYYMMDD) | Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Date |
03 | | L2000_DTP_MNT_EFF_D8 | Date (YYYYMMDD) | Maintenance Effective Date |
03 | | L2000_DTP_EMP_BGN_D8 | Date (YYYYMMDD) | Employment Begin Date |
03 | | L2000_DTP_EMP_END_D8 | Date (YYYYMMDD) | Employment End Date |
03 | | L2000_DTP_MDCR_BGN_D8 | Date (YYYYMMDD) | Medicare Begin Date |
03 | | L2000_DTP_MDCR_END_D8 | Date (YYYYMMDD) | Medicare End Date |
03 | | L2000_DTP_COBRA_BGN_D8 | Date (YYYYMMDD) | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin Date |
03 | | L2000_DTP_COBRA_END_D8 | Date (YYYYMMDD) | Consolidated Omnibus Budget Reconciliation Act (COBRA) End Date |
03 | | L2000_DTP_EDU_BGN_D8 | Date (YYYYMMDD) | Education Begin Date |
03 | | L2000_DTP_EDU_END_D8 | Date (YYYYMMDD) | Education End Date |
03 | | L2000_DTP_ELIG_BGN_D8 | Date (YYYYMMDD) | Eligibility Begin Date |
03 | | L2000_DTP_ELIG_END_D8 | Date (YYYYMMDD) | Eligibility End Date |
03 | | L2000_DTP_ADJ_HIR_D8 | Date (YYYYMMDD) | Adjusted Hire Date |
03 | | L2000_DTP_CRD_SVC_BGN_D8 | Date (YYYYMMDD) | Credited Service Begin Date |
03 | | L2000_DTP_CRD_SVC_END_D8 | Date (YYYYMMDD) | Credited Service End Date |
03 | | L2000_DTP_PLN_SUSP_D8 | Date (YYYYMMDD) | Plan Participation Suspension Date |
03 | | L2000_DTP_REHR_D8 | Date (YYYYMMDD) | Rehire Date |
03 | | L2000_DTP_MDCD_BGN_D8 | Date (YYYYMMDD) | Medicaid Begin Date |
03 | | L2000_DTP_MDCD_END_D8 | Date (YYYYMMDD) | Medicaid End Date |
L2100A - MEMBER NAME (Value Qualified) |
Mapping Prefix: L2100A_74 - Corrected Insured |
Mapping Prefix: L2100A_IL - Insured or Subscriber |
03 | | L2100A_yy_NM103_PERSN_LNM | String | Person Last Name |
04 | | L2100A_yy_NM104_MBR_FNM | String | Member First Name |
05 | | L2100A_yy_NM105_MBR_MNM | String | Member Middle Name |
06 | | L2100A_yy_NM106_MBR_PFX | String | Member Name Prefix |
07 | | L2100A_yy_NM107_MBR_SFX | String | Member Name Suffix |
09 | | L2100A_yy_NM109_SSN | String | Social Security Number |
09 | | L2100A_yy_NM109_MUTLY_DEFND | String | Mutually Defined |
L2100A | PER | Member Communications Numbers | | |
04 | | L2100A_yy_PER04_ALTRN_PHN_NR | String | Alternate Telephone |
04 | | L2100A_yy_PER04_BPR_NR | String | Beeper Number |
04 | | L2100A_yy_PER04_CELL_PHN | String | Cellular Phone |
04 | | L2100A_yy_PER04_EMAIL | String | Electronic Mail |
04 | | L2100A_yy_PER04_PHN_EXT | String | Telephone Extension |
04 | | L2100A_yy_PER04_FAX | String | Facsimile |
04 | | L2100A_yy_PER04_HM_PHN_NR | String | Home Phone Number |
04 | | L2100A_yy_PER04_PHN_NR | String | Telephone |
04 | | L2100A_yy_PER04_WRK_PHN_NR | String | Work Phone Number |
06 | | L2100A_yy_PER06_ALTRN_PHN_NR | String | Alternate Telephone |
06 | | L2100A_yy_PER06_BPR_NR | String | Beeper Number |
06 | | L2100A_yy_PER06_CELL_PHN | String | Cellular Phone |
06 | | L2100A_yy_PER06_EMAIL | String | Electronic Mail |
06 | | L2100A_yy_PER06_PHN_EXT | String | Telephone Extension |
06 | | L2100A_yy_PER06_FAX | String | Facsimile |
06 | | L2100A_yy_PER06_HM_PHN_NR | String | Home Phone Number |
06 | | L2100A_yy_PER06_PHN_NR | String | Telephone |
06 | | L2100A_yy_PER06_WRK_PHN_NR | String | Work Phone Number |
08 | | L2100A_yy_PER08_ALTRN_PHN_NR | String | Alternate Telephone |
08 | | L2100A_yy_PER08_BPR_NR | String | Beeper Number |
08 | | L2100A_yy_PER08_CELL_PHN | String | Cellular Phone |
08 | | L2100A_yy_PER08_EMAIL | String | Electronic Mail |
08 | | L2100A_yy_PER08_PHN_EXT | String | Telephone Extension |
08 | | L2100A_yy_PER08_FAX | String | Facsimile |
08 | | L2100A_yy_PER08_HM_PHN_NR | String | Home Phone Number |
08 | | L2100A_yy_PER08_PHN_NR | String | Telephone |
08 | | L2100A_yy_PER08_WRK_PHN_NR | String | Work Phone Number |
L2100A | N3 | Member Residence Street Address | | |
01 | | L2100A_yy_N301_MBR_ADDR | String | Member Address Line |
02 | | L2100A_yy_N302_MBR_ADDR | String | Member Address Line |
L2100A | N4 | Member City, State, ZIP Code | | |
01 | | L2100A_yy_N401_MBR_CITY | String | Member City Name |
02 | | L2100A_yy_N402_MBR_STAT | String | Member State Code |
03 | | L2100A_yy_N403_MBR_ZIP | String | Member Postal Zone or Zip Code |
04 | | L2100A_yy_N404_CNTRY_CD | String | Country Code |
06 | | L2100A_yy_N406_AREA | String | Area |
06 | | L2100A_yy_N406_COUNTY | String | County/Parish |
07 | | L2100A_yy_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100A | DMG | Member Demographics | | |
02 | | L2100A_yy_DMG02_D8 | DateTime | Member Birth Date |
03 | | L2100A_yy_DMG03_GENDR_CD | String | Gender Code |
04 | | L2100A_yy_DMG04_MARTL_STAT | String | Marital Status Code |
05 | 01 | L2100A_yy_DMG0501_RC_CD | String | Race or Ethnicity Code |
05 | 03 | L2100A_yy_DMG0503_RC_CD | String | Classification of Race or Ethnicity |
06 | | L2100A_yy_DMG06_CTZN_STATS_CD | String | Citizenship Status Code |
11 | | L2100A_yy_DMG11_RAC_ETH_COLL_CD | String | Race or Ethnicity Collection Code |
01 | | L2100A_yy_nnEC01_EMPMT_CLSS_CD | String | Employment Class Code |
02 | | L2100A_yy_nnEC02_EMPMT_CLSS_CD | String | Employment Class Code |
03 | | L2100A_yy_nnEC03_EMPMT_CLSS_CD | String | Employment Class Code |
02 | | L2100A_yy_ICM02_YTD | Number | Year-to-Date |
02 | | L2100A_yy_ICM02_SINGL | Number | Single |
02 | | L2100A_yy_ICM02_HRLY | Number | Hourly |
02 | | L2100A_yy_ICM02_QUARTLY | Number | Quarterly |
02 | | L2100A_yy_ICM02_SEMIANNL | Number | Semiannual |
02 | | L2100A_yy_ICM02_UNKWN | Number | Unknown |
02 | | L2100A_yy_ICM02_WKLY | Number | Weekly |
02 | | L2100A_yy_ICM02_BIWKLY | Number | Biweekly |
02 | | L2100A_yy_ICM02_SEMIMTHLY | Number | Semimonthly |
02 | | L2100A_yy_ICM02_MNTHLY | Number | Monthly |
02 | | L2100A_yy_ICM02_DAILY | Number | Daily |
02 | | L2100A_yy_ICM02_ANNUL | Number | Annual |
02 | | L2100A_yy_ICM02_2CAL_MOS | Number | Two Calendar Months |
02 | | L2100A_yy_ICM02_LMPSM_SEP_ALNC | Number | Lump-Sum Separation Allowance |
03 | | L2100A_yy_ICM03_WRK_HRS_CT | Number | Work Hours Count |
04 | | L2100A_yy_ICM04_LOC_ID_CD | String | Location Identification Code |
05 | | L2100A_yy_ICM05_SALARY_GRD_CD | String | Salary Grade Code |
L2100A | AMT | Member Policy Amounts | | |
02 | | L2100A_yy_AMT02_COINS_ACTL | Number | Co-insurance - Actual |
02 | | L2100A_yy_AMT02_COPAY_AMT | Number | Co-Payment Amount |
02 | | L2100A_yy_AMT02_DED_AMT | Number | Deductible Amount |
02 | | L2100A_yy_AMT02_EXP_EXP_AMT | Number | Expected Expenditure Amount |
02 | | L2100A_yy_AMT02_OTH_UNLS_AMT | Number | Other Unlisted Amount |
02 | | L2100A_yy_AMT02_PREM_AMT | Number | Premium Amount |
02 | | L2100A_yy_AMT02_SPENDOWN | Number | Spend Down |
L2100A | HLH | Member Health Information | | |
01 | | L2100A_yy_HLH01_HLTH_REL_CD | String | Health Related Code |
02 | | L2100A_yy_HLH02_MBR_HGT | Number | Member Height |
03 | | L2100A_yy_HLH03_MBR_WGT | Number | Member Weight |
02 | | L2100A_yy_nnLUI02_ISO3953_LGCD | String | NISO Z39.53 Language Codes |
02 | | L2100A_yy_nnLUI02_I639_LANG_CD | String | ISO 639 Language Codes |
03 | | L2100A_yy_nnLUI03_LANG_DESC | String | Language Description |
04 | | L2100A_yy_nnLUI04_LANG_USE_IND | String | Language Use Indicator |
L2100B - INCORRECT MEMBER NAME |
L2100B | NM1 | Incorrect Member Name | | |
03 | | L2100B_NM103_PERSN_LNM | String | Person Last Name |
04 | | L2100B_NM104_PRI_INC_MBR_FNM | String | Prior Incorrect Member First Name |
05 | | L2100B_NM105_PRI_INC_MBR_MNM | String | Prior Incorrect Member Middle Name |
06 | | L2100B_NM106_PRI_INC_MBR_PFX | String | Prior Incorrect Member Name Prefix |
07 | | L2100B_NM107_PRI_INC_MBR_SFX | String | Prior Incorrect Member Name Suffix |
09 | | L2100B_NM109_SSN | String | Social Security Number |
09 | | L2100B_NM109_MUTLY_DEFND | String | Mutually Defined |
L2100B | DMG | Incorrect Member Demographics | | |
02 | | L2100B_DMG02_D8 | DateTime | Prior Incorrect Insured Birth Date |
03 | | L2100B_DMG03_PRI_INC_GENDR_CD | String | Prior Incorrect Insured Gender Code |
04 | | L2100B_DMG04_MARTL_STAT | String | Marital Status Code |
05 | 01 | L2100B_DMG0501_RAC_ETH_CD | String | Race or Ethnicity Code |
05 | 02 | L2100B_DMG0502_CD_LST_QL | String | Code List Qualifier Code |
05 | 03 | L2100B_DMG0503_RAC_ETH_CD | String | Race or Ethnicity Code |
06 | | L2100B_DMG06_CTZN_STATS_CD | String | Citizenship Status Code |
10 | | L2100B_DMG10_CD_LST_QL | String | Code List Qualifier Code |
11 | | L2100B_DMG11_RACETH_COLL_CD | String | Race or Ethnicity Collection Code |
L2100C - MEMBER MAILING ADDRESS |
L2100C | NM1 | Member Mailing Address | | |
L2100C | N3 | Member Mail Street Address | | |
01 | | L2100C_N301_MBR_ADDR | String | Member Address Line |
02 | | L2100C_N302_MBR_ADDR | String | Member Address Line |
L2100C | N4 | Member Mail City, State, ZIP Code | | |
01 | | L2100C_N401_MBR_MAIL_CITY | String | Member Mail City Name |
02 | | L2100C_N402_MBR_MAIL_STAT | String | Member Mail State Code |
03 | | L2100C_N403_MBR_MAIL_ZIP | String | Member Mail Postal Zone or ZIP Code |
04 | | L2100C_N404_CNTRY_CD | String | Country Code |
07 | | L2100C_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100D - MEMBER EMPLOYER (Single Iteration) |
02 | | L2100D_xx_NM102_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2100D_xx_NM103_MBR_EMP_NM | String | Member Employer Name |
04 | | L2100D_xx_NM104_MBR_EMPLR_FNM | String | Member Employer First Name |
05 | | L2100D_xx_NM105_MBR_EMP_MNM | String | Member Employer Middle Name |
06 | | L2100D_xx_NM106_MBR_EMPLR_PFX | String | Member Employer Name Prefix |
07 | | L2100D_xx_NM107_MBR_EMP_SFX | String | Member Employer Name Suffix |
09 | | L2100D_xx_NM109_EMP_ID_NR | String | Employer's Identification Number |
09 | | L2100D_xx_NM109_SSN | String | Social Security Number |
L2100D | PER | Member Employer Communications Numbers | | |
02 | | L2100D_xx_PER02_MBR_EMP_CM_CON | String | Member Employer Communications Contact |
04 | | L2100D_xx_PER04_ALTRN_PHN_NR | String | Alternate Telephone |
04 | | L2100D_xx_PER04_BPR_NR | String | Beeper Number |
04 | | L2100D_xx_PER04_CELL_PHN | String | Cellular Phone |
04 | | L2100D_xx_PER04_EMAIL | String | Electronic Mail |
04 | | L2100D_xx_PER04_PHN_EXT | String | Telephone Extension |
04 | | L2100D_xx_PER04_FAX | String | Facsimile |
04 | | L2100D_xx_PER04_PHN_NR | String | Telephone |
06 | | L2100D_xx_PER06_ALTRN_PHN_NR | String | Alternate Telephone |
06 | | L2100D_xx_PER06_BPR_NR | String | Beeper Number |
06 | | L2100D_xx_PER06_CELL_PHN | String | Cellular Phone |
06 | | L2100D_xx_PER06_EMAIL | String | Electronic Mail |
06 | | L2100D_xx_PER06_PHN_EXT | String | Telephone Extension |
06 | | L2100D_xx_PER06_FAX | String | Facsimile |
06 | | L2100D_xx_PER06_PHN_NR | String | Telephone |
08 | | L2100D_xx_PER08_ALTRN_PHN_NR | String | Alternate Telephone |
08 | | L2100D_xx_PER08_BPR_NR | String | Beeper Number |
08 | | L2100D_xx_PER08_CELL_PHN | String | Cellular Phone |
08 | | L2100D_xx_PER08_EMAIL | String | Electronic Mail |
08 | | L2100D_xx_PER08_PHN_EXT | String | Telephone Extension |
08 | | L2100D_xx_PER08_FAX | String | Facsimile |
08 | | L2100D_xx_PER08_PHN_NR | String | Telephone |
L2100D | N3 | Member Employer Street Address | | |
01 | | L2100D_xx_N301_MBR_EMP_ADDR | String | Member Employer Address Line |
02 | | L2100D_xx_N302_MBR_EMP_ADDR | String | Member Employer Address Line |
L2100D | N4 | Member Employer City, State, ZIP Code | | |
01 | | L2100D_xx_N401_MBR_EMP_CITY | String | Member Employer City Name |
02 | | L2100D_xx_N402_MBR_EMP_STAT | String | Member Employer State Code |
03 | | L2100D_xx_N403_MBR_EMP_ZIP | String | Member Employer Postal Zone or ZIP Code |
04 | | L2100D_xx_N404_CNTRY_CD | String | Country Code |
07 | | L2100D_xx_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100E - MEMBER SCHOOL (Single Iteration) |
03 | | L2100E_xx_NM103_NONPSNENT_NM | String | Non-Person Entity Name |
L2100E | PER | Member School Commmunications Numbers | | |
02 | | L2100E_xx_PER02_MBR_SCH_CMMCON | String | Member School Communications Contact Name |
04 | | L2100E_xx_PER04_EMAIL | String | Electronic Mail |
04 | | L2100E_xx_PER04_PHN_EXT | String | Telephone Extension |
04 | | L2100E_xx_PER04_FAX | String | Facsimile |
04 | | L2100E_xx_PER04_PHN_NR | String | Telephone |
06 | | L2100E_xx_PER06_EMAIL | String | Electronic Mail |
06 | | L2100E_xx_PER06_PHN_EXT | String | Telephone Extension |
06 | | L2100E_xx_PER06_FAX | String | Facsimile |
06 | | L2100E_xx_PER06_PHN_NR | String | Telephone |
08 | | L2100E_xx_PER08_EMAIL | String | Electronic Mail |
08 | | L2100E_xx_PER08_PHN_EXT | String | Telephone Extension |
08 | | L2100E_xx_PER08_FAX | String | Facsimile |
08 | | L2100E_xx_PER08_PHN_NR | String | Telephone |
L2100E | N3 | Member School Street Address | | |
01 | | L2100E_xx_N301_SCHL_ADDR | String | School Address Line |
02 | | L2100E_xx_N302_SCHL_ADDR | String | School Address Line |
L2100E | N4 | Member School City, State, ZIP Code | | |
01 | | L2100E_xx_N401_MBR_SCH_CITY | String | Member School City Name |
02 | | L2100E_xx_N402_MBR_SCH_STAT | String | Member School State Code |
03 | | L2100E_xx_N403_MBR_SCH_ZIP | String | Member School Postal Zone or ZIP Code |
04 | | L2100E_xx_N404_CNTRY_CD | String | Country Code |
07 | | L2100E_xx_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100F - CUSTODIAL PARENT |
L2100F | NM1 | Custodial Parent | | |
03 | | L2100F_NM103_PERSN_LNM | String | Person Last Name |
04 | | L2100F_NM104_CUST_PAR_FNM | String | Custodial Parent First Name |
05 | | L2100F_NM105_CUST_PAR_MNM | String | Custodial Parent Middle Name |
06 | | L2100F_NM106_CUST_PAR_PFX | String | Custodial Parent Name Prefix |
07 | | L2100F_NM107_CUST_PAR_SFX | String | Custodial Parent Name Suffix |
09 | | L2100F_NM109_SSN | String | Social Security Number |
09 | | L2100F_NM109_MUTLY_DEFND | String | Mutually Defined |
L2100F | PER | Custodial Parent Communications Numbers | | |
04 | | L2100F_PER04_ALTRN_PHN_NR | String | Alternate Telephone |
04 | | L2100F_PER04_BPR_NR | String | Beeper Number |
04 | | L2100F_PER04_CELL_PHN | String | Cellular Phone |
04 | | L2100F_PER04_EMAIL | String | Electronic Mail |
04 | | L2100F_PER04_PHN_EXT | String | Telephone Extension |
04 | | L2100F_PER04_FAX | String | Facsimile |
04 | | L2100F_PER04_HM_PHN_NR | String | Home Phone Number |
04 | | L2100F_PER04_PHN_NR | String | Telephone |
04 | | L2100F_PER04_WRK_PHN_NR | String | Work Phone Number |
06 | | L2100F_PER06_ALTRN_PHN_NR | String | Alternate Telephone |
06 | | L2100F_PER06_BPR_NR | String | Beeper Number |
06 | | L2100F_PER06_CELL_PHN | String | Cellular Phone |
06 | | L2100F_PER06_EMAIL | String | Electronic Mail |
06 | | L2100F_PER06_PHN_EXT | String | Telephone Extension |
06 | | L2100F_PER06_FAX | String | Facsimile |
06 | | L2100F_PER06_HM_PHN_NR | String | Home Phone Number |
06 | | L2100F_PER06_PHN_NR | String | Telephone |
06 | | L2100F_PER06_WRK_PHN_NR | String | Work Phone Number |
08 | | L2100F_PER08_ALTRN_PHN_NR | String | Alternate Telephone |
08 | | L2100F_PER08_BPR_NR | String | Beeper Number |
08 | | L2100F_PER08_CELL_PHN | String | Cellular Phone |
08 | | L2100F_PER08_EMAIL | String | Electronic Mail |
08 | | L2100F_PER08_PHN_EXT | String | Telephone Extension |
08 | | L2100F_PER08_HM_PHN_NR | String | Home Phone Number |
08 | | L2100F_PER08_PHN_NR | String | Telephone |
08 | | L2100F_PER08_WRK_PHN_NR | String | Work Phone Number |
L2100F | N3 | Custodial Parent Street Address | | |
01 | | L2100F_N301_CUST_PAR_ADDR | String | Custodial Parent Address Line |
02 | | L2100F_N302_CUST_PAR_ADDR | String | Custodial Parent Address Line |
L2100F | N4 | Custodial Parent City, State, ZIP Code | | |
01 | | L2100F_N401_CUST_PAR_CITY | String | Custodial Parent City Name |
02 | | L2100F_N402_CUST_PAR_STAT | String | Custodial Parent State Code |
03 | | L2100F_N403_CUST_PAR_ZIP | String | Custodial Parent Postal Zone or ZIP Code |
04 | | L2100F_N404_CNTRY_CD | String | Country Code |
07 | | L2100F_N407_CNTRY_SUBDV_CD | String | Country 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 |
L2100G | NM1 | Responsible Person | | |
03 | | L2100G_yy_NM103_PERSN_LNM | String | Person Last Name |
04 | | L2100G_yy_NM104_RESP_PRTY_FNAM | String | Responsible Party First Name |
05 | | L2100G_yy_NM105_RESP_MNM | String | Responsible Party Middle Name |
06 | | L2100G_yy_NM106_RSP_PRTY_PFX | String | Responsible Party Name Prefix |
07 | | L2100G_yy_NM107_RSP_PARTY_SFX | String | Responsible Party Suffix Name |
09 | | L2100G_yy_NM109_SSN | String | Social Security Number |
09 | | L2100G_yy_NM109_MUTLY_DEFND | String | Mutually Defined |
L2100G | PER | Responsible Person Communications Numbers | | |
04 | | L2100G_yy_PER04_ALTRN_PHN_NR | String | Alternate Telephone |
04 | | L2100G_yy_PER04_BPR_NR | String | Beeper Number |
04 | | L2100G_yy_PER04_CELL_PHN | String | Cellular Phone |
04 | | L2100G_yy_PER04_EMAIL | String | Electronic Mail |
04 | | L2100G_yy_PER04_PHN_EXT | String | Telephone Extension |
04 | | L2100G_yy_PER04_FAX | String | Facsimile |
04 | | L2100G_yy_PER04_HM_PHN_NR | String | Home Phone Number |
04 | | L2100G_yy_PER04_PHN_NR | String | Telephone |
04 | | L2100G_yy_PER04_WRK_PHN_NR | String | Work Phone Number |
06 | | L2100G_yy_PER06_ALTRN_PHN_NR | String | Alternate Telephone |
06 | | L2100G_yy_PER06_BPR_NR | String | Beeper Number |
06 | | L2100G_yy_PER06_CELL_PHN | String | Cellular Phone |
06 | | L2100G_yy_PER06_EMAIL | String | Electronic Mail |
06 | | L2100G_yy_PER06_PHN_EXT | String | Telephone Extension |
06 | | L2100G_yy_PER06_FAX | String | Facsimile |
06 | | L2100G_yy_PER06_HM_PHN_NR | String | Home Phone Number |
06 | | L2100G_yy_PER06_PHN_NR | String | Telephone |
06 | | L2100G_yy_PER06_WRK_PHN_NR | String | Work Phone Number |
08 | | L2100G_yy_PER08_ALTRN_PHN_NR | String | Alternate Telephone |
08 | | L2100G_yy_PER08_BPR_NR | String | Beeper Number |
08 | | L2100G_yy_PER08_CELL_PHN | String | Cellular Phone |
08 | | L2100G_yy_PER08_EMAIL | String | Electronic Mail |
08 | | L2100G_yy_PER08_PHN_EXT | String | Telephone Extension |
08 | | L2100G_yy_PER08_FAX | String | Facsimile |
08 | | L2100G_yy_PER08_HM_PHN_NR | String | Home Phone Number |
08 | | L2100G_yy_PER08_PHN_NR | String | Telephone |
08 | | L2100G_yy_PER08_WRK_PHN_NR | String | Work Phone Number |
L2100G | N3 | Responsible Person Street Address | | |
01 | | L2100G_yy_N301_RSP_PRTY_ADDR | String | Responsible Party Address Line |
02 | | L2100G_yy_N302_RSP_PRTY_ADDR | String | Responsible Party Address Line |
L2100G | N4 | Responsible Person City, State, ZIP Code | | |
01 | | L2100G_yy_N401_RSP_PERS_CITY | String | Responsible Person City Name |
02 | | L2100G_yy_N402_RSP_PERS_STAT | String | Responsible Person State Code |
03 | | L2100G_yy_N403_RESP_PRSN_ZIP | String | Responsible Person Postal Zone or ZIP Code |
04 | | L2100G_yy_N404_CNTRY_CD | String | Country Code |
07 | | L2100G_yy_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100H - DROP OFF LOCATION |
L2100H | NM1 | Drop Off Location | | |
03 | | L2100H_NM103_NM_LAST_ORG_NM | String | Name Last or Organization Name |
04 | | L2100H_NM104_FNM | String | Name First |
05 | | L2100H_NM105_NM_MID | String | Name Middle |
06 | | L2100H_NM106_PFX | String | Name Prefix |
07 | | L2100H_NM107_SFX | String | Name Suffix |
L2100H | N3 | Drop Off Location Street Address | | |
01 | | L2100H_N301_DROPOFF_LOC_ADDR | String | Drop Off Location Address Line |
02 | | L2100H_N302_DROPOFF_LOC_ADDR | String | Drop Off Location Address Line |
L2100H | N4 | Drop Off Location City, State, ZIP Code | | |
01 | | L2100H_N401_DROPOFF_LOC_CITY | String | Drop Off Location City Name |
02 | | L2100H_N402_DROPOFF_LOC_STAT | String | Drop Off Location State Code |
03 | | L2100H_N403_DROPOFF_LOC_ZIP | String | Drop Off Location Postal Zone or ZIP Code |
04 | | L2100H_N404_CNTRY_CD | String | Country Code |
07 | | L2100H_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2200 - DISABILITY INFORMATION |
L2200 | DSB | Disability Information | | |
01 | | L2200_DSB01_DISABTY_TYP_CD | String | Disability Type Code |
08 | | L2200_DSB08_ICD9_DIAG | String | International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis |
08 | | L2200_DSB08_MUTLY_DEF | String | Mutually Defined |
L2200 | DTP | Disability Eligibility Dates | | |
03 | | L2200_DTP_DIS_BGN_D8 | Date (YYYYMMDD) | Initial Disability Period Start Date |
03 | | L2200_DTP_DIS_END_D8 | Date (YYYYMMDD) | Initial Disability Period End Date |
01 | | L2300_HD01_MAINT_TYP_CD | String | Maintenance Type Code |
03 | | L2300_HD03_INS_LIN_CD | String | Insurance Line Code |
04 | | L2300_HD04_PLN_CVG_DSC | String | Plan Coverage Description |
05 | | L2300_HD05_COVG_LVL_CD | String | Coverage Level Code |
09 | | L2300_HD09_LAT_ENRL_IND | String | Late Enrollment Indicator |
L2300 | DTP | Health Coverage Dates | | |
03 | | L2300_DTP_ENRL_SIG_D8 | Date (YYYYMMDD) | Enrollment Signature Date Date |
03 | | L2300_DTP_ENRL_SIG_RD8_1 | Start Date (YYYYMMDD) | Enrollment Signature Date Date |
03 | | L2300_DTP_ENRL_SIG_RD8_2 | End Date (YYYYMMDD) | Enrollment Signature Date Date |
03 | | L2300_DTP_MNT_EFF_D8 | Date (YYYYMMDD) | Maintenance Effective Date |
03 | | L2300_DTP_MNT_EFF_RD8_1 | Start Date (YYYYMMDD) | Maintenance Effective Date |
03 | | L2300_DTP_MNT_EFF_RD8_2 | End Date (YYYYMMDD) | Maintenance Effective Date |
03 | | L2300_DTP_PRM_PD_END_D8 | Date (YYYYMMDD) | Premium Paid to Date End Date |
03 | | L2300_DTP_PRM_PD_END_RD8_1 | Start Date (YYYYMMDD) | Premium Paid to Date End Date |
03 | | L2300_DTP_PRM_PD_END_RD8_2 | End Date (YYYYMMDD) | Premium Paid to Date End Date |
03 | | L2300_DTP_BNFT_BGN_D8 | Date (YYYYMMDD) | Benefit Begin Date |
03 | | L2300_DTP_BNFT_BGN_RD8_1 | Start Date (YYYYMMDD) | Benefit Begin Date |
03 | | L2300_DTP_BNFT_BGN_RD8_2 | End Date (YYYYMMDD) | Benefit Begin Date |
03 | | L2300_DTP_BNFT_END_D8 | Date (YYYYMMDD) | Benefit End Date |
03 | | L2300_DTP_BNFT_END_RD8_1 | Start Date (YYYYMMDD) | Benefit End Date |
03 | | L2300_DTP_BNFT_END_RD8_2 | End Date (YYYYMMDD) | Benefit End Date |
03 | | L2300_DTP_PRM_PD_D8 | Date (YYYYMMDD) | Last Premium Paid Date Date |
03 | | L2300_DTP_PRM_PD_RD8_1 | Start Date (YYYYMMDD) | Last Premium Paid Date Date |
03 | | L2300_DTP_PRM_PD_RD8_2 | End Date (YYYYMMDD) | Last Premium Paid Date Date |
03 | | L2300_DTP_PRV_PERD_D8 | Date (YYYYMMDD) | Previous Period Date |
03 | | L2300_DTP_PRV_PERD_RD8_1 | Start Date (YYYYMMDD) | Previous Period Date |
03 | | L2300_DTP_PRV_PERD_RD8_2 | End Date (YYYYMMDD) | Previous Period Date |
L2300 | AMT | Health Coverage Policy | | |
02 | | L2300_AMT02_COINS_ACTL | Number | Co-insurance - Actual |
02 | | L2300_AMT02_COPAY_AMT | Number | Co-Payment Amount |
02 | | L2300_AMT02_DED_AMT | Number | Deductible Amount |
02 | | L2300_AMT02_EXP_EXP_AMT | Number | Expected Expenditure Amount |
02 | | L2300_AMT02_OTH_UNLS_AMT | Number | Other Unlisted Amount |
02 | | L2300_AMT02_PREM_AMT | Number | Premium Amount |
02 | | L2300_AMT02_SPENDOWN | Number | Spend Down |
L2300 | REF | Health Coverage Policy Number | | |
02 | | L2300_REF_CLT_RPT_CAT | String | Client Reporting Category |
02 | | L2300_REF_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2300_REF_PMT_CAT | String | Payment Category |
02 | | L2300_REF_CLSS_CONT | String | Class of Contract Code |
02 | | L2300_REF_COVG_NR | String | Service Contract (Coverage) Number |
02 | | L2300_REF_MDCL_ASST_CAT | String | Medical Assistance Category |
02 | | L2300_REF_PROG_ID | String | Program Identification Number |
02 | | L2300_REF_RAT_CD_NR | String | Rate code number |
02 | | L2300_REF_INT_CTL_NR | String | Internal Control Number |
02 | | L2300_REF_ISSR_NR | String | Issuer Number |
02 | | L2300_REF_SP_PROG_CD | String | Special Program Code |
02 | | L2300_REF_SVC_AREA_CD | String | Service Area Code |
02 | | L2300_REF_CNTY_CD | String | County Code |
02 | | L2300_REF_MUTLY_DEF | String | Mutually Defined |
L2300 | REF | Prior Coverage Months | | |
02 | | L2300_REF_UNIT_NR | String | Unit Number |
L2300 | IDC | Identification Card | | |
01 | | L2300_nnIDC01_PLN_CVG_DSC | String | Plan Coverage Description |
02 | | L2300_nnIDC02_ID_TYP_CD | String | Identification Card Type Code |
03 | | L2300_nnIDC03_ID_CRD_CT | Number | Identification Card Count |
04 | | L2300_nnIDC04_ACTN_CD | String | Action Code |
L2310 - PROVIDER INFORMATION |
L2310 | LX | Provider Information | | |
01 | | L2310_LX01_ASSGD_NR | Integer | Assigned Number |
| | 3D | | Obstetrics and Gynecology Facility |
| | Y2 | | Managed Care Organization |
01 | | L2310_NM1yy01_ENTY_ID_CD | String | Entity Identifier Code |
02 | | L2310_NM1yy02_ENT_TYP_QUAL | String | Entity Type Qualifier |
03 | | L2310_NM1yy03_PVR_LNM | String | Provider Last or Organization Name |
04 | | L2310_NM1yy04_PVR_FNM | String | Provider First Name |
05 | | L2310_NM1yy05_PVR_MNM | String | Provider Middle Name |
06 | | L2310_NM1yy06_PVR_PFX | String | Provider Name Prefix |
07 | | L2310_NM1yy07_PVR_SFX | String | Provider Name Suffix |
09 | | L2310_NM1yy09_SSN | String | Social Security Number |
09 | | L2310_NM1yy09_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2310_NM1yy09_SVC_PROV_NR | String | Service Provider Number |
09 | | L2310_NM1yy09_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
10 | | L2310_NM1yy10_ENTY_REL_CD | String | Entity Relationship Code |
01 | | L2310_nnN301_PVR_ADDR | String | Provider Address Line |
02 | | L2310_nnN302_PVR_ADDR | String | Provider Address Line |
L2310 | N4 | Provider City, State, ZIP Code | | |
01 | | L2310_N401_PVR_CITY | String | Provider City Name |
02 | | L2310_N402_PVR_STAT | String | Provider State Code |
03 | | L2310_N403_PVR_ZIP | String | Provider Postal Zone or ZIP Code |
04 | | L2310_N404_CNTRY_CD | String | Country Code |
07 | | L2310_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2310 | PER | Provider Communications Numbers | | |
04 | | L2310_nnPER04_ALTRN_PHN_NR | String | Alternate Telephone |
04 | | L2310_nnPER04_BPR_NR | String | Beeper Number |
04 | | L2310_nnPER04_CELL_PHN | String | Cellular Phone |
04 | | L2310_nnPER04_EMAIL | String | Electronic Mail |
04 | | L2310_nnPER04_PHN_EXT | String | Telephone Extension |
04 | | L2310_nnPER04_FAX | String | Facsimile |
04 | | L2310_nnPER04_HM_PHN_NR | String | Home Phone Number |
04 | | L2310_nnPER04_PHN_NR | String | Telephone |
04 | | L2310_nnPER04_WRK_PHN_NR | String | Work Phone Number |
06 | | L2310_nnPER06_ALTRN_PHN_NR | String | Alternate Telephone |
06 | | L2310_nnPER06_BPR_NR | String | Beeper Number |
06 | | L2310_nnPER06_CELL_PHN | String | Cellular Phone |
06 | | L2310_nnPER06_EMAIL | String | Electronic Mail |
06 | | L2310_nnPER06_PHN_EXT | String | Telephone Extension |
06 | | L2310_nnPER06_FAX | String | Facsimile |
06 | | L2310_nnPER06_HM_PHN_NR | String | Home Phone Number |
06 | | L2310_nnPER06_PHN_NR | String | Telephone |
06 | | L2310_nnPER06_WRK_PHN_NR | String | Work Phone Number |
08 | | L2310_nnPER08_ALTRN_PHN_NR | String | Alternate Telephone |
08 | | L2310_nnPER08_BPR_NR | String | Beeper Number |
08 | | L2310_nnPER08_CELL_PHN | String | Cellular Phone |
08 | | L2310_nnPER08_EMAIL | String | Electronic Mail |
08 | | L2310_nnPER08_PHN_EXT | String | Telephone Extension |
08 | | L2310_nnPER08_FAX | String | Facsimile |
08 | | L2310_nnPER08_HM_PHN_NR | String | Home Phone Number |
08 | | L2310_nnPER08_PHN_NR | String | Telephone |
08 | | L2310_nnPER08_WRK_PHN_NR | String | Work Phone Number |
L2310 | PLA | Provider Change Reason | | |
03 | | L2310_PLA03_PVR_EFF_D8 | Date (YYYYMMDD) | Provider Effective Date |
05 | | L2310_PLA05_MAINT_RSN_CD | String | Maintenance Reason Code |
L2320 - COORDINATION OF BENEFITS (Single Iteration) |
L2320 | COB | Coordination of Benefits | | |
01 | | L2320_xx_COB01_PYR_RESP_SEQ_NR | String | Payer Responsibility Sequence Number Code |
02 | | L2320_xx_COB02_MBR_GRP_POL_NR | String | Member Group or Policy Number |
03 | | L2320_xx_COB03_COB_CD | String | Coordination of Benefits Code |
04 | | L2320_xx_COB04_Enn_SVC_TYP_CD | String | Service Type Code |
L2320 | REF | Additional Coordination of Benefits Identifiers | | |
02 | | L2320_xx_REF_ACCT_SFX | String | Account Suffix Code |
02 | | L2320_xx_REF_GRP_NR | String | Group Number |
02 | | L2320_xx_REF_SSN | String | Social Security Number |
02 | | L2320_xx_REF_MUTLY_DEF | String | Mutually Defined |
L2320 | DTP | Coordination of Benefits Eligibility Dates | | |
03 | | L2320_xx_DTP_COBRA_BGN_D8 | Date (YYYYMMDD) | Coordination of Benefits Begin Date |
03 | | L2320_xx_DTP_COBRA_END_D8 | Date (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 |
L2330 | NM1 | Coordination of Benefits Related Entity | | |
03 | | L2330_xxyy_NM103_COB_INS_NM | String | Coordination of Benefits Insurer Name |
09 | | L2330_xxyy_NM109_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2330_xxyy_NM109_NAIC_ID | String | National Association of Insurance Commissioners (NAIC) Identification |
09 | | L2330_xxyy_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
L2330 | N3 | Coordination of Benefits Related Entity Address | | |
01 | | L2330_xxyy_N301_ADDR_NFO | String | Address Information |
02 | | L2330_xxyy_N302_ADDR_NFO | String | Address Information |
L2330 | N4 | Coordination of Benefits Other Insurance Company City, State, ZIP Code | | |
01 | | L2330_xxyy_N401_COB_OTH_INS | String | Coordination of Benefits Other Insurance adequate to specify a location. |
02 | | L2330_xxyy_N402_COB_OINS | String | Coordination of Benefits Other Insurance implementation guide, do not send. |
03 | | L2330_xxyy_N403_COB_OINS | String | Coordination of Benefits Other Insurance implementation guide, do not send. |
04 | | L2330_xxyy_N404_CNTRY_CD | String | Country Code |
07 | | L2330_xxyy_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2330 | PER | Administrative Communications Contact | | |
04 | | L2330_xxyy_PER04_PHN_NR | String | Telephone |
L2710 - MEMBER REPORTING CATEGORIES |
L2710 | LS | Additional Reporting Categories | | |
01 | | L2710_LS01_LOOP_ID_CD | String | Loop Identifier Code |
L2750 - REPORTING CATEGORY |
L2750 | LX | Member Reporting Categories | | |
01 | | L2750_LX01_ASSGD_NR | Integer | Assigned Number |
L2750 | N1 | Reporting Category | | |
02 | | L2750_N102_MBR_REP_CAT_NM | String | Member Reporting Category Name |
L2750 | REF | Reporting Category Reference | | |
02 | | L2750_REF_DST_NR | String | Contracting District Number |
02 | | L2750_REF_CLT_RPT_CAT | String | Client Reporting Category |
02 | | L2750_REF_PLAN_NR | String | Plan Number |
02 | | L2750_REF_DIV_ID | String | Division Identifier |
02 | | L2750_REF_UNION_NR | String | Union Number |
02 | | L2750_REF_BRNCH_ID | String | Branch Identifier |
02 | | L2750_REF_APP_NR | String | Application Number |
02 | | L2750_REF_PMT_CAT | String | Payment Category |
02 | | L2750_REF_ACCT_CAT | String | Account Category |
02 | | L2750_REF_GEO_NR | String | Geographic Number |
02 | | L2750_REF_LOC_NR | String | Location Number |
02 | | L2750_REF_PROG_ID | String | Program Identification Number |
02 | | L2750_REF_SP_PROG_CD | String | Special Program Code |
02 | | L2750_REF_SVC_AREA_CD | String | Service Area Code |
02 | | L2750_REF_GEO_KEY | String | Geographic Key |
02 | | L2750_REF_MUTLY_DEF | String | Mutually Defined |
L2750 | DTP | Reporting Category Date | | |
03 | | L2750_DTP_EFF_D8 | Date (YYYYMMDD) | Effective Date |
03 | | L2750_DTP_EFF_RD8_1 | Start Date (YYYYMMDD) | Effective Date |
03 | | L2750_DTP_EFF_RD8_2 | End Date (YYYYMMDD) | Effective Date |
L2710 | LE | Additional Reporting Categories Loop Termination | | |
01 | | L2710_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 |