Eligibility 4010A1 To 5010

4010A1
Element
Identifier
Description
ISA
INTERCHANGE
CONTROL HEADER
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ISA
INTERCHANGE
CONTROL HEADER
ID
Min.
Max.
270 4010A1
ID
2-2
AN
10-10
ISA03
ISA04
ID
AN
2-2
10-10
R
R
ISA05
Interchange ID Qualifier
ID
2-2
ISA06
Interchange Sender ID
AN
15-15
ISA01
ISA02
ID
2-2
AN
10-10
ID
AN
2-2
10-10
R
R
ID
2-2
ISA06
Interchange Sender ID
AN
15-15
ISA07
Interchange ID Qualifier ID
Interchange Receiver
ID
AN
Interchange Date
DT
Interchange Time
TM
2-2
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
15-15
6-6
4-4
R
R
R
YYMMDD
HHMM
1-1
ISA03
ISA04
ISA05
ISA01
ISA02
00, 01
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
ID
2-2
ISA08
ISA09
ISA10
Interchange Receiver ID
Interchange Date
Interchange Time
Interchange Control
Standards ID
Interchange Control
Version Number
Interchange Control
Number
Acknowledgement
Requested
AN
DT
TM
15-15
6-6
4-4
R
R
R
ID
1-1
ID
1-1
Usage Indicator
Component Element
Separator
ID
1-1
ISA15
1-1
ISA16
GS
ISA13
ISA14
YYMMDD
HHMM
U
ISA08
ISA09
ISA10
5-5
N0
9-9
ISA12
ISA13
0, 1
ISA14
P, T
ISA15
ISA16
GS
GS01
GS02
GS03
GS04
GS05
GS06
GS07
FUNCTIONAL GROUP
HEADER
Functional Identifier
Code
Application Sender's
Code
Application Receiver's
Code
Date
Time
Group Control Number
Responsible Agency
Code
HB, HS
ID
2-2
GS01
AN
2-15
GS02
AN
DT
TM
2-15
8-8
4-8
R
R
R
N0
1-9
ID
1-2
CCYYMMDD
HHMM
00, 03
00, 01
GS03
GS04
GS05
GS06
X
GS07
Repetition Separator
Interchange Control
Version Number
Interchange Control
Number
Acknowledgement
Requested
Interchange Usage
Indicator
Component Element
Separator
FUNCTIONAL GROUP
HEADER
Code
Code
Code
Date
Time
Responsible Agency
Code
00501
ID
5-5
N0
9-9
ID
1-1
ID
1-1
1-1
0, 1
P, T
ID
2-2
AN
2-15
AN
DT
TM
2-15
8-8
4-8
R
R
R
N0
1-9
ID
1-2
Version/ Release/
Industry Identifier Code
ST
ST01
Page 1 of 20
TRANSACTION SET
HEADER
Transaction Set
Identifier Code
AN
005010X279
1-12
GS08
ST
3-3
270
ID
CCYYMMDD
HHMM
004010X092
GS08
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
New Element
ISA11
00401
ID
Values
ISA12
Loop
Authorization
Information Qualifier
Authorization
Information
Security Information
Qualifier
ISA07
ISA11
270 Notes
Loop
Repeat
270 5010
00, 03
Authorization
Authorization
Information
Qualifier
Usage
Reg.
ST01
Version/Release/
Industry Identifier Code
AN
1-12
TRANSACTION SET
HEADER
Transaction Set
Identifier Code
ID
3-3
270
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ST02
Transaction Set Control

Number
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
AN
4-9
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
ST02

Number
AN
ST03
Implementation
Convention Reference AN
4-9
R
005010X279
BHT02
BEGINNING OF
HIERARCHICAL
TRANSACTION
Hierarchical Structure
Code
Transaction Set Purpose
Code
BHT03
Reference Identification
AN
1-30
BHT04
BHT05
Date
Time
DT
TM
8-8
4-8
R
R
BHT06
Transaction Type Code
ID
2-2
HL
INFORMATION
SOURCE LEVEL
AN
1-12
AN
1-12
N/U
BHT
BHT01
1-35
ID
4-4
ID
2-2
1-50
BHT04
BHT05
Reference Identification AN
Transaction Set
Creation Date
DT
Time
TM
8-8
4-8
R
R
BHT06
Transaction Type Code
2-2
HL
INFORMATION
SOURCE LEVEL
BHT
0022
ID
4-4
BHT01
ID
2-2
BHT02
BHT03
01,13,36
BEGINNING OF
HIERARCHICAL
TRANSACTION
Code
Transaction Set
Purpose Code
New Element
0022
01,13
Code Removed
Increase
CCYYMMDD
CCYYMMDD
RT, RU
HL01
HL02
Hierarchical ID Number
Hierarchical Parent ID
Number
2000A
>1
RT
ID
AN
1-12
HL02
Number
AN
1-12
N/U
HL03
Hierarchical Level Code
ID
1-2
HL04
Hierarchical Child Code
ID
1-1
INFORMATION
SOURCE NAME
Entity Identifier Code
Entity Type Qualifier
Name Last or
Organization Name
ID
ID
1
2-3
1-1
R
R
R
AN
1-60
AN
AN
AN
AN
1-35
1-25
1-10
1-10
S
S
N/U
S
HL01
2000A
>1
20
HL03
ID
1-2
20
1
HL04

INFORMATION
SOURCE NAME
Name Last or
Organization Name
NM1
NM101
NM102
NM103
ID
1-1
ID
ID
1
2-3
1-1
R
R
R
2100A
1
2B,36,GP,P5,PR
1,2
NM1
NM101
NM102
AN
1-35
NM103
AN
AN
AN
AN
1-25
1-25
1-10
1-10
S
S
N/U
S
NM104
NM105
NM106
NM107
NM108
NM109
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Qualifier
Identification Code
ID
AN
1-2
2-80
R
R
NM108
NM109
NM110
NM111
Entity Relationship Code

ID
ID
2-2
2-3
N/U
N/U
NM110
NM111
NM104
NM105
NM106
NM107
HL
Page 2 of 20
INFORMATION
RECEIVER LEVEL
NM112
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Qualifier
Identification Code
Entity Relationship
Code
Name Last or
Organization Name
HL
INFORMATION
RECEIVER LEVEL
24,46,FI,NI,PI,XV,XX
2000B
>1
Code Removed
New Situational Rule
2100A
1
2B,36,GP,P5,PR
1,2
24,46,FI, NI,PI,XV,XX
ID
AN
1-2
2-80
R
R
ID
ID
2-2
2-3
N/U
N/U
AN
1-60
N/U
2000B
New Note
Increase
Usage Change
Increase;
New Code Descriptions
>1
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
AN
1/12
HL02
Number
AN
1/12
HL03
ID
1/2
HL01
Usage
Reg.
270 Notes
Loop
Loop
Repeat
270 5010
AN
1-12
HL02
Number
AN
1-12
HL03
ID
1-2
HL04
ID
1-1
INFORMATION
RECEIVER NAME
Name Last or
Organization Name
ID
ID
1
2-3
1-1
R
R
R
AN
1-60
AN
AN
AN
AN
1-35
1-25
1-10
1-10
S
S
N/U
S
HL01
21
21
1
HL04
ID
1/1
ID
ID
1
2/3
1/1
R
R
R
AN
1/35
NM103
AN
AN
AN
AN
1/25
1/25
1-10
1-10
S
S
N/U
S
NM104
NM105
NM106
NM107
NM108
NM109
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Qualifier
Identification Code
ID
AN
1-2
2-80
R
R
NM110
NM111

ID
ID
2-2
2-3
N/U
N/U
INFORMATION
RECEIVER NAME
Name Last or
Organization Name
NM1
NM101
NM102
NM103
NM104
NM105
NM106
NM107
INFORMATION
RECEIVER
ADDITIONAL
IDENTIFICATION
REF
REF01
Qualifier
ID
2-3
REF04
N3
N301
N302
INFORMATION
RECEIVER ADDRESS
Address Information
Address Information
N4
N401
INFORMATION
RECEIVER CITY/
STATE/ ZIPCODE
City Name
AN
1
2-30
S
R
N402
N403
State or Province Code

Postal Code
ID
ID
2-2
3-15
R
R
AN
AN
AN
AN
1-30
1-80
1
1-55
1-55
1
1P,2B,36,80,FA,GP,P5,PR
1, 2
24,34,FI,PI,PP,
SV,XV, XX
NM1
NM101
NM102
NM112
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Qualifier
Identification Code
Entity Relationship
Code
Name Last or
Organization Name
REF
INFORMATION
RECEIVER
ADDITIONAL
IDENTIFICATION
REF01
Qualifier
NM108
NM109
NM110
NM111
2100B
0B, 1C, 1D, 1J, 4A, CT,EL,
EO, HPI, JD, N5, N7,
Q4,SY,TJ
Description
REFERENCE
IDENTIFIER
REF02
REF03
2100B
R
S
REF02
REF03
N/U
REF04
S
R
S
2100B
2100B
Values
2100B
1
1P,2B,36,80,FA, GP, P5, PR
1, 2
Increase
Usage Change
New Situational Rule;
Increase
24,34,FI, PI,PP, SV, XV, XX

ID
AN
1-2
2-80
R
R
ID
ID
2-2
2-3
N/U
N/U
AN
1-60
N/U
ID
2-3
Description
AN
REFERENCE
IDENTIFIER
1-50
1-80
R
S

2100B
0B, 1C, 1D, 1J, 4A, CT, EL,
EO, HPI, JD, N5, N7, Q4, SY,
TJ
New Note;
New Code Description
New Situational rule
N/U
N3
N301
N302
INFORMATION
RECEIVER ADDRESS
Address Information
Address Information
1
1-55
1-55
S
R
S
2100B
AN
AN
N4
N401
INFORMATION
RECEIVER
CITY/STATE/ ZIP
CODE
City Name
1
2-30
S
R
2100B
AN
N402
N403

Postal Code
ID
ID
2-2
3-15
S
S
Page 3 of 20
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
N404
N405
N406
Country Code
Location Qualifier
Location Qualifier
ID
ID
AN
2-3
1-2
1-30
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
ID
ID
AN
2-3
1-2
1-30
S
N/U
N/U
N407
Country Code
Location Qualifier
Location Qualifier
Country Subdivision
Code
ID
1-3
PER
INFORMATION
RECEIVER CONTACT
INFORMATION
PRV
INFORMATION
RECEIVER PROVIDER
INFORMATION
270 4010A1
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
S
N/U
N/U
N404
N405
N406
New Situational rule;

New Element
Segment Deleted
PER
PER01
PER02
INFORMATION
RECEIVER CONTACT
INFORMATION
Contact Function Code
Name
Communication Number
Qualifier
ID
AN
3
2-2
1-60
S
R
S
ID
2-2
Qualifier
AN
1-80
ID
2-2
Qualifier
AN
1-80
ID
2-2
AN
1-80
PER09
Contact Inquiry
Reference
AN
1-20
N/U
PRV
INFORMATION
RECEIVER PROVIDER
INFORMATION
PER03
PER04
PER05
2100B
IC
ED, EM, FX, TE
ED, EM, EX, FX, TE

AAABBBCCCC
PER06
PER07
ED, EM, EX, FX, TE

AAABBBCCCC
PER08
2100B
ID
1-3
PRV02
Provider Code
Qualifier
AD, AT, BI, CO, CV, H, HH,

LA, OT, P1, P2, PC, PE, R,
RF, SB, SK, SU
ID
2-3
ZZ
PRV03
AN
1-30
PRV04
ID
2-2
N/U
PRV01
PRV06
PROVIDER SPECIALTY
INFORMATION
Provider Organization
Code
HL
SUBSCRIBER LEVEL
HL01
Number
PRV05
HL02
N/U
ID
3-3
N/U
AN
1-12
AN
1-12
2000C
>1
PRV01
PRV02
Provider Code
Qualifier
ID
1-3
ID
2-3
PRV03
1-50
PRV04
2-2
N/U
PRV05
PRV06
PROVIDER
SPECIALTY
INFORMATION
Code
HL
SUBSCRIBER LEVEL
HL01
HL02
Number
ID
1-2
HL03
HL04
ID
1-1
HL04
ID

Code Removed/Added
Increase
N/U
ID
3-3
N/U
AN
1-12
AN
1-12
ID
1-2
ID
1-1
2000C
>1
22
0, 1
Page 4 of 20

RF, SB, SK, SU
PXC
22
HL03
2100B
0, 1
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
TRN
TRN01
SUBSCRIBER TRACE
NUMBER
Trace Type Code
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
ID
2
1-2
S
R
2000C
AN
1-30
TRN02
TRN03
Originating Company
Identifier
AN
10-10
TRN03
TRN04
AN
1-30
TRN04
NM1
NM101
NM102
SUBSCRIBER NAME
Name Last or
Organization Name
ID
ID
1
2-3
1-1
R
R
R
AN
1-35
NM103
AN
AN
AN
AN
1-25
1-25
1-10
1-10
S
S
N/U
S
NM104
NM105
NM106
NM107
NM108
NM109
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Qualifier
Identification Code
ID
AN
1-2
2-80
S
S
NM108
NM109
NM110
NM111

ID
ID
2-2
2-3
N/U
N/U
NM110
NM111
TRN
TRN01
SUBSCRIBER TRACE
NUMBER
Trace Type Code
ID
2
1-2
S
R
AN
1-50
AN
10-10
1-50
ID
ID
1
2-3
1-1
R
R
R
AN
1-60
AN
AN
AN
AN
1-35
1-25
1-10
1-10
S
S
N/U
S
ID
AN
1-2
2-80
S
S
ID
ID
2-2
2-3
N/U
N/U
AN
1-60
N/U
2000C
1
Increase
TRN02
NM103
NM104
NM105
NM106
NM107
REF01
Qualifier
1
IL
1
NM1
NM101
NM102
2100C
SUBSCRIBER NAME
Name Last or
Organization Name
NM112
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Qualifier
Identification Code
Entity Relationship
Code
Name Last or
Organization Name
REF
SUBSCRIBER
ADDITIONAL
IDENTIFICATION
Qualifier
MI, ZZ
SUBSCRIBER
ADDITIONAL
IDENTIFICATION
REF
2100C
Reference Identifier
Originating Company
Identifier
18, 1L, 1W, 3H, 49, 6P, A6,

CT, EA, EJ
ID
2-3
REF01
AN
AN
1-30
1-80
R
N/U
REF02
REF03
N/U
REF04

Increase
2100C
1
IL
1
Increase
Increase
II, MI
ID
2-3
Description
AN
REFERENCE
IDENTIFIER
1-50
1-80
R
N/U

Code Removed/Added
2100C
18, 1L, 1W, 3H, 6P, CT, EA,
EJ, F6, GH, HJ, IG, N6, NQ,
SY, Y4
Codes Removed: 49, A6

Codes Added: 3H, Y4
Increase
REF04
Description
REFERENCE
IDENTIFIER
N3
N301
N302
SUBSCRIBER
ADDRESS
Address Information
Address Information
N4
N401
N402
N403
N404
REF02
REF03
S
R
S
2100C
AN
AN
1
1-55
1-55
SUBSCRIBER CITY/
STATE/ ZIPE CODE
City Name
S
S
2100C
AN
1
2-30
State or Province Name

Postal Code
Country Code
ID
ID
ID
2-2
3-15
2-3
S
S
S
Page 5 of 20
N/U
N3
N301
N302
SUBSCRIBER
ADDRESS
Address Information
Address Information
1
1-55
1-55
S
R
S
2100C
AN
AN
N4
N401
SUBSCRIBER
CITY/STATE/ZIP
CODE
City Name
1
2-30
S
R
2100C
AN
N402
N403
N404
State or Province Name

Postal Code
Country Code
ID
ID
ID
2-2
3-15
2-3
S
S
S
Usage Change
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
N405
N406
Location Qualifier
Location Qualifier
ID
AN
1-2
1-30
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
ID
AN
1-2
1-30
N/U
N/U
N407
Location Qualifier
Location Qualifier
Country Subdivision
Code
ID
1-3
PRV
PROVIDER
INFORMATION
270 4010A1
PROVIDER
INFORMATION
PRV
Provider Code
PRV01
ID
1-3
N405
N406
2100C
RF, SB, SK, SU
270 Notes
Loop
Loop
Repeat
Values
270 5010
N/U
N/U
Usage
Reg.
PRV01
Provider Code
ID
1-3
New Element
2100C
9K, D3, EI, HPI, SY, TJ, ZZ

RF, SK, SU
Code Removed: SB
9K, D3, EI, HPI, PXC, SY, TJ
PRV02
Qualifier
ID
2-3
PRV02
Qualifier
ID
2-3

Code Removed: ZZ
Code Added: PXC
New Code Description: HPI
PRV03
AN
1-30
PRV03
1-50

Increase
PRV04
ID
2-2
N/U
PRV04
ID
2-2
N/U
N/U
PRV05
N/U
PRV06
PROVIDER
SPECIALTY
INFORMATION
Code
ID
3-3
N/U
2-3
1-35
1-1
1-1
S
S
S
N/U
PRV05
PRV06
PROVIDER SPECIALTY
INFORMATION
Code
ID
3-3
DMG01
DMG02
DMG03
DMG04
SUBSCRIBER
DEMOGRAPHIC
INFORMATION
Date Time Period
Format Qualifier
Date Time Period
Gender Code
Marital Status Code
ID
AN
ID
ID
2-3
1-35
1-1
1-1
S
S
S
N/U
DMG05
Race or Ethnicity Code
ID
1-1
N/U
DMG05
DMG06
DMG07
Citizenship Status Code

Country Code
Basis of Verification
Code
Quantity
ID
ID
1-2
2-3
N/U
N/U
DMG06
DMG07
ID
R
1-2
1-15
N/U
N/U
DMG08
DMG09
DMG
DMG08
DMG09
2100C
DMG
D8
F, M
DMG01
DMG02
DMG03
DMG04
DMG10
DMG11
INS
INS01
INS02
INS03
INS04
INS05
SUBSCRIBER
RELATIONSHIP
Yes/No Condition or
Response Code
Individual Relationship
Code
Maintenance Type Code
Maintenance Reason
Code
Benefit Status Code
Page 6 of 20
1-1
2100C
INS
Y
ID
INS01
18
ID
2-2
INS02
ID
3-3
N/U
INS03
ID
ID
2-3
1-1
N/U
N/U
INS04
INS05
SUBSCRIBER
DEMOGRAPHIC
INFORMATION
Date Time Period
Format Qualifier
Date Time Period
Gender Code
Marital Status Code
Composite Race or
Ethnicity Information
Citizenship Status
Code
Country Code
Code
Quantity
Code List Qualifier
Code
Industry Code
MULTIPLE BIRTH
SEQUENCE NUMBER
Yes/No Condition or
Response Code
Code
Maintenance Type
Code
Maintenance Reason
Code
Benefit Status Code
N/U
ID
AN
ID
ID
2100C
D8
F, M

New Note
18
New Note
N/U
ID
ID
1-2
2-3
N/U
N/U
ID
R
1-2
1-15
N/U
N/U
ID
AN
1-3
1-30
N/U
N/U
ID
1-1
ID
2-2
ID
3-3
N/U
ID
ID
2-3
1-1
N/U
N/U
2100C
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
INS06
MEDICARE STATUS
CODE
ID
Min.
Max.
270 4010A1
Medicare Plan Code
INS06
INS11
INS12
INS13
INS14
Consolidated Omnibus
Budget Reconciliation
Act (COBRA) Qualifying
Employment Status
Code
Student Status Code
Yes/No Condition or
Response Code
Date Time Period
Format Qualifier
Date Time Period
Confidentiality Code
City Name
INS15
INS16
INS17

Country Code
Number
INS07
INS08
INS09
INS10
ID
1-1
N/U
270 Notes
Loop
Loop
Repeat
Values
270 5010
ID
1-2
N/U
INS07
ID
ID
2-2
1-1
N/U
N/U
INS08
INS09
ID
1-1
N/U
INS10
ID
AN
ID
AN
2-3
1-35
1-1
2-30
N/U
N/U
N/U
N/U
INS11
INS12
INS13
INS14
Act (COBRA)
Qualifying
Employment Status
Code
Student Status Code
Yes/No Condition or
Response Code
Date Time Period
Format Qualifier
Date Time Period
City Name
ID
ID
N0
2-2
2-3
1-9
N/U
N/U
R
INS15
INS16
INS17

Country Code
Number
HI
HI01
HI01 - 1
HI01 - 2
HI01 - 3
HI01 - 4
HI01 - 5
HI01 - 6
HI01 - 7
HI01 - 8
HI01 - 9
HI02
HI02 - 1
HI02 - 2
HI02 - 3
HI02 - 4
HI02 - 5
HI02 - 6
HI02 - 7
HI02 - 8
HI02 - 9
HI03
Page 7 of 20
Usage
Reg.
SUBSCRIBER
HEALTH CARE
DIAGNOSIS CODE
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
N/U
ID
1-2
N/U
ID
ID
2-2
1-1
N/U
N/U
ID
1-1
N/U
ID
AN
ID
AN
2-3
1-35
1-1
2-30
N/U
N/U
N/U
N/U
ID
ID
N0
2-2
2-3
1-9
N/U
N/U
R
New Segment
2100C
R
ABK, BK
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
270 4010A1
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
HI03 - 1
HI03 - 2
HI03 - 3
HI03 - 4
HI03 - 5
HI03 - 6
HI03 - 7
HI03 - 8
HI03 - 9
HI04
HI04 - 1
HI04 - 2
HI04 - 3
HI04 - 4
HI04 - 5
HI04 - 6
HI04 - 7
HI04 - 8
HI04 - 9
HI05
HI05 - 1
HI05 - 2
HI05 - 3
HI05 - 4
HI05 - 5
HI05 - 6
HI05 - 7
HI05 - 8
HI05 - 9
HI06
HI06 - 1
HI06 - 2
HI06 - 3
HI06 - 4
HI06 - 5
HI06 - 6
HI06 - 7
HI06 - 8
HI06 - 9
Page 8 of 20
Min.
Max.
Code List Qualifier

Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
ABF, BF
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
HI12
DTP
SUBSCRIBER DATE
DTP01
ID
DTP02
Date Time Qualifier

Date Time Period
Format Qualifier
ID
2-3
DTP03
Date Time Period
AN
1-35
EQ
SUBSCIBER
ELIGIBILITY/BENEFIT
INQUIRY
INFORMATION
HI07 - 1
HI07 - 2
HI07 - 3
HI07 - 4
HI07 - 5
HI07 - 6
HI07 - 7
HI07 - 8
HI07 - 9
HI08
HI08 - 1
HI08 - 2
HI08 - 3
HI08 - 4
HI08 - 5
HI08 - 6
HI08 - 7
HI08 - 8
HI08 - 9
HI09
HI10
HI11
DTP
SUBSCRIBER DATE
Date/Time Qualifier
Date Time Period
Format Qualifier
3-3
270 Notes
Loop
Loop
Repeat
2100C
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
N/U
N/U
N/U
N/U
3-3
2100C
102, 307, 435, 472
DTP02
DTP03
Date Time Period
EQ
SUBSCRIBER
ELIGIBILITY/ BENEFIT
INQUIRY
INFORMATION
Page 9 of 20
ID
102, 291
D8, RD8
ID
AN
2-3
1-35
R
CCYYMMDD, CCYYMMDDCCYYMMDD
2110C
Values
270 5010
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
HEALTH CARE CODE
INFORMATION
HEALTH CARE CODE
INFORMATION
HEALTH CARE CODE
INFORMATION
HI07
DTP01
Usage
Reg.
99
Code Added
Codes Removed
D8, RD8
2110C
99
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
270 4010A1
Min.
Max.
Usage
Reg.
Service Type Code
ID
1-2
COMPOSITE MEDICAL
PROCEDURE
IDENTIFIER
Product/Service ID
Qualifier
Product/Service ID
Procedure Modifier
Procedure Modifier
Procedure Modifier
Procedure Modifier
Description
ID
AN
AN
AN
AN
AN
AN
2-2
1-48
2-2
2-2
2-2
2-2
1-80
R
R
S
S
S
S
N/U
EQ03
Coverage Level Code
ID
3-3
EQ04
Insurance Type Code
ID
1-3
EQ02
EQ02 - 1
EQ02 - 2
EQ02 - 3
EQ02 - 4
EQ02 - 5
EQ02 - 6
EQ02 - 7
Loop
Values
270 5010
1, 2, 3, 4, 5, 6, 7, 8, 9,10,
11,12,13, 14, 15, 16, 17, 18,
19, 20, 21, 22, 23, 24, 25, 26,
27, 28, 30, 32, 33, 34, 35, 36,
37, 38, 39, 40, 41, 42, 43, 44,
45, 46, 47, 48, 49, 50, 51, 52,
53, 54, 55, 56, 57, 58, 59, 60,
61, 62, 63, 64, 65, 66, 67, 68,
69, 70, 71, 72, 73, 74, 75, 76,
77, 78, 79, 80, 81, 82, 83, 84,
85, 86, 87, 88, 89, 90, 91, 92,
93, 94, 95, 96, 97, 98, 99, A0,
A1, A2, A3, A4, A5, A6, A7,
A8, A9, AA, AB, AC, AD, AE,
AF, AG, AH, AI , AJ, AK, AL,
AM, AN ,AO, AQ, AR, BA,BB,
BC, BD, BE, BF, BG, BH, BI,
BJ, BK, BL, BM, BN, BP, BQ,
BR, BS
EQ01
270 Notes
Loop
Repeat
1, 2, 3, 4, 5, 6, 7, 8, 9,10,
11,12,13, 14, 15, 16, 17, 18,
19, 20, 21, 22, 23, 24, 25, 26,
27, 28, 30, 32, 33, 34, 35, 36,
37, 38, 39, 40, 41, 42, 43, 44,
45, 46, 47, 48, 49, 50, 51, 52,
53, 54, 55, 56, 57, 58, 59, 60,
61, 62, 63, 64, 65, 66, 67, 68,
69, 70, 71, 72, 73, 74, 75, 76,
77, 78, 79, 80, 81, 82, 83, 84,
85, 86, 87, 88, 89, 90, 91, 92,
93, 94, 95, 96, 97, 98, 99, A0,
A1, A2, A3, A4, A5, A6, A7,
AM, AN ,AO, AQ, AR, B1, B2,
B3, BA,BB, BC, BD, BE, BF,
BG, BH, BI, BJ, BK, BL, BM,
BN, BP, BQ, BR, BS, BT, BU,
BV, BW, BX, BY, BZ, C1, CA,
CB, CC, CD, CE, CF, CG, CH,
CI, CJ, CK, CL, CM, CN, CO,
CP, CQ, DG, DM, DS, GF, GN,
GY, IC, MH, NI, ON, PT, PU,
RN, RT, TC, TN, UC
EQ01
ID
1-2
S
EQ02 - 1
EQ02 - 2
EQ02 - 3
EQ02 - 4
EQ02 - 5
EQ02 - 6
EQ02 - 7
EQ02 - 8
COMPOSITE MEDICAL
PROCEDURE
IDENTIFIER
Product/Service ID
Qualifier
Product/Service ID
Procedure Modifier
Procedure Modifier
Procedure Modifier
Procedure Modifier
Description
Product/Service ID
ID
AN
AN
AN
AN
AN
AN
AN
2-2
1-48
2-2
2-2
2-2
2-2
1-80
1-48
R
R
S
S
S
S
N/U
N/U
EQ03
Coverage Level Code
ID
3-3
EQ04
Insurance Type Code
ID
1-3
N/U
EQ05
COMPOSITE
DIAGNOSIS CODE
POINTER
EQ02
AD, CJ, HC, ID, IV, N4, ZZ
CHD, DEP, ECH, EMP, ESP,

FAM, IND, SPC, SPO
AP, C1, CO, GP, HM, HN, IP,
MA, MB, MC, PR, PS, SP, WC
Service Type Code

Many New Codes Added;
New Notes
S

New Note
FAM

Codes Removed
New Element
S
New Element
EQ05 - 1
Page 10 of 20
Diagnosis Code Pointer N0
1-2
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
New Element
EQ05 - 2
1-2
EQ05 - 3
1-2
EQ05 - 4
1-2
New Element
New Element
AMT
SUBSCRIBER SPEND
DOWN AMOUNT
2110C
AMT
SUBSCRIBER SPEND
DOWN AMOUNT
2110C
AMT01
AMT02
Amount Qualifier Code

Monetary Amount
ID
R
1-3
1-18
R
N/U
AMT01
AMT02

Monetary Amount
ID
R
1-3
1-18
R
R
AMT03
Credit/Debit Flag Code
ID
1-1
N/U
AMT03
ID
1-1
N/U
AMT
SUBSCRIBER SPEND
DOWN TOTAL BILLED
AMOUNT
AMT01
AMT02

Monetary Amount
AMT03
Usage Change
New Segment
1
ID
R
1-3
1-18
R
R
ID
1-1
N/U
SUBSCRIBER
ELIGIBILITY/BENEFIT
ADDITIONAL INQUIRY
INFORMATION
Code List Qualifier
Code
10
ID
1-3
2110C
PB
III
SUBSCRIBER
ADDITIONAL INQUIRY
INFORMATION
III01
Code List Qualifier Code
III09
Industry Code
Code Category
Free-Form Message
Text
Quantity
COMPOSITE UNIT OF
MEASURE
Surface/Layer/Position
Code
Code
Code
REF
SUBSRIBER
ADDITIONAL
INFORMATION
III02
III03
III04
III05
III06
III07
III08
Page 11 of 20
ID
10
1-3
2110C
III
BF, BK, ZZ
If Ill01 = BK or BF: use
diagnosis code from code
source 131;
If III01 = ZZ: 11, 12, 21, 22,
23, 24, 25, 26, 31, 32, 33, 34,
41, 42, 50, 51, 52, 53, 54, 55,
56, 60, 61, 62, 65, 71, 72, 81,
99
III01
ID
2-2
N/U
III07
ID
2-2
N/U
III08
ID
2-2
N/U
III09
Industry Code
Code Category
Free-Form Message
Text
Quantity
COMPOSITE UNIT OF
MEASURE
Code
Code
Code
REF
SUBSCRIBER
ADDITIONAL
INFORMATION
1-30
2-2
R
N/U
AN
R
1-264
1-15
N/U
N/U
III04
III05
N/U
III06
2110C
Codes Removed
ZZ
Codes Added;
AN
ID
2110C
III02
III03
AN
ID
1-30
2-2
R
N/U
AN
R
1-264
1-15
N/U
N/U
01, 03, 04, 05, 06, 07, 08, 11,

12, 13, 14, 15, 20, 21, 22, 23,
24, 25, 26, 31, 32, 33, 34, 41,
42, 49, 50, 51, 52, 53, 54, 55,
56, 57, 60, 61, 62, 65, 71, 72,
81, 99
N/U
ID
2-2
N/U
ID
2-2
N/U
ID
2-2
N/U
2110C
8/11/200911:34 AM
4010A1
Element
Identifier
Description
REF01
Qualifier
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
Qualifier
ID
Min.
Max.
270 4010A1
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
9F,G1
ID
2-3
REF01
AN
AN
1-30
1-80
R
N/U
REF02
REF03
N/U
REF04
9F, G1
ID
2-3
Description
AN
REFERENCE
IDENTIFIER
1-50
1-80
R
N/U
Increase
REF04
Description
REFERENCE
IDENTIFIER
DTP
SUBSCRIBER/ELIGIBIL
ITY BENEFIT DATE
REF02
REF03
2110C
DTP
SUBSCRIBER
DATE
N/U
3-3
2110C
307, 435, 472
291
ID
DTP02
Date/Time Qualifier
Date Time Period
Format Qualifier
ID
2-3
DTP02
DTP03
Date Time Period
AN
1-35
DTP03
Date Time Qualifier

Date Time Period
Format Qualifier
Date Time Period
Format Qualifier
HL
DEPENDENT LEVEL
HL
DEPENDENT LEVEL
HL01
Number
AN
1-12
HL01
AN
1-12
HL02
Number
HL03
DTP01
HL02
3-3
DTP01
D8, RD8
2000D
>1
ID
ID
2-3
AN
1-35
AN
1-12
AN
1-12
ID
1-2
HL04
ID
1-1
TRN
TRN01
DEPENDENT TRACE
NUMBER
Trace Type Code
ID
2
1-2
S
R
2000D
>1
23
23
HL03
ID
1-2
HL04
ID
1-1
TRN
TRN01
DEPENDENT TRACE
NUMBER
Trace Type Code
ID
2
1-2
S
R
AN
1-30
TRN02
TRN03
Originating Company
Identifier
AN
10-10
TRN04
AN
1-30
NM1
NM101
NM102
DEPENDENT NAME
Name Last or
Organization Name
ID
ID
1
2-3
1-1
R
R
R
AN
1-35
NM103
AN
AN
AN
AN
1-25
1-25
1-10
1-10
S
S
N/U
S
NM104
NM105
NM106
NM107
NM108
NM109
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Qualifier
Identification Code
ID
AN
1-2
2-80
N/U
N/U
NM108
NM109
NM110
NM111

ID
ID
2-2
2-3
N/U
N/U
NM110
NM111
2000D
1
Code Added
Codes Removed
D8, RD8
2000D
1
Increase
TRN02
NM103
NM104
NM105
NM106
NM107
Page 12 of 20
2100D
1
03
1
1-50
TRN03
Originating Company
Identifier
AN
10-10
TRN04
1-50
ID
ID
1
2-3
1-1
R
R
R
AN
1-60
AN
AN
AN
AN
1-35
1-25
1-10
1-10
S
S
N/U
S
ID
AN
1-2
2-80
N/U
N/U
ID
ID
2-2
2-3
N/U
N/U
NM1
NM101
NM102
DEPENDENT NAME
Name Last or
Organization Name
Name First
Name Middle
Name Prefix
Name Suffix
Identification Code
Qualifier
Identification Code
Entity Relationship
Code
Increase;
2100D
1
03
1
Increase;
Increase;
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
NM112
Name Last or
Organization Name
REF
DEPENDENT
ADDITIONAL
IDENTIFICATION
Qualifier
ID
Min.
Max.
270 4010A1
DEPENDENT
ADDITIONAL
IDENTIFICATION
REF
REF01
Qualifier
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
2100D
18,1L,1W,49,6P,A6,CT,EA,EJ
,F6,CJ,HC,ID,IV,N4,ZZ
ID
2-3
REF01
AN
AN
1-30
1-80
R
N/U
REF02
REF03
N/U
REF04
AN
1-60
N/U
ID
2-3
Description
AN
REFERENCE
IDENTIFIER
1-50
1-80
R
N/U
2100D
18, 1L, 6P, CT, EA, EJ, F6,
GH, HJ, IF, IG, MRC, N6, SY,
Y4
Code Removed: A6
Codes Added: MRC, Y4
Increase
REF04
Description
REFERENCE
IDENTIFIER
N3
N301
N302
DEPENDENT
ADDRESS
Address Information
Address Information
N4
N401
N402
N403
N404
N405
N406
REF02
REF03
S
R
S
2100D
AN
AN
1
1-55
1-55
DEPENDENT CITY/
STATE/ ZIP CODE
City Name
S
S
2100D
AN
1
2-30

Postal Code
Country Code
Location Qualifier
Location Qualifier
ID
ID
ID
ID
AN
2-2
3-15
2-3
1-2
1-30
S
S
S
N/U
N/U
PROVIDER
INFORMATION
PRV
PRV01
Provider Code
PRV02
Qualifier
ID
2-3
PRV03
AN
1-30
PRV04
ID
2-2
PRV05
PRV06
PROVIDER
SPECIALITY
INFORMATION
Code
DMG
DEPENDENT
DEMOGRAPHIC
INFORMATION
Page 13 of 20
ID
ID
1-3
3-3
N3
N301
N302
DEPENDENT
ADDRESS
Address Information
Address Information
1
1-55
1-55
S
R
S
2100D
AN
AN
N4
N401
DEPENDENT
CITY/STATE/ZIP
CODE
City Name
1
2-30
S
R
2100D
AN
ID
ID
ID
ID
AN
2-2
3-15
2-3
1-2
1-30
S
S
S
N/U
N/U
ID
1-3
N407

Postal Code
Country Code
Location Qualifier
Location Qualifier
Country Subdivision
Code
PRV
PROVIDER
INFORMATION
N402
N403
N404
N405
N406
2100D
RF, SB, SK, SU
N/U
Provider Code
PRV02
Qualifier
ID
2-3
PRV03
1-50
N/U
PRV04
2-2
N/U
N/U
PRV05
N/U
PRV06
PROVIDER
SPECIALITY
INFORMATION
Code
DMG
DEPENDENT
DEMOGRAPHIC
INFORMATION
2100D
Usage Change
New Element
PRV01
ID
ID
1-3
2100D
RF, SK, SU
9K, D3, EI, HPI,PXC, SY, TJ

Code Removed: SB
Code Removed: ZZ
Code Added: PXC;
Increase
N/U
ID
3-3
N/U
2100D
8/11/200911:34 AM
4010A1
Description
DMG01
DMG02
DMG03
DMG04
Date Time Period

Format Qualifier
Date Time Period
Gender Code
Marital Status Code
ID
AN
ID
ID
2-3
1-35
1-1
1-1
S
S
S
N/U
DMG05
Race or Ethnicity Code
ID
1-1
N/U
DMG05
DMG06
DMG07
Citizenship Status Code

Country Code
Code
Quantity
ID
ID
1-2
2-3
N/U
N/U
DMG06
DMG07
ID
R
1-2
1-15
N/U
N/U
DMG08
DMG09
ID
Min.
Max.
Usage
Reg.
5010
Element
Identifier
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
DMG08
DMG09
INS01
DEPENDENT
RELATIONSHIP
Yes/No Condition or
Response Code
Code
CCYYMMDD
F, M
DMG01
DMG02
DMG03
DMG04
2100D
INS
N
ID
1-1
ID
2-2
INS02
ID
3-3
N/U
INS03
INS04
INS05
Maintenance Type Code

Maintenance Reason
Code
Benefit Status Code
ID
ID
2-3
1-1
N/U
N/U
INS04
INS05
INS06
Medicare Plan Code
ID
1-1
N/U
INS06
INS02
INS03
INS11
INS12
INS13
INS14
Act (COBRA) Qualifying
Employment Status
Code
Student Status Code
Yes/No Condition or
Response Code
Date Time Period
Format Qualifier
Date Time Period
City Name
INS15
INS16
INS17

Country Code
Number
INS07
INS08
INS09
INS10
INS01
01, 19, 34
Date Time Period

Format Qualifier
Date Time Period
Gender Code
Marital Status Code
Composite Race or
Ethnicity Code
Citizenship Status
Code
Country Code
Code
Quantity
Code List Qualifier
Code
Industry Code
DEPENDENT
RELATIONSHIP
Yes/No Condition or
Response Code
Code
Maintenance Type
Code
Maintenance Reason
Code
Benefit Status Code
MEDICARE STATUS
CODE
ID
1-2
N/U
INS07
ID
ID
2-2
1-1
N/U
N/U
INS08
INS09
ID
1-1
N/U
INS10
ID
AN
ID
AN
2-3
1-35
1-1
2-30
N/U
N/U
N/U
N/U
INS11
INS12
INS13
INS14
Act (COBRA)
Qualifying
Employment Status
Code
Student Status Code
Yes/No Condition or
Response Code
Date Time Period
Format Qualifier
Date Time Period
City Name
ID
ID
N0
2-2
2-3
1-9
N/U
N/U
S
INS15
INS16
INS17

Country Code
Number
HI
DEPENDENT HEALTH
CARE DIAGNOSIS
CODE
HEALTH CARE CODE
INFORMATION
HI01
Page 14 of 20
270 Notes
Loop
Loop
Repeat
Values
270 5010
D8
DMG10
DMG11
INS
Usage
Reg.
ID
AN
ID
ID
2-3
1-35
1-1
1-1
S
S
S
N/U
D8
CCYYMMDD
F, M

N/U
ID
ID
1-2
2-3
N/U
N/U
ID
R
1-2
1-15
N/U
N/U
ID
AN
1-3
1-30
N/U
N/U
ID
1-1
ID
2-2
ID
3-3
N/U
ID
ID
2-3
1-1
N/U
N/U
2100D
N
01, 19, 34
N/U
ID
1-2
N/U
ID
ID
2-2
1-1
N/U
N/U
ID
1-1
N/U
ID
AN
ID
AN
2-3
1-35
1-1
2-30
N/U
N/U
N/U
N/U
ID
ID
N0
2-2
2-3
1-9
N/U
N/U
S

New Segment
2100D
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
270 4010A1
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
HI01 - 1
HI01 - 2
HI01 - 3
HI01 - 4
HI01 - 5
HI01 - 6
HI01 - 7
HI01 - 8
HI01 - 9
HI02
HI02 - 1
HI02 - 2
HI02 - 3
HI02 - 4
HI02 - 5
HI02 - 6
HI02 - 7
HI02 - 8
HI02 - 9
HI03
HI03 - 1
HI03 - 2
HI03 - 3
HI03 - 4
HI03 - 5
HI03 - 6
HI03 - 7
HI03 - 8
HI03 - 9
HI04
HI04 - 1
HI04 - 2
HI04 - 3
HI04 - 4
HI04 - 5
HI04 - 6
HI04 - 7
HI04 - 8
HI04 - 9
Page 15 of 20
Min.
Max.
Code List Qualifier

Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
ABK, BK
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
ABF, BF
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
270 4010A1
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
HI05
HI05 - 1
HI05 - 2
HI05 - 3
HI05 - 4
HI05 - 5
HI05 - 6
HI05 - 7
HI05 - 8
HI05 - 9
HI06
HI06 - 1
HI06 - 2
HI06 - 3
HI06 - 4
HI06 - 5
HI06 - 6
HI06 - 7
HI06 - 8
HI06 - 9
HI07
HI07 - 1
HI07 - 2
HI07 - 3
HI07 - 4
HI07 - 5
HI07 - 6
HI07 - 7
HI07 - 8
HI07 - 9
HI08
HI08 - 1
HI08 - 2
HI08 - 3
HI08 - 4
HI08 - 5
HI08 - 6
HI08 - 7
HI08 - 8
Page 16 of 20
Min.
Max.
HEALTH CARE CODE

INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
Code List Qualifier
Code
Industry Code
Date Time Period
Format Qualifier
Date Time Period
Monetary Amount
Quantity
Version Identifier
Industry Code
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
ID
1-1
N/U
S
ABF, BF
S
ABF, BF
ID
AN
1-3
1-30
R
R
ID
AN
R
R
AN
AN
2-3
1-35
1-18
1-15
1-30
1-30
N/U
N/U
N/U
N/U
N/U
N/U
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
HI12
DTP
DEPENDENT DATE
DTP01
DTP02
Date Time Qualifier

Date Time Period
Format Qualifier
DTP03
Date Time Period
EQ
DEPENDENT
ELIGIBILITY/BENEFIT
INQUIRY
HI09
HI10
HI11
DEPENDENT DATE
270 Notes
Loop
Loop
Repeat
2100D
ID
1-1
N/U
N/U
N/U
N/U
N/U
ID
3-3
ID
2-3
AN
1-35
2100D
102,307,435,472
ID
3-3
DTP02
Date/Time Qualifier
Date Time Period
Format Qualifier
ID
2-3
DTP03
Date Time Period
AN
1-35
EQ
DEPENDENT
INQUIRY
INFORMATION
DTP01
Page 17 of 20
102, 291
D8, RD8
2110D
Values
270 5010
Yes/No Condition or
Response Code
HEALTH CARE CODE
INFORMATION
HEALTH CARE CODE
INFORMATION
HEALTH CARE CODE
INFORMATION
HEALTH CARE CODE
INFORMATION
HI08 - 9
DTP
Usage
Reg.
99
Codes Removed;
Code Added;
Note Added
D8, RD8
2110D
99
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
270 4010A1
Min.
Max.
Usage
Reg.
Service Type Code
ID
1-2
COMPOSITE MEDICAL
PROCEDURE
IDENTIFIER
Product/Service ID
Qualifier
Product/Service ID
Procedure Modifier
Procedure Modifier
Procedure Modifier
Procedure Modifier
Description
ID
AN
AN
AN
AN
AN
AN
2-2
1-48
2-2
2-2
2-2
2-2
1-80
R
R
S
S
S
S
N/U
EQ03
Coverage Level Code
ID
3-3
EQ04
Insurance Type Code
ID
1-3
EQ02
EQ02 - 1
EQ02 - 2
EQ02 - 3
EQ02 - 4
EQ02 - 5
EQ02 - 6
EQ02 - 7
Loop
Values
270 5010
1, 2, 3, 4, 5, 6, 7, 8, 9,10,
11,12, 13, 14, 15, 16, 17, 18,
19, 20, 21, 22, 23, 24, 25, 26,
27, 28, 30, 32, 33, 34, 35, 36,
37, 38, 39, 40, 41, 42, 43, 44,
45, 46, 47, 48, 49, 50, 51, 52,
53, 54, 55, 56, 57, 58, 59, 60,
61, 62, 63, 64, 65, 66, 67, 68,
69, 70, 71, 72, 73, 74, 75, 76,
77, 78, 79, 80, 81, 82, 83, 84,
85, 86, 87, 88, 89, 90, 91, 92,
93, 94, 95, 96, 97, 98, 99, A0,
A1, A2, A3, A4, A5, A6, A7,
AM, AN ,AO, AQ, AR, BA,BB,
BR, BS
EQ01
270 Notes
Loop
Repeat
1, 2, 3, 4, 5, 6, 7, 8, 9,10,
11,12,13, 14, 15, 16, 17, 18,
19, 20,
21,22,23,24,25,26,27,28,30,32
,33,34,35,36,37,38,39,40,41,
42, 43, 44, 45, 46, 47, 48, 49,
50, 51, 52, 53, 54, 55, 56, 57,
58, 59, 60, 61, 62, 63, 64, 65,
66, 67, 68, 69, 70, 71, 72, 73,
74, 75, 76, 77, 78, 79, 80, 81,
82, 83, 84, 85, 86, 87, 88, 89,
90, 91, 92, 93, 94, 95, 96, 97,
98, 99, A0, A1, A2, A3, A4,
A5, A6, A7, A8, A9, AA, AB,
AC, AD, AE, AF, AG, AH, AI ,
AJ, AK, AL, AM, AN ,AO, AQ,
AR, B1, B2, B3, BA,BB, BC,
BD, BE, BF, BG, BH, BI, BJ,
BK, BL, BM, BN, BP, BQ, BR,
BS, BT, BU, BV, BW, BX, BY,
BZ, C1, CA, CB, CC, CD, CE,
CF, CG, CH, CI, CJ, CK, CL,
CM, CN ,CO, CP, CQ, DG,
DM, DS, GF, GN, GY, IC, MH,
NI, ON, PY, PU, RN, RT, TC,
TN, UC
EQ01
ID
1-2
S
EQ02 - 1
EQ02 - 2
EQ02 - 3
EQ02 - 4
EQ02 - 5
EQ02 - 6
EQ02 - 7
EQ02 - 8
COMPOSITE MEDICAL
PROCEDURE
IDENTIFIER
Product/Service ID
Qualifier
Product/Service ID
Procedure Modifier
Procedure Modifier
Procedure Modifier
Procedure Modifier
Description
Product/Service ID
ID
AN
AN
AN
AN
AN
AN
AN
2-2
1-48
2-2
2-2
2-2
2-2
1-80
1-48
R
R
S
S
S
S
N/U
N/U
EQ03
Coverage Level Code
ID
3-3
N/U
EQ04
Insurance Type Code
ID
1-3
N/U
EQ05
COMPOSITE
DIAGNOSIS CODE
POINTER
EQ02

FAM, IND, SPC, SPO
AP, C1, CO, GP, HM, IP, OT,
PR, PS, SP, WC
Service Type Code

New Code;
New Note
S
New Note
New Element
S
New Element
EQ05 - 1
Page 18 of 20
1-2
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
Usage
Reg.
270 Notes
Loop
Loop
Repeat
Values
270 5010
New Element
EQ05 - 2
1-2
EQ05 - 3
1-2
EQ05 - 4
1-2
DEPENDENT
ELIGIBILITY/BENEFIT
ADDITIONAL INQUIRY
Code List Qualifier
Code
10
1-3
New Element
New Element
III
DEPENDENT
ADDITIONAL INQUIRY
INFORMATION
III01
Code List Qualifier Code
10
1-3
2110D
III
BF, BK, ZZ
III02
III03
III04
III05
III06
III07
III08
III09
REF
REF01
Industry Code
Code Category
Free-Form Message
Text
Quantity
COMPOSITE UNIT OF
MEASURE
Code
Code
Code
DEPENDENT
ADDITIONAL
INFORMATION
Qualifier
ID
III01
If Ill01 = BK or BF, use
diagnosis code from code
source 131;
If III01 = ZZ: 11, 12, 21, 22,
23, 24, 25, 26, 31, 32, 33, 34,
41, 42, 50, 51, 52, 53, 54, 55,
56, 60, 61, 62, 65, 71, 72, 81,
99
AN
ID
1-30
2-2
R
N/U
III02
III03
AN
R
1-264
1-15
N/U
N/U
III04
III05
N/U
III06
ID
2-2
N/U
III07
ID
2-2
N/U
III08
ID
2-2
N/U
III09
ID
2-3
2110D
REF01
REF
AN
AN
1-30
1-80
R
N/U
REF02
REF03
N/U
REF04
9F,G1
Industry Code
Code Category
Free-Form Message
Text
Quantity
COMPOSITE UNIT OF
MEASURE
Code
Code
Code
ID
AN
ID
1-30
2-2
R
N/U
AN
R
1-264
1-15
N/U
N/U
ZZ
Codes Removed
01, 03, 04, 05, 06, 07, 08, 11,

12, 13, 14, 15, 20, 21, 22, 23,
24, 25, 26, 31, 32, 33, 34, 41,
42, 49, 50, 51, 52, 53, 54, 55,
56,57, 60, 61, 62, 65, 71, 72,
81, 99
Codes Added;
N/U
ID
2-2
N/U
ID
2-2
N/U
ID
2-2
N/U
ID
2-3
Description
AN
REFRENCE
IDENTIFIER
1-50
1-80
R
N/U
DEPENDENT
ADDITIONAL
INFORMATION
Qualifier
2110D
2110D
9F, G1
Increase
REF04
Description
REFERENCE
IDENTIFIER
DTP
DEPENDENT
DATE
REF02
REF03
2110D
DTP
DEPENDENT
DATE
N/U
307,435,472
ID
3-3
DTP02
Date/Time Qualifier
Date Time Period
Format Qualifier
ID
2-3
DTP03
Date Time Period
AN
1-35
DTP01
Page 19 of 20
291
ID
3-3
DTP02
Date Time Qualifier

Date Time Period
Format Qualifier
ID
2-3
DTP03
Date Time Period
AN
1-35
DTP01
D8, RD8
2110D
Code Added;
Codes Removed
D8, RD8
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
5010
Loop
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
270 4010A1
SE02
TRANSACTION SET
TRAILER
Number of Included
Segments
Number
GE
FUNCTIONAL GROUP
TRAILER
GE01
Number of Transaction
Sets Included
SE
SE01
SE
N0
1-10
SE01
AN
4-9
SE02
1-6
TRANSACTION SET
TRAILER
Number of Included
Segments
N0
Number
AN
1-10
4-9
GE
FUNCTIONAL GROUP
TRAILER
GE01
Number of Transaction
Sets Included
N0
1-6
N0
1-9
N0
1-5
N0
9-9
Must=GS06
GE02
IEA
IEA01
IEA02

INTERCHANGE
CONTROL TRAILER
Number of Included
Functional Groups
Interchange Control
Number
Page 20 of 20
N0
270 Notes
Loop
Loop
Repeat
Values
270 5010
N0
Usage
Reg.
Must=GS06
1-9
GE02
IEA
N0
1-5
IEA01
N0
9-9
IEA02
INTERCHANGE
CONTROL TRAILER
Number of Included
Functional Groups
Interchange Control
Number
8/11/200911:34 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
ISA
ISA01
ISA02
ISA03
INTERCHANGE
CONTROL HEADER
Authorization
Authorization
Information
Qualifier
ISA
2/2
AN
10/10
ID
2/2
AN
10/10
ID
2/2
AN
15/15
ISA08
ISA09
Interchange Date
ISA10
Interchange Time
Interchange Control
Standards ID
Interchange Control
Version Number
Interchange Control
Number
Acknowledgement
Requested
ISA04
ISA05
ISA06
ISA07
ISA11
ISA12
ISA13
ISA14
ISA01
ISA02
00, 01
Interchange ID
Qualifier
Interchange Sender
ID
Interchange ID
Qualifier
ID
ISA03
ISA04
01, 14, 20, 27, 28, 29, 30, 33,
ZZ
ISA05
ISA06
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
ID
2/2
AN
15/15
DT
6/6
YYMMDD
ISA09
TM
4/4
HHMM
ISA10
ISA07
ISA08
U
ID
1/1
ID
5/5
N0
9/9
ID
1/1
ISA11
00401
ISA12
ISA13
0, 1
ISA14
P, T
Usage Indicator
Component Element
Separator
ISA15
ISA16
GS
GS01
GS02
GS03
GS04
ID
FUNCTIONAL
GROUP HEADER
Code
ID
Code
AN
Code
AN
Date
DT
Time
Group Control
Number
GS05
GS06
GS08
Responsible Agency
Code
Version/ Release/
Industry Identifier
Code
ST
TRANSACTION SET
HEADER
GS07
Page 1 of 32
271 Notes
Loop
Loop
Repeat
Values
271 5010
00, 03
ID
Usage
Reg.
1/1
ISA15
1/1
ISA16
INTERCHANGE
CONTROL HEADER
Authorization
Authorization
Information
Qualifier
ID
2-2
AN
10-10
ID
2-2
10-10
2-2
15-15
2-2
15-15
6-6
YYMMDD
4-4
HHMM
1-1
ID
5-5
N0
9-9
ID
1-1
00, 03
00, 01
Security Information AN
Interchange ID
Qualifier
ID
Interchange Sender
ID
AN
Interchange ID
Qualifier
ID
ID
AN
Interchange Date
DT
Interchange Time
Repetition
Separator
Interchange Control
Version Number
Interchange Control
Number
Acknowledgement
Requested
Interchange Usage
Indicator
Component Element
Separator
TM
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
01, 14, 20, 27, 28, 29, 30, 33,

ZZ
New Element
00501
0, 1
P, T
ID
1-1
1-1
ID
2-2
AN
2-15
AN
2-15
2/2
GS01
2/15
GS02
2/15
GS03
FUNCTIONAL
GROUP HEADER
Code
Code
Application
Receiver's Code
8/8
CCYYMMDD
GS04
Date
DT
8-8
CCYYMMDD
TM
4/8
HHMM
GS05
TM
4-8
HHMM
N0
1/9
Time
Group Control
Number
N0
1-9
ID
1-2
GS
HB, HS
GS06
X
ID
1/12
GS08
Responsible Agency
Code
Version/Release/
Industry Identifier
Code
ST
TRANSACTION SET
HEADER
1/2
GS07
004010X092A1
AN
X
005010X279
AN
1-12
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Transaction Set
Identifier Code
Transaction Set
Control Number
ST01
ST02
ID
3-3
ST01
AN
4-9
ST02
ST03
BHT
BHT01
BHT02
BHT03
BHT04
BHT06
Time
Transaction Type
Code
HL
INFORMATION
SOURCE LEVEL
BHT05
HL01
HL02
HL03
HL04
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
AAA01
AAA02
R
R
BHT
0022
BHT01
11
2-2
BHT02
1-30
8-8
CCYYMMDD
BHT04
TM
4-8
HHMM
BHT05
ID
2-2
N/U
Hierarchical ID
Number
AN
Number
AN
Hierarchical Level
Code
ID
Hierarchical Child
Code
ID
AAA
1
4-4
1-12
1-12
N/U
BHT03
2000A
>1
1-1
HL
INFORMATION
SOURCE LEVEL
HL02
HL03
0,1
HL04
AAA
N, Y
ID
1-1
ID
2-2
N/U
Loop
AAA01
AAA02
3-3
AN
4-9
R
005010X279
AN
4-4
AAA04
Reject Reason Code

Follow-up Action
Code
NM1
INFORMATION
SOURCE NAME
NM101
ID
2-2
ID
1-1
2-2
R
S
8-8
CCYYMMDD
TM
4-8
HHMM
ID
2-2
N/U
1-12
1-12
N/U
1-2
1-1
2000A
>1
0,1
ID
1-1
ID
2-2
N/U
ID
2-2
ID
1-1
2000A
N, Y
04, 41, 42, 79
AAA04
NM1
INFORMATION
SOURCE NAME
NM101
ID
2-3
NM102
ID
1-1
AN
1-60
AN
1-35
C, N, P, R, S, Y
C, N, P, R, S, Y
2B,36,GP,P5,PR
ID
2-3
R
1,2
ID
1-1
NM103
AN
1-35
NM103

Name Last or
Organization Name
NM104
Name First
AN
1-25
NM104
Name First
Page 2 of 32
2100A
1
2B, 36, GP, P5, PR

Name Last or
Organization Name
NM102
Code Added
New Note
Increase
20
Reject Reason Code

Follow-up Action
Code
AAA03
2100A
New Element
0022
06, 11
1-50
Hierarchical ID
Number
AN
Number
AN
Hierarchical Level
Code
ID
Hierarchical Child
Code
ID
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
1-35
04, 41, 42, 79

AAA03
Values
271
ID
BEGINNING OF
HIERARCHICAL
TRANSACTION
Code
ID
Transaction Set
Purpose Code
ID
Reference
Identification
AN
Date
DT
BHT06
HL01
2000A
Transaction Set
Identifier Code
Transaction Set
Control Number
Implementation
Convention
Reference
Time
Transaction Type
Code
20
1-2
271 Notes
Loop
Repeat
271 5010
271
BEGINNING OF
HIERARCHICAL
TRANSACTION
Code
ID
Transaction Set
Purpose Code
ID
Reference
Identification
AN
Date
DT
Usage
Reg.
1, 2
Increase
Usage Change
Increase
8/11/200911:35 AM
4010A1
Usage
Reg.
5010
Element
Identifier
Description
ID
Min.
Max.
Element
Identifier
Description
ID
Min.
Max.
NM105
Name Middle
AN
1-25
NM105
Name Middle
AN
1-25
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
Identification Code
Qualifier
AN
1-10
NM107
Name Suffix
Identification Code
Qualifier
AN
1-10
ID
1-2
NM108
AN
2-80
NM109
NM110
Identification Code
Entity Relationship
Code
ID
1-2
Identification Code
Entity Relationship
Code
AN
2-80
ID
2-2
N/U
NM110
NM111
ID
2-2
N/U
ID
2-3
N/U
AN
1-60
N/U
Loop
Loop
Repeat
Values
271 4010A1
NM108
NM109
2-3
N/U
NM111
NM112
INFORMATION
SOURCE
ADDITIONAL
IDENTIFICATION
REF
271 Notes
Loop
Loop
Repeat
Values
271 5010
24,46,FI,NI,PI,XV,XX
ID
Usage
Reg.

Name Last or
Organization Name

24, 46, FI, NI, PI, XV, XX
Deleted Segment
2100A
18, 55
REF01
REF02
Reference
Identification Qualifier
Reference
Identification
Description
REFERENCE
INDENTIFIER
REF03
REF04
PER
PER01
INFORMATION
SOURCE CONTACT
INFORMATION
Contact Function
Code
PER02
PER03
PER04
PER05
PER06
PER07
PER08
PER09
AAA
AAA01
Page 3 of 32
Name
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Contact Inquiry
Reference
REQUEST
VALIDATION
Yes/No Condition or
Response Code
ID
2-3
AN
1-30
AN
1-80
S
N/U
2100A
PER
IC
ID
2-2
AN
1-60
PER01
PER02
ED, EM, FX, TE
ID
2-2
AN
1-80
ID
2-2
AN
1-80
ID
2-2
PER03
AAABBBCCCC
PER04
ED, EM, EX, FX, TE
PER05
AAABBBCCCC
PER06
ED, EM, EX, FX, TE
PER07
AAABBBCCCC
AN
1-80
PER08
AN
1-20
N/U
PER09
2100A
AAA
N, Y
ID
1-1
AAA01
PAYER CONTACT
INFORMATION
Contact Function
Code
Name
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Contact Inquiry
Reference
REQUEST
VALIDATION
Yes/No Condition or
Response Code
ID
2-2
AN
1-60
2100A
IC
ED, EM, TE, FX, UR
ID
2-2
AN
1-256
ID
2-2
AN
1-256
ID
2-2
AN
1-256
AN
1-20
N/U
1-1
AAABBBCCCC
ED, EM, TE, FX, EX, UR
AAABBBCCCC
ED, EM, TE, FX, EX, UR
AAABBBCCCC

Code Added
Increase
Code Added
Increase
Code Added
Increase
2100A
N, Y
ID
8/11/200911:35 AM
4010A1
Element
Identifier
Description
AAA02
Agency Qualifier
Code
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
AAA02
Agency Qualifier
Code
ID
Min.
Max.
271 4010A1
ID
2-2
Usage
Reg.
271 Notes
Loop
Loop
Repeat
271 5010
N/U
ID
2-2
N/U
ID
2-2
ID
1-1
1-12
1-12
1-2
1-1
04, 41, 42, 79, 80, T4

AAA03
AAA04
HL
HL01
HL02
HL03
HL04
Reject Reason Code

Follow-up Action
Code
2-2
ID
1-1
AAA03
1-12
HL01
1-12
HL02
C, N, P, R, S, W, X, Y
INFORMATION
RECEIVER NAME
NM1
04, 41, 42, 79, 80, T4
ID
INFORMATION
RECEIVER LEVEL
Hierarchical ID
Number
AN
Number
AN
Hierarchical Level
Code
ID
Hierarchical Child
Code
ID
AAA04
2000B
>1
HL
21
1-2
1-1
HL03
0,1
HL04
2100B
Values
Reject Reason Code

Follow-up Action
Code
New Note
C, N, P, R, S, W, X, Y
INFORMATION
RECEIVER LEVEL
Hierarchical ID
Number
AN
Number
AN
Hierarchical Level
Code
ID
Hierarchical Child
Code
ID
2000B
>1
21
0, 1
NM1
INFORMATION
RECEIVER NAME
NM101
ID
2-3
NM102

Name Last or
Organization Name
ID
1-1
AN
1-60
2100B
1P,2B,36,80,FA,GP,P5,PR
1
1P, 2B, 36, 80, FA, GP, P5,
PR
1, 2
NM101
ID
2-3
NM102

Name Last or
Organization Name
ID
1-1
AN
1-35
NM103
NM104
Name First
AN
1-25
NM104
Name First
AN
1-35

Increase
Increase
NM105
Name Middle
AN
1-25
NM105
Name Middle
AN
1-25
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
Identification Code
Qualifier
AN
1-10
NM107
AN
1-10
ID
1-2
NM108
Name Suffix
Identification Code
Qualifier
ID
1-2
AN
2-80
NM109
2-80
ID
2-2
N/U
NM110
Identification Code
Entity Relationship
Code
AN
NM110
Identification Code
Entity Relationship
Code
ID
2-2
N/U
NM111
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112

Name Last or
Organization Name
AN
1-60
N/U
REF
INFORMATION
RECEIVER
ADDITIONAL
IDENTIFICATION
2-3
1-50
1-80
NM103
NM108
NM109
REF01
REF02
24,34,FI,PI,PP,SV,XV,XX
INFORMATION
RECEIVER
ADDITIONAL
IDENTIFICATION
REF
Reference
Reference
Identification
REF03
REF04
Page 4 of 32
Description
REFERENCE
IDENTIFIER
1, 2
2100B
0B, 1C, 1D, 1J, 4A, CT, EL,
EO, HPI
ID
2-3
REF01
AN
1-30
REF02
AN
1-80
REF03
N/U
REF04
Reference
Identification Qualifier ID
Reference
Identification
AN
Description
AN
REFERENCE
IDENTIFIER

24, 34, FI, PI, PP, SV, XV, XX
0B, 1C, 1D, 1J, 4A, CT, EL,

EO, HPI, JD, N5, N7, Q4, SY,
TJ

New Note
2100B
Increase
N/U
8/11/200911:35 AM
4010A1
Element
Identifier
Description
AAA
INFORMATION
RECEIVER
REQUEST
VALIDATION
AAA01
AAA02
Yes/ No Condition or
Response Code
Agency Qualifier
Code
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
AAA
INFORMATION
RECEIVER
VALIDATION
REQUEST
271 4010A1
9
2100B
N, Y
ID
1-1
ID
2-2
N/U
AAA03
Reject Reason Code
ID
2-2
AAA04
Follow-up Action
Code
ID
1-1
HL01
HL02
HL03
HL04
TRN01
TRN02
TRN03
TRN04
Trace Type Code

Reference
Identification
Originating Company
Identifier
Reference
Identification
Page 5 of 32
>1
ID
2-2
N/U
AAA04
Follow-up Action
Code
ID
1-1
PRV
INFORMATION
RECEIVER
PROVIDER
INFORMATION
PRV01
Provider Code
PRV05
PRV06
Code
1-12
1-12
1-2
1-1
ID
1-2
AN
1-30
TRN02
AN
10-10
TRN03
AN
1-30
TRN04
HL01
HL02
22
HL03
0, 1
HL04
TRN
TRN01
ID
2100B
15, 41, 43, 44, 45, 46, 47, 48,

50, 51, 79, 97, T4
C, N, R, S, W, X, Y
2100B
1-3

RF, SB, SK, SU
2-3
PXC
1-50
2-2
N/U
N/U
ID
SUBSCRIBER
LEVEL
Hierarchical ID
Number
Hierarchical
Parent ID AN
Number
AN
Hierarchical Level
Code
ID
Hierarchical Child
Code
ID
SUBSCRIBER
TRACE NUMBER
Trace Type Code
Reference
Identification
Originating Company
Identifier
Reference
Identification
Values
New Segment
Reference
Reference
Identification
AN
State or Province
Code
ID
Provider Specialty
Information
Loop
N, Y
HL
1,2
1-1
2-2
2000C
ID
ID
SUBSCRIBER
TRACE NUMBER
TRN
2000C
Reject Reason Code
PRV04
SUBSCRIBER
LEVEL
Hierarchical ID
Number
Hierarchical
Parent ID AN
Number
AN
Hierarchical Level
Code
ID
Hierarchical Child
Code
ID
AAA03
PRV03
271 Notes
Loop
Repeat
271 5010
AAA02
PRV02
HL
Usage
Reg.
Response Code
Agency Qualifier
Code
AAA01
15, 41, 43, 44, 45, 46, 47, 48,

50, 51, 79, 97, T4
C, N, R, S, W, X, Y
ID
Min.
Max.
3-3
N/U
1-12
1-12
1-2
1-1
2000C
>1
22
0, 1
ID
1-2
AN
1-50
AN
10-10
AN
1-50
2000C
1, 2
New Note
Increase

Increase
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
NM1
SUBSCRIBER NAME
2100C
Usage
Reg.
271 Notes
Loop
NM1
SUBSCRIBER NAME
NM101
NM102
ID
2-3
ID
1-1
Name Last or
Organization Name
AN
1-60
2100C
ID
2-3
NM102
ID
1-1
NM103
Name Last or
Organization Name
AN
1-35
NM103
NM104
Name First
AN
1-25
NM104
Name First
AN
1-35
NM105
Name Middle
AN
1-25
NM105
Name Middle
AN
1-25
NM106
Name Prefix
AN
1-10
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
Identification Code
Qualifier
AN
1-10
NM107
Name Suffix
Identification Code
Qualifier
AN
1-10
ID
1-2
Identification Code
Entity Relationship
Code
AN
2-80
ID
2-2
N/U
ID
2-3
N/U
AN
1-60
N/U
MI,ZZ
1-2
NM108
AN
2-80
NM109
NM110
Identification Code
Entity Relationship
Code
ID
2-2
N/U
NM110
NM111
ID
2-3
N/U
NM111
NM109
SUBSCRIBER
ADDITIONAL
IDENTIFICATION
REF
REF01
REF02
Reference
Reference
Identification
REF04
Description
REFERENCE
IDENTIFIER
N3
SUBSCRIBER
ADDRESS
N301
Address Information
N302
Address Information
N4
SUBSCRIBER CITY/
STATE/ ZIP CODE
REF03
2100C
NM112

Name Last or
Organization Name
REF
SUBSCRIBER
ADDITIONAL
IDENTIFICATION
18, 1L, 1W, 3H, 49, 6P, A6,

EA, EJ, F6, GH, HJ, IF, IG,
ML, N6, NQ, Q4, SY
ID
2-3
REF01
AN
1-30
REF02
AN
1-80
REF03
N/U
REF04
SUBSCRIBER
ADDRESS
N301
Address Information
N302
Address Information
N4
SUBSCRIBER
CITY/STATE/ZIP
CODE
AN
1-55
AN
1-55
2100C
1
Increase
Reference
Reference
Identification
AN
Description
AN
REFERENCE
IDENTIFIER
N3
1
IL
NM101
ID
Values
271 5010
IL
NM108
Loop
Repeat

II, MI
Code Removed
Code Added
18, 1L, 1W, 3H, 49, 6P, CT,

EA, EJ, F6, GH, HJ, IF, IG,
N6, NQ, Q4, SY, Y4
Codes Removed: A6, ML

Code Added: Y4
New Notes
2-3
1-50
1-80
Increase
2100C
New Note
Increase
S
N/U
AN
1-55
AN
1-55
AN
2-30
ID
2-2
ID
3-15
2100C
2-30
2100C
AN
N402
City Name
State or Province
Code
ID
2-2
N402
City Name
State or Province
Code
N403
Postal Code
ID
3-15
N403
Postal Code
N401
Page 6 of 32
N401
2100C
Usage Change
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
N404
Country Code
ID
2-3
N405
Location Qualifier
ID
1-2
N406
Location Qualifier
AN
1-30
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
N404
Country Code
ID
2-3
N405
Location Qualifier
ID
1-2
N/U
N406
Location Qualifier
Country Subdivision
Code
AN
1-30
N/U
ID
1-3
271 4010A1
PER
PER01
Name
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Contact Inquiry
Reference
PER02
PER03
PER04
PER05
PER06
PER07
PER08
PER09
SUBSCRIBER
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
AAA
AAA01
AAA02
AAA03
AAA04
Reject Reason Code

Follow-up Action
Code
271 Notes
Loop
Loop
Repeat
Values
271 5010
CY, FI
N407
SUBSCRIBER
CONTACT
INFORMATION
Contact Function
Code
Usage
Reg.
New Element
Deleted Segment
3
ID
2-2
AN
1-60
ID
2-2
2100C
IC
HP, TE, WP
AAABBBCCCC
AN
1-80
ID
2-2
AN
1-80
ID
2-2
AN
1-80
AN
1-20
N/U
EX, HP, TE, WP

AAABBBCCCC
EX, HP, TE, WP
2100C
AAA
N,Y
ID
1-1
ID
2-2
N/U
ID
2-2
ID
1-1
AAA01
AAA02
15, 42, 43, 45, 47, 48, 49, 51,
52, 56, 57, 58, 60, 61, 62, 63,
64, 65, 66, 67, 68, 71, 72, 73,
74,N,75,
77,X,
78Y
C,
R, 76,
S, W,
SUBSCRIBER
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
AAA04
Reject Reason Code

Follow-up Action
Code
PRV
PROVIDER
INFORMATION
AAA03
ID
1-1
ID
2-2
N/U
2100C
N,Y
ID
2-2
ID
1-1
15, 35, 42, 43, 45, 47, 48, 49,

51, 52, 56, 57, 58, 60, 61, 62,
63, 71, 72, 73, 74, 75, 76, 77,
C, N, R, 78
S, W, X, Y
Codes Removed: 64-68, 77

Code Added: 35
New Notes
New Segment
PRV01
PRV02
PRV03
Page 7 of 32
Provider Code
ID
Reference
Reference
Identification
AN
2100C
1-3

RF, SK, SU
2-3
PXC
1-50
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
PRV04
State or Province
Code
ID
Min.
Max.
271 4010A1
PRV06
DMG01
SUBSCRIBER
DEMOGRAPHIC
INFORMATION
Date Time Period
Format Qualifier
ID
2-3
DMG02
Date Time Period
AN
1-35
DMG03
Gender Code
ID
1-1
DMG04
Marital Status Code
ID
1-1
N/U
ID
1-1
N/U
DMG05
271 Notes
Loop
Loop
Repeat
Values
271 5010
PRV05
DMG
Usage
Reg.
2100C
PROVIDER
SPECIALITY
INFORMATION
Code
ID
2-2
N/U
N/U
ID
3-3
N/U
DMG01
SUBSCRIBER
DEMOGRAPHIC
INFORMATION
Date Time Period
Format Qualifier
ID
2-3
DMG02
Date Time Period
AN
1-35
DMG03
Gender Code
ID
1-1
DMG04
Marital Status Code

COMPOSITE RACE
OR ETHNICITY
INFORMATION
Citizenship Status
Code
ID
1-1
N/U
ID
1-2
N/U
ID
2-3
N/U
ID
1-2
N/U
1-15
N/U
DMG
D8
2100C
D8

Race or Ethnicity
Code
Citizenship Status
Code
DMG05
DMG06
F, M, U
F, M, U
N/U
ID
1-2
N/U
DMG06
ID
2-3
N/U
DMG07
DMG08
Country Code
Code
ID
1-2
N/U
DMG08
Country Code
Code
DMG09
Quantity
1-15
N/U
DMG09
Quantity
DMG10
Code List Qualifier

Code
ID
1-3
N/U
DMG11
Industry Code
AN
1-30
N/U
ID
1-1
ID
2-2
18
ID
3-3
001
ID
2-3
25
ID
1-1
N/U
DMG07
INS
INS01
INS02
INS03
INS04
SUBSCRIBER
REALTIONSHIP
Response Code
Individual
Relationship Code
Maintenance Type
Code
Maintenance Reason
Code
2100C
INS
ID
1-1
INS01
ID
2-2
18
INS02
ID
3-3
001
INS03
ID
2-3
25
INS04
INS05
Benefit Status Code
ID
1-1
N/U
INS05
INS06
Medicare Plan Code
ID
1-1
N/U
INS06
INS08
Consolidated
Omnibus Budget
Reconciliation Act
(COBRA) Qualifying
Employment Status
Code
INS09
Student Status Code
INS07
Page 8 of 32
SUBSCRIBER
RELATIONSHIP
Response Code
Individual
Relationship Code
Maintenance Type
Code
Maintenance Reason
Code
Benefit Status Code
MEDICARE STATUS
CODE
ID
1-2
N/U
INS07
ID
2-2
N/U
INS08
Consolidated
Omnibus Budget
Reconciliation Act
(COBRA) Qualifying
Employment Status
Code
ID
1-1
INS09
Student Status Code
F, N, P
2100C

N/U
ID
1-2
N/U
ID
2-2
N/U
ID
1-1
N/U
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Usage
Reg.
INS11
ID
2-3
N/U
INS11
Response Code
Date Time Period
Format Qualifier
ID
2-3
N/U
INS12
Date Time Period
AN
1-35
N/U
INS12
Date Time Period
AN
1-35
N/U
INS13
ID
1-1
N/U
INS13
ID
1-1
N/U
INS14
AN
2-30
N/U
INS14
2-30
N/U
ID
2-2
N/U
INS15
City Name
State or Province
Code
AN
INS15
City Name
State or Province
Code
ID
2-2
N/U
INS16
Country Code
ID
2-3
N/U
INS16
Country Code
ID
2-3
N/U
INS17
Number
N0
1-9
INS17
Number
N0
1-9
ID
1-1
Loop
Values
271 5010
Response Code
Date Time Period
Format Qualifier
INS10
271 Notes
Loop
Repeat
N,Y
INS10
HI01
SUBSCRIBER
HEALTH CARE
DIAGNOSIS CODE
HEALTH CARE
CODE
INFORMATION
HI01 - 1
Code List Qualifier

Code
HI
ID
1-1
N/U
New Segment
1
2100C
R
ABK, BK
ID
1-3
AN
1-30
HI01 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI01 - 4
Date Time Period
AN
1-35
N/U
HI01 - 5
Monetary Amount
1-18
N/U
HI01 - 6
Quantity
1-15
N/U
HI01 - 7
Version Identifier
AN
1-30
N/U
HI01 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
AN
1-30
HI02 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI02 - 4
Date Time Period
AN
1-35
N/U
HI02 - 5
Monetary Amount
1-18
N/U
HI02 - 6
Quantity
1-15
N/U
HI02 - 7
Version Identifier
AN
1-30
N/U
HI02 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
HI01 - 2
HI01 - 9
HI02
HI02 - 1
HI02 - 2
HI02 - 9
HI03
HI03 - 1
Page 9 of 32
S
ABF, BF
S
ABF, BF
ID
1-3
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
Industry Code
Date Time Period
Format Qualifier
AN
1-30
ID
2-3
N/U
HI03 - 4
Date Time Period
AN
1-35
N/U
HI03 - 5
Monetary Amount
1-18
N/U
HI03 - 6
Quantity
1-15
N/U
HI03 - 7
Version Identifier
AN
1-30
N/U
HI03 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
HI04 - 2
Industry Code
AN
1-30
HI04 - 3
Date Time Period

Format Qualifier
ID
2-3
N/U
HI04 - 4
Date Time Period
AN
1-35
N/U
HI04 - 5
Monetary Amount
1-18
N/U
HI04 - 6
Quantity
1-15
N/U
HI04 - 7
Version Identifier
AN
1-30
N/U
HI04 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
AN
1-30
HI05 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI05 - 4
Date Time Period
AN
1-35
N/U
HI05 - 5
Monetary Amount
1-18
N/U
HI05 - 6
Quantity
1-15
N/U
HI05 - 7
Version Identifier
AN
1-30
N/U
HI05 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
Industry Code
Date Time Period
Format Qualifier
AN
1-30
ID
2-3
N/U
HI06 - 4
Date Time Period
AN
1-35
N/U
HI06 - 5
Monetary Amount
1-18
N/U
HI06 - 6
Quantity
1-15
N/U
271 4010A1
271 Notes
Loop
Loop
Repeat
Values
271 5010
HI03 - 2
HI03 - 3
HI03 - 9
HI04
HI04 - 1
HI04 - 9
HI05
HI05 - 1
HI05 - 2
HI05 - 9
HI06
HI06 - 1
HI06 - 2
HI06 - 3
Page 10 of 32
Usage
Reg.
S
ABF, BF
S
ABF, BF
S
ABF, BF
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
HI06 - 7
Version Identifier
AN
1-30
N/U
HI06 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
AN
1-30
HI07 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI07 - 4
Date Time Period
AN
1-35
N/U
HI07 - 5
Monetary Amount
1-18
N/U
HI07 - 6
Quantity
1-15
N/U
HI07 - 7
Version Identifier
AN
1-30
N/U
HI07 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
AN
1-30
HI08 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI08 - 4
Date Time Period
AN
1-35
N/U
HI08 - 5
Monetary Amount
1-18
N/U
HI08 - 6
Quantity
1-15
N/U
HI08 - 7
Version Identifier
AN
1-30
N/U
HI08 - 8
Industry Code
AN
1-30
N/U
ID
1-1
N/U
271 4010A1
HI07
HI07 - 1
HI07 - 2
HI07 - 9
HI08
HI08 - 1
HI08 - 2
HI12
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
HEALTH CARE
CODE
INFORMATION
HEALTH
CARE
CODE
INFORMATION
HEALTH CARE
CODE
INFORMATION
DTP
SUBSCRIBER DATE
HI08 - 9
HI09
HI10
HI11
SUBSCRIBER DATE
Page 11 of 32
2100C
271 Notes
Loop
Loop
Repeat
Values
271 5010
HI06 - 9
DTP
Usage
Reg.
S
ABF, BF
S
ABF, BF
N/U
N/U
N/U
N/U
2100C
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Usage
Reg.
271 Notes
Loop
Loop
Repeat
271 5010
102, 152, 291, 307, 318, 340,
341, 342, 343, 346, 347, 356,
357, 382, 435, 442, 458, 472,
539, 540, 636, 771
ID
DTP02
Date/Time Qualifier
Date Time Period
Format Qualifier
ID
2-3
DTP03
Date Time Period
AN
1-35
DTP01
3-3
096, 102, 152, 291, 307, 318,

340, 341, 342, 343, 346, 347,
356, 357, 382, 435, 442, 458,
472, 539, 540, 636, 771
ID
3-3
DTP02
Date Time Qualifier

Date Time Period
Format Qualifier
ID
2-3
DTP03
Date Time Period
AN
1-35
DTP01
D8, RD8
CCYYMMDD-CCYYMMDD
MPI01
SUBSCRIBER
MILITARY
PERSONNEL
INFORMATION
Information Status
Code
MPI02
Employment Status
Code
MPI03
Government Service
Affiliation Code
MPI04
Description
MPI
MPI06
Military Service Rank

Code
Date Time Period
Format Qualifier
MPI07
Date Time Period
EB
SUBSCRIBER
ELIGIBILITY/
BENEFIT
INFORMATION
MPI05
EB
EB01
EB02
Eligibility or Benefit
Information
Coverage Level Code
Page 12 of 32
ID
ID
1-2
3-3
2110C
>1
Code Added: 096

New Note
D8, RD8
CCYYMMDD-CCYYMMDD
SUBSCRIBER
ELIGIBILITY/
BENEFIT
INFORMATION
Values
New Segment
1-1
2100C
A, C, L, O, P, S, T
ID
ID
2-2
ID
1-1
AN
1-80
ID
2-2
ID
2-3
AN
1-35
AE, AO, AS, AT, AU, CC, DD,

HD, ,IR, LX, PE, RE, RM, RR,
RU
A, B, C, D, E, F, G, H, I, J, K,
L, M, N, O, Q, R, S, U, W
A1, A2, A3, B1, B2, C1, C2,

C3, C4, C5, C6, C7, C8, C9,
E1, F1, F2, F3, F4, G1, G4,
L1, L2, L3, L4, L5, L6, M1, M2,
M3, M4, M5, M6, P1, P2, P3,
P4, P5, R1, S1, S2, S3, S4,
S5, S6, S7, S8, S9, SA, SB,
SC, T1, V1, W1
D8, RD8
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C,
CB, D, E, F, G, H, I, J, K, L, M,
MC, N, O, P, Q, R, S, T, U, V,
W, X, Y
EB01
Information
ID
1-2

FAM, IND, SPC, SPO
EB02
Coverage Level Code
ID
3-3
2110C
>1
New Notes
1, 2, 3, 4, 5, 6, 7, 8, A, B, C,
CB, D, E, F, G, H, I, J, K, L, M,
MC, N, O, P, Q, R, S, T, U, V,
W, X, Y

FAM, IND, SPC, SPO
New Note
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Usage
Reg.
EB04
EB05
Service Type Code
Insurance Type Code

Plan Coverage
Description
ID
1-2
ID
1-3
AN
1-50
Loop
Values
271 5010
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19,
20, 21, 22, 23, 24, 25, 26, 27,
28, 30, 32, 33, 34, 35, 36, 37,
38, 39, 40, 41, 42, 43, 44, 45,
46, 47, 48, 49, 50, 51, 52, 53,
54, 44, 56, 57, 58, 59, 60, 61,
62, 63, 64, 65, 66, 67, 68, 69,
70, 71, 72, 73, 74, 75, 76, 77,
78, 79, 80, 81, 82, 83, 84, 85,
86, 87, 99, 89, 90, 91, 92, 93,
94, 95, 96, 97, 98, 99, A0, A1,
A2, A3, A4, A5, A6, A7, A8,
A9, AA, AB, AC, AD, AE, AF,
AG, AH, AI, AJ, AK, AL, AM,
AN, AO, AQ, AR, BA, BB, BC,
BK, BL BM, BN, BP, BQ, BR,
BS
EB03
271 Notes
Loop
Repeat
EB03
12, 13, 14, 15, 16, 41, 42, 43,
47, AP, C1, CO, CP, D, DB,
EP, FF, GP, HM, HN, HS, IN,
LC, LD, LI, LT, MA, MB, MC,
MH, MI, MP, OT, PE, PL, PP,
PR, PS, QM, RP, SP, TF, WC,
WU
EB04
EB05
6, 7, 13, 21, 22, 23, 24, 25, 26,

27, 28, 29, 30, 31, 32, 33, 34,
35, 36
Service Type Code
ID
Insurance Type Code ID

Plan Coverage
Description
AN
1-2
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19,
20, 21, 22, 23, 24, 25, 26, 27,
28, 30, 32, 33, 34, 35, 36, 37,
38, 39, 40, 41, 42, 43, 44, 45,
46, 47, 48, 49, 50, 51, 52, 53,
54, 44, 56, 57, 58, 59, 60, 61,
62, 63, 64, 65, 66, 67, 68, 69,
70, 71, 72, 73, 74, 75, 76, 77,
78, 79, 80, 81, 82, 83, 84, 85,
86, 87, 99, 89, 90, 91, 92, 93,
94, 95, 96, 97, 98, 99, A0, A1,
A2, A3, A4, A5, A6, A7, A8,
A9, AA, AB, AC, AD, AE, AF,
AG, AH, AI, AJ, AK, AL, AM,
AN, AO, AQ, AR, B1, B2, B3,
BA, BB, BC, BD, BE, BF, BG,
BH, BI, BJ, BK, BL BM, BN,
BP, BQ, BR, BS, BT, BU, BV,
BW, BX, BY, BZ, C1, CA, CB,
CC, CD, CE, CF, CG, CH, CI,
CJ, CK, CL, CM, CN, CO, CP,
CQ, DG, DM, DS, GF, GY, IC,
MH, NI, ON, PT, PU, RN, RT,
TC, TN, UC

New Notes
Codes Added
New Repetition Code
12, 13, 14, 15, 16, 41, 42, 43,

47, AP, C1, CO, CP, D, DB,
IP, LC, LD, LI, LT, MA, MB,
MC, MH, MI, MP, OT, PE, PL,
PP, PR, PS, QM, RP, SP, TF,
WC, WU

New Note
1-3
1-50
EB06
Time Period Qualifier
ID
1-2
EB06
ID
1-2
EB07
Monetary Amount
1-18
EB07
1-18
EB08
Percent
1-10
EB08
Monetary Amount
Percentage as
Decimal
1-10
6, 7, 13, 21, 22, 23, 24, 25, 26,

27, 28, 29, 30, 31, 32, 33, 34,
35, 36

99, CA, CE, DB, DY, HS, LA,

LE, MN, P6, QA, S7, S8, VS,
YY
8H, 99, CA, CE, DB, DY, HS,

LA, LE, M2, MN, P6, QA, S7,
S8, VS, YY
EB09
Quantity Qualifier
ID
2-2
EB09
Quantity Qualifier
ID
2-2
EB10
Quantity
1-15
EB10
Quantity
1-15
EB11
Yes/No Condition or
Response Code
ID
1-1
EB11
Yes/No Condition or
Response Code
ID
1-1

Codes Added: 8H D3 M2
Page 13 of 32
N,U,Y
N,U,Y

New Note
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Usage
Reg.
271 Notes
Loop
EB12
ID
1-1
EB13 - 1
EB13 - 2
COMPOSITE
MEDICAL
PROCEDURE
IDENTIFIER
Product/Service ID
Qualifier
Product/Service ID
ID
AN
2-2
1-48
R
R
EB13 - 3
Procedure Modifier
AN
2-2
EB13 - 4
Procedure Modifier
AN
EB13 - 5
Procedure Modifier
AN
EB13 - 6
Procedure Modifier
EB13 - 7
Description
EB13
N,U,W,Y
EB12
Yes/No Condition or
Response Code
ID
1-1

Code Added
New Note
EB13 - 1
EB13 - 2
COMPOSITE
MEDICAL
PROCEDURE
IDENTIFIER
Product/Service ID
Qualifier
Product/Service ID
ID
AN
2-2
1-48
R
R
EB13 - 3
Procedure Modifier
AN
2-2
New Note
2-2
EB13 - 4
Procedure Modifier
AN
2-2
2-2
EB13 - 5
Procedure Modifier
AN
2-2
AN
2-2
EB13 - 6
Procedure Modifier
AN
2-2
AN
1-80
N/U
EB13 - 7
Description
AN
1-80
N/U
EB13 - 8
AN
1-48
EB14 - 4
Product/Service ID
COMPOSITE
DIAGNOSIS CODE
POINTER
Diagnosis Code
Pointer
Diagnosis Code
Pointer
Diagnosis Code
Pointer
Diagnosis Code
Pointer
EB13
EB14
EB14 - 1
EB14 - 2
EB14 - 3
HSD
HEALTH CARE
SERVICES
DELIVERY
HSD01
Quantity Qualifier
ID
2-2
HSD02
Quantity
Unit or Basis for
Measurement Code
1-15
ID
2-2
HSD03
Values
271 5010
N,U,Y
Yes/No Condition or
Response Code
Loop
Repeat
2110C
DY, FL, HS, MN, VS
S
New Element
N0
1-2
N0
1-2
N0
1-2
N0
1-2
New Element
New Element
New Element
HSD
HSD01
Quantity Qualifier
ID
2-2
HSD02
Quantity
Unit or Basis for
Measurement Code
1-15
ID
2-2
HSD03
New Element
HEALTH CARE
SERVICES
DELIVERY
DA, MO, VS, WK, YR
New Note
2110C
DY, FL, HS, MN, VS
DA, MO, VS, WK, YR

Sample Selection
Modulus
HSD04
1-6
HSD04
Sample Selection
Modulus
1-6
6, 7, 21, 22, 23, 24, 25, 26, 27,

28, 29, 30, 31, 32, 33, 34, 35
6, 7, 21, 22, 23, 24, 25, 26, 27,

28, 29, 30, 31, 32, 33, 34, 35
HSD05
ID
1-2
HSD05
ID
1-2
HSD06
Number of Periods
N0
1-3
HSD06
Number of Periods
N0
1-3
HSD07
Ship/Delivery or
Calendar Pattern
Code
Ship/Delivery Pattern
Time Code
HSD07
Ship/Delivery or
Calendar Pattern
Code
Time Code
HSD08
Page 14 of 32
ID
1-2
ID
1-1
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C,
D, E, F, G, ,H, J, K, L ,M N, O,
P, Q, R, S, SG, SL, SP, SX,
SY,
U,E,V,F,W,
A, SZ,
B, C,T,D,
G,X,YY
HSD08
ID
1-2
ID
1-1

1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C,
D, E, F, G, ,H, J, K, L ,M N, O,
SY,
U,E,V,F,W,
A, SZ,
B, C,T,D,
G,X,YY
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
REF
REF01
REF02
SUBSCRIBER
ADDITIONAL
IDENTIFICATION
Reference
Reference
Identification
Usage
Reg.
271 Notes
Loop
Loop
Repeat
Values
271 5010
2110C
REF
18, 1L, 1W, 49, 6P, 9F, A6,
F6, G1, IG, N6, NQ
ID
2-3
REF01
AN
1-30
REF02
SUBSCRIBER
ADDITIONAL
IDENTIFICATION
Reference
Reference
Identification
AN
2-3
1-50
2110C
18, 1L, 1W, 49, 6P, 9F, ALS,
CLI, F6, FO, G1, IG, M7, N6,
NQ
Code Removed: A6
Codes Added: ALS CLI FO M7
New Notes
Increase
REF03
Description
REF04
REFERENCE
IDENTIFIER
DTP
SUBSCRIBER
ELIGIBILITY/
BENEFIT DATE
AN
1-80
S
N/U
20
2110C
REF03
Description
REF04
REFERENCE
IDENTIFIER
DTP
SUBSCRIBER
ELIGIBILITY/
BENEFIT DATE
AN
1-80
S
N/U
20
2110C
193, 194, 198, 290, 292, 295,

304, 307, 318, 348, 349, 356,
357, 435, 472, 636
DTP01
DTP02
Date/Time Qualifier
Date Time Period
Format Qualifier
ID
3-3
ID
3-3
DTP02
Date Time Qualifier

Date Time Period
Format Qualifier
ID
2-3
DTP03
Date Time Period
AN
1-35
ID
1-1
ID
2-2
N/U
DTP01
D8, RD8
ID
2-3
096, 193, 194, 198, 290, 291,

292, 295, 304, 307,
318, 346, 348, 349, 356, 357,
435, 472, 636, 771
R8, RD8
CCYYMMDD-CCYYMMDD
Date Time Period
DTP03
AAA
AAA01
AAA02
SUBSCRIBER
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
AN
1-35
ID
1-1
ID
2-2
N/U
2110C
CCYYMMDD-CCYYMMDD
AAA
N, Y
AAA01
AAA02
AAA03
Reject Reason Code
ID
2-2
15, 52, 53, 55, 56, 57, 60, 61,

62, 63, 69, 70
AAA03
AAA04
Follow-up Action code
ID
1-1
C, N, R, W, X, Y
AAA04
MSG
10
MSG01
MESSAGE TEXT
Free-Form Message
Text
AN
1-264
MSG02
Printer Carriage
Control Code
ID
2-2
N/U
Page 15 of 32
2110C
Codes Added
New Notes
SUBSCRIBER
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
Reject Reason Code

Follow-up Action
code
ID
2-2
ID
1-1
10
MSG01
MESSAGE TEXT
Free-Form Message
Text
AN
1-264
MSG02
Printer Carriage
Control Code
ID
2-2
N/U
MSG
2110C
N, Y
15, 33, 52, 53, 54, 55, 56, 57, Codes Added: 33 98 AA AE AF AG
AO CI E8 IA MA
60, 61, 62, 63, 69, 70, 98, AA,
New Notes
AE, AF, AG, AO, CI, E8, IA,
MA
C, N, R, W, X, Y
2110C
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
MSG03
Number
N0
1-9
III
SUBSCRIBER
ELIGIBILITY/
BENEFIT
ADDITIONAL
INFORMATION
III01
Code List Quantifier

Code
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
MSG03
Number
N0
1-9
N/U
III
SUBSCRIBER
ELIGIBILITY/BENEFI
T ADDITIONAL
INFORMATION
III01
Code List Quantifier

Code
271 4010A1
ID
1-3
If III01=ZZ: 11, 12, 21, 22, 23,

24, 25, 26, 31, 32, 33, 34, 41,
42, 50, 51, 52, 53, 54, 55, 56,
60, 61, 62, 65, 71, 72, 81, 99
N/U
III03
ID
2-2
44
1-264
N/U
III04
Code Category
Free-Form Message
Text
AN
1-264
1-15
N/U
III05
1-15
N/U
N/U
III06
N/U
III07
ID
2-2
N/U
2-2
N/U
III08
ID
2-2
N/U
ID
2-2
N/U
III09
ID
2-2
N/U
AN
1-6
AN
1-4
Code Category
Free-Form Message
Text
ID
2-2
AN
R
ID
2-2
ID
III09
LS
LOOP HEADER
LS01
Loop Identifier Code
NM1
SUBSCRIBER
BENEFIT RELATED
ENTITY NAME
GR, NI, ZZ
1-30
III03
III08
1-3
2110C
2120
2120C
Quantity
COMPOSITE UNIT
OF MEASURE
Surface/Layer/Positio
n Code
n Code
n Code
LS
LOOP HEADER
LS01
NM1
SUBSCRIBER
BENEFIT RELATED
ENTITY NAME
NM101
ID
2-3
NM102

Name Last or
Organization Name
ID
1-1
AN
1-35
NM103
NM104
Name First
AN
1-25
NM105
Name Middle
AN
1-25
NM106
Name Prefix
AN
1-10
NM107
Name Suffix
AN
1-10
Page 16 of 32
NM101
ID
2-3
NM102

Name Last or
Organization Name
ID
1-1
AN
1-60
NM104
Name First
AN
1-35
NM105
Name Middle
AN
1-25
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
1, 2

Codes Removed
Codes Added
Codes Added
New Notes

Code Added
New Note
N/U
13, 1P, 2B, 36, 73, FA, GP, IL,

LR, P3, P4, P5, PR, PRP,
SEP, TTP, VN, X3
NM103
10
AN
III07
ID
2115C
Industry Code
1-30
III06
Values
III02
AN
Quantity
COMPOSITE UNIT
OF MEASURE
n Code
n Code
n Code
Loop
If III01=ZZ: 01, 03, 04, 05, 06,

07, 08, 11, 12, 13, 14, 15, 20,
21, 22, 23, 24, 25, 26, 31, 32,
33, 34, 41, 42, 49, 50, 51, 52,
53, 54, 55, 56, 57, 60, 61, 62,
65, 71, 72, 81, 99
Industry Code
III05
10
BF, BK, ZZ
III02
III04
2115C
271 Notes
Loop
Repeat
271 5010
N/U
Usage
Reg.
2110C
2120C
2120
Decrease
13, 1I, 1P, 2B, 36, 73, FA, GP,

GW, I3, IL, LR, OC, P3,
P4,P5, PR, PRP, SEP, TTP,
VN, VY, X3
Codes Added: 1I GW I3 OC VY
New Notes
23
1, 2
Increase
Increase
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Usage
Reg.
271 Notes
Loop
Identification Code
Qualifier
1-2
NM108
AN
2-80
NM109
NM110
Identification Code
Entity Relationship
Code
ID
2-2
N/U
NM110
NM111
ID
2-3
N/U
NM111
N3
SUBSCRIBER
RELATED ENTITY
ADDRESS
N301
Address Information
N302
Address Information
N4
SUBSCRIBER
BENEFIT RELATED
CITY/STATE/ZIP
CODE
Identification Code
Qualifier
Identification Code
Entity Relationship
Code
1-2
AN
2-80
ID
2-2
NM112

Name Last or
Organization Name
ID
2-3
N/U
AN
1-60
N/U
N3
SUBSCRIBER
BENEFIT RELATED
ENTITY ADDRESS
AN
1-55
N301
Address Information
AN
1-55
AN
1-55
N302
Address Information
AN
1-55
N4
SUBSCRIBER
BENEFIT RELATED
ENTITY
CITY/STATE/ZIP
CODE
AN
2-30
2-30
2120C
ID

Code Removed: ZZ
Code Added: II
24, 34, 46, FA, FI, II, MI, NI,

PI, PP, SV, XV, XX
ID
NM109
2110C
AN
N402
City Name
State or Province
Code
ID
2-2
N402
City Name
State or Province
Code
ID
2-2
N403
Postal Code
ID
3-15
N403
Postal Code
ID
3-15
N404
Country Code
ID
2-3
N404
Country Code
ID
2-3
N405
Location Qualifier
ID
1-2
N405
Location Qualifier
ID
1-2
N401
Values
271 5010
24, 34, 46, FA, FI, MI, NI, PI,
PP, SV, XV, XX, ZZ
NM108
Loop
Repeat
N401
RJ
01, 02, 27, 41, 48, 65, 72

Codes Added
2120C
2120C
Usage Change
RJ

Location Qualifier
N406
AN
1-30
N406
N407
PER
PER01
SUBSCRIBER
BENEFIT RELATED
ENTITY CONTACT
INFORMATION
Contact Function
Code
PER02
PER03
PER04
PER05
Page 17 of 32
Name
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
2-2
2120C
PER
IC
ID
AN
1-60
PER01
PER02
ED, EM, FX, TE, WP
ID
2-2
PER03
AAABBBCCCC
AN
1-80
PER04
ED, EM, FX, TE, WP
ID
2-2
PER05
Location Qualifier
Country Subdivision
Code
SUBSCRIBER
BENEFIT RELATED
ENTITY CONTACT
INFORMATION
Contact Function
Code
Name
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
AN
1-30
ID
1-3
ID
2-2
AN
1-60
New Element
2120C
IC
ED, EM, FX, TE, UR, WP
ID
2-2
S
AAABBBCCCC
AN
1-256
ID
2-2

Code Added
Increase
Code Added
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
PER09
Communication
Number
Communication
Number Qualifier
Communication
Number
Contact Inquiry
Reference
PRV
SUBSCRIBER
BENEFIT RELATED
PROVIDER
INFORMATION
PER06
PER07
PER08
Provider Code
PRV01
PRV02
PRV03
PRV04
PRV05
PRV06
LE
LOOP TRAILER
HL01
HL02
HL04
TRN
DEPENDENT TRACE
NUMBER
TRN01
TRN02
TRN03
ID
2-2
AN
1-80
PER08
AN
1-20
N/U
PER09
PRV
SUBSCRIBER
BENEFIT RELATED
PROVIDER
INFORMATION
Trace Type Code

Reference
Identification
Originating Company
Identifier
Page 18 of 32
PER06
ED, EM, FX, TE, WP
PER07
AAABBBCCCC
ID
AN
DEPENDENT LEVEL
Hierarchical ID
Number
AN
Number
AN
Hierarchical Level
Code
Hierarchical Child
Code
HL03
1-80
Reference
Reference
Identification
AN
State or Province
Code
ID
PROVIDER
SPECIALTY
INFORMATION
Code
ID
LE01
HL
AN
1-3
2-3
2120C
RF, SB, SK, SU
PRV01
PRV02
1-30
PRV03
2-2
N/U
PRV04
N/U
PRV05
N/U
PRV06
3-3
1-6
1-12
1-12
2110C
2120
2000D
271 Notes
Loop
Loop
Repeat
Values
271 5010
Communication
Number
Communication
Number Qualifier
Communication
Number
Contact Inquiry
Reference
AAABBBCCCC
Usage
Reg.
>1
LE
LOOP TRAILER
HL01
HL02
23
HL04
TRN
DEPENDENT
TRACE NUMBER
1-2
HL03
ID
1-1
ID
1-2
AN
1-30
TRN02
AN
10-10
TRN03
1,2
TRN01
ID
2-2
AN
1-256
AN
1-20
N/U

AAABBBCCCC
ID
Trace Type Code

Reference
Identification
Originating Company
Identifier
1-3
2-3

RF, SB, SK, SU
PXC

Codes Removed
Code Added
Increase
2120
Decrease
1-50
2-2
N/U

Increase
Code Added
Increase
2120C
N/U
3-3
N/U
1-4
1-12
1-12
ID
1-2
ID
1-1
ID
1-2
AN
1-50
AN
10-10
AN
DEPENDENT LEVEL
Hierarchical ID
Number
AN
Number
AN
Hierarchical Level
Code
Hierarchical Child
Code
ID
1-256
Reference
Reference
Identification
AN
State or Province
Code
ID
PROVIDER
SPECIALTY
INFORMATION
Code
ID
LE01
HL
2000D
Provider Code
AAABBBCCCC
AN
2120C
2000D
>1
23
0
2000D
1,2
Increase
8/11/200911:35 AM
4010A1
Element
Identifier
Description
TRN04
Reference
Identification
NM1
DEPENDENT NAME
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
TRN04
Reference
Identification
NM1
DEPENDENT NAME
NM101
NM102

Name Last or
Organization Name
ID
Min.
Max.
271 4010A1
AN
1-30
2100D
Usage
Reg.
271 Notes
Loop
AN
1-50
ID
2-3
ID
1-1
AN
1-60

Increase
2100D
ID
2-3
NM102

Name Last or
Organization Name
ID
1-1
AN
1-35
NM103
NM104
Name First
AN
1-25
NM104
Name First
AN
1-35
NM105
Name Middle
AN
1-25
NM105
Name Middle
AN
1-25
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
Identification Code
Qualifier
AN
1-10
NM107
AN
1-10
ID
1-2
NM108
Name Suffix
Identification Code
Qualifier
ID
1-2
N/U
AN
2-80
NM109
2-80
N/U
ID
2-2
N/U
NM110
Identification Code
Entity Relationship
Code
AN
NM110
Identification Code
Entity Relationship
Code
ID
2-2
N/U
NM111
ID
2-3
N/U
NM111
ID
2-3
N/U
NM112

Name Last or
Organization Name
AN
1-60
N/U
REF
DEPENDENT
ADDITIONAL
IDENTIFICATION
NM109
REF
REF01
REF02
MI, ZZ
DEPENDENT
ADDITIONAL
IDENTIFICATION
Reference
Reference
Identification
REF04
Description
REFERENCE
IDENTIFIER
N3
DEPENDENT
ADDRESS
N301
Address Information
N302
Address Information
N4
DEPENDENT
CITY/STATE/ZIP
CODE
REF03
2100D
18,1L,1W,49,6P,A6, CT,
EA,EJ,F6,CJ, HC, ID, IV, N4,
ZZ
ID
2-3
AN
1-30
REF02
AN
1-80
REF03
N/U
REF04
REF01
DEPENDENT
ADDRESS
N301
Address Information
N302
Address Information
N4
DEPENDENT
CITY/STATE/ZIP
CODE
AN
1-55
AN
1-55
2100D
2-3
1-50
1-80
Increase
2100D
18, 1L, 49, 6P, CT, EA, EJ,
F6, GH, HJ, IF, IG, MRC, N6,
NQ, Q4, SY, Y4
Codes Removed: 1W A6 M7
Code Added: Y4
New Notes
New Note
Increase
N/U
AN
1-55
AN
1-55
City Name
State or Province
Code
AN
2-30
ID
2-2
2100D
City Name
State or Province
Code
AN
2-30
N401
ID
2-2
N402
N403
Postal Code
ID
3-15
N403
Postal Code
ID
3-15
N404
Country Code
ID
2-3
N404
Country Code
ID
2-3
N401
N402
Page 19 of 32
2100D
1
Increase
Reference
Reference
Identification
AN
Description
AN
REFERENCE
IDENTIFIER
N3
1
03
NM101
NM108
Values
271 5010
03
NM103
Loop
Repeat
2100D
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
N405
Location Qualifier
ID
1-2
N406
Location Qualifier
AN
1-30
Usage
Reg.
5010
Element
Identifier
Description
ID
Min.
Max.
N/U
N405
Location Qualifier
ID
1-2
N/U
N/U
N406
Location Qualifier
Country Subdivision
Code
AN
1-30
N/U
ID
1-3
Loop
Loop
Repeat
Values
271 4010A1
PER
PER01
Name
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Contact Inquiry
Reference
PER02
PER03
PER04
PER05
PER06
PER07
PER08
PER09
AAA
AAA01
AAA02
DEPENDENT
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
Loop
Values
New Element
Deleted Segment
3
2100D
IC
ID
2-2
AN
1-60
ID
2-2
AN
1-80
AAABBBCCCC
HP, TE, WP
ID
2-2
EX, HP, TE, WP
AN
1-80
AAABBBCCCC
ID
2-2
HP, TE, WP, EX
AN
1-80
AAABBBCCCC
AN
1-20
N/U
ID
1-1
ID
2-2
N/U
2100D
AAA
N, Y
AAA01
AAA02
AAA03
Reject Reason Code
ID
2-2
15, 42, 43, 45, 47, 48, 49, 51,

52, 56, 57, 58, 60, 61, 62, 63,
64, 65, 66, 67, 68, 71
AAA04
Follow-up Action
Code
ID
1-1
C, N, R, S, W, X, Y
DEPENDENT
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
ID
1-1
ID
2-2
N/U
2100D
N, Y
AAA03
Reject Reason Code
ID
2-2
15, 35, 42, 43, 45, 47, 48, 49,

51, 52, 56, 57, 58, 60, 61, 62,
63, 64, 65, 66, 67, 68, 71, 77
AAA04
Follow-up Action
Code
ID
1-1
C, N, R, S, W, X, Y
PRV
PROVIDER
INFORMATION
PRV01
PRV02
PRV03
Page 20 of 32
271 Notes
Loop
Repeat
271 5010
N407
DEPENDENT
CONTACT
INFORMATION
Contact Function
Code
Usage
Reg.
Provider Code
Codes Added: 35 77
New Notes
New Segment
ID
1-3
Reference
Reference
Identification
AN
2-3
1-50
2100D
SK, SU
PXC
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
PRV05
PRV06
DMG01
DEPENDENT
DEMOGRAPHIC
INFORMATION
Date Time Period
Format Qualifier
ID
2-3
DMG02
Date Time Period
AN
1-35
DMG03
DMG04
Gender Code
Marital Status Code
ID
ID
1-1
1-1
S
N/U
ID
1-1
N/U
DMG05
DMG05
DMG06
Race or Ethnicity
Code
Citizenship Status
Code
2100D
ID
2-2
ID
3-3
N/U
DMG01
ID
2-3
DMG02
Date Time Period
AN
1-35
DMG03
DMG04
Gender Code
Marital Status Code
COMPOSITE RACE
OR ETHNICITY
INFORMATION
Citizenship Status
Code
ID
ID
1-1
1-1
S
N/U
ID
1-2
N/U
ID
2-3
N/U
DMG
N/U
DMG06
2-3
N/U
DMG07
DMG08
ID
1-2
N/U
DMG08
Country Code
Code
ID
1-2
N/U
DMG09
Quantity
1-15
N/U
DMG09
Quantity
1-15
N/U
DMG10
Code List Qualifier

Code
ID
1-3
N/U
DMG11
Industry Code
AN
1-30
N/U
ID
1-1
ID
2-2
ID
3-3
ID
2-3
ID
1-1
N/U
INS01
INS02
INS03
INS04
2100D
INS
N
ID
1-1
INS01
ID
2-2
ID
3-3
ID
2-3
INS04
01, 19, 21, 34

INS02
001
INS03
25
INS05
Benefit Status Code
ID
1-1
N/U
INS05
INS06
Medicare Plan Code
ID
1-1
N/U
INS06
INS07
INS08
Consolidated
Omnibus Budget
Reconciliation Act
(COBRA) Qualifying
Employment Status
Code
ID
1-2
N/U
ID
2-2
N/U
DEPENDENT
RELATIONSHIP
Yes/No Condition or
Response Code
Individual
Relationship Code
Maintenance Type
Code
Maintenance Reason
Code
Benefit Status Code
MEDICARE STATUS
CODE
INS08
Consolidated
Omnibus Budget
Reconciliation Act
(COBRA) Qualifying
Employment Status
Code
INS09
Student Status Code
INS07
F, M, U
N/U
1-2
2100D
D8
ID
DEPENDENT
RELATIONSHIP
Yes/No Condition or
Response Code
Individual
Relationship Code
Maintenance Type
Code
Maintenance Reason
Code
Values
N/U
ID
INS
Loop
N/U
DEPENDENT
DEMOGRAPHIC
INFORMATION
Date Time Period
Format Qualifier
D8
F, M, U
State or Province
Code
PROVIDER
SPECIALTY
INFORMATION
Code
Country Code
Code
DMG07
271 Notes
Loop
Repeat
271 5010
PRV04
DMG
Usage
Reg.
2100D
N
001
Code Removed: 34
Codes Added
25
01, 19, 20, 21, 39, 40, 53, G8
N/U
ID
1-2
N/U
ID
2-2
N/U
ID
1-1
N/U
F, N, P
INS09
Student Status Code
Page 21 of 32
ID
1-1
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Usage
Reg.
INS11
ID
2-3
N/U
INS11
Yes/No Condition or
Response Code
Date Time Period
Format Qualifier
ID
2-3
N/U
INS12
Date Time Period
AN
1-35
N/U
INS12
Date Time Period
AN
1-35
N/U
INS13
ID
1-1
N/U
INS13
ID
1-1
N/U
INS14
AN
2-30
N/U
INS14
2-30
N/U
ID
2-2
N/U
INS15
City Name
State or Province
Code
AN
INS15
City Name
State or Province
Code
ID
2-2
N/U
INS16
Country Code
ID
2-3
N/U
INS16
Country Code
ID
2-3
N/U
INS17
Number
N0
1-9
INS17
Number
N0
1-9
N, Y
ID
1-1
INS10
HI
HI01
HI01 - 1
DEPENDENT
HEALTH CARE
DIAGNOSIS CODE
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
ID
1-1
N/U
Values
ABK, BK
R
AN
1-30
HI01 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI01 - 4
Date Time Period
AN
1-35
N/U
HI01 - 5
Monetary Amount
1-18
N/U
HI01 - 6
Quantity
1-15
N/U
HI01 - 7
Version Identifier
AN
1-30
N/U
HI01 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
AN
1-30
HI02 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI02 - 4
Date Time Period
AN
1-35
N/U
HI02 - 5
Monetary Amount
1-18
N/U
HI02 - 6
Quantity
1-15
N/U
HI02 - 7
Version Identifier
AN
1-30
N/U
HI02 - 8
AN
1-30
N/U
ID
1-1
N/U
HI03 - 1
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
ID
1-3
HI03 - 2
Industry Code
AN
1-30
HI02
HI02 - 1
HI02 - 2
HI02 - 9
HI03
2100D
R
1-3
HI01 - 9

New Segment
ID
HI01 - 2
Page 22 of 32
Loop
271 5010
Yes/No Condition or
Response Code
Date Time Period
Format Qualifier
INS10
271 Notes
Loop
Repeat
S
ABF, BF
S
ABF, BF
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
HI03 - 3
Date Time Period

Format Qualifier
ID
2-3
N/U
HI03 - 4
Date Time Period
AN
1-35
N/U
HI03 - 5
Monetary Amount
1-18
N/U
HI03 - 6
Quantity
1-15
N/U
HI03 - 7
Version Identifier
AN
1-30
N/U
HI03 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
Industry Code
Date Time Period
Format Qualifier
AN
1-30
ID
2-3
N/U
HI04 - 4
Date Time Period
AN
1-35
N/U
HI04 - 5
Monetary Amount
1-18
N/U
HI04 - 6
Quantity
1-15
N/U
HI04 - 7
Version Identifier
AN
1-30
N/U
HI04 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
AN
1-30
HI05 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI05 - 4
Date Time Period
AN
1-35
N/U
HI05 - 5
Monetary Amount
1-18
N/U
HI05 - 6
Quantity
1-15
N/U
HI05 - 7
Version Identifier
AN
1-30
N/U
HI05 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
AN
1-30
HI06 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI06 - 4
Date Time Period
AN
1-35
N/U
HI06 - 5
Monetary Amount
1-18
N/U
ID
Min.
Max.
271 4010A1
271 Notes
Loop
Loop
Repeat
Values
271 5010
HI03 - 9
HI04
HI04 - 1
HI04 - 2
HI04 - 3
HI04 - 9
HI05
HI05 - 1
HI05 - 2
HI05 - 9
HI06
HI06 - 1
HI06 - 2
Page 23 of 32
Usage
Reg.
S
ABF, BF
S
ABF, BF
S
ABF, BF
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
HI06 - 6
Quantity
1-15
N/U
HI06 - 7
Version Identifier
AN
1-30
N/U
HI06 - 8
Industry Code
Yes/No Condition or
Response Code
AN
1-30
N/U
ID
1-1
N/U
271 4010A1
271 Notes
Loop
Loop
Repeat
Values
271 5010
HI06 - 9
HI07
HI07 - 1
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
S
ABF, BF
ID
1-3
Industry
Date
TimeCode
Period
Format Qualifier
AN
1-30
ID
2-3
N/U
HI07 - 4
Date Time Period
AN
1-35
N/U
HI07 - 5
Monetary Amount
1-18
N/U
HI07 - 6
Quantity
1-15
N/U
HI07 - 7
Version Identifier
AN
1-30
N/U
HI07 - 8
Industry Code
Yes/No Condition or
Response Code
HEALTH CARE
CODE
INFORMATION
Code List Qualifier
Code
AN
1-30
N/U
ID
1-1
N/U
ID
1-3
AN
1-30
HI08 - 3
Industry Code
Date Time Period
Format Qualifier
ID
2-3
N/U
HI08 - 4
Date Time Period
AN
1-35
N/U
HI08 - 5
Monetary Amount
1-18
N/U
HI08 - 6
Quantity
1-15
N/U
HI08 - 7
Version Identifier
AN
1-30
N/U
HI08 - 8
AN
1-30
N/U
HI08 - 9
Industry Code
Yes/No Condition or
Response Code
ID
1-1
N/U
HI09
HEALTH CARE
CODE
INFORMATION
N/U
HI10
HEALTH CARE
CODE
INFORMATION
N/U
HI11
HEALTH CARE
CODE
INFORMATION
N/U
HI07 - 2
HI07 - 3
HI07 - 9
HI08
HI08 - 1
HI08 - 2
Page 24 of 32
Usage
Reg.
S
ABF, BF
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
HI12
HEALTH CARE
CODE
INFORMATION
DTP
DEPENDENT DATE
ID
Min.
Max.
271 4010A1
DTP
DEPENDENT DATE
Usage
Reg.
271 Notes
Loop
Date/Time Qualifier
ID
3-3
2100D
N/U
2100D
096, 102, 152, 291, 307, 318,

340, 341, 342, 343, 346, 347,
356 357, 382, 435, 442, 458,
472, 539, 540, 636, 771
DTP01
Date Time Qualifier
DTP02
Date Time Period

Format Qualifier
ID
2-3
DTP03
Date Time Period
AN
1-35
MPI
DEPENDENT
MILITARY
PERSONNEL
INFORMATION
Information
Status
MPI01
Code
ID
3-3
DTP02
ID
2-3
D8, RD8
CCYYMMDD-CCYYMMDD
Date Time Period
DTP03
AN
1-35
Codes Added
New Note
D8, RD8
Date Time Period
Format Qualifier
Values
271 5010
102,152,291,307,318,340,341,
342,343,346,347,382,435,442,
458,472,539,540,636
DTP01
Loop
Repeat
CCYYMMDD-CCYYMMDD
New Segment
ID
1-1
A, C, L, O, P, S, T
2-2
AE, AO, AS, AT, AU, CC, DD,

HD, ,IR, LX, PE, RE, RM, RR,
RU
A, B, C, D, E, F, G, H, I, J, K,
L, M, N, O, Q, R, S, U, W
MPI02
Employment Status
Code
MPI03
Government Service
Affiliation Code
ID
1-1
MPI04
Description
AN
1-80
ID
MPI05
Military Service Rank

Code
MPI06
Date Time Period

Format Qualifier
ID
2-3
MPI07
Date Time Period
AN
1-35
EB
DEPENDENT
ELIGIBILITY/BENEFI
T INFORMATION
2110D
ID
2-2
2100D
A1, A2, A3, B1, B2, C1, C2,

C3, C4, C5, C6, C7, C8, C9,
E1, F1, F2, F3, F4, G1, G4,
L1, L2, L3, L4, L5, L6, M1, M2,
M3, M4, M5, M6, P1, P2, P3,
P4, P5, R1, S1, S2, S3, S4,
S5, S6, S7, S8, S9, SA, SB,
SC, T1, V1, W1
D8, RD8
EB
DEPENDENT
ELIGIBILITY/BENEFI
T INFORMATION
Page 25 of 32
2110D
>1
>1
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Eligibility/ Benefit
Information
EB01
EB02
EB03
Coverage Level Code
Service Type Code
ID
ID
ID
1-2
3-3
1-2
R
S
EB05
EB06
ID
2-2
EB07
Monetary Amount
1-18
EB08
Percent
1-10
ID
1-3
AN
1-50
CHD, DEP, ECH, ESP, FAM,

IND, SPC, SPO
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18, 19,
20, 21, 22, 23, 24, 25, 26, 27,
28, 29, 30, 32, 33, 34, 35, 36,
37, 38, 39, 40, 41, 42, 43, 44,
45, 46, 47, 48, 49, 50, 51, 52,
53, 54, 55, 56, 57, 58, 59, 60,
61, 62, 63, 64, 65, 66, 67, 68,
69, 70, 71, 72, 73, 74, 75, 76,
77, 78, 79, 80, 81, 82, 83, 84,
85, 86, 87, 88, 89, 90, 91, 92,
93, 94, 95, 96, 97, 98, 99, A0,
A1, A2, A3, A4, A5, A6, A7,
AF, AG, AH, AI, AJ, AK, AL,
AM, AN, AO, AQ, AR, BA, BB,
BR, BS
Information Code
ID
1-2
EB02
Coverage Level Code
ID
3-3

FAM, IND, SPC, SPO
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12,
13, 14, 15, 16, 17, 18, 19, 20, 21,
22, 23, 24, 25, 26, 27, 28, 30, 32,
33, 34, 35, 36, 37, 38, 39, 40, 41,
42, 43, 44, 45, 46, 47, 48, 49, 50,
51, 52, 53, 54, 44, 56, 57, 58, 59,
60, 61, 62, 63, 64, 65, 66, 67, 68,
69, 70, 71, 72, 73, 74, 75, 76, 77,
78, 79, 80, 81, 82, 83, 84, 85, 86,
87, 99, 89, 90, 91, 92, 93, 94, 95,
96, 97, 98, 99, A0, A1, A2, A3,
A4, A5, A6, A7, A8, A9, AA, AB,
AC, AD, AE, AF, AG, AH, AI,
AJ, AK, AL, AM, AN, AO, AQ,
AR, B1, B2, B3, BA, BB, BC,
BK, BL BM, BN, BP, BQ, BR,
BS, BT, BU, BV, BW, BX, BY,
BZ, C1, CA, CB, CC, CD, CE,
CF, CG, CH, CI, CJ, CK, CL,
CM, CN, CO, CP, CQ, DG, DM,
DS, GF, GY, IC, MH, NI, ON, PT,
PU, RN, RT, TC, TN, UC
EB03
12, 13, 14, 15, 16, 41, 42, 43,
47, AP, C1, CO, CP, D, DB,
WC, WU
6, 7, 13, 21, 22, 23, 24, 25, 26,

27, 28, 29, 30, 31, 32, 33, 34,
35, 36
Service Type Code
ID
1-2
EB05
Insurance Type Code ID

Plan Coverage
Description
AN
EB06
ID
1-2
EB07
Monetary Amount
Percentage as
Decimal
1-18
1-10
EB04
EB08
1-3
1-50
ID
2-2
EB09
Quantity Qualifier
ID
2-2
1-15
EB10
Quantity
Yes/No Condition or
Response Code
1-15
Yes/No Condition or
Response Code
Page 26 of 32
ID
1-1
6, 7, 13, 21, 22, 23, 24, 25, 26,

27, 28, 29, 30, 31, 32, 33, 34,
35, 36
ID
1-1
Yes/No Condition or
Response Code
ID
1-1

Codes Added: 8H D3 M2
N,U,W,Y
EB12
N,U,Y
N, U, Y
EB12

New Note
Quantity
Yes/No Condition or
Response Code
EB11

New Note
New Notes
Codes Added
New Repetition Code
Quantity Qualifier
12, 13, 14, 15, 16, 41, 42, 43,

47, AP, C1, CO, CP, D, DB,
WC, WU
8H, 99, CA, CE, D3, DB, DY,

HS, LA, LE, M2, MN, P6, QA,
S7, S8, VS, YY
N, U, Y
New Notes
EB10
1-1
Values
EB01
EB09
ID
Loop
1, 2, 3, 4, 5, 6, 7, 8, A, B, C,
CB, D, E, F, G, H, I, J, K, L, M,
MC, N, O, P, Q, R, S, T, U, V,
W, X, Y
99, CA, CE, DB, DY, HS, LA,

LE, MN, P6, S7, S8, VS, YY
EB11
271 Notes
Loop
Repeat
271 5010
1, 2, 3, 4, 5, 6, 7, 8, A, B, C,
CB, D, E, F, G, H, I, J, K, L, M,
MC, N, O, P, Q, R, S,T, U, V,
W, X, Y
Insurance Type Code

Plan Coverage
Description
EB04
Usage
Reg.

New note
New Code
New Note
8/11/200911:35 AM
4010A1
Element
Identifier
Description
EB13
COMPOSITE
MEDICAL
PROCEDURE
IDENTIFIER
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
EB13
COMPOSITE
MEDICAL
PROCEDURE
IDENTIFIER
ID
Min.
Max.
271 4010A1
Usage
Reg.
271 Notes
Loop
Loop
Repeat
Values
271 5010
AD, CJ, HC, ID, ND, ZZ
Codes Added: IV N4
Code Removed: ND
New Note
EB13 - 1
Product/Service ID
Qualifier
ID
2-2
EB13 - 1
Product/Service ID
Qualifier
ID
2-2
EB13 - 2
Product/Service ID
AN
1-48
EB13 - 2
Product/Service ID
AN
1-48
New Note
EB13 - 3
Procedure Modifier
AN
2-2
EB13 - 3
Procedure Modifier
AN
2-2
EB13 - 4
Procedure Modifier
AN
2-2
EB13 - 4
Procedure Modifier
AN
2-2
EB13 - 5
Procedure Modifier
AN
2-2
EB13 - 5
Procedure Modifier
AN
2-2
EB13 - 6
Procedure Modifier
AN
2-2
EB13 - 6
Procedure Modifier
AN
2-2
EB13 - 7
Description
AN
1-80
N/U
EB13 - 7
Description
AN
1-80
N/U
EB13 - 8
AN
1-48
N0
1-2
N0
1-2
N0
1-2
EB14 - 4
Product/Service ID
COMPOSITE
DIAGNOSIS CODE
POINTER
Diagnosis Code
Pointer
Diagnosis Code
Pointer
Diagnosis Code
Pointer
Diagnosis Code
Pointer
N0
1-2
EB14
EB14 - 1
EB14 - 2
EB14 - 3
HSD
HEALTH CARE
SERVICES
DELIVERY
HSD01
Quantity Qualifier
ID
2-2
HSD02
1-15
ID
2-2
HSD03
HSD04
Quantity
Unit or Basis for
Measurement Code
Sample Selection
Modulus
1-6
HSD05
ID
1-2
HSD06
Number of Periods
N0
1-3
HSD03
2110D
DY, FL, HS, MN, VS
S
New Element
New Element
New Element
New Element
HSD
HEALTH CARE
SERVICES
DELIVERY
2110C
HSD01
Quantity Qualifier
ID
2-2
HSD02
1-15
ID
2-2
HSD04
Quantity
Unit or Basis for
Measurement Code
Sample Selection
Modulus
1-6
HSD05
ID
1-2
HSD06
Number of Periods
N0
1-3
DA, MO, VS, WK, YR
New Element
Note
New Element
DY, FL, HS, MN, VS

DA, MO, VS, WK, YR
6, 7, 21, 22, 23, 24, 25, 26, 27,

28, 29, 30, 31, 32, 33, 34, 35
HSD08
Ship/Delivery or
Calendar Pattern
Code
Time Code
REF
DEPENDENT
ADDITIONAL
IDENTIFICATION
HSD07
Page 27 of 32
6, 7, 21, 22, 23, 24, 25, 26, 27,

28, 29, 30, 31, 32, 33, 34, 35
1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C,
D, E, F, G, H, I, J, K, L, M, N,
O, P, Q, R, S, SG, SL, SP, SX,
SY, SZ, T, U, V, W, X, Y
ID
1-2
HSD08
Ship/Delivery or
Calendar Pattern
Code
Time Code
REF
DEPENDENT
ADDITIONAL
IDENTIFICATION
HSD07
A, B, C, D, E, F, G, Y
ID
1-1
2110D
ID
1-2
ID
1-1

1, 2, 3, 4, 5, 6, 7, 8, 9, A, B, C,
D, E, F, G, ,H, J, K, L ,M N, O,
SY, SZ, T, U, V, W, X, Y
A, B, C, D, E, F, G, Y
2110D
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
REF01
REF02
Reference
Reference
Identification
Usage
Reg.
271 Notes
Loop
Loop
Repeat
Values
271 5010
18,1L,1W,49,6P,9F,A6,F6,G1,
IG,N6,NQ
ID
2-3
REF01
AN
1-30
REF02
Reference
Reference
Identification
AN
18, 1L, 1W, 49, 6P, 9F, ALS,

CLI, F6, FO, G1, IG, N6, NQ
2-3
1-50
Code Removed: A6
Codes Added: ALS CLI FO
New Notes
Increase
REF04
Description
REFERENCE
IDENTIFIER
DTP
DEPENDENT
ELIGIBILITY/BENEFI
T DATE
DTP01
Date/Time Qualifier
ID
3-3
DTP02
Date Time Period

Format Qualifier
ID
2-3
REF03
AN
1-80
20
REF03
N/U
REF04
Description
REFERENCE
IDENTIFIER
DTP
DEPENDENT
ELIGIBILITY/BENEFI
T DATE
DTP01
Date Time Qualifier
DTP02
DTP03
2110D
193,194,198,290,292,295,304,
307,318,348,349,356,357,435,
472,636,771
D8, RD8
AN
1-80
S
N/U
20
ID
3-3
Date Time Period

Format Qualifier
ID
2-3
Date Time Period
AN
1-35
ID
1-1
ID
2-2
N/U
2110D
096, 193, 194, 198, 290, 291,
292, 295, 304, 307, 318, 346,
348, 349, 356, 357, 435, 472,
D8, RD8
CCYYMMDD-CCYYMMDD
CCYYMMDD-CCYYMMDD
Date Time Period
DTP03
AAA
AAA01
AAA02
DEPENDENT
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
AN
1-35
2110D
AAA
N, Y
ID
1-1
ID
2-2
N/U
AAA01
AAA02
DEPENDENT
REQUEST
VALIDATION
Yes/No Condition or
Response Code
Agency Qualifier
Code
2110D
N, Y
15, 52, 53, 54, 55, 56, 57, 60,

61, 62, 63, 69, 70
AAA03
AAA04
Reject Reason Code

Follow-up Action
Code
ID
2-2
ID
1-1
10
MSG01
MESSAGE TEXT
Free-Form Message
Text
AN
1-264
MSG02
Printer Carriage
Control Code
ID
2-2
MSG03
Number
N0
1-9
MSG
Page 28 of 32
AAA03
C, N, R, W, X, Y
AAA04
Reject Reason Code

Follow-up Action
Code
ID
2-2
15, 33, 52, 53, 54, 55, 56, 57,

60, 61, 62, 63, 69, 70, 98, AA,
AE, AF, AG, AO, CI, E8, IA,
MA
ID
1-1
C, N, R, W, X, Y
10
MSG01
MESSAGE TEXT
Free-Form Message
Text
AN
1-264
N/U
MSG02
Printer Carriage
Control Code
ID
2-2
N/U
N/U
MSG03
Number
N0
1-9
N/U
2110D
MSG
Codes Added
New Notes
Codes Added
New Notes
2110D
8/11/200911:35 AM
4010A1
Element
Identifier
Description
III
DEPENDENT
ELIGIBILITY/BENEFI
T ADDITIONAL
INFORMATION
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
III
DEPENDENT
ELIGIBILITY/BENEFI
T ADDITIONAL
INFORMATION
271 4010A1
1
2115D
10
ID
Min.
Max.
Usage
Reg.
271 Notes
Loop
Loop
Repeat
271 5010
1
2115D
10
BF, BK, ZZ
III01
Code List Qualifier

Code
ID
1-3
III01
Code List Qualifier

Code
ID
1-3
III02
Industry Code
AN
1-30
III02
Industry Code
AN
1-30
III03
Code Category
Free-Form Message
Text
ID
2-2
N/U
III03
ID
2-2
AN
1-264
N/U
III04
Code Category
Free-Form Message
Text
AN
1-264
N/U
1-15
N/U
III05
1-15
N/U
N/U
III06
III05
III06
III07
Quantity
COMPOSITE UNIT
OF MEASURE
n Code
III09
n Code
n Code
III08
LS
DEPENDENT
ELIGIBILITY/
BENEFIT
INFORMATION
LS01
NM1
DEPENDENT
BENEFIT RELATED
ENTITY NAME
ID
2-2
N/U
III07
ID
2-2
N/U
III08
ID
2-2
N/U
III09
AN
1-6
2110D
2120
2120D
Quantity
COMPOSITE UNIT
OF MEASURE
n Code
n Code
n Code
LS
LOOP HEADER
LS01
NM1
DEPENDENT
BENEFIT RELATED
ENTITY NAME
ID
2-3
NM102
ID
1-1
NM103

Name Last or
Organization Name
AN
1-35
NM104
Name First
AN
1-25
Page 29 of 32
1, 2

Codes Added
Codes Removed
If III01=ZZ: 01, 03, 04, 05, 06,

07, 08, 11, 12, 13, 14, 15, 20,
21, 22, 23, 24, 25, 26, 31, 32,
33, 34, 41, 42, 49, 50, 51, 52,
53, 54, 55, 56, 57, 60, 61, 62,
65, 71, 72, 81, 99

Codes Added
New Notes
44

Code Added
2120
Decrease
13, 1I, 1P, 2B, 36, 73, FA, GP,

GW, I3, IL, LR, OC, P3, P4,
PR, PRP, SEP, TTP, VN, VY,
X3
Codes Added: 1I GW I3 OC VY
New Notes
N/U
ID
2-2
N/U
ID
2-2
N/U
ID
2-2
N/U
AN
1-4
13, 1P, 2B, 36, 73, FA, GP, IL,

LR, P3, P4, P5, PR, PRP,
SEP, TTP, VN, X3
NM101
GR, NI, ZZ
If III01=ZZ: 11, 12, 21, 22, 23,

24, 25, 26, 31, 32, 33, 34, 41,
42, 50, 51, 52, 53, 54, 55, 56,
60, 61, 62, 65, 71, 72, 81, 99
III04
Values
NM101
ID
2-3
NM102
ID
1-1
NM103

Name Last or
Organization Name
AN
1-60
NM104
Name First
AN
1-35
2115D
2120D
23
1, 2
Increase
Increase
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
Usage
Reg.
271 Notes
Loop
Loop
Repeat
Values
271 5010
NM105
Name Middle
AN
1-25
NM105
Name Middle
AN
1-25
NM106
Name Prefix
AN
1-10
N/U
NM106
Name Prefix
AN
1-10
N/U
NM107
Name Suffix
AN
1-10
NM107
Name Suffix
AN
1-10
24, 34, 46, FA, FI, MI, NI, PI,

PP, SV, XV, XX, ZZ
NM108
Identification Code
Qualifier
ID
1-2

Code Removed: ZZ
Code Added: II
Identification Code
Entity Relationship
Code
AN
2-80
ID
2-2
ID
2-3
N/U
NM112

Name Last or
Organization Name
AN
1-60
N/U
N3
DEPENDENT
BENEFIT RELATED
ENTITY ADDRESS
AN
1-55
AN
1-55
AN
2-30
24, 34, 46, FA, FI, II, MI, NI,

PI, PP, SV, XV, XX
ID
1-2
NM108
AN
2-80
NM109
NM110
Identification Code
Entity Relationship
Code
ID
2-2
N/U
NM110
NM111
ID
2-3
N/U
NM111
NM109
Identification Code
Qualifier
N3
DEPENDENT
BENEFIT RELATED
ENTITY ADDRESS
N301
Address Information
AN
1-55
N301
Address Information
N302
Address Information
AN
1-55
N302
Address Information
N4
DEPENDENT
BENEFIT RELATED
ENTITY
CITY/STATE/ZIP
CODE
N4
DEPENDENT
BENEFIT RELATED
ENTITY
CITY/STATE/ZIP
CODE
2-30
2120D
2120D
AN
N402
City Name
State or Province
Code
ID
2-2
N402
City Name
State or Province
Code
ID
2-2
N403
Postal Code
ID
3-15
N403
Postal Code
ID
3-15
N404
Country Code
ID
2-3
N404
Country Code
ID
2-3
N405
Location Qualifier
ID
1-2
N405
Location Qualifier
ID
1-2
N401
N401
RJ
01, 02, 27, 41, 48, 65, 72

Codes Added
2120D
2120D
Usage Change
RJ

Location Qualifier
N406
AN
1-30
N406
N407
PER01
DEPENDENT
BENEFIT RELATED
ENTITY CONTACT
INFORMATION
Contact Function
Code
ID
2-2
PER02
Name
AN
1-60
PER
Page 30 of 32
2120D
Location Qualifier
Country Subdivision
Code
AN
1-30
ID
1-3
New Element
PER01
DEPENDENT
BENEFIT RELATED
ENTITY CONTACT
INFORMATION
Contact Function
Code
ID
2-2
PER02
Name
AN
1-60
PER
IC
2120D
IC
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
PER08
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
PER09
Contact Inquiry
PRV
DEPENDENT
BENEFIT RELATED
PROVIDER
INFORMATION
PER03
PER04
PER05
PER06
PER07
Provider Code
PRV01
PRV02
PRV03
PRV04
PRV05
PRV06
LE
LOOP TRAILER
SE01
SE02
GE
GE01
GE02
1-80
PER08
AN
1-20
N/U
PER09
PRV
DEPENDENT
BENEFIT RELATED
PROVIDER
INFORMATION
PRV01
Provider Code
AN
1-80
ID
2-2
AN
1-80
ID
2-2
TRANSACTION SET
TRAILER
Number of Included
Segments
Transaction Set
Control Number
FUNCTIONAL
GROUP TRAILER
Number of
Transaction Sets
Included
Group Control
Number
Page 31 of 32
PER03
AAABBBCCCC
PER04
ED, EM, EX, FX, TE, WP
PER05
AAABBBCCCC
PER06
ED, EM, EX, FX, TE, WP
PER07
AAABBBCCCC
ID
Reference
Reference
Identification
State
or Province
AN
Code
ID
PROVIDER
SPECIALTY
INFORMATION
Code
ID
LE01
SE
AN
2-2
1-3
2120D
RF, SB, SK, SU
2-3
PRV02
1-30
2-2
R
N/U
PRV03
PRV04
N/U
PRV05
N/U
PRV06
3-3
Loop
Values
2110D
LE
LOOP TRAILER
S
R
SE
N0
1-10
SE01
AN
4-9
SE02
2120
GE
N0
1-6
GE01
N0
1-9
GE02

ID
2-2
AN
1-256
ID
2-2
AN
1-256
ID
2-2
AN
1-256
AN
1-20
N/U
AAABBBCCCC
ED, EM, EX, FX, TE, UR, WP
AAABBBCCCC
ED, EM, EX, FX, TE, UR, WP
AAABBBCCCC
ID
Reference
Reference
Identification
State
or Province
AN
Code
ID
PROVIDER
SPECIALTY
INFORMATION
Code
ID
LE01
1
1-6
AN
271 Notes
Loop
Repeat
271 5010
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Communication
Number Qualifier
Communication
Number
Contact Inquiry
Reference
ED, EM, FX, TE, WP

ID
Usage
Reg.
TRANSACTION SET
TRAILER
Number of Included
Segments
Transaction Set
Control Number
FUNCTIONAL
GROUP TRAILER
Number of
Transaction Sets
Included
Group Control
Number
1-3
2-3
1-50
2-2
S
N/U
2120D
RF, SB, SK, SU
PXC

Codes Removed
Code Added
New Situational Rule:
Increase
N/U
3-3
N/U
1-4
N0
1-10
AN
4-9
N0
1-6
N0
1-9
AN

Code Added
Increase
Code Added
Increase
Code Added
Increase
2120
8/11/200911:35 AM
4010A1
Element
Identifier
Description
ID
Min.
Max.
Usage
Reg.
Loop
5010
Loop
Repeat
Values
Element
Identifier
Description
ID
Min.
Max.
271 4010A1
IEA
IEA01
IEA02
INTERCHANGE
CONTROL TRAILER
Number of Included
Functional Groups
Interchange Control
Number
Page 32 of 32
Usage
Reg.
271 Notes
Loop
Loop
Repeat
Values
271 5010
IEA
N0
1-5
IEA01
N0
9-9
IEA02
INTERCHANGE
CONTROL TRAILER
Number of Included
Functional Groups
Interchange Control
Number
N0
1-5
N0
9-9
8/11/200911:35 AM

Eligibility 4010A1 To 5010

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Eligibility 4010A1 To 5010

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4010A1

01, 14, 20, 27, 28, 29, 30, 33,

01, 14, 20, 27, 28, 29, 30, 33,

01, 14, 20, 27, 28, 29, 30, 33,

01, 14, 20, 27, 28, 29, 30, 33,

Transaction Set Control

Transaction Set Control

Transaction Type Code

Transaction Type Code

Hierarchical Level Code

Hierarchical Child Code

Hierarchical Level Code

Hierarchical Child Code

Entity Relationship Code

Hierarchical Level Code

Hierarchical Level Code

Hierarchical Child Code

Hierarchical Child Code

Entity Relationship Code

State or Province Code

24,34,FI, PI,PP, SV, XV, XX

New Situational Rule

New Situational rule

State or Province Code

New Situational rule

New Situational rule

New Situational rule

New Situational rule;

ED, EM, EX, FX, TE

ED, EM, EX, FX, TE

AD, AT, BI, CO, CV, H, HH,

State or Province Code

State or Province Code

Hierarchical Level Code

Hierarchical Child Code

New Situational Rule;

Hierarchical Level Code

Hierarchical Child Code

AD, AT, BI, CO, CV, H, HH,

Entity Relationship Code

18, 1L, 1W, 3H, 49, 6P, A6,

New Situational Rule;

New Situational Rule

Codes Removed: 49, A6

State or Province Name

State or Province Name

New Situational Rule

9K, D3, EI, HPI, SY, TJ, ZZ

AD, AT, BI, CO, CV, H, HH,

9K, D3, EI, HPI, PXC, SY, TJ

New Situational Rule;

New Situational Rule;

State or Province Code

State or Province Code

Race or Ethnicity Code

Citizenship Status Code

New Situational Rule

New Situational Rule

State or Province Code

State or Province Code

Code List Qualifier

Date Time Qualifier

Date Time Period