(C) Copyright 2012 Chiapas EDI Technologies, Inc.
4010_834 4010 Benefit Enrollment and Maintenance - Code:H0
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 | BGN | Beginning Segment | |
| STHDR | BGN01 | Transaction Set Purpose Code | STHDR_S02_BGN01_TS_PURPS_CD |
| STHDR | BGN02 | Transaction Set Identifier Code | STHDR_S02_BGN02_TS_ID_CD |
| STHDR | BGN03 | Transaction Set Creation Date | STHDR_S02_BGN03_TS_CREATN_DT |
| STHDR | BGN04 | Transaction Set Creation Time | STHDR_S02_BGN04_TS_CREATN_TIM |
| STHDR | BGN05 | Time Zone Code | STHDR_S02_BGN05_TIM_ZON_CD |
| STHDR | BGN06 | Transaction Set Identifier Code | STHDR_S02_BGN06_TS_ID_CD |
| STHDR | BGN08 | Action Code | STHDR_S02_BGN08_ACTN_CD |
| STHDR | REF | Transaction Set Policy Number | |
| STHDR | REF02 | Master Policy Number | STHDR_S03_REF02_MASTR_POLCY_NR_OVL_MASTR_POLCY_NR |
| STHDR | DTP | File Effective Date | |
| STHDR | DTP03 | Effective (D8) | STHDR_S04_DTP03_DT_TM_PERD_OVL_EFF_D8 |
| STHDR | DTP03 | Maintenance Effective (D8) | STHDR_S04_DTP03_DT_TM_PERD_OVL_MAINTNC_EFF_D8 |
| STHDR | DTP03 | Enrollment (D8) | STHDR_S04_DTP03_DT_TM_PERD_OVL_ENRLMNT_D8 |
| STHDR | DTP03 | Payment Commencement (D8) | STHDR_S04_DTP03_DT_TM_PERD_OVL_PMT_COMNCMNT_D8 |
| STHDR | SE | Transaction Set Trailer | |
| STHDR | SE01 | Transaction Segment Count | STHDR_S09_SE01_SEG_CT |
| STHDR | SE02 | Transaction Set Control Number | STHDR_S09_SE02_TCN |
1000A - SPONSOR NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L1000A | N1 | Sponsor Name | |
| L1000A | N102 | Plan Sponsor Name | L1000A_S01_N102_PLAN_SPONSR_NM |
| L1000A | N104 | Federal Taxpayer’s Identification Number | L1000A_S01_N104_SPONSR_ID_OVL_FED_TAX_ID_NR |
| L1000A | N104 | Mutually Defined | L1000A_S01_N104_SPONSR_ID_OVL_MUTLY_DEFND |
1000B - PAYER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L1000B | N1 | Payer | |
| L1000B | N102 | Insurer Name | L1000B_S01_N102_INSR_NM |
| L1000B | N104 | Federal Taxpayer’s Identification Number | L1000B_S01_N104_INSR_ID_CD_OVL_FED_TAX_ID_NR |
| L1000B | N104 | Health Care Financing Administration National PlanID | L1000B_S01_N104_INSR_ID_CD_OVL_HCFA_NATNL_PLAND |
1000C - TPA/BROKER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 1000C | Qualified Loop | ||
| L1000C | Broker or Sales Office | L1000C_BO | |
| L1000C | Third Party Administrator (TPA) | L1000C_TV | |
| L1000C | N1 | TPA/Broker Name | |
| L1000C | N102 | TPA or Broker Name | L1000C_XX_S01_N102_BROKR_NM |
| L1000C | N104 | Code assigned by the organization that is the | L1000C_XX_S01_N104_TPA_BROKR_ID_CD_OVL_CD_ASGND_DESTNTN_ORG |
| L1000C | N104 | Federal Taxpayer’s Identification Number | L1000C_XX_S01_N104_TPA_BROKR_ID_CD_OVL_FED_TAX_ID_NR |
| L1000C | N104 | Health Care Financing Administration National PlanID | L1000C_XX_S01_N104_TPA_BROKR_ID_CD_OVL_HCFA_NATNL_PLAND |
1100C - TPA/BROKER ACCOUNT INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L1100C | ACT | TPA/Broker Account Information | |
| L1100C | ACT01 | TPA or Broker Account Number | L1100C_S01_ACT01_TPA_BROKR_ACNT_NR |
| L1100C | ACT06 | TPA or Broker Account Number | L1100C_S01_ACT06_TPA_BROKR_ACNT_NR |
2000 - MEMBER LEVEL DETAIL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2000 | INS | Member Level Detail | |
| L2000 | INS01 | Insured Indicator | L2000_S01_INS01_INSRD_IND |
| L2000 | INS02 | Individual Relationship Code | L2000_S01_INS02_INDVDL_REL_CD |
| L2000 | INS03 | Maintenance Type Code | L2000_S01_INS03_MAINTNC_TYPE_CD |
| L2000 | INS04 | Maintenance Reason Code | L2000_S01_INS04_MAINTNC_RSN_CD |
| L2000 | INS05 | Benefit Status Code | L2000_S01_INS05_BENFT_STATS_CD |
| L2000 | INS06 | Medicare Plan Code | L2000_S01_INS06_MEDCR_PLAN_CD |
| L2000 | INS07 | Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualified Beneficiary | L2000_S01_INS07_COBRA_QUALFD_BENFCRY |
| L2000 | INS08 | Employment Status Code | L2000_S01_INS08_EMPLYMNT_STATS_CD |
| L2000 | INS09 | Student Status Code | L2000_S01_INS09_STUDNT_STATS_CD |
| L2000 | INS10 | Handicap Indicator | L2000_S01_INS10_HANDCP_IND |
| L2000 | INS12 | Date Expressed in Format CCYYMMDD | L2000_S01_INS12_INSRD_INDVDL_DEATH_DT_OVL_DT_CCYYMMDD |
| L2000 | INS17 | Birth Sequence Number | L2000_S01_INS17_BIRTH_SEQNC_NR |
| L2000 | REF | Subscriber Number | |
| L2000 | REF02 | Subscriber Number | L2000_S02_REF02_SUB_ID_OVL_SUB_NR |
| L2000 | REF | Member Policy Number | |
| L2000 | REF02 | Group or Policy Number | L2000_S03_REF02_INSRD_GRP_POLCY_NR_OVL_GRP_POLCY_NR |
| L2000 | REF | Member Identification Number | |
| L2000 | REF02 | Client Reporting Category | L2000_S04_REF02_SUB_SUPP_ID_OVL_CLIENT_REPRTNG_CATGRY |
| L2000 | REF02 | Client Number | L2000_S04_REF02_SUB_SUPP_ID_OVL_CLIENT_NR |
| L2000 | REF02 | Case Number | L2000_S04_REF02_SUB_SUPP_ID_OVL_CAS_NR |
| L2000 | REF02 | Department/Agency Number | L2000_S04_REF02_SUB_SUPP_ID_OVL_DEPRTMNT_GNCY_NR |
| L2000 | REF02 | Health Insurance Claim (HIC) Number | L2000_S04_REF02_SUB_SUPP_ID_OVL_HIC_NR |
| L2000 | REF02 | Prior Identifier Number | L2000_S04_REF02_SUB_SUPP_ID_OVL_PRI_ID_NR |
| L2000 | REF02 | Mutually Defined | L2000_S04_REF02_SUB_SUPP_ID_OVL_MUTLY_DEFND |
| L2000 | REF | Prior Coverage Months | |
| L2000 | REF02 | Unit Number | L2000_S05_REF02_PRI_COVG_MONTH_CT_OVL_UNT_NR |
| L2000 | DTP | Member Level Dates | |
| L2000 | DTP03 | Retirement (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_RETRMNT_D8 |
| L2000 | DTP03 | Return to Work (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_RETRN_TO_WORK_D8 |
| L2000 | DTP03 | Date Last Worked (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_DAT_LAST_WORKD_D8 |
| L2000 | DTP03 | Enrollment Signature Date (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_ENRLMNT_SIGNTR_DT_D8 |
| L2000 | DTP03 | Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_COBRA_QUAL_EVNT_D8 |
| L2000 | DTP03 | Maintenance Effective (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_MAINTNC_EFF_D8 |
| L2000 | DTP03 | Employment Begin (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_EMPLYMNT_BEGN_D8 |
| L2000 | DTP03 | Employment End (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_EMPLYMNT_END_D8 |
| L2000 | DTP03 | Medicare Begin (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_MEDCR_BEGN_D8 |
| L2000 | DTP03 | Medicare End (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_MEDCR_END_D8 |
| L2000 | DTP03 | Consolidated Omnibus Budget Reconciliation Act (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_COBRA_D8 |
| L2000 | DTP03 | Consolidated Omnibus Budget Reconciliation Act (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_COBRA_D8 |
| L2000 | DTP03 | Education Begin (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_EDCTN_BEGN_D8 |
| L2000 | DTP03 | Education End (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_EDCTN_END_D8 |
| L2000 | DTP03 | Eligibility Begin (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_ELIG_BEGN_D8 |
| L2000 | DTP03 | Eligibility End (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_ELIG_END_D8 |
| L2000 | DTP03 | Adjusted Hire (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_ADJSTD_HIR_D8 |
| L2000 | DTP03 | Plan Participation Suspension (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_PLAN_PARTCPTN_SUSPNSN_D8 |
| L2000 | DTP03 | Rehire (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_REHR_D8 |
| L2000 | DTP03 | Medicaid Begin (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_MEDCD_BEGN_D8 |
| L2000 | DTP03 | Medicaid End (D8) | L2000_S06_DTP03_STATS_NFO_EFF_DT_OVL_MEDCD_END_D8 |
2100A - MEMBER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2100A | Qualified Loop | ||
| L2100A | Corrected Insured | L2100A_74 | |
| L2100A | Insured or Subscriber | L2100A_IL | |
| L2100A | NM1 | Member Name | |
| L2100A | NM103 | Person | L2100A_XX_S01_NM103_SUB_LNAME_OVL_PERSN |
| L2100A | NM104 | Subscriber First Name | L2100A_XX_S01_NM104_SUB_FNAME |
| L2100A | NM105 | Subscriber Middle Name | L2100A_XX_S01_NM105_SUB_MNAME |
| L2100A | NM106 | Subscriber Name Prefix | L2100A_XX_S01_NM106_SUB_NM_PREFX |
| L2100A | NM107 | Subscriber Name Suffix | L2100A_XX_S01_NM107_SUB_NM_SUFX |
| L2100A | NM109 | Social Security Number | L2100A_XX_S01_NM109_SUB_ID_OVL_SSN |
| L2100A | NM109 | Mutually Defined | L2100A_XX_S01_NM109_SUB_ID_OVL_MUTLY_DEFND |
| L2100A | PER | Member Communications Numbers | |
| L2100A | PER01 | Contact Function Code | L2100A_XX_S02_PER01_CONTCT_FUNCTN_CD |
| L2100A | PER04 | Electronic Mail | L2100A_XX_S02_PER04_COMM_NR_OVL_EMAIL |
| L2100A | PER04 | Telephone Extension | L2100A_XX_S02_PER04_COMM_NR_OVL_PHN_EXTNS |
| L2100A | PER04 | Facsimile | L2100A_XX_S02_PER04_COMM_NR_OVL_FACSML |
| L2100A | PER04 | Home Phone Number | L2100A_XX_S02_PER04_COMM_NR_OVL_HOM_PHON_NR |
| L2100A | PER04 | Telephone | L2100A_XX_S02_PER04_COMM_NR_OVL_TELPHN |
| L2100A | PER04 | Work Phone Number | L2100A_XX_S02_PER04_COMM_NR_OVL_WORK_PHON_NR |
| L2100A | PER06 | Telephone | L2100A_XX_S02_PER06_COMM_NR_OVL_TELPHN |
| L2100A | PER06 | Work Phone Number | L2100A_XX_S02_PER06_COMM_NR_OVL_WORK_PHON_NR |
| L2100A | PER08 | Electronic Mail | L2100A_XX_S02_PER08_COMM_NR_OVL_EMAIL |
| L2100A | PER08 | Telephone Extension | L2100A_XX_S02_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2100A | PER08 | Facsimile | L2100A_XX_S02_PER08_COMM_NR_OVL_FACSML |
| L2100A | PER08 | Home Phone Number | L2100A_XX_S02_PER08_COMM_NR_OVL_HOM_PHON_NR |
| L2100A | PER08 | Telephone | L2100A_XX_S02_PER08_COMM_NR_OVL_TELPHN |
| L2100A | PER08 | Work Phone Number | L2100A_XX_S02_PER08_COMM_NR_OVL_WORK_PHON_NR |
| L2100A | N3 | Member Residence Street Address | |
| L2100A | N301 | Subscriber Address Line | L2100A_XX_S03_N301_SUB_ADRS_LIN |
| L2100A | N302 | Subscriber Address Line | L2100A_XX_S03_N302_SUB_ADRS_LIN |
| L2100A | N4 | Member Residence City, State, ZIP Code | |
| L2100A | N401 | Subscriber City Name | L2100A_XX_S04_N401_SUB_CITY_NM |
| L2100A | N402 | Subscriber State Code | L2100A_XX_S04_N402_SUB_STAT_CD |
| L2100A | N403 | Subscriber Postal Zone or ZIP Code | L2100A_XX_S04_N403_SUB_POSTL_ZON_ZIP_CD |
| L2100A | N404 | Country Code | L2100A_XX_S04_N404_CNTRY_CD |
| L2100A | N406 | Area | L2100A_XX_S04_N406_LOC_ID_CD_OVL_AR |
| L2100A | N406 | County/Parish | L2100A_XX_S04_N406_LOC_ID_CD_OVL_COUNTY_PRSH |
| L2100A | DMG | Member Demographics | |
| L2100A | DMG02 | Date Expressed in Format CCYYMMDD | L2100A_XX_S05_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2100A | DMG03 | Gender Code | L2100A_XX_S05_DMG03_GENDR_CD |
| L2100A | DMG04 | Marital Status Code | L2100A_XX_S05_DMG04_MARTL_STATS_CD |
| L2100A | DMG05 | Race or Ethnicity Code | L2100A_XX_S05_DMG05_RAC_ETHNCTY_CD |
| L2100A | DMG06 | Citizenship Status Code | L2100A_XX_S05_DMG06_CITZNSHP_STATS_CD |
| L2100A | ICM | Member Income | |
| L2100A | ICM02 | Weekly | L2100A_XX_S06_ICM02_WAG_AMT_OVL_WEKLY |
| L2100A | ICM02 | Biweekly | L2100A_XX_S06_ICM02_WAG_AMT_OVL_BIWKLY |
| L2100A | ICM02 | Semimonthly | L2100A_XX_S06_ICM02_WAG_AMT_OVL_SEMNTHLY |
| L2100A | ICM02 | Monthly | L2100A_XX_S06_ICM02_WAG_AMT_OVL_MONTHLY |
| L2100A | ICM02 | Daily | L2100A_XX_S06_ICM02_WAG_AMT_OVL_DAILY |
| L2100A | ICM02 | Annual | L2100A_XX_S06_ICM02_WAG_AMT_OVL_ANL |
| L2100A | ICM02 | Two Calendar Months | L2100A_XX_S06_ICM02_WAG_AMT_OVL_TWO_CALNDR_MONTHS |
| L2100A | ICM02 | Lump-Sum Separation Allowance | L2100A_XX_S06_ICM02_WAG_AMT_OVL_LUMPSM_SEPRTN_ALWNC |
| L2100A | ICM02 | Year-to-Date | L2100A_XX_S06_ICM02_WAG_AMT_OVL_YEARTDT |
| L2100A | ICM02 | Single | L2100A_XX_S06_ICM02_WAG_AMT_OVL_SINGL |
| L2100A | ICM02 | Hourly | L2100A_XX_S06_ICM02_WAG_AMT_OVL_HOURLY |
| L2100A | ICM02 | Quarterly | L2100A_XX_S06_ICM02_WAG_AMT_OVL_QUARTRLY |
| L2100A | ICM02 | Semiannual | L2100A_XX_S06_ICM02_WAG_AMT_OVL_SEMNL |
| L2100A | ICM02 | Unknown | L2100A_XX_S06_ICM02_WAG_AMT_OVL_UNKNWN |
| L2100A | ICM03 | Work Hours Count | L2100A_XX_S06_ICM03_WORK_HOURS_CT |
| L2100A | ICM04 | Location Identification Code | L2100A_XX_S06_ICM04_LOC_ID_CD |
| L2100A | ICM05 | Salary Grade Code | L2100A_XX_S06_ICM05_SALRY_GRAD_CD |
| L2100A | AMT | Member Policy Amounts | |
| L2100A | AMT02 | Co-insurance - Actual | L2100A_XX_S07_AMT02_CONTRCT_AMT_OVL_CONSRNC_ACTL |
| L2100A | AMT02 | Co-Payment Amount | L2100A_XX_S07_AMT02_CONTRCT_AMT_OVL_COPYMNT_AMT |
| L2100A | AMT02 | Deductible Amount | L2100A_XX_S07_AMT02_CONTRCT_AMT_OVL_DEDCTBL_AMT |
| L2100A | AMT02 | Premium Amount | L2100A_XX_S07_AMT02_CONTRCT_AMT_OVL_PREM_AMT |
| L2100A | HLH | Member Health Information | |
| L2100A | HLH01 | Health Related Code | L2100A_XX_S08_HLH01_RELTD_CD |
| L2100A | HLH02 | Member Height | L2100A_XX_S08_HLH02_MEM_HEIGHT |
| L2100A | HLH03 | Member Weight | L2100A_XX_S08_HLH03_MEM_WEIGHT |
| L2100A | LUI | Member Language | |
| L2100A | LUI02 | NISO Z39.53 Language Codes | L2100A_XX_S09_LUI02_LANG_CD_OVL_NIS_Z3953_LANG_CD |
| L2100A | LUI02 | ISO 639 Language Codes | L2100A_XX_S09_LUI02_LANG_CD_OVL_IS_639_LANG_CD |
| L2100A | LUI03 | Language Description | L2100A_XX_S09_LUI03_LANG_DESCRPTN |
| L2100A | LUI04 | Language Use Indicator | L2100A_XX_S09_LUI04_LANG_US_IND |
2100B - INCORRECT MEMBER NAME
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100B | NM1 | Incorrect Member Name | |
| L2100B | NM103 | Person | L2100B_S01_NM103_PRI_INCRCT_INSRD_LNAME_OVL_PERSN |
| L2100B | NM104 | Prior Incorrect Insured First Name | L2100B_S01_NM104_PRI_INCRCT_INSRD_FNAME |
| L2100B | NM105 | Prior Incorrect Insured Middle Name | L2100B_S01_NM105_PRI_INCRCT_INSRD_MNAME |
| L2100B | NM106 | Prior Incorrect Insured Name Prefix | L2100B_S01_NM106_PRI_INCRCT_INSRD_NM_PREFX |
| L2100B | NM107 | Prior Incorrect Insured Name Suffix | L2100B_S01_NM107_PRI_INCRCT_INSRD_NM_SUFX |
| L2100B | NM109 | Social Security Number | L2100B_S01_NM109_PRI_INCRCT_INSRD_ID_OVL_SSN |
| L2100B | NM109 | Mutually Defined | L2100B_S01_NM109_PRI_INCRCT_INSRD_ID_OVL_MUTLY_DEFND |
| L2100B | DMG | Incorrect Member Demographics | |
| L2100B | DMG02 | Date Expressed in Format CCYYMMDD | L2100B_S02_DMG02_PRI_INCRCT_INSRD_BIRTH_DT_OVL_DT_CCYYMMDD |
| L2100B | DMG03 | Prior Incorrect Insured Gender Code | L2100B_S02_DMG03_PRI_INCRCT_INSRD_GENDR_CD |
2100C - MEMBER MAILING ADDRESS
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100C | NM1 | Member Mailing Address | |
| L2100C | NM102 | Entity Type Qualifier | L2100C_S01_NM102_ENTY_TYPE_QUAL |
| L2100C | N3 | Member Mail Street Address | |
| L2100C | N301 | Subscriber Address Line | L2100C_S02_N301_SUB_ADRS_LIN |
| L2100C | N302 | Subscriber Address Line | L2100C_S02_N302_SUB_ADRS_LIN |
| L2100C | N4 | Member Mail City, State, Zip | |
| L2100C | N401 | Subscriber City Name | L2100C_S03_N401_SUB_CITY_NM |
| L2100C | N402 | Subscriber State Code | L2100C_S03_N402_SUB_STAT_CD |
| L2100C | N403 | Subscriber Postal Zone or ZIP Code | L2100C_S03_N403_SUB_POSTL_ZON_ZIP_CD |
| L2100C | N404 | Country Code | L2100C_S03_N404_CNTRY_CD |
2100D - MEMBER EMPLOYER
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100D | NM1 | Member Employer | |
| L2100D | NM102 | Entity Type Qualifier | L2100D_S01_NM102_ENTY_TYPE_QUAL |
| L2100D | NM103 | Insured Employer Name | L2100D_S01_NM103_INSRD_EMPLYR_NM |
| L2100D | NM104 | Insured Employer First Name | L2100D_S01_NM104_INSRD_EMPLYR_FNAME |
| L2100D | NM105 | Insured Employer Middle Name | L2100D_S01_NM105_INSRD_EMPLYR_MNAME |
| L2100D | NM107 | Insured Employer Name Suffix | L2100D_S01_NM107_INSRD_EMPLYR_NM_SUFX |
| L2100D | NM109 | Mutually Defined | L2100D_S01_NM109_INSRD_EMPLYR_ID_OVL_MUTLY_DEFND |
| L2100D | PER | Member Employer Communications Numbers | |
| L2100D | PER01 | Contact Function Code | L2100D_S02_PER01_CONTCT_FUNCTN_CD |
| L2100D | PER04 | Electronic Mail | L2100D_S02_PER04_COMM_NR_OVL_EMAIL |
| L2100D | PER04 | Telephone Extension | L2100D_S02_PER04_COMM_NR_OVL_PHN_EXTNS |
| L2100D | PER04 | Facsimile | L2100D_S02_PER04_COMM_NR_OVL_FACSML |
| L2100D | PER04 | Telephone | L2100D_S02_PER04_COMM_NR_OVL_TELPHN |
| L2100D | PER05 | Communication Number Qualifier | L2100D_S02_PER05_COMM_NR_QUAL |
| L2100D | PER06 | Communication Number | L2100D_S02_PER06_COMM_NR |
| L2100D | PER08 | Electronic Mail | L2100D_S02_PER08_COMM_NR_OVL_EMAIL |
| L2100D | PER08 | Telephone Extension | L2100D_S02_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2100D | PER08 | Facsimile | L2100D_S02_PER08_COMM_NR_OVL_FACSML |
| L2100D | PER08 | Telephone | L2100D_S02_PER08_COMM_NR_OVL_TELPHN |
| L2100D | N3 | Member Employer Street Address | |
| L2100D | N301 | Insured Employer Address Line | L2100D_S03_N301_INSRD_EMPLYR_ADRS_LIN |
| L2100D | N302 | Insured Employer Address Line | L2100D_S03_N302_INSRD_EMPLYR_ADRS_LIN |
| L2100D | N4 | Member Employer City, State, Zip | |
| L2100D | N401 | Insured Employer City Name | L2100D_S04_N401_INSRD_EMPLYR_CITY_NM |
| L2100D | N402 | Insured Employer State Code | L2100D_S04_N402_INSRD_EMPLYR_STAT_CD |
| L2100D | N403 | Insured Employer Postal Zone or ZIP Code | L2100D_S04_N403_INSRD_EMPLYR_POSTL_ZON_ZIP_CD |
| L2100D | N404 | Country Code | L2100D_S04_N404_CNTRY_CD |
2100E - MEMBER SCHOOL
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100E | NM1 | Member School | |
| L2100E | NM103 | Non-Person Entity | L2100E_S01_NM103_SCHOL_NM_OVL_NONPRSN_ENTY |
| L2100E | PER | Member School Commmunications Numbers | |
| L2100E | PER01 | Contact Function Code | L2100E_S02_PER01_CONTCT_FUNCTN_CD |
| L2100E | PER04 | Electronic Mail | L2100E_S02_PER04_COMM_NR_OVL_EMAIL |
| L2100E | PER04 | Telephone Extension | L2100E_S02_PER04_COMM_NR_OVL_PHN_EXTNS |
| L2100E | PER04 | Facsimile | L2100E_S02_PER04_COMM_NR_OVL_FACSML |
| L2100E | PER04 | Telephone | L2100E_S02_PER04_COMM_NR_OVL_TELPHN |
| L2100E | PER05 | Communication Number Qualifier | L2100E_S02_PER05_COMM_NR_QUAL |
| L2100E | PER06 | Communication Number | L2100E_S02_PER06_COMM_NR |
| L2100E | PER08 | Electronic Mail | L2100E_S02_PER08_COMM_NR_OVL_EMAIL |
| L2100E | PER08 | Telephone Extension | L2100E_S02_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2100E | PER08 | Facsimile | L2100E_S02_PER08_COMM_NR_OVL_FACSML |
| L2100E | PER08 | Telephone | L2100E_S02_PER08_COMM_NR_OVL_TELPHN |
| L2100E | N3 | Member School Street Address | |
| L2100E | N301 | School Address Line | L2100E_S03_N301_ADRS_LIN |
| L2100E | N302 | School Address Line | L2100E_S03_N302_ADRS_LIN |
| L2100E | N4 | Member School City, State, Zip | |
| L2100E | N401 | School City Name | L2100E_S04_N401_CITY_NM |
| L2100E | N402 | School State Code | L2100E_S04_N402_STAT_CD |
| L2100E | N403 | School Postal Zone or ZIP Code | L2100E_S04_N403_SCHOL_POSTL_ZON_ZIP_CD |
| L2100E | N404 | Country Code | L2100E_S04_N404_CNTRY_CD |
2100F - CUSTODIAL PARENT
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2100F | NM1 | Custodial Parent | |
| L2100F | NM103 | Person | L2100F_S01_NM103_PARNT_LNAME_OVL_PERSN |
| L2100F | NM104 | Custodial Parent First Name | L2100F_S01_NM104_PARNT_FNAME |
| L2100F | NM105 | Custodial Parent Middle Name | L2100F_S01_NM105_PARNT_MNAME |
| L2100F | NM106 | Custodial Parent Name Prefix | L2100F_S01_NM106_CUSTDL_PARNT_NM_PREFX |
| L2100F | NM107 | Custodial Parent Name Suffix | L2100F_S01_NM107_CUSTDL_PARNT_NM_SUFX |
| L2100F | NM109 | Social Security Number | L2100F_S01_NM109_PARNT_ID_OVL_SSN |
| L2100F | NM109 | Mutually Defined | L2100F_S01_NM109_PARNT_ID_OVL_MUTLY_DEFND |
| L2100F | PER | Custodial Parent Communications Numbers | |
| L2100F | PER01 | Contact Function Code | L2100F_S02_PER01_CONTCT_FUNCTN_CD |
| L2100F | PER04 | Electronic Mail | L2100F_S02_PER04_COMM_NR_OVL_EMAIL |
| L2100F | PER04 | Telephone Extension | L2100F_S02_PER04_COMM_NR_OVL_PHN_EXTNS |
| L2100F | PER04 | Facsimile | L2100F_S02_PER04_COMM_NR_OVL_FACSML |
| L2100F | PER04 | Home Phone Number | L2100F_S02_PER04_COMM_NR_OVL_HOM_PHON_NR |
| L2100F | PER04 | Telephone | L2100F_S02_PER04_COMM_NR_OVL_TELPHN |
| L2100F | PER04 | Work Phone Number | L2100F_S02_PER04_COMM_NR_OVL_WORK_PHON_NR |
| L2100F | PER06 | Telephone | L2100F_S02_PER06_COMM_NR_OVL_TELPHN |
| L2100F | PER06 | Work Phone Number | L2100F_S02_PER06_COMM_NR_OVL_WORK_PHON_NR |
| L2100F | PER08 | Electronic Mail | L2100F_S02_PER08_COMM_NR_OVL_EMAIL |
| L2100F | PER08 | Telephone Extension | L2100F_S02_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2100F | PER08 | Home Phone Number | L2100F_S02_PER08_COMM_NR_OVL_HOM_PHON_NR |
| L2100F | PER08 | Telephone | L2100F_S02_PER08_COMM_NR_OVL_TELPHN |
| L2100F | PER08 | Work Phone Number | L2100F_S02_PER08_COMM_NR_OVL_WORK_PHON_NR |
| L2100F | N3 | Custodial Parent Street Address | |
| L2100F | N301 | Custodial Parent Address Line | L2100F_S03_N301_CUSTDL_PARNT_ADRS_LIN |
| L2100F | N302 | Custodial Parent Address Line | L2100F_S03_N302_CUSTDL_PARNT_ADRS_LIN |
| L2100F | N4 | Custodial Parent City, State, Zip | |
| L2100F | N401 | Custodial Parent City Name | L2100F_S04_N401_CUSTDL_PARNT_CITY_NM |
| L2100F | N402 | Custodial Parent State Code | L2100F_S04_N402_CUSTDL_PARNT_STAT_CD |
| L2100F | N403 | Custodial Parent Postal Zone or ZIP Code | L2100F_S04_N403_POSTL_ZON_ZIP_CD |
| L2100F | N404 | Country Code | L2100F_S04_N404_CNTRY_CD |
2100G - RESPONSIBLE PERSON
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| 2100G | Qualified Loop | ||
| L2100G | Executor of Estate | L2100G_EI | |
| L2100G | Ex-spouse | L2100G_EXS | |
| L2100G | Guardian | L2100G_GD | |
| L2100G | Power of Attorney | L2100G_J6 | |
| L2100G | Responsible Party | L2100G_QD | |
| L2100G | NM1 | Responsible Person | |
| L2100G | NM103 | Person | L2100G_XX_S01_NM103_RESPNSBL_PARTY_LAST_ORG_NM_OVL_PERSN |
| L2100G | NM104 | Responsible Party First Name | L2100G_XX_S01_NM104_PARTY_FNAME |
| L2100G | NM105 | Responsible Party Middle Name | L2100G_XX_S01_NM105_PARTY_MNAME |
| L2100G | NM106 | Responsible Party Name Prefix | L2100G_XX_S01_NM106_RESPNSBL_PARTY_NM_PREFX |
| L2100G | NM107 | Responsible Party Suffix Name | L2100G_XX_S01_NM107_RESPNSBL_PARTY_SUFX_NM |
| L2100G | NM109 | Social Security Number | L2100G_XX_S01_NM109_PARTY_ID_OVL_SSN |
| L2100G | NM109 | Mutually Defined | L2100G_XX_S01_NM109_PARTY_ID_OVL_MUTLY_DEFND |
| L2100G | PER | Responsible Person Communications Numbers | |
| L2100G | PER01 | Contact Function Code | L2100G_XX_S02_PER01_CONTCT_FUNCTN_CD |
| L2100G | PER04 | Electronic Mail | L2100G_XX_S02_PER04_COMM_NR_OVL_EMAIL |
| L2100G | PER04 | Telephone Extension | L2100G_XX_S02_PER04_COMM_NR_OVL_PHN_EXTNS |
| L2100G | PER04 | Facsimile | L2100G_XX_S02_PER04_COMM_NR_OVL_FACSML |
| L2100G | PER04 | Home Phone Number | L2100G_XX_S02_PER04_COMM_NR_OVL_HOM_PHON_NR |
| L2100G | PER04 | Telephone | L2100G_XX_S02_PER04_COMM_NR_OVL_TELPHN |
| L2100G | PER04 | Work Phone Number | L2100G_XX_S02_PER04_COMM_NR_OVL_WORK_PHON_NR |
| L2100G | PER06 | Telephone | L2100G_XX_S02_PER06_COMM_NR_OVL_TELPHN |
| L2100G | PER06 | Work Phone Number | L2100G_XX_S02_PER06_COMM_NR_OVL_WORK_PHON_NR |
| L2100G | PER08 | Electronic Mail | L2100G_XX_S02_PER08_COMM_NR_OVL_EMAIL |
| L2100G | PER08 | Telephone Extension | L2100G_XX_S02_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2100G | PER08 | Facsimile | L2100G_XX_S02_PER08_COMM_NR_OVL_FACSML |
| L2100G | PER08 | Home Phone Number | L2100G_XX_S02_PER08_COMM_NR_OVL_HOM_PHON_NR |
| L2100G | PER08 | Telephone | L2100G_XX_S02_PER08_COMM_NR_OVL_TELPHN |
| L2100G | PER08 | Work Phone Number | L2100G_XX_S02_PER08_COMM_NR_OVL_WORK_PHON_NR |
| L2100G | N3 | Responsible Person Street Address | |
| L2100G | N301 | Responsible Party Address Line | L2100G_XX_S03_N301_RESPNSBL_PARTY_ADRS_LIN |
| L2100G | N302 | Responsible Party Address Line | L2100G_XX_S03_N302_RESPNSBL_PARTY_ADRS_LIN |
| L2100G | N4 | Responsible Person City, State, Zip | |
| L2100G | N401 | Responsible Party City Name | L2100G_XX_S04_N401_RESPNSBL_PARTY_CITY_NM |
| L2100G | N402 | Responsible Party State Code | L2100G_XX_S04_N402_RESPNSBL_PARTY_STAT_CD |
| L2100G | N403 | Responsible Party Postal Zone or ZIP Code | L2100G_XX_S04_N403_RESPNSBL_PARTY_POSTL_ZON_ZIP_CD |
| L2100G | N404 | Country Code | L2100G_XX_S04_N404_CNTRY_CD |
2200 - DISABILITY INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2200 | DSB | Disability Information | |
| L2200 | DSB01 | Disability Type Code | L2200_S01_DSB01_TYPE_CD |
| L2200 | DSB08 | International Classification of Diseases Clinical Modification (ICD-9-CM) - Diagnosis | L2200_S01_DSB08_DIAG_CD_OVL_ICD9CM_DIAG |
| L2200 | DTP | Disability Eligibility Dates | |
| L2200 | DTP03 | Disability Begin (D8) | L2200_S02_DTP03_ELIG_DT_OVL_DISBLTY_BEGN_D8 |
| L2200 | DTP03 | Disability End (D8) | L2200_S02_DTP03_ELIG_DT_OVL_DISBLTY_END_D8 |
2300 - HEALTH COVERAGE
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2300 | HD | Health Coverage | |
| L2300 | HD01 | Maintenance Type Code | L2300_S01_HD01_MAINTNC_TYPE_CD |
| L2300 | HD03 | Insurance Line Code | L2300_S01_HD03_INS_LIN_CD |
| L2300 | HD04 | Plan Coverage Description | L2300_S01_HD04_PLAN_COVG_DESCRPTN |
| L2300 | HD05 | Coverage Level Code | L2300_S01_HD05_COVG_LEVL_CD |
| L2300 | DTP | Health Coverage Dates | |
| L2300 | DTP03 | Maintenance Effective (D8) | L2300_S02_DTP03_COVG_PERD_OVL_MAINTNC_EFF_D8 |
| L2300 | DTP03 | Benefit Begin (D8) | L2300_S02_DTP03_COVG_PERD_OVL_BENFT_BEGN_D8 |
| L2300 | DTP03 | Benefit End (D8) | L2300_S02_DTP03_COVG_PERD_OVL_BENFT_END_D8 |
| L2300 | DTP03 | Last Premium Paid Date (D8) | L2300_S02_DTP03_COVG_PERD_OVL_LAST_PREM_PD_DT_D8 |
| L2300 | AMT | Health Coverage Policy | |
| L2300 | AMT02 | Co-insurance - Actual | L2300_S03_AMT02_CONTRCT_AMT_OVL_CONSRNC_ACTL |
| L2300 | AMT02 | Co-Payment Amount | L2300_S03_AMT02_CONTRCT_AMT_OVL_COPYMNT_AMT |
| L2300 | AMT02 | Deductible Amount | L2300_S03_AMT02_CONTRCT_AMT_OVL_DEDCTBL_AMT |
| L2300 | AMT02 | Premium Amount | L2300_S03_AMT02_CONTRCT_AMT_OVL_PREM_AMT |
| L2300 | REF | Health Coverage Policy Number | |
| L2300 | REF02 | Client Reporting Category | L2300_S04_REF02_INSRD_GRP_POLCY_NR_OVL_CLIENT_REPRTNG_CATGRY |
| L2300 | REF02 | Group or Policy Number | L2300_S04_REF02_INSRD_GRP_POLCY_NR_OVL_GRP_POLCY_NR |
| L2300 | REF02 | Mutually Defined | L2300_S04_REF02_INSRD_GRP_POLCY_NR_OVL_MUTLY_DEFND |
| L2300 | IDC | Identification Card | |
| L2300 | IDC01 | Plan Coverage Description | L2300_S05_IDC01_PLAN_COVG_DESCRPTN |
| L2300 | IDC02 | Identification Card Type Code | L2300_S05_IDC02_ID_CARD_TYPE_CD |
| L2300 | IDC03 | Identification Card Count | L2300_S05_IDC03_CARD_CT |
| L2300 | IDC04 | Action Code | L2300_S05_IDC04_ACTN_CD |
2310 - PROVIDER INFORMATION
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2310 | LX | Provider Information | |
| L2310 | LX01 | Assigned Number | L2310_S01_LX01_ASGND_NR |
| L2310 | NM1 | Provider Name | |
| L2310 | NM101 | Entity Identifier Code | L2310_S02_NM101_ENTY_ID_CD |
| L2310 | NM102 | Entity Type Qualifier | L2310_S02_NM102_ENTY_TYPE_QUAL |
| L2310 | NM103 | Provider Last or Organization Name | L2310_S02_NM103_PROV_LAST_ORG_NM |
| L2310 | NM104 | Provider First Name | L2310_S02_NM104_PROV_FNAME |
| L2310 | NM105 | Provider Middle Name | L2310_S02_NM105_PROV_MNAME |
| L2310 | NM106 | Provider Name Prefix | L2310_S02_NM106_NM_PREFX |
| L2310 | NM107 | Provider Name Suffix | L2310_S02_NM107_NM_SUFX |
| L2310 | NM109 | Social Security Number | L2310_S02_NM109_PROV_ID_OVL_SSN |
| L2310 | NM109 | Federal Taxpayer’s Identification Number | L2310_S02_NM109_PROV_ID_OVL_FED_TAX_ID_NR |
| L2310 | NM109 | Health Care Financing Administration National | L2310_S02_NM109_PROV_ID_OVL_HCFA_NATNL |
| L2310 | NM110 | Entity Relationship Code | L2310_S02_NM110_ENTY_REL_CD |
| L2310 | N4 | Provider City, State, ZIP Code | |
| L2310 | N401 | Member City Name | L2310_S03_N401_MEM_CITY_NM |
| L2310 | N402 | Member State Code | L2310_S03_N402_MEM_STAT_CD |
| L2310 | N403 | Member Postal Zone or Zip Code | L2310_S03_N403_MEM_POSTL_ZON_ZIP_CD |
| L2310 | N404 | Country Code | L2310_S03_N404_CNTRY_CD |
| L2310 | N406 | Area | L2310_S03_N406_LOC_ID_CD_OVL_AR |
| L2310 | N406 | County/Parish | L2310_S03_N406_LOC_ID_CD_OVL_COUNTY_PRSH |
| L2310 | N406 | Region | L2310_S03_N406_LOC_ID_CD_OVL_REGN |
| L2310 | PER | Provider Communications Numbers | |
| L2310 | PER01 | Contact Function Code | L2310_S04_PER01_CONTCT_FUNCTN_CD |
| L2310 | PER04 | Electronic Mail | L2310_S04_PER04_COMM_NR_OVL_EMAIL |
| L2310 | PER04 | Telephone Extension | L2310_S04_PER04_COMM_NR_OVL_PHN_EXTNS |
| L2310 | PER04 | Facsimile | L2310_S04_PER04_COMM_NR_OVL_FACSML |
| L2310 | PER04 | Home Phone Number | L2310_S04_PER04_COMM_NR_OVL_HOM_PHON_NR |
| L2310 | PER04 | Telephone | L2310_S04_PER04_COMM_NR_OVL_TELPHN |
| L2310 | PER04 | Work Phone Number | L2310_S04_PER04_COMM_NR_OVL_WORK_PHON_NR |
| L2310 | PER06 | Electronic Mail | L2310_S04_PER06_COMM_NR_OVL_EMAIL |
| L2310 | PER06 | Telephone Extension | L2310_S04_PER06_COMM_NR_OVL_PHN_EXTNS |
| L2310 | PER06 | Facsimile | L2310_S04_PER06_COMM_NR_OVL_FACSML |
| L2310 | PER06 | Home Phone Number | L2310_S04_PER06_COMM_NR_OVL_HOM_PHON_NR |
| L2310 | PER06 | Telephone | L2310_S04_PER06_COMM_NR_OVL_TELPHN |
| L2310 | PER06 | Work Phone Number | L2310_S04_PER06_COMM_NR_OVL_WORK_PHON_NR |
| L2310 | PER08 | Electronic Mail | L2310_S04_PER08_COMM_NR_OVL_EMAIL |
| L2310 | PER08 | Telephone Extension | L2310_S04_PER08_COMM_NR_OVL_PHN_EXTNS |
| L2310 | PER08 | Facsimile | L2310_S04_PER08_COMM_NR_OVL_FACSML |
| L2310 | PER08 | Home Phone Number | L2310_S04_PER08_COMM_NR_OVL_HOM_PHON_NR |
| L2310 | PER08 | Telephone | L2310_S04_PER08_COMM_NR_OVL_TELPHN |
| L2310 | PER08 | Work Phone Number | L2310_S04_PER08_COMM_NR_OVL_WORK_PHON_NR |
| L2310 | PLA | PCP Change Reason | |
| L2310 | PLA01 | Action Code | L2310_S05_PLA01_ACTN_CD |
| L2310 | PLA02 | Entity Identifier Code | L2310_S05_PLA02_ENTY_ID_CD |
| L2310 | PLA03 | Provider Effective Date | L2310_S05_PLA03_PROV_EFF_DT |
| L2310 | PLA05 | Maintenance Reason Code | L2310_S05_PLA05_MAINTNC_RSN_CD |
2320 - COORDINATION OF BENEFITS
| Loop | Segment | Segment Name | Chiapas Gate Mapping |
| L2320 | COB | Coordination of Benefits | |
| L2320 | COB01 | Payer Responsibility Sequence Number Code | L2320_S01_COB01_PAYR_RESP_SEQNC_NR_CD |
| L2320 | COB02 | Insured Group or Policy Number | L2320_S01_COB02_INSRD_GRP_POLCY_NR |
| L2320 | COB03 | Coordination of Benefits Code | L2320_S01_COB03_COB_CD |
| L2320 | REF | Additional Coordination of Benefits Identifiers | |
| L2320 | REF02 | Account Suffix Code | L2320_S02_REF02_INSRD_GRP_POLCY_NR_OVL_ACNT_SUFX_CD |
| L2320 | REF02 | Group Number | L2320_S02_REF02_INSRD_GRP_POLCY_NR_OVL_GRP_NR |
| L2320 | REF02 | Employee Identification Number | L2320_S02_REF02_INSRD_GRP_POLCY_NR_OVL_EMPLY_ID_NR |
| L2320 | REF02 | Social Security Number | L2320_S02_REF02_INSRD_GRP_POLCY_NR_OVL_SSN |
| L2320 | REF02 | Mutually Defined | L2320_S02_REF02_INSRD_GRP_POLCY_NR_OVL_MUTLY_DEFND |
| L2320 | N1 | Other Insurance Company Name | |
| L2320 | N101 | Entity Identifier Code | L2320_S03_N101_ENTY_ID_CD |
| L2320 | N102 | Insurer Name | L2320_S03_N102_INSR_NM |
| L2320 | N104 | Federal Taxpayer’s Identification Number | L2320_S03_N104_INSRD_GRP_POLCY_NR_OVL_FED_TAX_ID_NR |
| L2320 | N104 | National Association of Insurance Commissioners | L2320_S03_N104_INSRD_GRP_POLCY_NR_OVL_NAIC |
| L2320 | N104 | Health Care Financing Administration National PlanID | L2320_S03_N104_INSRD_GRP_POLCY_NR_OVL_HCFA_NATNL_PLAND |
| L2320 | DTP | Coordination of Benefits Eligibility Dates | |
| L2320 | DTP03 | Coordination of Benefits Begin (D8) | L2320_S04_DTP03_COB_DT_OVL_COB_BEGN_D8 |
| L2320 | DTP03 | Coordination of Benefits End (D8) | L2320_S04_DTP03_COB_DT_OVL_COB_END_D8 |