Chiapas EDI 2012 Mapping Guide

5010_270 5010 Health Care Eligibility Benefit Inquiry - Code:M0

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	ST03	Implementation Convention Reference	STHDR_S01_ST03_IMPLMNTN_CONVNTN_REFNC
STHDR	BHT	Beginning of Hierarchical Transaction
STHDR	BHT01	Hierarchical Structure Code	STHDR_S02_BHT01_STRUCTR_CD
STHDR	BHT02	Transaction Set Purpose Code	STHDR_S02_BHT02_TS_PURPS_CD
STHDR	BHT03	Submitter Transaction Identifier	STHDR_S02_BHT03_SUBMTR_TRANSCTN_ID
STHDR	BHT04	Transaction Set Creation Date	STHDR_S02_BHT04_TS_CREATN_DT
STHDR	BHT05	Transaction Set Creation Time	STHDR_S02_BHT05_TS_CREATN_TIM
STHDR	BHT06	Transaction Type Code	STHDR_S02_BHT06_TRANSCTN_TYPE_CD
STHDR	SE	Transaction Set Trailer
STHDR	SE01	Transaction Segment Count	STHDR_S04_SE01_SEG_CT
STHDR	SE02	Transaction Set Control Number	STHDR_S04_SE02_TCN

2000A - INFORMATION SOURCE LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000A	HL	Information Source Level
L2000A	HL01	Hierarchical ID Number	L2000A_S01_HL01_HIERCHCL_ID_NR
L2000A	HL04	Hierarchical Child Code	L2000A_S01_HL04_HIERCHCL_CHILD_CD

2100A - INFORMATION SOURCE NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
2100A		Qualified Loop
L2100A		Third-Party Administrator	L2100A_2B
L2100A		Employer	L2100A_36
L2100A		Gateway Provider	L2100A_GP
L2100A		Plan Sponsor	L2100A_P5
L2100A		Payer	L2100A_PR
L2100A	NM1	Information Source Name
L2100A	NM103	Person	L2100A_XX_S01_NM103_NFO_SOURC_LAST_ORG_NM_OVL_PERSN
L2100A	NM103	Non-Person Entity	L2100A_XX_S01_NM103_NFO_SOURC_LAST_ORG_NM_OVL_NONPRSN_ENTY
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	Centers for Medicare and Medicaid Services PlanID	L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_PLAND
L2100A	NM109	Centers for Medicare and Medicaid Services National Provider Identifier	L2100A_XX_S01_NM109_NFO_SOURC_PRIMRY_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID

2000B - INFORMATION RECEIVER LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000B	HL	Information Receiver Level
L2000B	HL01	Hierarchical ID Number	L2000B_S01_HL01_HIERCHCL_ID_NR
L2000B	HL02	Hierarchical Parent ID Number	L2000B_S01_HL02_HIERCHCL_PARNT_ID_NR
L2000B	HL04	Hierarchical Child Code	L2000B_S01_HL04_HIERCHCL_CHILD_CD

2100B - INFORMATION RECEIVER NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
2100B		Qualified Loop
L2100B		Provider	L2100B_1P
L2100B		Third-Party Administrator	L2100B_2B
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	NM103	Person	L2100B_XX_S01_NM103_NFO_RECVR_LAST_ORG_NM_OVL_PERSN
L2100B	NM103	Non-Person Entity	L2100B_XX_S01_NM103_NFO_RECVR_LAST_ORG_NM_OVL_NONPRSN_ENTY
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	Centers for Medicare and Medicaid Services PlanID	L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_MDCR_MDCD_SVCS_PLAND
L2100B	NM109	Centers for Medicare and Medicaid Services	L2100B_XX_S01_NM109_NFO_RECVR_ID_NR_OVL_CENTRS_MEDCR_MEDCD_SVCS
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	Centers for Medicare and Medicaid Services	L2100B_XX_S02_REF02_NFO_RECVR_ADDL_ID_OVL_CENTRS_MEDCR_MEDCD_SVCS
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	Information Receiver Additional Identifier State	L2100B_XX_S02_REF03_NFO_RECVR_ADDL_ID_STAT
L2100B	N3	Information Receiver Address
L2100B	N301	Information Receiver Address Line	L2100B_XX_S03_N301_NFO_RECVR_ADRS_LIN
L2100B	N302	Information Receiver Additional Address Line	L2100B_XX_S03_N302_NFO_RECVR_ADDL_ADRS_LIN
L2100B	N4	Information Receiver City, State, ZIP Code
L2100B	N401	Information Receiver City Name	L2100B_XX_S04_N401_NFO_RECVR_CITY_NM
L2100B	N402	Information Receiver State Code	L2100B_XX_S04_N402_NFO_RECVR_STAT_CD
L2100B	N403	Information Receiver Postal Zone or ZIP Code	L2100B_XX_S04_N403_NFO_RECVR_POSTL_ZON_ZIP_CD
L2100B	N404	Country Code	L2100B_XX_S04_N404_CNTRY_CD
L2100B	N407	Country Subdivision Code	L2100B_XX_S04_N407_COUNTRY_SUBDVSN_CD
L2100B	PRV	Information Receiver Provider Information
L2100B	PRV01	Provider Code	L2100B_XX_S05_PRV01_PROV_CD
L2100B	PRV03	Health Care Provider Taxonomy Code	L2100B_XX_S05_PRV03_RECVR_PROV_TAXNMY_CD_OVL_HLTHCR_PROV_TAXNMY_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 or Initial	L2100C_S01_NM105_MNAME_INTL
L2100C	NM107	Subscriber Name Suffix	L2100C_S01_NM107_NM_SUFX
L2100C	NM109	Standard Unique Health Identifier for each Individual in the United States	L2100C_S01_NM109_PRIMRY_ID_OVL_STANDRD_UNQ_HEALTH_ID
L2100C	NM109	Member Identification Number	L2100C_S01_NM109_PRIMRY_ID_OVL_MEM_ID_NR
L2100C	REF	Subscriber Additional Identification
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	Group Number	L2100C_S02_REF02_SUPP_ID_OVL_GRP_NR
L2100C	REF02	Contract Number	L2100C_S02_REF02_SUPP_ID_OVL_CONTRCT_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	Insurance Policy Number	L2100C_S02_REF02_SUPP_ID_OVL_INS_POLCY_NR
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	Social Security Number	L2100C_S02_REF02_SUPP_ID_OVL_SSN
L2100C	REF02	Agency Claim Number	L2100C_S02_REF02_SUPP_ID_OVL_AGNCY_CLM_NR
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	N407	Country Subdivision Code	L2100C_S04_N407_COUNTRY_SUBDVSN_CD
L2100C	PRV	Provider Information
L2100C	PRV01	Provider Code	L2100C_S05_PRV01_PROV_CD
L2100C	PRV03	Servicer	L2100C_S05_PRV03_PROV_ID_OVL_SERVCR
L2100C	PRV03	National Council for Prescription Drug Programs Pharmacy Number	L2100C_S05_PRV03_PROV_ID_OVL_NATL_COUNCL_RX_DRUG_PROG_PHAMRCY_NR
L2100C	PRV03	Employer’s Identification Number	L2100C_S05_PRV03_PROV_ID_OVL_EMPLYR_ID_NR
L2100C	PRV03	Centers for Medicare and Medicaid Services National Provider Identifier	L2100C_S05_PRV03_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2100C	PRV03	Health Care Provider Taxonomy Code	L2100C_S05_PRV03_PROV_ID_OVL_HLTHCR_PROV_TAXNMY_CD
L2100C	PRV03	Social Security Number	L2100C_S05_PRV03_PROV_ID_OVL_SSN
L2100C	PRV03	Federal Taxpayer’s Identification Number	L2100C_S05_PRV03_PROV_ID_OVL_FED_TAX_ID_NR
L2100C	DMG	Subscriber Demographic Information
L2100C	DMG02	Date Expressed in Format CCYYMMDD	L2100C_S06_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD
L2100C	DMG03	Subscriber Gender Code	L2100C_S06_DMG03_GENDR_CD
L2100C	INS	Multiple Birth Sequence Number
L2100C	INS01	Insured Indicator	L2100C_S07_INS01_INSRD_IND
L2100C	INS02	Individual Relationship Code	L2100C_S07_INS02_INDVDL_REL_CD
L2100C	INS17	Birth Sequence Number	L2100C_S07_INS17_SEQNC_NR
L2100C	HI	Subscriber Health Care Diagnosis Code
L2100C	HI01-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis	L2100C_S08_HI01_02_DIAG_CD_OVL_ICD10CM_PRINCPL_DIAG
L2100C	HI01-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis	L2100C_S08_HI01_02_DIAG_CD_OVL_ICD9CM_PRINCPL_DIAG
L2100C	HI02-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100C_S08_HI02_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100C	HI02-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100C_S08_HI02_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100C	HI03-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100C_S08_HI03_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100C	HI03-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100C_S08_HI03_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100C	HI04-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100C_S08_HI04_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100C	HI04-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100C_S08_HI04_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100C	HI05-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100C_S08_HI05_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100C	HI05-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100C_S08_HI05_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100C	HI06-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100C_S08_HI06_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100C	HI06-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100C_S08_HI06_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100C	HI07-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100C_S08_HI07_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100C	HI07-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100C_S08_HI07_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100C	HI08-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100C_S08_HI08_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100C	HI08-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100C_S08_HI08_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100C	DTP	Subscriber Date
L2100C	DTP03	Issue (D8)	L2100C_S09_DTP03_DT_TM_PERD_OVL_ISSU_D8
L2100C	DTP03	Plan (D8)	L2100C_S09_DTP03_DT_TM_PERD_OVL_PLAN_D8
L2100C	DTP03	Issue (RD8)	L2100C_S09_DTP03_DT_TM_PERD_OVL_ISSU_RD8
L2100C	DTP03	Plan (RD8)	L2100C_S09_DTP03_DT_TM_PERD_OVL_PLAN_RD8

2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2110C	EQ	Subscriber Eligibility or Benefit Inquiry
L2110C	EQ01	Service Type Code	L2110C_S01_EQ01_SVC_TYPE_CD
L2110C	EQ02-02	American Dental Association Codes	L2110C_S01_EQ02_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD
L2110C	EQ02-02	Current Procedural Terminology (CPT) Codes	L2110C_S01_EQ02_02_PROC_CD_OVL_CPT_CD
L2110C	EQ02-02	Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes	L2110C_S01_EQ02_02_PROC_CD_OVL_HCPCS_CD
L2110C	EQ02-02	International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) -	L2110C_S01_EQ02_02_PROC_CD_OVL_ICD9CM
L2110C	EQ02-02	Home Infusion EDI Coalition (HIEC) Product/Service Code	L2110C_S01_EQ02_02_PROC_CD_OVL_HIEC_PRODCT_SRVC_CD
L2110C	EQ02-02	National Drug Code in 5-4-2 Format	L2110C_S01_EQ02_02_PROC_CD_OVL_NDC_542_FORMT
L2110C	EQ02-02	Mutually Defined	L2110C_S01_EQ02_02_PROC_CD_OVL_MUTLY_DEFND
L2110C	EQ02-03	Procedure Modifier	L2110C_S01_EQ02_03_PROC_MODFR
L2110C	EQ02-04	Procedure Modifier	L2110C_S01_EQ02_04_PROC_MODFR
L2110C	EQ02-05	Procedure Modifier	L2110C_S01_EQ02_05_PROC_MODFR
L2110C	EQ02-06	Procedure Modifier	L2110C_S01_EQ02_06_PROC_MODFR
L2110C	EQ03	Coverage Level Code	L2110C_S01_EQ03_COVG_LEVL_CD
L2110C	EQ05-01	Diagnosis Code Pointer	L2110C_S01_EQ05_01_DIAG_CD_POINTR
L2110C	EQ05-02	Diagnosis Code Pointer	L2110C_S01_EQ05_02_DIAG_CD_POINTR
L2110C	EQ05-03	Diagnosis Code Pointer	L2110C_S01_EQ05_03_DIAG_CD_POINTR
L2110C	EQ05-04	Diagnosis Code Pointer	L2110C_S01_EQ05_04_DIAG_CD_POINTR
L2110C	AMT	Subscriber Spend Down Amount
L2110C	AMT02	Spend Down	L2110C_S02_AMT02_DOWN_AMT_OVL_SPEND_DOWN
L2110C	AMT	Subscriber Spend Down Total Billed Amount
L2110C	AMT02	Billed Amount	L2110C_S03_AMT02_AMT_OVL_BILD_AMT
L2110C	III	Subscriber Eligibility or Benefit Additional Inquiry Information
L2110C	III02	Mutually Defined	L2110C_S04_III02_INDSTRY_CD_OVL_MUTLY_DEFND
L2110C	REF	Subscriber Additional Information
L2110C	REF02	Referral Number	L2110C_S05_REF02_PRI_AUTH_REFL_NR_OVL_REFL_NR
L2110C	REF02	Prior Authorization Number	L2110C_S05_REF02_PRI_AUTH_REFL_NR_OVL_PRI_AUTH_NR
L2110C	DTP	Subscriber Eligibility/Benefit Date
L2110C	DTP03	Plan (D8)	L2110C_S06_DTP03_DT_TM_PERD_OVL_PLAN_D8
L2110C	DTP03	Plan (RD8)	L2110C_S06_DTP03_DT_TM_PERD_OVL_PLAN_RD8

2000D - DEPENDENT LEVEL

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2000D	HL	Dependent Level
L2000D	HL01	Hierarchical ID Number	L2000D_S01_HL01_HIERCHCL_ID_NR
L2000D	HL02	Hierarchical Parent ID Number	L2000D_S01_HL02_HIERCHCL_PARNT_ID_NR
L2000D	HL04	Hierarchical Child Code	L2000D_S01_HL04_HIERCHCL_CHILD_CD
L2000D	TRN	Dependent Trace Number
L2000D	TRN01	Trace Type Code	L2000D_S02_TRN01_TYPE_CD
L2000D	TRN02	Trace Number	L2000D_S02_TRN02_TRAC_NR
L2000D	TRN03	Trace Assigning Entity Identifier	L2000D_S02_TRN03_TRAC_ASGNG_ENTY_ID
L2000D	TRN04	Trace Assigning Entity Additional Identifier	L2000D_S02_TRN04_TRAC_ASGNG_ENTY_ADDL_ID

2100D - DEPENDENT NAME

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2100D	NM1	Dependent Name
L2100D	NM102	Entity Type Qualifier	L2100D_S01_NM102_ENTY_TYPE_QUAL
L2100D	NM103	Dependent Last Name	L2100D_S01_NM103_DEPNDNT_LNAME
L2100D	NM104	Dependent First Name	L2100D_S01_NM104_DEPNDNT_FNAME
L2100D	NM105	Dependent Middle Name	L2100D_S01_NM105_DEPNDNT_MNAME
L2100D	NM107	Dependent Name Suffix	L2100D_S01_NM107_NM_SUFX
L2100D	REF	Dependent Additional Identification
L2100D	REF02	Plan Number	L2100D_S02_REF02_SUPP_ID_OVL_PLAN_NR
L2100D	REF02	Group or Policy Number	L2100D_S02_REF02_SUPP_ID_OVL_GRP_POLCY_NR
L2100D	REF02	Group Number	L2100D_S02_REF02_SUPP_ID_OVL_GRP_NR
L2100D	REF02	Contract Number	L2100D_S02_REF02_SUPP_ID_OVL_CONTRCT_NR
L2100D	REF02	Medical Record Identification Number	L2100D_S02_REF02_SUPP_ID_OVL_MEDCL_RECRD_ID_NR
L2100D	REF02	Patient Account Number	L2100D_S02_REF02_SUPP_ID_OVL_PATNT_ACNT_NR
L2100D	REF02	Health Insurance Claim (HIC) Number	L2100D_S02_REF02_SUPP_ID_OVL_HIC_NR
L2100D	REF02	Identification Card Serial Number	L2100D_S02_REF02_SUPP_ID_OVL_ID_CARD_SERL_NR
L2100D	REF02	Identity Card Number	L2100D_S02_REF02_SUPP_ID_OVL_IDNTY_CARD_NR
L2100D	REF02	Issue Number	L2100D_S02_REF02_SUPP_ID_OVL_IS_NR
L2100D	REF02	Insurance Policy Number	L2100D_S02_REF02_SUPP_ID_OVL_INS_POLCY_NR
L2100D	REF02	Eligibility Category	L2100D_S02_REF02_SUPP_ID_OVL_ELIG_CATGRY
L2100D	REF02	Plan Network Identification Number	L2100D_S02_REF02_SUPP_ID_OVL_PLAN_NETWRK_ID_NR
L2100D	REF02	Social Security Number	L2100D_S02_REF02_SUPP_ID_OVL_SSN
L2100D	REF02	Agency Claim Number	L2100D_S02_REF02_SUPP_ID_OVL_AGNCY_CLM_NR
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	N407	Country Subdivision Code	L2100D_S04_N407_COUNTRY_SUBDVSN_CD
L2100D	PRV	Provider Information
L2100D	PRV01	Provider Code	L2100D_S05_PRV01_PROV_CD
L2100D	PRV03	Servicer	L2100D_S05_PRV03_PROV_ID_OVL_SERVCR
L2100D	PRV03	National Council for Prescription Drug Programs Pharmacy Number	L2100D_S05_PRV03_PROV_ID_OVL_NATL_COUNCL_RX_DRUG_PROG_PHAMRCY_NR
L2100D	PRV03	Employer’s Identification Number	L2100D_S05_PRV03_PROV_ID_OVL_EMPLYR_ID_NR
L2100D	PRV03	Centers for Medicare and Medicaid Services National Provider Identifier	L2100D_S05_PRV03_PROV_ID_OVL_MDCR_MDCD_SVCS_NATNL_PROV_ID
L2100D	PRV03	Health Care Provider Taxonomy Code	L2100D_S05_PRV03_PROV_ID_OVL_HLTHCR_PROV_TAXNMY_CD
L2100D	PRV03	Social Security Number	L2100D_S05_PRV03_PROV_ID_OVL_SSN
L2100D	PRV03	Federal Taxpayer’s Identification Number	L2100D_S05_PRV03_PROV_ID_OVL_FED_TAX_ID_NR
L2100D	DMG	Dependent Demographic Information
L2100D	DMG02	Date Expressed in Format CCYYMMDD	L2100D_S06_DMG02_BIRTH_DT_OVL_DT_CCYYMMDD
L2100D	DMG03	Dependent Gender Code	L2100D_S06_DMG03_GENDR_CD
L2100D	INS	Dependent Relationship
L2100D	INS01	Insured Indicator	L2100D_S07_INS01_INSRD_IND
L2100D	INS02	Individual Relationship Code	L2100D_S07_INS02_INDVDL_REL_CD
L2100D	INS17	Birth Sequence Number	L2100D_S07_INS17_BIRTH_SEQNC_NR
L2100D	HI	Dependent Health Care Diagnosis Code
L2100D	HI01-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis	L2100D_S08_HI01_02_DIAG_CD_OVL_ICD10CM_PRINCPL_DIAG
L2100D	HI01-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis	L2100D_S08_HI01_02_DIAG_CD_OVL_ICD9CM_PRINCPL_DIAG
L2100D	HI02-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100D_S08_HI02_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100D	HI02-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100D_S08_HI02_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100D	HI03-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100D_S08_HI03_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100D	HI03-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100D_S08_HI03_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100D	HI04-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100D_S08_HI04_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100D	HI04-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100D_S08_HI04_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100D	HI05-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100D_S08_HI05_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100D	HI05-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100D_S08_HI05_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100D	HI06-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100D_S08_HI06_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100D	HI06-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100D_S08_HI06_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100D	HI07-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100D_S08_HI07_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100D	HI07-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100D_S08_HI07_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100D	HI08-02	International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis	L2100D_S08_HI08_02_DIAG_CD_OVL_ICD10CM_DIAG
L2100D	HI08-02	International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis	L2100D_S08_HI08_02_DIAG_CD_OVL_ICD9CM_DIAG
L2100D	DTP	Dependent Date
L2100D	DTP03	Issue (D8)	L2100D_S09_DTP03_DT_TM_PERD_OVL_ISSU_D8
L2100D	DTP03	Plan (D8)	L2100D_S09_DTP03_DT_TM_PERD_OVL_PLAN_D8
L2100D	DTP03	Issue (RD8)	L2100D_S09_DTP03_DT_TM_PERD_OVL_ISSU_RD8
L2100D	DTP03	Plan (RD8)	L2100D_S09_DTP03_DT_TM_PERD_OVL_PLAN_RD8

2110D - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY

Loop	Segment	Segment Name	Chiapas Gate Mapping
L2110D	EQ	Dependent Eligibility or Benefit Inquiry
L2110D	EQ01	Service Type Code	L2110D_S01_EQ01_SVC_TYPE_CD
L2110D	EQ02-02	American Dental Association Codes	L2110D_S01_EQ02_02_PROC_CD_OVL_AMRCN_DENTL_ASCTN_CD
L2110D	EQ02-02	Current Procedural Terminology (CPT) Codes	L2110D_S01_EQ02_02_PROC_CD_OVL_CPT_CD
L2110D	EQ02-02	Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes	L2110D_S01_EQ02_02_PROC_CD_OVL_HCPCS_CD
L2110D	EQ02-02	International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) -	L2110D_S01_EQ02_02_PROC_CD_OVL_ICD9CM
L2110D	EQ02-02	Home Infusion EDI Coalition (HIEC) Product/Service Code	L2110D_S01_EQ02_02_PROC_CD_OVL_HIEC_PRODCT_SRVC_CD
L2110D	EQ02-02	National Drug Code in 5-4-2 Format	L2110D_S01_EQ02_02_PROC_CD_OVL_NDC_542_FORMT
L2110D	EQ02-02	Mutually Defined	L2110D_S01_EQ02_02_PROC_CD_OVL_MUTLY_DEFND
L2110D	EQ02-03	Procedure Modifier	L2110D_S01_EQ02_03_PROC_MODFR
L2110D	EQ02-04	Procedure Modifier	L2110D_S01_EQ02_04_PROC_MODFR
L2110D	EQ02-05	Procedure Modifier	L2110D_S01_EQ02_05_PROC_MODFR
L2110D	EQ02-06	Procedure Modifier	L2110D_S01_EQ02_06_PROC_MODFR
L2110D	EQ05-01	Diagnosis Code Pointer	L2110D_S01_EQ05_01_DIAG_CD_POINTR
L2110D	EQ05-02	Diagnosis Code Pointer	L2110D_S01_EQ05_02_DIAG_CD_POINTR
L2110D	EQ05-03	Diagnosis Code Pointer	L2110D_S01_EQ05_03_DIAG_CD_POINTR
L2110D	EQ05-04	Diagnosis Code Pointer	L2110D_S01_EQ05_04_DIAG_CD_POINTR
L2110D	III	Dependent Eligibility or Benefit Additional Inquiry Information
L2110D	III02	Mutually Defined	L2110D_S02_III02_INDSTRY_CD_OVL_MUTLY_DEFND
L2110D	REF	Dependent Additional Information
L2110D	REF02	Referral Number	L2110D_S03_REF02_PRI_AUTH_REFL_NR_OVL_REFL_NR
L2110D	REF02	Prior Authorization Number	L2110D_S03_REF02_PRI_AUTH_REFL_NR_OVL_PRI_AUTH_NR
L2110D	DTP	Dependent Eligibility/Benefit Date
L2110D	DTP03	Plan (D8)	L2110D_S04_DTP03_DT_TM_PERD_OVL_PLAN_D8
L2110D	DTP03	Plan (RD8)	L2110D_S04_DTP03_DT_TM_PERD_OVL_PLAN_RD8