(C) Copyright 2012 Chiapas EDI Technologies, Inc.
4010_271 4010 Health Care Eligibility Benefit Response - Code:B0
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 | 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 |
| L2000A | AAA | Request Validation | |
| L2000A | AAA01 | Valid Request Indicator | L2000A_S02_AAA01_REQST_IND |
| L2000A | AAA03 | Reject Reason Code | L2000A_S02_AAA03_REJCT_RSN_CD |
| L2000A | AAA04 | Follow-up Action Code | L2000A_S02_AAA04_FOLWP_ACTN_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 |
| L2100A | REF | Information Source Additional Identification | |
| L2100A | REF02 | Plan Number | L2100A_XX_S02_REF02_NFO_SOURC_ADDL_PLAN_ID_OVL_PLAN_NR |
| L2100A | REF02 | Sequence Number | L2100A_XX_S02_REF02_NFO_SOURC_ADDL_PLAN_ID_OVL_SEQNC_NR |
| L2100A | REF03 | Plan Name | L2100A_XX_S02_REF03_PLAN_NM |
| L2100A | PER | Information Source Contact Information | |
| L2100A | PER01 | Contact Function Code | L2100A_XX_S03_PER01_FUNCTN_CD |
| L2100A | PER02 | Information Source Contact Name | L2100A_XX_S03_PER02_NFO_SOURC_CONTCT_NM |
| L2100A | PER04 | Electronic Data Interchange Access Number | L2100A_XX_S03_PER04_NFO_SOURC_COMNCTN_NR_OVL_EDI_ACS_NR |
| L2100A | PER04 | Electronic Mail | L2100A_XX_S03_PER04_NFO_SOURC_COMNCTN_NR_OVL_EMAIL |
| L2100A | PER04 | Facsimile | L2100A_XX_S03_PER04_NFO_SOURC_COMNCTN_NR_OVL_FACSML |
| L2100A | PER04 | Telephone | L2100A_XX_S03_PER04_NFO_SOURC_COMNCTN_NR_OVL_TELPHN |
| L2100A | PER06 | Electronic Data Interchange Access Number | L2100A_XX_S03_PER06_NFO_SOURC_COMNCTN_NR_OVL_EDI_ACS_NR |
| L2100A | PER06 | Electronic Mail | L2100A_XX_S03_PER06_NFO_SOURC_COMNCTN_NR_OVL_EMAIL |
| L2100A | PER06 | Telephone Extension | L2100A_XX_S03_PER06_NFO_SOURC_COMNCTN_NR_OVL_PHN_EXTNS |
| L2100A | PER06 | Facsimile | L2100A_XX_S03_PER06_NFO_SOURC_COMNCTN_NR_OVL_FACSML |
| L2100A | PER06 | Telephone | L2100A_XX_S03_PER06_NFO_SOURC_COMNCTN_NR_OVL_TELPHN |
| L2100A | PER08 | Electronic Data Interchange Access Number | L2100A_XX_S03_PER08_NFO_SOURC_COMNCTN_NR_OVL_EDI_ACS_NR |
| L2100A | PER08 | Electronic Mail | L2100A_XX_S03_PER08_NFO_SOURC_COMNCTN_NR_OVL_EMAIL |
| L2100A | PER08 | Telephone Extension | L2100A_XX_S03_PER08_NFO_SOURC_COMNCTN_NR_OVL_PHN_EXTNS |
| L2100A | PER08 | Facsimile | L2100A_XX_S03_PER08_NFO_SOURC_COMNCTN_NR_OVL_FACSML |
| L2100A | PER08 | Telephone | L2100A_XX_S03_PER08_NFO_SOURC_COMNCTN_NR_OVL_TELPHN |
| L2100A | AAA | Request Validation | |
| L2100A | AAA01 | Valid Request Indicator | L2100A_XX_S04_AAA01_REQST_IND |
| L2100A | AAA03 | Reject Reason Code | L2100A_XX_S04_AAA03_REJCT_RSN_CD |
| L2100A | AAA04 | Follow-up Action Code | L2100A_XX_S04_AAA04_FOLWP_ACTN_CD |
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 | L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_HCFA_NATNL |
| 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 | AAA | Information Receiver Request Validation | |
| L2100B | AAA01 | Valid Request Indicator | L2100B_XX_S03_AAA01_REQST_IND |
| L2100B | AAA03 | Reject Reason Code | L2100B_XX_S03_AAA03_REJCT_RSN_CD |
| L2100B | AAA04 | Follow-up Action Code | L2100B_XX_S03_AAA04_FOLWP_ACTN_CD |
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 |
| L2100C | NM1 | Subscriber Name | |
| L2100C | NM102 | Entity Type Qualifier | L2100C_S01_NM102_ENTY_TYPE_QUAL |
| L2100C | NM103 | Subscriber Last Name | L2100C_S01_NM103_SUB_LNAME |
| L2100C | NM104 | Subscriber First Name | L2100C_S01_NM104_SUB_FNAME |
| L2100C | NM105 | Subscriber Middle Name | L2100C_S01_NM105_SUB_MNAME |
| L2100C | NM106 | Subscriber Name Prefix | L2100C_S01_NM106_NM_PREFX |
| L2100C | NM107 | Subscriber Name Suffix | L2100C_S01_NM107_NM_SUFX |
| L2100C | NM109 | Member Identification Number | L2100C_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR |
| L2100C | NM109 | Mutually Defined | L2100C_S01_NM109_PRIMRY_ID_OVL_MUTLY_DEFND |
| L2100C | REF | Subscriber Additional Identification | |
| L2100C | REF02 | Plan Network Identification Number | L2100C_S02_REF02_SUPP_ID_OVL_PLAN_NETWRK_ID_NR |
| L2100C | REF02 | Medicaid Recipient Identification Number | L2100C_S02_REF02_SUPP_ID_OVL_MEDCD_RECPNT_ID_NR |
| L2100C | REF02 | Prior Identifier Number | L2100C_S02_REF02_SUPP_ID_OVL_PRI_ID_NR |
| L2100C | REF02 | Social Security Number | L2100C_S02_REF02_SUPP_ID_OVL_SSN |
| L2100C | REF02 | Plan Number | L2100C_S02_REF02_SUPP_ID_OVL_PLAN_NR |
| L2100C | REF02 | Group or Policy Number | L2100C_S02_REF02_SUPP_ID_OVL_GRP_POLCY_NR |
| L2100C | REF02 | Member Identification Number | L2100C_S02_REF02_SUPP_ID_OVL_MEM_ID_NR |
| L2100C | REF02 | Case Number | L2100C_S02_REF02_SUPP_ID_OVL_CAS_NR |
| L2100C | REF02 | Family Unit Number | L2100C_S02_REF02_SUPP_ID_OVL_FAMLY_UNT_NR |
| L2100C | REF02 | Group Number | L2100C_S02_REF02_SUPP_ID_OVL_GRP_NR |
| L2100C | REF02 | Employee Identification Number | L2100C_S02_REF02_SUPP_ID_OVL_EMPLY_ID_NR |
| L2100C | REF02 | Medical Record Identification Number | L2100C_S02_REF02_SUPP_ID_OVL_MEDCL_RECRD_ID_NR |
| L2100C | REF02 | Patient Account Number | L2100C_S02_REF02_SUPP_ID_OVL_PATNT_ACNT_NR |
| L2100C | REF02 | Health Insurance Claim (HIC) Number | L2100C_S02_REF02_SUPP_ID_OVL_HIC_NR |
| L2100C | REF02 | Identification Card Serial Number | L2100C_S02_REF02_SUPP_ID_OVL_ID_CARD_SERL_NR |
| L2100C | REF02 | Identity Card Number | L2100C_S02_REF02_SUPP_ID_OVL_IDNTY_CARD_NR |
| L2100C | REF02 | Issue Number | L2100C_S02_REF02_SUPP_ID_OVL_IS_NR |
| L2100C | REF02 | Insurance Policy Number | L2100C_S02_REF02_SUPP_ID_OVL_INS_POLCY_NR |
| L2100C | REF02 | Military Rank/Civilian Pay Grade Number | L2100C_S02_REF02_SUPP_ID_OVL_MILTRY_RANK_CVLN_PAY_GRAD_NR |
| L2100C | REF03 | Plan Sponsor Name | L2100C_S02_REF03_PLAN_SPONSR_NM |
| L2100C | N3 | Subscriber Address | |
| L2100C | N301 | Subscriber Address Line | L2100C_S03_N301_ADRS_LIN |
| L2100C | N302 | Subscriber Address Line | L2100C_S03_N302_ADRS_LIN |
| L2100C | N4 | Subscriber City/State/ZIP Code | |
| L2100C | N401 | Subscriber City Name | L2100C_S04_N401_CITY_NM |
| L2100C | N402 | Subscriber State Code | L2100C_S04_N402_STAT_CD |
| L2100C | N403 | Subscriber Postal Zone or ZIP Code | L2100C_S04_N403_SUB_POSTL_ZON_ZIP_CD |
| L2100C | N404 | Country Code | L2100C_S04_N404_CNTRY_CD |
| L2100C | N406 | County/Parish | L2100C_S04_N406_LOC_ID_CD_OVL_COUNTY_PRSH |
| L2100C | N406 | Federal Information Processing Standards (FIPS) 55 (Named Populated Places) | L2100C_S04_N406_LOC_ID_CD_OVL_FIPS_55 |
| L2100C | PER | Subscriber Contact Information | |
| L2100C | PER01 | Contact Function Code | L2100C_S05_PER01_FUNCTN_CD |
| L2100C | PER02 | Subscriber Contact Name | L2100C_S05_PER02_CONTCT_NM |
| L2100C | PER04 | Home Phone Number | L2100C_S05_PER04_CONTCT_NR_OVL_HOM_PHON_NR |
| L2100C | PER04 | Telephone | L2100C_S05_PER04_CONTCT_NR_OVL_TELPHN |
| L2100C | PER04 | Work Phone Number | L2100C_S05_PER04_CONTCT_NR_OVL_WORK_PHON_NR |
| L2100C | PER06 | Telephone Extension | L2100C_S05_PER06_CONTCT_NR_OVL_PHN_EXTNS |
| L2100C | PER06 | Home Phone Number | L2100C_S05_PER06_CONTCT_NR_OVL_HOM_PHON_NR |
| L2100C | PER06 | Telephone | L2100C_S05_PER06_CONTCT_NR_OVL_TELPHN |
| L2100C | PER06 | Work Phone Number | L2100C_S05_PER06_CONTCT_NR_OVL_WORK_PHON_NR |
| L2100C | PER08 | Telephone Extension | L2100C_S05_PER08_CONTCT_NR_OVL_PHN_EXTNS |
| L2100C | PER08 | Home Phone Number | L2100C_S05_PER08_CONTCT_NR_OVL_HOM_PHON_NR |
| L2100C | PER08 | Telephone | L2100C_S05_PER08_CONTCT_NR_OVL_TELPHN |
| L2100C | PER08 | Work Phone Number | L2100C_S05_PER08_CONTCT_NR_OVL_WORK_PHON_NR |
| L2100C | AAA | Subscriber Request Validation | |
| L2100C | AAA01 | Valid Request Indicator | L2100C_S06_AAA01_REQST_IND |
| L2100C | AAA03 | Reject Reason Code | L2100C_S06_AAA03_REJCT_RSN_CD |
| L2100C | AAA04 | Follow-up Action Code | L2100C_S06_AAA04_FOLWP_ACTN_CD |
| L2100C | DMG | Subscriber Demographic Information | |
| L2100C | DMG02 | Date Expressed in Format CCYYMMDD | L2100C_S07_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2100C | DMG03 | Subscriber Gender Code | L2100C_S07_DMG03_GENDR_CD |
| L2100C | INS | Subscriber Relationship | |
| L2100C | INS01 | Insured Indicator | L2100C_S08_INS01_INSRD_IND |
| L2100C | INS02 | Individual Relationship Code | L2100C_S08_INS02_INDVDL_REL_CD |
| L2100C | INS03 | Maintenance Type Code | L2100C_S08_INS03_MAINTNC_TYPE_CD |
| L2100C | INS04 | Maintenance Reason Code | L2100C_S08_INS04_MAINTNC_RSN_CD |
| L2100C | INS09 | Student Status Code | L2100C_S08_INS09_STUDNT_STATS_CD |
| L2100C | INS10 | Handicap Indicator | L2100C_S08_INS10_HANDCP_IND |
| L2100C | INS17 | Birth Sequence Number | L2100C_S08_INS17_BIRTH_SEQNC_NR |
| L2100C | DTP | Subscriber Date | |
| L2100C | DTP03 | Issue (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ISSU_D8 |
| L2100C | DTP03 | Effective Date of Change (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_EFF_DAT_CHG_D8 |
| L2100C | DTP03 | Plan (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PLAN_D8 |
| L2100C | DTP03 | Eligibility (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ELGBLTY_D8 |
| L2100C | DTP03 | Added (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_AD_D8 |
| L2100C | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_COBRA_BGN_D8 |
| L2100C | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_COBRA_END_D8 |
| L2100C | DTP03 | Premium Paid to Date Begin (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PREM_PD_TO_DAT_BEGN_D8 |
| L2100C | DTP03 | Premium Paid to Date End (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PREM_PD_TO_DAT_END_D8 |
| L2100C | DTP03 | Plan Begin (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PLAN_BEGN_D8 |
| L2100C | DTP03 | Plan End (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PLAN_END_D8 |
| L2100C | DTP03 | Eligibility Begin (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ELIG_BEGN_D8 |
| L2100C | DTP03 | Eligibility End (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ELIG_END_D8 |
| L2100C | DTP03 | Enrollment (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ENRLMNT_D8 |
| L2100C | DTP03 | Admission (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ADMSN_D8 |
| L2100C | DTP03 | Date of Death (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_DAT_DEATH_D8 |
| L2100C | DTP03 | Certification (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_CERT_D8 |
| L2100C | DTP03 | Service (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_SVC_D8 |
| L2100C | DTP03 | Policy Effective (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_POLCY_EFF_D8 |
| L2100C | DTP03 | Policy Expiration (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_POLCY_EXPRTN_D8 |
| L2100C | DTP03 | Date of Last Update (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_DAT_LAST_UPDT_D8 |
| L2100C | DTP03 | Status (D8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_STATS_D8 |
| L2100C | DTP03 | Issue (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ISSU_RD8 |
| L2100C | DTP03 | Effective Date of Change (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_EFF_DAT_CHG_RD8 |
| L2100C | DTP03 | Plan (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PLAN_RD8 |
| L2100C | DTP03 | Eligibility (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ELGBLTY_RD8 |
| L2100C | DTP03 | Added (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_AD_RD8 |
| L2100C | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_COBRA_BGN_RD8 |
| L2100C | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_COBRA_END_RD8 |
| L2100C | DTP03 | Premium Paid to Date Begin (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PREM_PD_TO_DAT_BEGN_RD8 |
| L2100C | DTP03 | Premium Paid to Date End (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PREM_PD_TO_DAT_END_RD8 |
| L2100C | DTP03 | Plan Begin (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PLAN_BEGN_RD8 |
| L2100C | DTP03 | Plan End (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_PLAN_END_RD8 |
| L2100C | DTP03 | Eligibility Begin (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ELIG_BEGN_RD8 |
| L2100C | DTP03 | Eligibility End (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ELIG_END_RD8 |
| L2100C | DTP03 | Enrollment (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ENRLMNT_RD8 |
| L2100C | DTP03 | Admission (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_ADMSN_RD8 |
| L2100C | DTP03 | Date of Death (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_DAT_DEATH_RD8 |
| L2100C | DTP03 | Certification (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_CERT_RD8 |
| L2100C | DTP03 | Service (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_SVC_RD8 |
| L2100C | DTP03 | Policy Effective (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_POLCY_EFF_RD8 |
| L2100C | DTP03 | Policy Expiration (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_POLCY_EXPRTN_RD8 |
| L2100C | DTP03 | Date of Last Update (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_DAT_LAST_UPDT_RD8 |
| L2100C | DTP03 | Status (RD8) | L2100C_S09_DTP03_DT_TM_PERD_OVL_STATS_RD8 |
2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2110C | EB | Subscriber Eligibility or Benefit Information | |
| L2110C | EB01 | Eligibility or Benefit Information | L2110C_S01_EB01_BENFT_NFO |
| L2110C | EB02 | Benefit Coverage Level Code | L2110C_S01_EB02_BENFT_COVG_LEVL_CD |
| L2110C | EB03 | Service Type Code | L2110C_S01_EB03_SVC_TYPE_CD |
| L2110C | EB04 | Insurance Type Code | L2110C_S01_EB04_INS_TYPE_CD |
| L2110C | EB05 | Plan Coverage Description | L2110C_S01_EB05_PLAN_COVG_DESCRPTN |
| L2110C | EB07 | Hour | L2110C_S01_EB07_BENFT_AMT_OVL_HOUR |
| L2110C | EB07 | Day | L2110C_S01_EB07_BENFT_AMT_OVL_DAY |
| L2110C | EB07 | 24 Hours | L2110C_S01_EB07_BENFT_AMT_OVL_24_HOURS |
| L2110C | EB07 | Years | L2110C_S01_EB07_BENFT_AMT_OVL_YRS |
| L2110C | EB07 | Service Year | L2110C_S01_EB07_BENFT_AMT_OVL_SVC_YEAR |
| L2110C | EB07 | Calendar Year | L2110C_S01_EB07_BENFT_AMT_OVL_CALNDR_YEAR |
| L2110C | EB07 | Year to Date | L2110C_S01_EB07_BENFT_AMT_OVL_YEAR_TO_DT |
| L2110C | EB07 | Contract | L2110C_S01_EB07_BENFT_AMT_OVL_CONTRCT |
| L2110C | EB07 | Episode | L2110C_S01_EB07_BENFT_AMT_OVL_EPSD |
| L2110C | EB07 | Visit | L2110C_S01_EB07_BENFT_AMT_OVL_VIST |
| L2110C | EB07 | Outlier | L2110C_S01_EB07_BENFT_AMT_OVL_OUTLR |
| L2110C | EB07 | Remaining | L2110C_S01_EB07_BENFT_AMT_OVL_REMNG |
| L2110C | EB07 | Exceeded | L2110C_S01_EB07_BENFT_AMT_OVL_EXCD |
| L2110C | EB07 | Not Exceeded | L2110C_S01_EB07_BENFT_AMT_OVL_NOT_EXCD |
| L2110C | EB07 | Lifetime | L2110C_S01_EB07_BENFT_AMT_OVL_LIFTM |
| L2110C | EB07 | Lifetime Remaining | L2110C_S01_EB07_BENFT_AMT_OVL_LIFTM_REMNG |
| L2110C | EB07 | Month | L2110C_S01_EB07_BENFT_AMT_OVL_MONTH |
| L2110C | EB07 | Week | L2110C_S01_EB07_BENFT_AMT_OVL_WEK |
| L2110C | EB07 | Admisson | L2110C_S01_EB07_BENFT_AMT_OVL_ADMSN |
| L2110C | EB08 | Benefit Percent | L2110C_S01_EB08_BENFT_PERCNT |
| L2110C | EB10 | Quantity Used | L2110C_S01_EB10_BENFT_QTY_OVL_QTY_USD |
| L2110C | EB10 | Covered - Actual | L2110C_S01_EB10_BENFT_QTY_OVL_COVRD_ACTL |
| L2110C | EB10 | Covered - Estimated | L2110C_S01_EB10_BENFT_QTY_OVL_COVRD_EST |
| L2110C | EB10 | Deductible Blood Units | L2110C_S01_EB10_BENFT_QTY_OVL_DEDCTBL_BLOD_UNTS |
| L2110C | EB10 | Days | L2110C_S01_EB10_BENFT_QTY_OVL_DAYS |
| L2110C | EB10 | Hours | L2110C_S01_EB10_BENFT_QTY_OVL_HOURS |
| L2110C | EB10 | Life-time Reserve - Actual | L2110C_S01_EB10_BENFT_QTY_OVL_LIFTM_RESRV_ACTL |
| L2110C | EB10 | Life-time Reserve - Estimated | L2110C_S01_EB10_BENFT_QTY_OVL_LIFTM_RESRV_EST |
| L2110C | EB10 | Month | L2110C_S01_EB10_BENFT_QTY_OVL_MONTH |
| L2110C | EB10 | Number of Services or Procedures | L2110C_S01_EB10_BENFT_QTY_OVL_NR_SVCS_PROCS |
| L2110C | EB10 | Quantity Approved | L2110C_S01_EB10_BENFT_QTY_OVL_QTY_APRVD |
| L2110C | EB10 | Age, High Value | L2110C_S01_EB10_BENFT_QTY_OVL_AG_HIGH_VAL |
| L2110C | EB10 | Age, Low Value | L2110C_S01_EB10_BENFT_QTY_OVL_AG_LOW_VAL |
| L2110C | EB10 | Visits | L2110C_S01_EB10_BENFT_QTY_OVL_VISTS |
| L2110C | EB10 | Years | L2110C_S01_EB10_BENFT_QTY_OVL_YRS |
| L2110C | EB11 | Authorization or Certification Indicator | L2110C_S01_EB11_AUTH_CERT_IND |
| L2110C | EB12 | In Plan Network Indicator | L2110C_S01_EB12_IN_PLAN_NETWRK_IND |
| L2110C | EB13-02 | American Dental Association Codes | L2110C_S01_EB13_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD |
| L2110C | EB13-02 | Current Procedural Terminology (CPT) Codes | L2110C_S01_EB13_02_PROC_CD_OVL_CPT_CD |
| L2110C | EB13-02 | Health Care Financing Administration Common | L2110C_S01_EB13_02_PROC_CD_OVL_HCFA_COMN |
| L2110C | EB13-02 | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure | L2110C_S01_EB13_02_PROC_CD_OVL_ICD9CM_PROC |
| L2110C | EB13-02 | National Drug Code (NDC) | L2110C_S01_EB13_02_PROC_CD_OVL_NDC |
| L2110C | EB13-02 | Mutually Defined | L2110C_S01_EB13_02_PROC_CD_OVL_MUTLY_DEFND |
| L2110C | EB13-03 | Procedure Modifier | L2110C_S01_EB13_03_PROC_MODFR |
| L2110C | EB13-04 | Procedure Modifier | L2110C_S01_EB13_04_PROC_MODFR |
| L2110C | EB13-05 | Procedure Modifier | L2110C_S01_EB13_05_PROC_MODFR |
| L2110C | EB13-06 | Procedure Modifier | L2110C_S01_EB13_06_PROC_MODFR |
| L2110C | HSD | Health Care Services Delivery | |
| L2110C | HSD02 | Days | L2110C_S02_HSD02_BENFT_QTY_OVL_DAYS |
| L2110C | HSD02 | Units | L2110C_S02_HSD02_BENFT_QTY_OVL_UNTS |
| L2110C | HSD02 | Hours | L2110C_S02_HSD02_BENFT_QTY_OVL_HOURS |
| L2110C | HSD02 | Month | L2110C_S02_HSD02_BENFT_QTY_OVL_MONTH |
| L2110C | HSD02 | Visits | L2110C_S02_HSD02_BENFT_QTY_OVL_VISTS |
| L2110C | HSD04 | Days | L2110C_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_DAYS |
| L2110C | HSD04 | Months | L2110C_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_MONTHS |
| L2110C | HSD04 | Visit | L2110C_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_VIST |
| L2110C | HSD04 | Week | L2110C_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_WEK |
| L2110C | HSD04 | Years | L2110C_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_YRS |
| L2110C | HSD06 | Hour | L2110C_S02_HSD06_PERD_CT_OVL_HOUR |
| L2110C | HSD06 | Day | L2110C_S02_HSD06_PERD_CT_OVL_DAY |
| L2110C | HSD06 | Years | L2110C_S02_HSD06_PERD_CT_OVL_YRS |
| L2110C | HSD06 | Service Year | L2110C_S02_HSD06_PERD_CT_OVL_SVC_YEAR |
| L2110C | HSD06 | Calendar Year | L2110C_S02_HSD06_PERD_CT_OVL_CALNDR_YEAR |
| L2110C | HSD06 | Year to Date | L2110C_S02_HSD06_PERD_CT_OVL_YEAR_TO_DT |
| L2110C | HSD06 | Contract | L2110C_S02_HSD06_PERD_CT_OVL_CONTRCT |
| L2110C | HSD06 | Episode | L2110C_S02_HSD06_PERD_CT_OVL_EPSD |
| L2110C | HSD06 | Visit | L2110C_S02_HSD06_PERD_CT_OVL_VIST |
| L2110C | HSD06 | Outlier | L2110C_S02_HSD06_PERD_CT_OVL_OUTLR |
| L2110C | HSD06 | Remaining | L2110C_S02_HSD06_PERD_CT_OVL_REMNG |
| L2110C | HSD06 | Exceeded | L2110C_S02_HSD06_PERD_CT_OVL_EXCD |
| L2110C | HSD06 | Not Exceeded | L2110C_S02_HSD06_PERD_CT_OVL_NOT_EXCD |
| L2110C | HSD06 | Lifetime | L2110C_S02_HSD06_PERD_CT_OVL_LIFTM |
| L2110C | HSD06 | Lifetime Remaining | L2110C_S02_HSD06_PERD_CT_OVL_LIFTM_REMNG |
| L2110C | HSD06 | Month | L2110C_S02_HSD06_PERD_CT_OVL_MONTH |
| L2110C | HSD06 | Week | L2110C_S02_HSD06_PERD_CT_OVL_WEK |
| L2110C | HSD07 | Delivery Frequency Code | L2110C_S02_HSD07_DELVRY_FREQNCY_CD |
| L2110C | HSD08 | Delivery Pattern Time Code | L2110C_S02_HSD08_DELVRY_PATRN_TIM_CD |
| L2110C | REF | Subscriber Additional Identification | |
| L2110C | REF02 | Plan Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_PLAN_NR |
| L2110C | REF02 | Group or Policy Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_GRP_POLCY_NR |
| L2110C | REF02 | Member Identification Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_MEM_ID_NR |
| L2110C | REF02 | Family Unit Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_FAMLY_UNT_NR |
| L2110C | REF02 | Group Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_GRP_NR |
| L2110C | REF02 | Referral Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_REFL_NR |
| L2110C | REF02 | Employee Identification Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_EMPLY_ID_NR |
| L2110C | REF02 | Health Insurance Claim (HIC) Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_HIC_NR |
| L2110C | REF02 | Prior Authorization Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_PRI_AUTH_NR |
| L2110C | REF02 | Insurance Policy Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_INS_POLCY_NR |
| L2110C | REF02 | Plan Network Identification Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_PLAN_NETWRK_ID_NR |
| L2110C | REF02 | Medicaid Recipient Identification Number | L2110C_S03_REF02_SUB_ELIG_BENFT_ID_OVL_MEDCD_RECPNT_ID_NR |
| L2110C | REF03 | Plan Sponsor Name | L2110C_S03_REF03_PLAN_SPONSR_NM |
| L2110C | DTP | Subscriber Eligibility/Benefit Date | |
| L2110C | DTP03 | Period End (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PERD_END_D8 |
| L2110C | DTP03 | Completion (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_COMPLTN_D8 |
| L2110C | DTP03 | Coordination of Benefits (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_COB_D8 |
| L2110C | DTP03 | Benefit (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_D8 |
| L2110C | DTP03 | Primary Care Provider (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PRIMRY_CAR_PROV_D8 |
| L2110C | DTP03 | Latest Visit or Consultation (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_LATST_VIST_CONSLTN_D8 |
| L2110C | DTP03 | Eligibility (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELGBLTY_D8 |
| L2110C | DTP03 | Added (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_AD_D8 |
| L2110C | DTP03 | Benefit Begin (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_BEGN_D8 |
| L2110C | DTP03 | Benefit End (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_END_D8 |
| L2110C | DTP03 | Eligibility Begin (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELIG_BEGN_D8 |
| L2110C | DTP03 | Eligibility End (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELIG_END_D8 |
| L2110C | DTP03 | Admission (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ADMSN_D8 |
| L2110C | DTP03 | Service (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_SVC_D8 |
| L2110C | DTP03 | Date of Last Update (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_DAT_LAST_UPDT_D8 |
| L2110C | DTP03 | Period Start (D8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PERD_START_D8 |
| L2110C | DTP03 | Period End (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PERD_END_RD8 |
| L2110C | DTP03 | Completion (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_COMPLTN_RD8 |
| L2110C | DTP03 | Coordination of Benefits (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_COB_RD8 |
| L2110C | DTP03 | Benefit (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_RD8 |
| L2110C | DTP03 | Primary Care Provider (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PRIMRY_CAR_PROV_RD8 |
| L2110C | DTP03 | Latest Visit or Consultation (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_LATST_VIST_CONSLTN_RD8 |
| L2110C | DTP03 | Eligibility (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELGBLTY_RD8 |
| L2110C | DTP03 | Added (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_AD_RD8 |
| L2110C | DTP03 | Benefit Begin (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_BEGN_RD8 |
| L2110C | DTP03 | Benefit End (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_END_RD8 |
| L2110C | DTP03 | Eligibility Begin (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELIG_BEGN_RD8 |
| L2110C | DTP03 | Eligibility End (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELIG_END_RD8 |
| L2110C | DTP03 | Admission (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ADMSN_RD8 |
| L2110C | DTP03 | Service (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_SVC_RD8 |
| L2110C | DTP03 | Date of Last Update (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_DAT_LAST_UPDT_RD8 |
| L2110C | DTP03 | Period Start (RD8) | L2110C_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PERD_START_RD8 |
| L2110C | AAA | Subscriber Request Validation | |
| L2110C | AAA01 | Valid Request Indicator | L2110C_S05_AAA01_REQST_IND |
| L2110C | AAA03 | Reject Reason Code | L2110C_S05_AAA03_REJCT_RSN_CD |
| L2110C | AAA04 | Follow-up Action Code | L2110C_S05_AAA04_FOLWP_ACTN_CD |
| L2110C | MSG | Message Text | |
| L2110C | MSG01 | Free Form Message Text | L2110C_S06_MSG01_FRE_FORM_MESG_TEXT |
2115C - SUBSCRIBER ELIGIBILITY OR BENFIT ADDITIONAL INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2115C | III | Subscriber Eligibility or Benefit Additional Information | |
| L2115C | III02 | Diagnosis | L2115C_S01_III02_INDSTRY_CD_OVL_DIAG |
| L2115C | III02 | Principal Diagnosis | L2115C_S01_III02_INDSTRY_CD_OVL_PRINCPL_DIAG |
| L2115C | III02 | Mutually Defined | L2115C_S01_III02_INDSTRY_CD_OVL_MUTLY_DEFND |
2120CHDR - SUBSCRIBER BENEFIT SUBLOOP
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2120CHDR | LS | Loop Header | |
| L2120CHDR | LS01 | Loop Identifier Code | L2120CHDR_S01_LS01_LP_ID_CD |
| L2120CHDR | LE | Loop Trailer | |
| L2120CHDR | LE01 | Loop Identifier Code | L2120CHDR_S03_LE01_LP_ID_CD |
2120C - SUBSCRIBER BENEFIT RELATED ENTITY NAME ENTITY NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2120C | Qualified Loop | ||
| L2120C | Provider | L2120C_1P | |
| L2120C | Third-Party Administrator | L2120C_2B | |
| L2120C | Employer | L2120C_36 | |
| L2120C | Other Physician | L2120C_73 | |
| L2120C | Facility | L2120C_FA | |
| L2120C | Gateway Provider | L2120C_GP | |
| L2120C | Insured or Subscriber | L2120C_IL | |
| L2120C | Legal Representative | L2120C_LR | |
| L2120C | Primary Care Provider | L2120C_P3 | |
| L2120C | Prior Insurance Carrier | L2120C_P4 | |
| L2120C | Plan Sponsor | L2120C_P5 | |
| L2120C | Payer | L2120C_PR | |
| L2120C | Primary Payer | L2120C_PRP | |
| L2120C | Secondary Payer | L2120C_SEP | |
| L2120C | Tertiary Payer | L2120C_TTP | |
| L2120C | Vendor | L2120C_VN | |
| L2120C | Utilization Management Organization | L2120C_X3 | |
| L2120C | NM1 | Subscriber Benefit Related Entity Name | |
| L2120C | NM102 | Entity Type Qualifier | L2120C_XX_S01_NM102_TYPE_QUAL |
| L2120C | NM103 | Benefit Related Entity Last or Organization Name | L2120C_XX_S01_NM103_LAST_ORG_NM |
| L2120C | NM104 | Benefit Related Entity First Name | L2120C_XX_S01_NM104_BENFT_RELTD_ENTY_FNAME |
| L2120C | NM105 | Benefit Related Entity Middle Name | L2120C_XX_S01_NM105_BENFT_RELTD_ENTY_MNAME |
| L2120C | NM107 | Benefit Related Entity Name Suffix | L2120C_XX_S01_NM107_NM_SUFX |
| L2120C | NM109 | Employer’s Identification Number | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_EMPLYR_ID_NR |
| L2120C | NM109 | Social Security Number | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_SSN |
| L2120C | NM109 | Electronic Transmitter Identification Number (ETIN) | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_ETN_NR |
| L2120C | NM109 | Facility Identification | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_FACLTY_ID |
| L2120C | NM109 | Federal Taxpayer’s Identification Number | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_FED_TAX_ID_NR |
| L2120C | NM109 | Member Identification Number | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_MEM_ID_NR |
| L2120C | NM109 | National Association of Insurance Commissioners (NAIC) Identification | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_NAIC_ID |
| L2120C | NM109 | Payor Identification | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_PAYR_ID |
| L2120C | NM109 | Pharmacy Processor Number | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_PHARMCY_PROCSR_NR |
| L2120C | NM109 | Service Provider Number | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_SVC_PROV_NR |
| L2120C | NM109 | Health Care Financing Administration National PlanID | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_HCFA_NATNL_PLAND |
| L2120C | NM109 | Health Care Financing Administration National Provider Identifier | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_HCFA_NATNL_PROV_ID |
| L2120C | NM109 | Mutually Defined | L2120C_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_MUTLY_DEFND |
| L2120C | N3 | Subscriber Benefit Related Entity Address | |
| L2120C | N301 | Benefit Related Entity Address Line | L2120C_XX_S02_N301_ADRS_LIN |
| L2120C | N302 | Benefit Related Entity Address Line | L2120C_XX_S02_N302_ADRS_LIN |
| L2120C | N4 | Subscriber Benefit Related City/State/ZIP Code | |
| L2120C | N401 | Benefit Related Entity City Name | L2120C_XX_S03_N401_ENTY_CITY_NM |
| L2120C | N402 | Benefit Related Entity State Code | L2120C_XX_S03_N402_ENTY_STAT_CD |
| L2120C | N403 | Benefit Related Entity Postal Zone or ZIP Code | L2120C_XX_S03_N403_ENTY_POSTL_ZON_ZIP_CD |
| L2120C | N404 | Country Code | L2120C_XX_S03_N404_CNTRY_CD |
| L2120C | N406 | Region | L2120C_XX_S03_N406_DOD_HEALTH_SVC_REGN_CD_OVL_REGN |
| L2120C | PER | Subscriber Benefit Related Entity Contact Information | |
| L2120C | PER01 | Contact Function Code | L2120C_XX_S04_PER01_FUNCTN_CD |
| L2120C | PER02 | Benefit Related Entity Contact Name | L2120C_XX_S04_PER02_NM |
| L2120C | PER04 | Electronic Data Interchange Access Number | L2120C_XX_S04_PER04_COMM_NR_OVL_EDI_ACS_NR |
| L2120C | PER04 | Electronic Mail | L2120C_XX_S04_PER04_COMM_NR_OVL_EMAIL |
| L2120C | PER04 | Facsimile | L2120C_XX_S04_PER04_COMM_NR_OVL_FACSML |
| L2120C | PER04 | Telephone | L2120C_XX_S04_PER04_COMM_NR_OVL_TELPHN |
| L2120C | PER04 | Work Phone Number | L2120C_XX_S04_PER04_COMM_NR_OVL_WORK_PHON_NR |
| L2120C | PER06 | Electronic Data Interchange Access Number | L2120C_XX_S04_PER06_COMM_NR_OVL_EDI_ACS_NR |
| L2120C | PER06 | Electronic Mail | L2120C_XX_S04_PER06_COMM_NR_OVL_EMAIL |
| L2120C | PER06 | Telephone Extension | L2120C_XX_S04_PER06_COMM_NR_OVL_PHN_EXTNS |
| L2120C | PER06 | Facsimile | L2120C_XX_S04_PER06_COMM_NR_OVL_FACSML |
| L2120C | PER06 | Telephone | L2120C_XX_S04_PER06_COMM_NR_OVL_TELPHN |
| L2120C | PER06 | Work Phone Number | L2120C_XX_S04_PER06_COMM_NR_OVL_WORK_PHON_NR |
| L2120C | PER08 | Electronic Data Interchange Access Number | L2120C_XX_S04_PER08_COMM_NR_OVL_EDI_ACS_NR |
| L2120C | PER08 | Electronic Mail | L2120C_XX_S04_PER08_COMM_NR_OVL_EMAIL |
| L2120C | PER08 | Telephone Extension | L2120C_XX_S04_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2120C | PER08 | Facsimile | L2120C_XX_S04_PER08_COMM_NR_OVL_FACSML |
| L2120C | PER08 | Telephone | L2120C_XX_S04_PER08_COMM_NR_OVL_TELPHN |
| L2120C | PER08 | Work Phone Number | L2120C_XX_S04_PER08_COMM_NR_OVL_WORK_PHON_NR |
| L2120C | PRV | Subscriber Benefit Related Provider Information | |
| L2120C | PRV01 | Provider Code | L2120C_XX_S05_PRV01_PROV_CD |
| L2120C | PRV03 | Servicer | L2120C_XX_S05_PRV03_PROV_ID_OVL_SERVCR |
| L2120C | PRV03 | National Association of Boards of Pharmacy Number | L2120C_XX_S05_PRV03_PROV_ID_OVL_NATNL_ASCTN_BOARDS_PHARMCY_NR |
| L2120C | PRV03 | Employer’s Identification Number | L2120C_XX_S05_PRV03_PROV_ID_OVL_EMPLYR_ID_NR |
| L2120C | PRV03 | Health Care Financing Administration National Provider Identifier | L2120C_XX_S05_PRV03_PROV_ID_OVL_HCFA_NATNL_PROV_ID |
| L2120C | PRV03 | Social Security Number | L2120C_XX_S05_PRV03_PROV_ID_OVL_SSN |
| L2120C | PRV03 | Federal Taxpayer’s Identification Number | L2120C_XX_S05_PRV03_PROV_ID_OVL_FED_TAX_ID_NR |
| L2120C | PRV03 | Mutually Defined | L2120C_XX_S05_PRV03_PROV_ID_OVL_MUTLY_DEFND |
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 | NM109 | Member Identification Number | L2100D_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR |
| L2100D | NM109 | Mutually Defined | L2100D_S01_NM109_PRIMRY_ID_OVL_MUTLY_DEFND |
| 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 | Member Identification Number | L2100D_S02_REF02_SUPP_ID_OVL_MEM_ID_NR |
| L2100D | REF02 | Family Unit Number | L2100D_S02_REF02_SUPP_ID_OVL_FAMLY_UNT_NR |
| L2100D | REF02 | Group Number | L2100D_S02_REF02_SUPP_ID_OVL_GRP_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 | Medical Assistance Category | L2100D_S02_REF02_SUPP_ID_OVL_MEDCL_ASTNC_CATGRY |
| L2100D | REF02 | Plan Network Identification Number | L2100D_S02_REF02_SUPP_ID_OVL_PLAN_NETWRK_ID_NR |
| L2100D | REF02 | Medicaid Recipient Identification Number | L2100D_S02_REF02_SUPP_ID_OVL_MEDCD_RECPNT_ID_NR |
| L2100D | REF02 | Prior Identifier Number | L2100D_S02_REF02_SUPP_ID_OVL_PRI_ID_NR |
| L2100D | REF02 | Social Security Number | L2100D_S02_REF02_SUPP_ID_OVL_SSN |
| L2100D | REF03 | Plan Sponsor Name | L2100D_S02_REF03_PLAN_SPONSR_NM |
| 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 | PER | Dependent Contact Information | |
| L2100D | PER01 | Contact Function Code | L2100D_S05_PER01_FUNCTN_CD |
| L2100D | PER02 | Dependent Contact Name | L2100D_S05_PER02_CONTCT_NM |
| L2100D | PER04 | Home Phone Number | L2100D_S05_PER04_CONTCT_NR_OVL_HOM_PHON_NR |
| L2100D | PER04 | Telephone | L2100D_S05_PER04_CONTCT_NR_OVL_TELPHN |
| L2100D | PER04 | Work Phone Number | L2100D_S05_PER04_CONTCT_NR_OVL_WORK_PHON_NR |
| L2100D | PER06 | Telephone Extension | L2100D_S05_PER06_CONTCT_NR_OVL_PHN_EXTNS |
| L2100D | PER06 | Home Phone Number | L2100D_S05_PER06_CONTCT_NR_OVL_HOM_PHON_NR |
| L2100D | PER06 | Telephone | L2100D_S05_PER06_CONTCT_NR_OVL_TELPHN |
| L2100D | PER06 | Work Phone Number | L2100D_S05_PER06_CONTCT_NR_OVL_WORK_PHON_NR |
| L2100D | PER08 | Telephone Extension | L2100D_S05_PER08_CONTCT_NR_OVL_PHN_EXTNS |
| L2100D | PER08 | Home Phone Number | L2100D_S05_PER08_CONTCT_NR_OVL_HOM_PHON_NR |
| L2100D | PER08 | Telephone | L2100D_S05_PER08_CONTCT_NR_OVL_TELPHN |
| L2100D | PER08 | Work Phone Number | L2100D_S05_PER08_CONTCT_NR_OVL_WORK_PHON_NR |
| L2100D | AAA | Dependent Request Validation | |
| L2100D | AAA01 | Valid Request Indicator | L2100D_S06_AAA01_REQST_IND |
| L2100D | AAA03 | Reject Reason Code | L2100D_S06_AAA03_REJCT_RSN_CD |
| L2100D | AAA04 | Follow-up Action Code | L2100D_S06_AAA04_FOLWP_ACTN_CD |
| L2100D | DMG | Dependent Demographic Information | |
| L2100D | DMG02 | Date Expressed in Format CCYYMMDD | L2100D_S07_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2100D | DMG03 | Dependent Gender Code | L2100D_S07_DMG03_GENDR_CD |
| L2100D | INS | Dependent Relationship | |
| L2100D | INS01 | Insured Indicator | L2100D_S08_INS01_INSRD_IND |
| L2100D | INS02 | Individual Relationship Code | L2100D_S08_INS02_INDVDL_REL_CD |
| L2100D | INS03 | Maintenance Type Code | L2100D_S08_INS03_MAINTNC_TYPE_CD |
| L2100D | INS04 | Maintenance Reason Code | L2100D_S08_INS04_MAINTNC_RSN_CD |
| L2100D | INS09 | Student Status Code | L2100D_S08_INS09_STUDNT_STATS_CD |
| L2100D | INS10 | Handicap Indicator | L2100D_S08_INS10_HANDCP_IND |
| L2100D | INS17 | Birth Sequence Number | L2100D_S08_INS17_BIRTH_SEQNC_NR |
| L2100D | DTP | Dependent Date | |
| L2100D | DTP03 | Issue (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_ISSU_D8 |
| L2100D | DTP03 | Effective Date of Change (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_EFF_DAT_CHG_D8 |
| L2100D | DTP03 | Plan (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PLAN_D8 |
| L2100D | DTP03 | Eligibility (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_ELGBLTY_D8 |
| L2100D | DTP03 | Added (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_AD_D8 |
| L2100D | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_COBRA_BGN_D8 |
| L2100D | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_COBRA_END_D8 |
| L2100D | DTP03 | Premium Paid to Date Begin (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PREM_PD_TO_DAT_BEGN_D8 |
| L2100D | DTP03 | Premium Paid to Date End (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PREM_PD_TO_DAT_END_D8 |
| L2100D | DTP03 | Plan Begin (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PLAN_BEGN_D8 |
| L2100D | DTP03 | Plan End (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PLAN_END_D8 |
| L2100D | DTP03 | Enrollment (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_ENRLMNT_D8 |
| L2100D | DTP03 | Admission (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_ADMSN_D8 |
| L2100D | DTP03 | Date of Death (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_DAT_DEATH_D8 |
| L2100D | DTP03 | Certification (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_CERT_D8 |
| L2100D | DTP03 | Service (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_SVC_D8 |
| L2100D | DTP03 | Policy Effective (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_POLCY_EFF_D8 |
| L2100D | DTP03 | Policy Expiration (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_POLCY_EXPRTN_D8 |
| L2100D | DTP03 | Date of Last Update (D8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_DAT_LAST_UPDT_D8 |
| L2100D | DTP03 | Issue (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_ISSU_RD8 |
| L2100D | DTP03 | Effective Date of Change (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_EFF_DAT_CHG_RD8 |
| L2100D | DTP03 | Plan (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PLAN_RD8 |
| L2100D | DTP03 | Eligibility (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_ELGBLTY_RD8 |
| L2100D | DTP03 | Added (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_AD_RD8 |
| L2100D | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_COBRA_BGN_RD8 |
| L2100D | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) End (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_COBRA_END_RD8 |
| L2100D | DTP03 | Premium Paid to Date Begin (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PREM_PD_TO_DAT_BEGN_RD8 |
| L2100D | DTP03 | Premium Paid to Date End (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PREM_PD_TO_DAT_END_RD8 |
| L2100D | DTP03 | Plan Begin (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PLAN_BEGN_RD8 |
| L2100D | DTP03 | Plan End (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_PLAN_END_RD8 |
| L2100D | DTP03 | Enrollment (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_ENRLMNT_RD8 |
| L2100D | DTP03 | Admission (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_ADMSN_RD8 |
| L2100D | DTP03 | Date of Death (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_DAT_DEATH_RD8 |
| L2100D | DTP03 | Certification (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_CERT_RD8 |
| L2100D | DTP03 | Service (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_SVC_RD8 |
| L2100D | DTP03 | Policy Effective (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_POLCY_EFF_RD8 |
| L2100D | DTP03 | Policy Expiration (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_POLCY_EXPRTN_RD8 |
| L2100D | DTP03 | Date of Last Update (RD8) | L2100D_S09_DTP03_DT_TM_PERD_OVL_DAT_LAST_UPDT_RD8 |
2110D - DEPENDENT ELIGIBILITY OR BENEFIT INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2110D | EB | Dependent Eligibility or Benefit Information | |
| L2110D | EB01 | Eligibility or Benefit Information | L2110D_S01_EB01_BENFT_NFO |
| L2110D | EB02 | Benefit Coverage Level Code | L2110D_S01_EB02_BENFT_COVG_LEVL_CD |
| L2110D | EB03 | Service Type Code | L2110D_S01_EB03_SVC_TYPE_CD |
| L2110D | EB04 | Insurance Type Code | L2110D_S01_EB04_INS_TYPE_CD |
| L2110D | EB05 | Plan Coverage Description | L2110D_S01_EB05_PLAN_COVG_DESCRPTN |
| L2110D | EB07 | Hour | L2110D_S01_EB07_BENFT_AMT_OVL_HOUR |
| L2110D | EB07 | Day | L2110D_S01_EB07_BENFT_AMT_OVL_DAY |
| L2110D | EB07 | 24 Hours | L2110D_S01_EB07_BENFT_AMT_OVL_24_HOURS |
| L2110D | EB07 | Years | L2110D_S01_EB07_BENFT_AMT_OVL_YRS |
| L2110D | EB07 | Service Year | L2110D_S01_EB07_BENFT_AMT_OVL_SVC_YEAR |
| L2110D | EB07 | Calendar Year | L2110D_S01_EB07_BENFT_AMT_OVL_CALNDR_YEAR |
| L2110D | EB07 | Year to Date | L2110D_S01_EB07_BENFT_AMT_OVL_YEAR_TO_DT |
| L2110D | EB07 | Contract | L2110D_S01_EB07_BENFT_AMT_OVL_CONTRCT |
| L2110D | EB07 | Episode | L2110D_S01_EB07_BENFT_AMT_OVL_EPSD |
| L2110D | EB07 | Visit | L2110D_S01_EB07_BENFT_AMT_OVL_VIST |
| L2110D | EB07 | Outlier | L2110D_S01_EB07_BENFT_AMT_OVL_OUTLR |
| L2110D | EB07 | Remaining | L2110D_S01_EB07_BENFT_AMT_OVL_REMNG |
| L2110D | EB07 | Exceeded | L2110D_S01_EB07_BENFT_AMT_OVL_EXCD |
| L2110D | EB07 | Not Exceeded | L2110D_S01_EB07_BENFT_AMT_OVL_NOT_EXCD |
| L2110D | EB07 | Lifetime | L2110D_S01_EB07_BENFT_AMT_OVL_LIFTM |
| L2110D | EB07 | Lifetime Remaining | L2110D_S01_EB07_BENFT_AMT_OVL_LIFTM_REMNG |
| L2110D | EB07 | Month | L2110D_S01_EB07_BENFT_AMT_OVL_MONTH |
| L2110D | EB07 | Week | L2110D_S01_EB07_BENFT_AMT_OVL_WEK |
| L2110D | EB07 | Admisson | L2110D_S01_EB07_BENFT_AMT_OVL_ADMSN |
| L2110D | EB08 | Benefit Percent | L2110D_S01_EB08_BENFT_PERCNT |
| L2110D | EB10 | Quantity Used | L2110D_S01_EB10_BENFT_QTY_OVL_QTY_USD |
| L2110D | EB10 | Covered - Actual | L2110D_S01_EB10_BENFT_QTY_OVL_COVRD_ACTL |
| L2110D | EB10 | Covered - Estimated | L2110D_S01_EB10_BENFT_QTY_OVL_COVRD_EST |
| L2110D | EB10 | Deductible Blood Units | L2110D_S01_EB10_BENFT_QTY_OVL_DEDCTBL_BLOD_UNTS |
| L2110D | EB10 | Days | L2110D_S01_EB10_BENFT_QTY_OVL_DAYS |
| L2110D | EB10 | Hours | L2110D_S01_EB10_BENFT_QTY_OVL_HOURS |
| L2110D | EB10 | Life-time Reserve - Actual | L2110D_S01_EB10_BENFT_QTY_OVL_LIFTM_RESRV_ACTL |
| L2110D | EB10 | Life-time Reserve - Estimated | L2110D_S01_EB10_BENFT_QTY_OVL_LIFTM_RESRV_EST |
| L2110D | EB10 | Month | L2110D_S01_EB10_BENFT_QTY_OVL_MONTH |
| L2110D | EB10 | Number of Services or Procedures | L2110D_S01_EB10_BENFT_QTY_OVL_NR_SVCS_PROCS |
| L2110D | EB10 | Quantity Approved | L2110D_S01_EB10_BENFT_QTY_OVL_QTY_APRVD |
| L2110D | EB10 | Age, High Value | L2110D_S01_EB10_BENFT_QTY_OVL_AG_HIGH_VAL |
| L2110D | EB10 | Age, Low Value | L2110D_S01_EB10_BENFT_QTY_OVL_AG_LOW_VAL |
| L2110D | EB10 | Visits | L2110D_S01_EB10_BENFT_QTY_OVL_VISTS |
| L2110D | EB10 | Years | L2110D_S01_EB10_BENFT_QTY_OVL_YRS |
| L2110D | EB11 | Authorization or Certification Indicator | L2110D_S01_EB11_AUTH_CERT_IND |
| L2110D | EB12 | In Plan Network Indicator | L2110D_S01_EB12_IN_PLAN_NETWRK_IND |
| L2110D | EB13-02 | American Dental Association Codes | L2110D_S01_EB13_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD |
| L2110D | EB13-02 | Current Procedural Terminology (CPT) Codes | L2110D_S01_EB13_02_PROC_CD_OVL_CPT_CD |
| L2110D | EB13-02 | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes | L2110D_S01_EB13_02_PROC_CD_OVL_HCPCS_CD |
| L2110D | EB13-02 | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure | L2110D_S01_EB13_02_PROC_CD_OVL_ICD9CM_PROC |
| L2110D | EB13-02 | National Drug Code (NDC) | L2110D_S01_EB13_02_PROC_CD_OVL_NDC |
| L2110D | EB13-02 | Mutually Defined | L2110D_S01_EB13_02_PROC_CD_OVL_MUTLY_DEFND |
| L2110D | EB13-03 | Procedure Modifier | L2110D_S01_EB13_03_PROC_MODFR |
| L2110D | EB13-04 | Procedure Modifier | L2110D_S01_EB13_04_PROC_MODFR |
| L2110D | EB13-05 | Procedure Modifier | L2110D_S01_EB13_05_PROC_MODFR |
| L2110D | EB13-06 | Procedure Modifier | L2110D_S01_EB13_06_PROC_MODFR |
| L2110D | HSD | Health Care Services Delivery | |
| L2110D | HSD02 | Days | L2110D_S02_HSD02_BENFT_QTY_OVL_DAYS |
| L2110D | HSD02 | Units | L2110D_S02_HSD02_BENFT_QTY_OVL_UNTS |
| L2110D | HSD02 | Hours | L2110D_S02_HSD02_BENFT_QTY_OVL_HOURS |
| L2110D | HSD02 | Month | L2110D_S02_HSD02_BENFT_QTY_OVL_MONTH |
| L2110D | HSD02 | Visits | L2110D_S02_HSD02_BENFT_QTY_OVL_VISTS |
| L2110D | HSD04 | Days | L2110D_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_DAYS |
| L2110D | HSD04 | Months | L2110D_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_MONTHS |
| L2110D | HSD04 | Visit | L2110D_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_VIST |
| L2110D | HSD04 | Week | L2110D_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_WEK |
| L2110D | HSD04 | Years | L2110D_S02_HSD04_SAMPL_SELCTN_MODLS_OVL_YRS |
| L2110D | HSD06 | Hour | L2110D_S02_HSD06_PERD_CT_OVL_HOUR |
| L2110D | HSD06 | Day | L2110D_S02_HSD06_PERD_CT_OVL_DAY |
| L2110D | HSD06 | Years | L2110D_S02_HSD06_PERD_CT_OVL_YRS |
| L2110D | HSD06 | Service Year | L2110D_S02_HSD06_PERD_CT_OVL_SVC_YEAR |
| L2110D | HSD06 | Calendar Year | L2110D_S02_HSD06_PERD_CT_OVL_CALNDR_YEAR |
| L2110D | HSD06 | Year to Date | L2110D_S02_HSD06_PERD_CT_OVL_YEAR_TO_DT |
| L2110D | HSD06 | Contract | L2110D_S02_HSD06_PERD_CT_OVL_CONTRCT |
| L2110D | HSD06 | Episode | L2110D_S02_HSD06_PERD_CT_OVL_EPSD |
| L2110D | HSD06 | Visit | L2110D_S02_HSD06_PERD_CT_OVL_VIST |
| L2110D | HSD06 | Outlier | L2110D_S02_HSD06_PERD_CT_OVL_OUTLR |
| L2110D | HSD06 | Remaining | L2110D_S02_HSD06_PERD_CT_OVL_REMNG |
| L2110D | HSD06 | Exceeded | L2110D_S02_HSD06_PERD_CT_OVL_EXCD |
| L2110D | HSD06 | Not Exceeded | L2110D_S02_HSD06_PERD_CT_OVL_NOT_EXCD |
| L2110D | HSD06 | Lifetime | L2110D_S02_HSD06_PERD_CT_OVL_LIFTM |
| L2110D | HSD06 | Lifetime Remaining | L2110D_S02_HSD06_PERD_CT_OVL_LIFTM_REMNG |
| L2110D | HSD06 | Month | L2110D_S02_HSD06_PERD_CT_OVL_MONTH |
| L2110D | HSD06 | Week | L2110D_S02_HSD06_PERD_CT_OVL_WEK |
| L2110D | HSD07 | Delivery Frequency Code | L2110D_S02_HSD07_DELVRY_FREQNCY_CD |
| L2110D | HSD08 | Delivery Pattern Time Code | L2110D_S02_HSD08_DELVRY_PATRN_TIM_CD |
| L2110D | REF | Dependent Additional Identification | |
| L2110D | REF02 | Plan Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_PLAN_NR |
| L2110D | REF02 | Group or Policy Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_GRP_POLCY_NR |
| L2110D | REF02 | Member Identification Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_MEM_ID_NR |
| L2110D | REF02 | Family Unit Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_FAMLY_UNT_NR |
| L2110D | REF02 | Group Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_GRP_NR |
| L2110D | REF02 | Referral Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_REFL_NR |
| L2110D | REF02 | Employee Identification Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_EMPLY_ID_NR |
| L2110D | REF02 | Health Insurance Claim (HIC) Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_HIC_NR |
| L2110D | REF02 | Prior Authorization Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_PRI_AUTH_NR |
| L2110D | REF02 | Insurance Policy Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_INS_POLCY_NR |
| L2110D | REF02 | Plan Network Identification Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_PLAN_NETWRK_ID_NR |
| L2110D | REF02 | Medicaid Recipient Identification Number | L2110D_S03_REF02_DEPNDNT_ELIG_BENFT_ID_OVL_MEDCD_RECPNT_ID_NR |
| L2110D | REF03 | Plan Sponsor Name | L2110D_S03_REF03_PLAN_SPONSR_NM |
| L2110D | DTP | Dependent Eligibility/Benefit Date | |
| L2110D | DTP03 | Period Start (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PERD_START_D8 |
| L2110D | DTP03 | Period End (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PERD_END_D8 |
| L2110D | DTP03 | Completion (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_COMPLTN_D8 |
| L2110D | DTP03 | Coordination of Benefits (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_COB_D8 |
| L2110D | DTP03 | Benefit (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_D8 |
| L2110D | DTP03 | Primary Care Provider (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PRIMRY_CAR_PROV_D8 |
| L2110D | DTP03 | Latest Visit or Consultation (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_LATST_VIST_CONSLTN_D8 |
| L2110D | DTP03 | Eligibility (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELGBLTY_D8 |
| L2110D | DTP03 | Added (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_AD_D8 |
| L2110D | DTP03 | Benefit Begin (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_BEGN_D8 |
| L2110D | DTP03 | Benefit End (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_END_D8 |
| L2110D | DTP03 | Eligibility Begin (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELIG_BEGN_D8 |
| L2110D | DTP03 | Eligibility End (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELIG_END_D8 |
| L2110D | DTP03 | Admission (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ADMSN_D8 |
| L2110D | DTP03 | Service (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_SVC_D8 |
| L2110D | DTP03 | Date of Last Update (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_DAT_LAST_UPDT_D8 |
| L2110D | DTP03 | Status (D8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_STATS_D8 |
| L2110D | DTP03 | Period Start (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PERD_START_RD8 |
| L2110D | DTP03 | Period End (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PERD_END_RD8 |
| L2110D | DTP03 | Completion (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_COMPLTN_RD8 |
| L2110D | DTP03 | Coordination of Benefits (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_COB_RD8 |
| L2110D | DTP03 | Benefit (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_RD8 |
| L2110D | DTP03 | Primary Care Provider (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_PRIMRY_CAR_PROV_RD8 |
| L2110D | DTP03 | Latest Visit or Consultation (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_LATST_VIST_CONSLTN_RD8 |
| L2110D | DTP03 | Eligibility (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELGBLTY_RD8 |
| L2110D | DTP03 | Added (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_AD_RD8 |
| L2110D | DTP03 | Benefit Begin (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_BEGN_RD8 |
| L2110D | DTP03 | Benefit End (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_BENFT_END_RD8 |
| L2110D | DTP03 | Eligibility Begin (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELIG_BEGN_RD8 |
| L2110D | DTP03 | Eligibility End (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ELIG_END_RD8 |
| L2110D | DTP03 | Admission (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_ADMSN_RD8 |
| L2110D | DTP03 | Service (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_SVC_RD8 |
| L2110D | DTP03 | Date of Last Update (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_DAT_LAST_UPDT_RD8 |
| L2110D | DTP03 | Status (RD8) | L2110D_S04_DTP03_ELIG_BENFT_DT_TM_PERD_OVL_STATS_RD8 |
| L2110D | AAA | Dependent Request Validation | |
| L2110D | AAA01 | Valid Request Indicator | L2110D_S05_AAA01_REQST_IND |
| L2110D | AAA03 | Reject Reason Code | L2110D_S05_AAA03_REJCT_RSN_CD |
| L2110D | AAA04 | Follow-up Action Code | L2110D_S05_AAA04_FOLWP_ACTN_CD |
| L2110D | MSG | Message Text | |
| L2110D | MSG01 | Free Form Message Text | L2110D_S06_MSG01_FRE_FORM_MESG_TEXT |
2115D - DEPENDENT ELIGIBILITY OR BENEFIT ADDITIONAL INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2115D | III | Dependent Eligibility or Benefit Additional Information | |
| L2115D | III02 | Diagnosis | L2115D_S01_III02_INDSTRY_CD_OVL_DIAG |
| L2115D | III02 | Principal Diagnosis | L2115D_S01_III02_INDSTRY_CD_OVL_PRINCPL_DIAG |
| L2115D | III02 | Mutually Defined | L2115D_S01_III02_INDSTRY_CD_OVL_MUTLY_DEFND |
2120DHDR - DEPENDENT BENEFIT SUBLOOP
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2120DHDR | LS | Dependent Eligibility or Benefit Information | |
| L2120DHDR | LS01 | Loop Identifier Code | L2120DHDR_S01_LS01_LP_ID_CD |
| L2120DHDR | LE | Loop Trailer | |
| L2120DHDR | LE01 | Loop Identifier Code | L2120DHDR_S03_LE01_LP_ID_CD |
2120D - DEPENDENT BENEFIT RELATED ENTITY NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2120D | Qualified Loop | ||
| L2120D | Provider | L2120D_1P | |
| L2120D | Third-Party Administrator | L2120D_2B | |
| L2120D | Employer | L2120D_36 | |
| L2120D | Other Physician | L2120D_73 | |
| L2120D | Facility | L2120D_FA | |
| L2120D | Gateway Provider | L2120D_GP | |
| L2120D | Insured or Subscriber | L2120D_IL | |
| L2120D | Legal Representative | L2120D_LR | |
| L2120D | Primary Care Provider | L2120D_P3 | |
| L2120D | Prior Insurance Carrier | L2120D_P4 | |
| L2120D | Plan Sponsor | L2120D_P5 | |
| L2120D | Payer | L2120D_PR | |
| L2120D | Primary Payer | L2120D_PRP | |
| L2120D | Secondary Payer | L2120D_SEP | |
| L2120D | Tertiary Payer | L2120D_TTP | |
| L2120D | Vendor | L2120D_VN | |
| L2120D | Utilization Management Organization | L2120D_X3 | |
| L2120D | NM1 | Dependent Benefit Related Entity Name | |
| L2120D | NM102 | Entity Type Qualifier | L2120D_XX_S01_NM102_TYPE_QUAL |
| L2120D | NM103 | Benefit Related Entity Last or Organization Name | L2120D_XX_S01_NM103_LAST_ORG_NM |
| L2120D | NM104 | Benefit Related Entity First Name | L2120D_XX_S01_NM104_BENFT_RELTD_ENTY_FNAME |
| L2120D | NM105 | Benefit Related Entity Middle Name | L2120D_XX_S01_NM105_BENFT_RELTD_ENTY_MNAME |
| L2120D | NM107 | Benefit Related Entity Name Suffix | L2120D_XX_S01_NM107_NM_SUFX |
| L2120D | NM109 | Employer’s Identification Number | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_EMPLYR_ID_NR |
| L2120D | NM109 | Social Security Number | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_SSN |
| L2120D | NM109 | Electronic Transmitter Identification Number (ETIN) | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_ETN_NR |
| L2120D | NM109 | Facility Identification | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_FACLTY_ID |
| L2120D | NM109 | Federal Taxpayer’s Identification Number | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_FED_TAX_ID_NR |
| L2120D | NM109 | Member Identification Number | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_MEM_ID_NR |
| L2120D | NM109 | National Association of Insurance Commissioners (NAIC) Identification | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_NAIC_ID |
| L2120D | NM109 | Payor Identification | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_PAYR_ID |
| L2120D | NM109 | Pharmacy Processor Number | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_PHARMCY_PROCSR_NR |
| L2120D | NM109 | Service Provider Number | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_SVC_PROV_NR |
| L2120D | NM109 | Health Care Financing Administration National PlanID | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_HCFA_NATNL_PLAND |
| L2120D | NM109 | Health Care Financing Administration National Provider Identifier | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_HCFA_NATNL_PROV_ID |
| L2120D | NM109 | Mutually Defined | L2120D_XX_S01_NM109_BENFT_RELTD_ENTY_ID_OVL_MUTLY_DEFND |
| L2120D | N3 | Dependent Benefit Related Entity Address | |
| L2120D | N301 | Benefit Related Entity Address Line | L2120D_XX_S02_N301_ADRS_LIN |
| L2120D | N302 | Benefit Related Entity Address Line | L2120D_XX_S02_N302_ADRS_LIN |
| L2120D | N4 | Dependent Benefit Related Entity City/State/ZIP Code | |
| L2120D | N401 | Benefit Related Entity City Name | L2120D_XX_S03_N401_CITY_NM |
| L2120D | N402 | Benefit Related Entity State Code | L2120D_XX_S03_N402_STAT_CD |
| L2120D | N403 | Benefit Related Entity Postal Zone or ZIP Code | L2120D_XX_S03_N403_POSTL_ZON_ZIP_CD |
| L2120D | N404 | Country Code | L2120D_XX_S03_N404_CNTRY_CD |
| L2120D | N406 | Region | L2120D_XX_S03_N406_DOD_HEALTH_SVC_REGN_CD_OVL_REGN |
| L2120D | PER | Dependent Benefit Related Entity Contact Information | |
| L2120D | PER01 | Contact Function Code | L2120D_XX_S04_PER01_FUNCTN_CD |
| L2120D | PER02 | Benefit Related Entity Contact Name | L2120D_XX_S04_PER02_NM |
| L2120D | PER04 | Electronic Data Interchange Access Number | L2120D_XX_S04_PER04_COMM_NR_OVL_EDI_ACS_NR |
| L2120D | PER04 | Electronic Mail | L2120D_XX_S04_PER04_COMM_NR_OVL_EMAIL |
| L2120D | PER04 | Facsimile | L2120D_XX_S04_PER04_COMM_NR_OVL_FACSML |
| L2120D | PER04 | Telephone | L2120D_XX_S04_PER04_COMM_NR_OVL_TELPHN |
| L2120D | PER04 | Work Phone Number | L2120D_XX_S04_PER04_COMM_NR_OVL_WORK_PHON_NR |
| L2120D | PER06 | Electronic Data Interchange Access Number | L2120D_XX_S04_PER06_COMM_NR_OVL_EDI_ACS_NR |
| L2120D | PER06 | Electronic Mail | L2120D_XX_S04_PER06_COMM_NR_OVL_EMAIL |
| L2120D | PER06 | Telephone Extension | L2120D_XX_S04_PER06_COMM_NR_OVL_PHN_EXTNS |
| L2120D | PER06 | Facsimile | L2120D_XX_S04_PER06_COMM_NR_OVL_FACSML |
| L2120D | PER06 | Telephone | L2120D_XX_S04_PER06_COMM_NR_OVL_TELPHN |
| L2120D | PER06 | Work Phone Number | L2120D_XX_S04_PER06_COMM_NR_OVL_WORK_PHON_NR |
| L2120D | PER08 | Electronic Data Interchange Access Number | L2120D_XX_S04_PER08_COMM_NR_OVL_EDI_ACS_NR |
| L2120D | PER08 | Electronic Mail | L2120D_XX_S04_PER08_COMM_NR_OVL_EMAIL |
| L2120D | PER08 | Telephone Extension | L2120D_XX_S04_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2120D | PER08 | Facsimile | L2120D_XX_S04_PER08_COMM_NR_OVL_FACSML |
| L2120D | PER08 | Telephone | L2120D_XX_S04_PER08_COMM_NR_OVL_TELPHN |
| L2120D | PER08 | Work Phone Number | L2120D_XX_S04_PER08_COMM_NR_OVL_WORK_PHON_NR |
| L2120D | PRV | Dependent Benefit Related Provider Information | |
| L2120D | PRV01 | Provider Code | L2120D_XX_S05_PRV01_PROV_CD |
| L2120D | PRV03 | Servicer | L2120D_XX_S05_PRV03_PROV_ID_OVL_SERVCR |
| L2120D | PRV03 | National Association of Boards of Pharmacy Number | L2120D_XX_S05_PRV03_PROV_ID_OVL_NATNL_ASCTN_BOARDS_PHARMCY_NR |
| L2120D | PRV03 | Employer’s Identification Number | L2120D_XX_S05_PRV03_PROV_ID_OVL_EMPLYR_ID_NR |
| L2120D | PRV03 | Health Care Financing Administration National | L2120D_XX_S05_PRV03_PROV_ID_OVL_HCFA_NATNL |
| L2120D | PRV03 | Social Security Number | L2120D_XX_S05_PRV03_PROV_ID_OVL_SSN |
| L2120D | PRV03 | Federal Taxpayer’s Identification Number | L2120D_XX_S05_PRV03_PROV_ID_OVL_FED_TAX_ID_NR |
| L2120D | PRV03 | Mutually Defined | L2120D_XX_S05_PRV03_PROV_ID_OVL_MUTLY_DEFND |