(C) Copyright 2012 Chiapas EDI Technologies, Inc.
4010_270 4010 Health Care Eligibility Benefit Inquiry - Code:A0
ISA - GROUP HEADERS
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| OEISA | ISA | Interchange Control Header | |
| OEISA | ISA02 | No Authorization Information Present | OEISA_S01_ISA02_AUTH_NFO_OVL_NO_AUTH_NFO |
| OEISA | ISA02 | Additional Data Identification | OEISA_S01_ISA02_AUTH_NFO_OVL_ADDL_ID |
| OEISA | ISA04 | No Security Information Present | OEISA_S01_ISA04_SEC_NFO_OVL_NO_SEC_NFO |
| OEISA | ISA04 | Password | OEISA_S01_ISA04_SEC_NFO_OVL_PASSWD |
| OEISA | ISA06 | Dun and Brandstreet | OEISA_S01_ISA06_SENDR_ID_OVL_DUNS_ID |
| OEISA | ISA06 | Duns Plus Suffix | OEISA_S01_ISA06_SENDR_ID_OVL_DUNS_SUFFX_ID |
| OEISA | ISA06 | Health Industry Number | OEISA_S01_ISA06_SENDR_ID_OVL_HIN_ID |
| OEISA | ISA06 | Carrier Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_CARR_ID |
| OEISA | ISA06 | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_FIIN_ID |
| OEISA | ISA06 | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA06_SENDR_ID_OVL_HCFA_MEDCR_ID |
| OEISA | ISA06 | US Federal Tax Identification Number | OEISA_S01_ISA06_SENDR_ID_OVL_TAX_ID |
| OEISA | ISA06 | National Association of Insurance Commissioners Company Code | OEISA_S01_ISA06_SENDR_ID_OVL_NAIC_ID |
| OEISA | ISA06 | Mutually Defined | OEISA_S01_ISA06_SENDR_ID_OVL_MUTLY_DEFND_ID |
| OEISA | ISA08 | Dun and Brandstreet | OEISA_S01_ISA08_RECVR_ID_OVL_DUNS_ID |
| OEISA | ISA08 | Duns Plus Suffix | OEISA_S01_ISA08_RECVR_ID_OVL_DUNS_SUFFX_ID |
| OEISA | ISA08 | Health Industry Number | OEISA_S01_ISA08_RECVR_ID_OVL_HIN_ID |
| OEISA | ISA08 | Carrier Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_CARR_ID |
| OEISA | ISA08 | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_FIIN_ID |
| OEISA | ISA08 | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration | OEISA_S01_ISA08_RECVR_ID_OVL_HCFA_MEDCR_ID |
| OEISA | ISA08 | US Federal Tax Identification Number | OEISA_S01_ISA08_RECVR_ID_OVL_TAX_ID |
| OEISA | ISA08 | National Association of Insurance Commissioners Company Code | OEISA_S01_ISA08_RECVR_ID_OVL_NAIC_ID |
| OEISA | ISA08 | Mutually Defined | OEISA_S01_ISA08_RECVR_ID_OVL_MUTLY_DEFND_ID |
| OEISA | ISA09 | Interchange Date | OEISA_S01_ISA09_DT |
| OEISA | ISA10 | Interchange Time | OEISA_S01_ISA10_TM |
| OEISA | ISA11 | Repetition Separator | OEISA_S01_ISA11_REPTN_SEPRTR |
| OEISA | ISA12 | Interchang Control Version Number | OEISA_S01_ISA12_VERSN_NR |
| OEISA | ISA13 | Interchange Control Number | OEISA_S01_ISA13_ICN |
| OEISA | ISA14 | Acknowledgment Requested | OEISA_S01_ISA14_ACK_REQ |
| OEISA | ISA15 | Interchange Usage Indicator | OEISA_S01_ISA15_USG_IND |
| OEISA | ISA16 | Component Element Separator | OEISA_S01_ISA16_SUBELE_SEP |
| OEISA | IEA | Interchange Control Trailer | |
| OEISA | IEA01 | Number of Included Functional Groups | OEISA_S03_IEA01_GS_CT |
| OEISA | IEA02 | Interchange Control Number | OEISA_S03_IEA02_ICN |
GSHDR - GROUP HEADER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| GSHDR | GS | Functional Group Header | |
| GSHDR | GS01 | Functional Identifier Code | GSHDR_S01_GS01_FUNCTL_ID_CD |
| GSHDR | GS02 | Application Senders Code | GSHDR_S01_GS02_APP_SENDR_CD |
| GSHDR | GS03 | Application Receivers Code | GSHDR_S01_GS03_APP_RECVR_CD |
| GSHDR | GS04 | Date | GSHDR_S01_GS04_DT |
| GSHDR | GS05 | Time | GSHDR_S01_GS05_TM |
| GSHDR | GS06 | Group Control Number | GSHDR_S01_GS06_GCN |
| GSHDR | GS07 | Responsible Agency Code | GSHDR_S01_GS07_RESP_AGNCY_CD |
| GSHDR | GE | Functional Group Trailer | |
| GSHDR | GE01 | Number of Transaction Sets Included | GSHDR_S03_GE01_TS_CT |
| GSHDR | GE02 | Group Control Number | GSHDR_S03_GE02_GCN |
STHDR - TRANSACTION SET HEADER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| STHDR | ST | Transaction Set Header | |
| STHDR | ST01 | Transaction Set Identifier Code | STHDR_S01_ST01_ID_CD |
| STHDR | ST02 | Transaction Set Control Number | STHDR_S01_ST02_CONTRL_NR |
| STHDR | BHT | Beginning of Hierarchical Transaction | |
| STHDR | BHT01 | Hierarchical Structure Code | STHDR_S02_BHT01_STRUCTR_CD |
| STHDR | BHT02 | Transaction Set Purpose Code | STHDR_S02_BHT02_TS_PURPS_CD |
| STHDR | BHT03 | Submitter Transaction Identifier | STHDR_S02_BHT03_SUBMTR_TRANSCTN_ID |
| STHDR | BHT04 | Transaction Set Creation Date | STHDR_S02_BHT04_TS_CREATN_DT |
| STHDR | BHT05 | Transaction Set Creation Time | STHDR_S02_BHT05_TS_CREATN_TIM |
| STHDR | BHT06 | Transaction Type Code | STHDR_S02_BHT06_TRANSCTN_TYPE_CD |
| STHDR | SE | Transaction Set Trailer | |
| STHDR | SE01 | Transaction Segment Count | STHDR_S04_SE01_SEG_CT |
| STHDR | SE02 | Transaction Set Control Number | STHDR_S04_SE02_TCN |
2000A - INFORMATION SOURCE LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000A | HL | Information Source Level | |
| L2000A | HL01 | Hierarchical ID Number | L2000A_S01_HL01_HIERCHCL_ID_NR |
| L2000A | HL04 | Hierarchical Child Code | L2000A_S01_HL04_HIERCHCL_CHILD_CD |
2100A - INFORMATION SOURCE NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2100A | Qualified Loop | ||
| L2100A | Gateway Provider | L2100A_GP | |
| L2100A | Plan Sponsor | L2100A_P5 | |
| L2100A | Payer | L2100A_PR | |
| L2100A | NM1 | Information Source Name | |
| L2100A | NM102 | Entity Type Qualifier | L2100A_XX_S01_NM102_ENTY_TYPE_QUAL |
| L2100A | NM103 | Information Source Last or Organization Name | L2100A_XX_S01_NM103_NFO_SOURC_LAST_ORG_NM |
| L2100A | NM104 | Information Source First Name | L2100A_XX_S01_NM104_NFO_SOURC_FNAME |
| L2100A | NM105 | Information Source Middle Name | L2100A_XX_S01_NM105_NFO_SOURC_MNAME |
| L2100A | NM107 | Information Source Name Suffix | L2100A_XX_S01_NM107_NFO_SOURC_NM_SUFX |
| L2100A | NM109 | Employer’s Identification Number | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_EMPLYR_ID_NR |
| L2100A | NM109 | Electronic Transmitter Identification Number (ETIN) | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_ETN_NR |
| L2100A | NM109 | Federal Taxpayer’s Identification Number | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_FED_TAX_ID_NR |
| L2100A | NM109 | National Association of Insurance Commissioners (NAIC) Identification | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_NAIC_ID |
| L2100A | NM109 | Payor Identification | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_PAYR_ID |
| L2100A | NM109 | Health Care Financing Administration National | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_HCFA_NATNL |
| L2100A | NM109 | Health Care Financing Administration National Provider Identifier | L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_HCFA_NATNL_PROV_ID |
2000B - INFORMATION RECEIVER LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000B | HL | Information Receiver Level | |
| L2000B | HL01 | Hierarchical ID Number | L2000B_S01_HL01_HIERCHCL_ID_NR |
| L2000B | HL02 | Hierarchical Parent ID Number | L2000B_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000B | HL04 | Hierarchical Child Code | L2000B_S01_HL04_HIERCHCL_CHILD_CD |
2100B - INFORMATION RECEIVER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2100B | Qualified Loop | ||
| L2100B | Employer | L2100B_36 | |
| L2100B | Hospital | L2100B_80 | |
| L2100B | Facility | L2100B_FA | |
| L2100B | Gateway Provider | L2100B_GP | |
| L2100B | Plan Sponsor | L2100B_P5 | |
| L2100B | Payer | L2100B_PR | |
| L2100B | NM1 | Information Receiver Name | |
| L2100B | NM102 | Entity Type Qualifier | L2100B_XX_S01_NM102_ENTY_TYPE_QUAL |
| L2100B | NM103 | Information Receiver Last or Organization Name | L2100B_XX_S01_NM103_NFO_RECVR_LAST_ORG_NM |
| L2100B | NM104 | Information Receiver First Name | L2100B_XX_S01_NM104_NFO_RECVR_FNAME |
| L2100B | NM105 | Information Receiver Middle Name | L2100B_XX_S01_NM105_NFO_RECVR_MNAME |
| L2100B | NM107 | Information Receiver Name Suffix | L2100B_XX_S01_NM107_NFO_RECVR_NM_SUFX |
| L2100B | NM109 | Employer’s Identification Number | L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_EMPLYR_ID_NR |
| L2100B | NM109 | Social Security Number | L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_SSN |
| L2100B | NM109 | Federal Taxpayer’s Identification Number | L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_FED_TAX_ID_NR |
| L2100B | NM109 | Payor Identification | L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_PAYR_ID |
| L2100B | NM109 | Pharmacy Processor Number | L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_PHARMCY_PROCSR_NR |
| L2100B | NM109 | Service Provider Number | L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_SVC_PROV_NR |
| L2100B | NM109 | Health Care Financing Administration National Provider Identifier | L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_HCFA_NATNL_PROV_ID |
| L2100B | REF | Information Receiver Additional Identification | |
| L2100B | REF02 | State License Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_STAT_LICNS_NR |
| L2100B | REF02 | Medicare Provider Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_MEDCR_PROV_NR |
| L2100B | REF02 | Medicaid Provider Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_MEDCD_PROV_NR |
| L2100B | REF02 | Facility ID Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_FACLTY_ID_NR |
| L2100B | REF02 | Personal Identification Number (PIN) | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_PIN |
| L2100B | REF02 | Contract Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_CONTRCT_NR |
| L2100B | REF02 | Electronic device pin number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_ELCTRNC_DEVC_PIN_NR |
| L2100B | REF02 | Submitter Identification Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_SUBMTR_ID_NR |
| L2100B | REF02 | Health Care Financing Administration National Provider Identifier | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_HCFA_NATNL_PROV_ID |
| L2100B | REF02 | User Identification | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_USR_ID |
| L2100B | REF02 | Provider Plan Network Identification Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_PROV_PLAN_NETWRK_ID_NR |
| L2100B | REF02 | Facility Network Identification Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_FACLTY_NETWRK_ID_NR |
| L2100B | REF02 | Prior Identifier Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_PRI_ID_NR |
| L2100B | REF02 | Social Security Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_SSN |
| L2100B | REF02 | Federal Taxpayer’s Identification Number | L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_FED_TAX_ID_NR |
| L2100B | REF03 | License Number State Code | L2100B_XX_S02_REF03_LICNS_NR_STAT_CD |
| L2100B | N3 | Information Receiver Address | |
| L2100B | N301 | Information Receiver Address Line | L2100B_XX_S03_N301_NFO_RECVR_ADRS_LIN |
| L2100B | N302 | Information Receiver Additional Address Line | L2100B_XX_S03_N302_NFO_RECVR_ADDL_ADRS_LIN |
| L2100B | N4 | Information Receiver City/State/ZIP Code | |
| L2100B | N401 | Information Receiver City Name | L2100B_XX_S04_N401_NFO_RECVR_CITY_NM |
| L2100B | N402 | Information Receiver State Code | L2100B_XX_S04_N402_NFO_RECVR_STAT_CD |
| L2100B | N403 | Information Receiver Postal Zone or ZIP Code | L2100B_XX_S04_N403_NFO_RECVR_POSTL_ZON_ZIP_CD |
| L2100B | N404 | Country Code | L2100B_XX_S04_N404_CNTRY_CD |
| L2100B | PER | Information Receiver Contact Information | |
| L2100B | PER01 | Contact Function Code | L2100B_XX_S05_PER01_FUNCTN_CD |
| L2100B | PER02 | Information Receiver Contact Name | L2100B_XX_S05_PER02_NFO_RECVR_CONTCT_NM |
| L2100B | PER04 | Electronic Data Interchange Access Number | L2100B_XX_S05_PER04_NFO_RECVR_COMNCTN_NR_OVL_EDI_ACS_NR |
| L2100B | PER04 | Electronic Mail | L2100B_XX_S05_PER04_NFO_RECVR_COMNCTN_NR_OVL_EMAIL |
| L2100B | PER04 | Facsimile | L2100B_XX_S05_PER04_NFO_RECVR_COMNCTN_NR_OVL_FACSML |
| L2100B | PER04 | Telephone | L2100B_XX_S05_PER04_NFO_RECVR_COMNCTN_NR_OVL_TELPHN |
| L2100B | PER06 | Electronic Data Interchange Access Number | L2100B_XX_S05_PER06_NFO_RECVR_COMNCTN_NR_OVL_EDI_ACS_NR |
| L2100B | PER06 | Electronic Mail | L2100B_XX_S05_PER06_NFO_RECVR_COMNCTN_NR_OVL_EMAIL |
| L2100B | PER06 | Telephone Extension | L2100B_XX_S05_PER06_NFO_RECVR_COMNCTN_NR_OVL_PHN_EXTNS |
| L2100B | PER06 | Facsimile | L2100B_XX_S05_PER06_NFO_RECVR_COMNCTN_NR_OVL_FACSML |
| L2100B | PER06 | Telephone | L2100B_XX_S05_PER06_NFO_RECVR_COMNCTN_NR_OVL_TELPHN |
| L2100B | PER08 | Electronic Data Interchange Access Number | L2100B_XX_S05_PER08_NFO_RECVR_COMNCTN_NR_OVL_EDI_ACS_NR |
| L2100B | PER08 | Electronic Mail | L2100B_XX_S05_PER08_NFO_RECVR_COMNCTN_NR_OVL_EMAIL |
| L2100B | PER08 | Telephone Extension | L2100B_XX_S05_PER08_NFO_RECVR_COMNCTN_NR_OVL_PHN_EXTNS |
| L2100B | PER08 | Facsimile | L2100B_XX_S05_PER08_NFO_RECVR_COMNCTN_NR_OVL_FACSML |
| L2100B | PER08 | Telephone | L2100B_XX_S05_PER08_NFO_RECVR_COMNCTN_NR_OVL_TELPHN |
| L2100B | PRV | Information Receiver Provider Information | |
| L2100B | PRV01 | Provider Code | L2100B_XX_S06_PRV01_PROV_CD |
| L2100B | PRV03 | Mutually Defined | L2100B_XX_S06_PRV03_RECVR_PROV_SPEC_CD_OVL_MUTLY_DEFND |
2000C - SUBSCRIBER LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000C | HL | Subscriber Level | |
| L2000C | HL01 | Hierarchical ID Number | L2000C_S01_HL01_HIERCHCL_ID_NR |
| L2000C | HL02 | Hierarchical Parent ID Number | L2000C_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000C | HL04 | Hierarchical Child Code | L2000C_S01_HL04_HIERCHCL_CHILD_CD |
| L2000C | TRN | Subscriber Trace Number | |
| L2000C | TRN01 | Trace Type Code | L2000C_S02_TRN01_TYPE_CD |
| L2000C | TRN02 | Trace Number | L2000C_S02_TRN02_TRAC_NR |
| L2000C | TRN03 | Trace Assigning Entity Identifier | L2000C_S02_TRN03_TRAC_ASGNG_ENTY_ID |
| L2000C | TRN04 | Trace Assigning Entity Additional Identifier | L2000C_S02_TRN04_TRAC_ASGNG_ENTY_ADDL_ID |
2100C - SUBSCRIBER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2100C | Qualified Loop | ||
| L2100C | Provider | L2100C_1P | |
| L2100C | Third-Party Administrator | L2100C_2B | |
| L2100C | Employer | L2100C_36 | |
| L2100C | Hospital | L2100C_80 | |
| L2100C | Facility | L2100C_FA | |
| L2100C | Gateway Provider | L2100C_GP | |
| L2100C | Plan Sponsor | L2100C_P5 | |
| L2100C | Payer | L2100C_PR | |
| L2100C | NM1 | Subscriber Name | |
| L2100C | NM102 | Entity Type Qualifier | L2100C_XX_S01_NM102_ENTY_TYPE_QUAL |
| L2100C | NM103 | Subscriber Last Name | L2100C_XX_S01_NM103_SUB_LNAME |
| L2100C | NM104 | Subscriber First Name | L2100C_XX_S01_NM104_SUB_FNAME |
| L2100C | NM105 | Subscriber Middle Name | L2100C_XX_S01_NM105_SUB_MNAME |
| L2100C | NM107 | Subscriber Name Suffix | L2100C_XX_S01_NM107_NM_SUFX |
| L2100C | NM109 | Member Identification Number | L2100C_XX_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR |
| L2100C | NM109 | Mutually Defined | L2100C_XX_S01_NM109_PRIMRY_ID_OVL_MUTLY_DEFND |
| L2100C | REF | Subscriber Additional Identification | |
| L2100C | REF02 | Plan Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_PLAN_NR |
| L2100C | REF02 | Group or Policy Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_GRP_POLCY_NR |
| L2100C | REF02 | Member Identification Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_MEM_ID_NR |
| L2100C | REF02 | Family Unit Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_FAMLY_UNT_NR |
| L2100C | REF02 | Group Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_GRP_NR |
| L2100C | REF02 | Employee Identification Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_EMPLY_ID_NR |
| L2100C | REF02 | Contract Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_CONTRCT_NR |
| L2100C | REF02 | Medical Record Identification Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_MEDCL_RECRD_ID_NR |
| L2100C | REF02 | Patient Account Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_PATNT_ACNT_NR |
| L2100C | REF02 | Health Insurance Claim (HIC) Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_HIC_NR |
| L2100C | REF02 | Identification Card Serial Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_ID_CARD_SERL_NR |
| L2100C | REF02 | Identity Card Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_IDNTY_CARD_NR |
| L2100C | REF02 | Insurance Policy Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_INS_POLCY_NR |
| L2100C | REF02 | Plan Network Identification Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_PLAN_NETWRK_ID_NR |
| L2100C | REF02 | Medicaid Recipient Identification Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_MEDCD_RECPNT_ID_NR |
| L2100C | REF02 | Social Security Number | L2100C_XX_S02_REF02_SUPP_ID_OVL_SSN |
| L2100C | N3 | Subscriber Address | |
| L2100C | N301 | Subscriber Address Line | L2100C_XX_S03_N301_ADRS_LIN |
| L2100C | N302 | Subscriber Address Line | L2100C_XX_S03_N302_ADRS_LIN |
| L2100C | N4 | Subscriber City/State/ZIP Code | |
| L2100C | N401 | Subscriber City Name | L2100C_XX_S04_N401_CITY_NM |
| L2100C | N402 | Subscriber State Code | L2100C_XX_S04_N402_STAT_CD |
| L2100C | N403 | Subscriber Postal Zone or ZIP Code | L2100C_XX_S04_N403_SUB_POSTL_ZON_ZIP_CD |
| L2100C | N404 | Country Code | L2100C_XX_S04_N404_CNTRY_CD |
| L2100C | PRV | Provider Information | |
| L2100C | PRV01 | Provider Code | L2100C_XX_S05_PRV01_PROV_CD |
| L2100C | PRV03 | Servicer | L2100C_XX_S05_PRV03_PROV_ID_OVL_SERVCR |
| L2100C | PRV03 | National Association of Boards of Pharmacy Number | L2100C_XX_S05_PRV03_PROV_ID_OVL_NATNL_ASCTN_BOARDS_PHARMCY_NR |
| L2100C | PRV03 | Employer’s Identification Number | L2100C_XX_S05_PRV03_PROV_ID_OVL_EMPLYR_ID_NR |
| L2100C | PRV03 | Health Care Financing Administration National Provider Identifier | L2100C_XX_S05_PRV03_PROV_ID_OVL_HCFA_NATNL_PROV_ID |
| L2100C | PRV03 | Social Security Number | L2100C_XX_S05_PRV03_PROV_ID_OVL_SSN |
| L2100C | PRV03 | Federal Taxpayer’s Identification Number | L2100C_XX_S05_PRV03_PROV_ID_OVL_FED_TAX_ID_NR |
| L2100C | PRV03 | Mutually Defined | L2100C_XX_S05_PRV03_PROV_ID_OVL_MUTLY_DEFND |
| L2100C | DMG | Subscriber Demographic Information | |
| L2100C | DMG02 | Date Expressed in Format CCYYMMDD | L2100C_XX_S06_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2100C | DMG03 | Subscriber Gender Code | L2100C_XX_S06_DMG03_GENDR_CD |
| L2100C | INS | Subscriber Relationship | |
| L2100C | INS01 | Insured Indicator | L2100C_XX_S07_INS01_INSRD_IND |
| L2100C | INS02 | Individual Relationship Code | L2100C_XX_S07_INS02_INDVDL_REL_CD |
| L2100C | INS17 | Birth Sequence Number | L2100C_XX_S07_INS17_BIRTH_SEQNC_NR |
| L2100C | DTP | Subscriber Date | |
| L2100C | DTP03 | Issue (D8) | L2100C_XX_S08_DTP03_DT_TM_PERD_OVL_ISSU_D8 |
| L2100C | DTP03 | Eligibility (D8) | L2100C_XX_S08_DTP03_DT_TM_PERD_OVL_ELGBLTY_D8 |
| L2100C | DTP03 | Admission (D8) | L2100C_XX_S08_DTP03_DT_TM_PERD_OVL_ADMSN_D8 |
| L2100C | DTP03 | Service (D8) | L2100C_XX_S08_DTP03_DT_TM_PERD_OVL_SVC_D8 |
| L2100C | DTP03 | Issue (RD8) | L2100C_XX_S08_DTP03_DT_TM_PERD_OVL_ISSU_RD8 |
| L2100C | DTP03 | Eligibility (RD8) | L2100C_XX_S08_DTP03_DT_TM_PERD_OVL_ELGBLTY_RD8 |
| L2100C | DTP03 | Admission (RD8) | L2100C_XX_S08_DTP03_DT_TM_PERD_OVL_ADMSN_RD8 |
| L2100C | DTP03 | Service (RD8) | L2100C_XX_S08_DTP03_DT_TM_PERD_OVL_SVC_RD8 |
2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2110C | EQ | Subscriber Eligibility or Benefit Inquiry Information | |
| L2110C | EQ01 | Service Type Code | L2110C_S01_EQ01_SVC_TYPE_CD |
| L2110C | EQ02-02 | American Dental Association Codes | L2110C_S01_EQ02_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD |
| L2110C | EQ02-02 | Current Procedural Terminology (CPT) Codes | L2110C_S01_EQ02_02_PROC_CD_OVL_CPT_CD |
| L2110C | EQ02-02 | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | L2110C_S01_EQ02_02_PROC_CD_OVL_HCPCS_CD |
| L2110C | EQ02-02 | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure | L2110C_S01_EQ02_02_PROC_CD_OVL_ICD9CM_PROC |
| L2110C | EQ02-02 | Home Infusion EDI Coalition (HIEC) Product/Service Code | L2110C_S01_EQ02_02_PROC_CD_OVL_HIEC_PRODCT_SRVC_CD |
| L2110C | EQ02-02 | National Drug Code (NDC) | L2110C_S01_EQ02_02_PROC_CD_OVL_NDC |
| L2110C | EQ02-02 | Mutually Defined | L2110C_S01_EQ02_02_PROC_CD_OVL_MUTLY_DEFND |
| L2110C | EQ02-03 | Procedure Modifier | L2110C_S01_EQ02_03_PROC_MODFR |
| L2110C | EQ02-04 | Procedure Modifier | L2110C_S01_EQ02_04_PROC_MODFR |
| L2110C | EQ02-05 | Procedure Modifier | L2110C_S01_EQ02_05_PROC_MODFR |
| L2110C | EQ02-06 | Procedure Modifier | L2110C_S01_EQ02_06_PROC_MODFR |
| L2110C | EQ03 | Benefit Coverage Level Code | L2110C_S01_EQ03_BENFT_COVG_LEVL_CD |
| L2110C | EQ04 | Insurance Type Code | L2110C_S01_EQ04_INS_TYPE_CD |
| L2110C | AMT | Subscriber Spend Down Amount | |
| L2110C | AMT02 | Spend Down | L2110C_S02_AMT02_DOWN_AMT_OVL_SPEND_DOWN |
| L2110C | III | Subscriber Eligibility or Benefit Additional Inquiry Information | |
| L2110C | III02 | Diagnosis | L2110C_S03_III02_INDSTRY_CD_OVL_DIAG |
| L2110C | III02 | Principal Diagnosis | L2110C_S03_III02_INDSTRY_CD_OVL_PRINCPL_DIAG |
| L2110C | III02 | Mutually Defined | L2110C_S03_III02_INDSTRY_CD_OVL_MUTLY_DEFND |
| L2110C | REF | Subscriber Additional Information | |
| L2110C | REF02 | Referral Number | L2110C_S04_REF02_PRI_AUTH_REFL_NR_OVL_REFL_NR |
| L2110C | REF02 | Prior Authorization Number | L2110C_S04_REF02_PRI_AUTH_REFL_NR_OVL_PRI_AUTH_NR |
| L2110C | DTP | Subscriber Eligibility/Benefit Date | |
| L2110C | DTP03 | Eligibility (D8) | L2110C_S05_DTP03_DT_TM_PERD_OVL_ELGBLTY_D8 |
| L2110C | DTP03 | Admission (D8) | L2110C_S05_DTP03_DT_TM_PERD_OVL_ADMSN_D8 |
| L2110C | DTP03 | Service (D8) | L2110C_S05_DTP03_DT_TM_PERD_OVL_SVC_D8 |
| L2110C | DTP03 | Eligibility (RD8) | L2110C_S05_DTP03_DT_TM_PERD_OVL_ELGBLTY_RD8 |
| L2110C | DTP03 | Admission (RD8) | L2110C_S05_DTP03_DT_TM_PERD_OVL_ADMSN_RD8 |
| L2110C | DTP03 | Service (RD8) | L2110C_S05_DTP03_DT_TM_PERD_OVL_SVC_RD8 |
2000D - DEPENDENT LEVEL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000D | HL | Dependent Level | |
| L2000D | HL01 | Hierarchical ID Number | L2000D_S01_HL01_HIERCHCL_ID_NR |
| L2000D | HL02 | Hierarchical Parent ID Number | L2000D_S01_HL02_HIERCHCL_PARNT_ID_NR |
| L2000D | HL04 | Hierarchical Child Code | L2000D_S01_HL04_HIERCHCL_CHILD_CD |
| L2000D | TRN | Dependent Trace Number | |
| L2000D | TRN01 | Trace Type Code | L2000D_S02_TRN01_TYPE_CD |
| L2000D | TRN02 | Trace Number | L2000D_S02_TRN02_TRAC_NR |
| L2000D | TRN03 | Trace Assigning Entity Identifier | L2000D_S02_TRN03_TRAC_ASGNG_ENTY_ID |
| L2000D | TRN04 | Trace Assigning Entity Additional Identifier | L2000D_S02_TRN04_TRAC_ASGNG_ENTY_ADDL_ID |
2100D - DEPENDENT NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100D | NM1 | Dependent Name | |
| L2100D | NM102 | Entity Type Qualifier | L2100D_S01_NM102_ENTY_TYPE_QUAL |
| L2100D | NM103 | Dependent Last Name | L2100D_S01_NM103_DEPNDNT_LNAME |
| L2100D | NM104 | Dependent First Name | L2100D_S01_NM104_DEPNDNT_FNAME |
| L2100D | NM105 | Dependent Middle Name | L2100D_S01_NM105_DEPNDNT_MNAME |
| L2100D | NM107 | Dependent Name Suffix | L2100D_S01_NM107_NM_SUFX |
| L2100D | REF | Dependent Additional Identification | |
| L2100D | REF02 | Plan Number | L2100D_S02_REF02_SUPP_ID_OVL_PLAN_NR |
| L2100D | REF02 | Group or Policy Number | L2100D_S02_REF02_SUPP_ID_OVL_GRP_POLCY_NR |
| L2100D | REF02 | Group Number | L2100D_S02_REF02_SUPP_ID_OVL_GRP_NR |
| L2100D | REF02 | Employee Identification Number | L2100D_S02_REF02_SUPP_ID_OVL_EMPLY_ID_NR |
| L2100D | REF02 | Contract Number | L2100D_S02_REF02_SUPP_ID_OVL_CONTRCT_NR |
| L2100D | REF02 | Medical Record Identification Number | L2100D_S02_REF02_SUPP_ID_OVL_MEDCL_RECRD_ID_NR |
| L2100D | REF02 | Patient Account Number | L2100D_S02_REF02_SUPP_ID_OVL_PATNT_ACNT_NR |
| L2100D | REF02 | Health Insurance Claim (HIC) Number | L2100D_S02_REF02_SUPP_ID_OVL_HIC_NR |
| L2100D | REF02 | Identification Card Serial Number | L2100D_S02_REF02_SUPP_ID_OVL_ID_CARD_SERL_NR |
| L2100D | REF02 | Identity Card Number | L2100D_S02_REF02_SUPP_ID_OVL_IDNTY_CARD_NR |
| L2100D | REF02 | Issue Number | L2100D_S02_REF02_SUPP_ID_OVL_IS_NR |
| L2100D | REF02 | Insurance Policy Number | L2100D_S02_REF02_SUPP_ID_OVL_INS_POLCY_NR |
| L2100D | REF02 | Plan Network Identification Number | L2100D_S02_REF02_SUPP_ID_OVL_PLAN_NETWRK_ID_NR |
| L2100D | REF02 | Social Security Number | L2100D_S02_REF02_SUPP_ID_OVL_SSN |
| L2100D | N3 | Dependent Address | |
| L2100D | N301 | Dependent Address Line | L2100D_S03_N301_ADRS_LIN |
| L2100D | N302 | Dependent Address Line | L2100D_S03_N302_ADRS_LIN |
| L2100D | N4 | Dependent City/State/ZIP Code | |
| L2100D | N401 | Dependent City Name | L2100D_S04_N401_CITY_NM |
| L2100D | N402 | Dependent State Code | L2100D_S04_N402_STAT_CD |
| L2100D | N403 | Dependent Postal Zone or ZIP Code | L2100D_S04_N403_DEPNDNT_POSTL_ZON_ZIP_CD |
| L2100D | N404 | Country Code | L2100D_S04_N404_CNTRY_CD |
| L2100D | PRV | Provider Information | |
| L2100D | PRV01 | Provider Code | L2100D_S05_PRV01_PROV_CD |
| L2100D | PRV03 | Servicer | L2100D_S05_PRV03_PROV_ID_OVL_SERVCR |
| L2100D | PRV03 | National Association of Boards of Pharmacy Number | L2100D_S05_PRV03_PROV_ID_OVL_NATNL_ASCTN_BOARDS_PHARMCY_NR |
| L2100D | PRV03 | Employer’s Identification Number | L2100D_S05_PRV03_PROV_ID_OVL_EMPLYR_ID_NR |
| L2100D | PRV03 | Health Care Financing Administration National Provider Identifier | L2100D_S05_PRV03_PROV_ID_OVL_HCFA_NATNL_PROV_ID |
| L2100D | PRV03 | Social Security Number | L2100D_S05_PRV03_PROV_ID_OVL_SSN |
| L2100D | PRV03 | Federal Taxpayer’s Identification Number | L2100D_S05_PRV03_PROV_ID_OVL_FED_TAX_ID_NR |
| L2100D | PRV03 | Mutually Defined | L2100D_S05_PRV03_PROV_ID_OVL_MUTLY_DEFND |
| L2100D | DMG | Dependent Demographic Information | |
| L2100D | DMG02 | Date Expressed in Format CCYYMMDD | L2100D_S06_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2100D | DMG03 | Dependent Gender Code | L2100D_S06_DMG03_GENDR_CD |
| L2100D | INS | Dependent Relationship | |
| L2100D | INS01 | Insured Indicator | L2100D_S07_INS01_INSRD_IND |
| L2100D | INS02 | Individual Relationship Code | L2100D_S07_INS02_INDVDL_REL_CD |
| L2100D | INS17 | Birth Sequence Number | L2100D_S07_INS17_BIRTH_SEQNC_NR |
| L2100D | DTP | Dependent Date | |
| L2100D | DTP03 | Issue (D8) | L2100D_S08_DTP03_DT_TM_PERD_OVL_ISSU_D8 |
| L2100D | DTP03 | Eligibility (D8) | L2100D_S08_DTP03_DT_TM_PERD_OVL_ELGBLTY_D8 |
| L2100D | DTP03 | Admission (D8) | L2100D_S08_DTP03_DT_TM_PERD_OVL_ADMSN_D8 |
| L2100D | DTP03 | Service (D8) | L2100D_S08_DTP03_DT_TM_PERD_OVL_SVC_D8 |
| L2100D | DTP03 | Issue (RD8) | L2100D_S08_DTP03_DT_TM_PERD_OVL_ISSU_RD8 |
| L2100D | DTP03 | Eligibility (RD8) | L2100D_S08_DTP03_DT_TM_PERD_OVL_ELGBLTY_RD8 |
| L2100D | DTP03 | Admission (RD8) | L2100D_S08_DTP03_DT_TM_PERD_OVL_ADMSN_RD8 |
| L2100D | DTP03 | Service (RD8) | L2100D_S08_DTP03_DT_TM_PERD_OVL_SVC_RD8 |
2110D - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2110D | EQ | Dependent Eligibility or Benefit Inquiry Information | |
| L2110D | EQ01 | Service Type Code | L2110D_S01_EQ01_SVC_TYPE_CD |
| L2110D | EQ02-02 | American Dental Association Codes | L2110D_S01_EQ02_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD |
| L2110D | EQ02-02 | Current Procedural Terminology (CPT) Codes | L2110D_S01_EQ02_02_PROC_CD_OVL_CPT_CD |
| L2110D | EQ02-02 | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | L2110D_S01_EQ02_02_PROC_CD_OVL_HCPCS_CD |
| L2110D | EQ02-02 | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure | L2110D_S01_EQ02_02_PROC_CD_OVL_ICD9CM_PROC |
| L2110D | EQ02-02 | Home Infusion EDI Coalition (HIEC) Product/Service Code | L2110D_S01_EQ02_02_PROC_CD_OVL_HIEC_PRODCT_SRVC_CD |
| L2110D | EQ02-02 | National Drug Code (NDC) | L2110D_S01_EQ02_02_PROC_CD_OVL_NDC |
| L2110D | EQ02-02 | Mutually Defined | L2110D_S01_EQ02_02_PROC_CD_OVL_MUTLY_DEFND |
| L2110D | EQ02-03 | Procedure Modifier | L2110D_S01_EQ02_03_PROC_MODFR |
| L2110D | EQ02-04 | Procedure Modifier | L2110D_S01_EQ02_04_PROC_MODFR |
| L2110D | EQ02-05 | Procedure Modifier | L2110D_S01_EQ02_05_PROC_MODFR |
| L2110D | EQ02-06 | Procedure Modifier | L2110D_S01_EQ02_06_PROC_MODFR |
| L2110D | EQ03 | Benefit Coverage Level Code | L2110D_S01_EQ03_BENFT_COVG_LEVL_CD |
| L2110D | EQ04 | Insurance Type Code | L2110D_S01_EQ04_INS_TYPE_CD |
| L2110D | III | Dependent Eligibility or Benefit Additional Inquiry Information | |
| L2110D | III02 | Diagnosis | L2110D_S02_III02_INDSTRY_CD_OVL_DIAG |
| L2110D | III02 | Principal Diagnosis | L2110D_S02_III02_INDSTRY_CD_OVL_PRINCPL_DIAG |
| L2110D | III02 | Mutually Defined | L2110D_S02_III02_INDSTRY_CD_OVL_MUTLY_DEFND |
| L2110D | REF | Dependent Additional Information | |
| L2110D | REF02 | Referral Number | L2110D_S03_REF02_PRI_AUTH_REFL_NR_OVL_REFL_NR |
| L2110D | REF02 | Prior Authorization Number | L2110D_S03_REF02_PRI_AUTH_REFL_NR_OVL_PRI_AUTH_NR |
| L2110D | DTP | Dependent Eligibility/Benefit Date | |
| L2110D | DTP03 | Eligibility (D8) | L2110D_S04_DTP03_DT_TM_PERD_OVL_ELGBLTY_D8 |
| L2110D | DTP03 | Admission (D8) | L2110D_S04_DTP03_DT_TM_PERD_OVL_ADMSN_D8 |
| L2110D | DTP03 | Service (D8) | L2110D_S04_DTP03_DT_TM_PERD_OVL_SVC_D8 |
| L2110D | DTP03 | Eligibility (RD8) | L2110D_S04_DTP03_DT_TM_PERD_OVL_ELGBLTY_RD8 |
| L2110D | DTP03 | Admission (RD8) | L2110D_S04_DTP03_DT_TM_PERD_OVL_ADMSN_RD8 |
| L2110D | DTP03 | Service (RD8) | L2110D_S04_DTP03_DT_TM_PERD_OVL_SVC_RD8 |