Eligibility JSON-to-EDI API Mapping

Preface

X12 is a non-profit organization chartered by the American National Standards Institute (ANSI) to develop and maintain business to business transaction standards. Several of the X12 Implementation Guides (X12 Type 3 Technical Report (TR3), also known as an X12 Implementation Guide (IG)) have been adopted under HIPAA for use by covered entities in the health care and insurance industry. These standards are widely adopted across providers, payers, and technology vendors such as Change Healthcare. We intend these TR3s and the X12 metadata contained in them to be used in conjunction with Change Healthcare’s APIs, so your organization can access the reference industry standards that include the codes and rules necessary to submit Eligibility, Claims, and Claim Status transactions. To obtain a license that also provides access to the full requirements for these transactions, you can visit https://x12.org/licensing. We make every effort to ensure consistency between Change Healthcare’s APIs and the X12 TR3. If there is a discrepancy, the X12 TR3 is the final authority.

How to Use this Document

Use this document with our Open API Spec (Swagger) as a reference for development. Notes on the data in the following sections include:

  • The Constraints column describes the minimum and maximum number of alphanumeric characters that a field entry can occupy: For example, 1/60 R is a Required field with a minimum of one and maximum of 60 characters.
  • If a field is required, the Constraints entry notes it.

For the Constraints column in each table, the following letters stand for specific meanings:

R = Required (must be used if/when the object is part of the transaction);
S = Situational (may be required depending on how the transaction content is structured).

Situational loops, segments, or elements can be Situational in two forms:

  • Required IF a condition is met, but can be used at the discretion of the sender if it isn't required (for example, some descriptive notes can be added to a claim if necessary);
  • Required IF a condition is met, but if not, the sender must not use it in their request ("Do not send").

The Consolidated 270/271 Implementation Guide, p. 54 discusses this in further detail.

Contents

Eligibility 270 Request

Transaction Header (Request)

Subscriber Trace Number (Request) 2000C/D

Provider (Request) 2100B

Information Receiver Address

Subscriber (Request) 2100C

Dependent (Request) 2100D

Encounter (Request) 2110C/D

Eligibility 271 Response

Identification Leader (Response)

Subscriber Trace Number (Response) 2000C/D

Payer (Response) 2100A

Provider (Response) 2100B

Subscriber (Response) 2100C

Dependent (Response) 2100D

Plan Information (Response) 2100C/D

Plan Date Information (Response) 2100C/D

Plan Status (Response) 2110C/D

Eligibility Benefit Information (Response) 2110C/D

Benefit Date Information (Response) 2110C/D

Benefits Information (Response) 2110C/D

Additional Benefit Information (Response) 2110C/D

Benefits Related Entity (Response) 2120C/D

Eligibility Information (Response) 2115C/D

Contact Information (Response) 2100B, 2120C/D

Provider Information (Response) 2100B, 2110C/D

Benefits Service Delivery (Response) 2110C/D

Additional Information (Response) 2110C/D

Error Response

Change Log

DateDescription
5/17/19Added field information V1.
5/10/21Conversion to Markdown, integration into live docs
11/12/21Various content updates.

Eligibility 270 Request

FieldDescriptionConstraints
controlNumber



Transaction Set Control Number.
This is provided by the submitter.
Unique ID used to trace the request.
Value goes in ISA13 (no loop)
R 9/9



tradingPartnerServiceId





ID used by the CHC Clearinghouse
for the trading partner.
Loop 2100A, NM109.
Get the serviceId through
your ConnectCenter account,
from the Payer Lists page.
R 2/80





submitterTransactionIdentifier





Derived from BHT03 in the
BHT segment that defines the
transaction set (no loop).
Because the 270 transaction
is processed through an API,
this field is required.
R 1/50





See Page 92-93 of the 270/271 Implementation Guide for further detail.

NameElementLoopDescriptionConstraints
subscriberTraceNumber (Object)Identify a transaction to the payer.S
  traceTypeCodeTRN012000C/DDefines the referenced transaction.1/2 R
  traceType


TRN02


2000C/D


The trace number,
from either the information receiver
or from the clearinghouse.
1/50 R


  referenceIdentification



TRN04



2000C/D



Trace number used in the
270 TRN segment, or used by payer
for more-specific identification.
Based on value in TRN01.
10/10 S



  originatingCompanyIdentifier


TRN03


2000C/D


Id for the company that
assigned the trace/reference number
in the TRN02 element.
10/10 R


NameElementLoopDescriptionConstraints
provider (Object)
  organizationName



NM103



2100B



Provider’s
organization name.
Can use organization
or last name.
1/60 R



  firstNameNM1042100BProvider first name.1/35
  lastName

NM103

2100B

Provider last name (Can use
organization or last name).
1/60 R

One of the following NM109 ID’s is required.
  npi


NM109


2100B


National Provider
Identification
value. NM108=XX
2/80


  serviceProviderNumber

NM109

2100B

Service Provider number.
NM108=SV
2/80

  payorIDNM1092100BPayor ID value. NM108=PI2/80
  taxId



NM109



2100B



Electronic Transmitter
Identification
Number (ETIN) value.
NM108=FI
2/80



  ssn

NM109

2100B

Social Security number.
NM108=34
2/80

  pharmacyProcessorNumber


NM109


2100B


Pharmacy
processor number.
NM108=PP
2/80


  servicesPlanID

NM109

2100B

See annotation in OpenAPI spec2/80

  employersId

NM109

2100B

See annotation in OpenAPI spec2/80

  providerCode





PRV01






2100B






Identifies the
type of provider.
Ex: AD = Admitting Provider
Required if Ref Id PRV03 is
provided.
See annotation in OpenAPI spec.
1/3 R






  referenceIdentification

PRV03

2100B

Healthcare Provider
Taxonomy code value.
1/50 S

  providerType


MN101


2100B


Insurance provider type.
See annotation in OpenAPI spec.
1/60 S


  address (Object)
    address1N3012100C/DProvider’s address line 11/35 R
    address2N3022100C/DProvider’s address line 21/35 S
    cityN4012100C/DProvider’s city1/60 R
    stateN4022100C/DProvider’s state1/35 S
    postalCodeN4032100C/DProvider’s postal code1/1 S

Required when the information available in Loop 2100B NM1 isn't enough to fully identify the information receiver. Because this is not required in the TR3, the submitter can send this content at their discretion; it is not required by the Eligibility query recipient.

NameElementLoopDescriptionConstraints
One of the following REF02 ID’s is required.
portalUsername

REF02

2100B

User Identification
REF01=JD
1/50

portalPassword


REF02


2100B


Personal Identification
Number (PIN)
REF01=4A
1/50


informationReceiverName (Object)S
  stateLicenceNumber

REF02

2100B

State License Number
REF01=0B
1/50

  medicareProviderNumber


REF02


2100B


Medicare Provider
Number
REF01=1C
1/50


  medicaidProviderNumber


REF02


2100B


Medicaid Provider
Number
REF01=1D
1/50


  facilityIdNumber

REF02

2100B

Facility ID Number
REF01=1J
1/50

  contactNumber

REF02

2100B

Contract Number
REF01=CT
1/50

  devicePinNumber


REF02


2100B


Electronic device
pin number
REF01=EL
1/50


  submitterIdNumber



REF02



2100B



Submitter
Identification
Number
REF01=EO
1/50


  nationalProviderIdentifier




REF02




2100B




Centers for Medicare
and Medicaid Services
National Provider
Identifier.
REF01=HPI
1/50




  providerPlanNetworkIdNumber


REF02


2100B


Provider Plan Network
Identification Number
REF01=N5
1/50


  facilityNetworkIdNumber


REF02


2100B


Facility Network
Identification Number
REF01=N7
1/50


  priorIdentifierNumber

REF02

2100B

Prior Identifier Number
REF01=Q4
1/50

  socialSecurityNumber

REF02

2100B

Social Security Number
REF01=SY
1/50

  federalTaxpayerIdentificationNumber


REF02


2100B

Federal Taxpayer’s
Identification Number
REF01=TJ
1/50


Element RFE03 may be required if REF01=0B
  informationReceiverAdditionalIdentifierState




REF03




2100B




Information Receiver
Additional Identifier
State
See annotation in OpenAPI spec
1/80




The subscriber for the insurance policy.

NameElementLoopDescriptionConstraints
subscriber (Object)
  memberId


NM109


2100C


Member ID for
the subscriber.
NM108=MI
2/80 S


  firstName



NM104



2100C



Subscriber's
first name
as shown on
their policy
1/35 S



  lastName



NM103



2100C



Subscriber's
last name
as shown on
their policy
1/60 S



  suffix

NM107

2100C

Subscriber’s
Name Suffix
1/10 S

Subscriber Additional Identification



2100C



One of the following
REF02 ID’s is
required.
S



  groupNumber




REF02




2100C




Subscriber's
group or policy
number as shown
on their policy.
REF01=6P
1/50




  idCard

REF02


2100C


Identity
Card value.
REF01=HJ
1/50


  ssn


REF02


2100C


Social
Security value.
REF01=SY
1/50


  caseNumber

REF02

2100C

Case Number.
REF01=3H
1/50

  medicaidRecipientIdentificationNumber



REF02



2100C



Medicaid
Recipient
Ident'n Number.
REF01=NQ
1/50



  planNumber

REF02

2100C

Plan Number.
REF01=18

1/50

  policyNumber


REF02


2100C


Group or
Policy Number.
REF01=1L
1/50


  memberIdentificationNumber


REF02


2100C


Member Ident'n
Number.
REF01=1W
1/50


  contractNumber

REF02

2100C

Contract Number.
REF01=CT
1/50

  medicalRecordIdentificationNumber



REF02



2100C


Medical Record
Identification Number.
REF01=EA
1/50



  medicalRecordIdentificationNumber



REF02



2100C



Medical Record
Identification Number.
REF01=EA
1/50



  patientAccountNumber


REF02


2100C


Patient Account
Number.
REF01=EJ
1/50


  healthInsuranceClaimNumber


REF02


2100C


Health Insurance
Claim (HIC) Number.
REF01=F6
1/50


  identificationCardSerialNumber


REF02


2100C


Identification Card
Serial Number.
REF01=GH
1/50


  insurancePolicyNumber


REF02


2100C


Insurance
Policy Number.
REF01=IG
1/50


  planNetworkIdentificationNumber


REF02


2100C


Plan Network
Ident'n Number.
REF01=N6
1/50


  agencyClaimNumber


REF02


2100C


Agency
Claim Number.
REF01=Y4
1/50


  subscriberAddress (Object)S
    address1

N301

2100C

Subscriber’s
address line 1
1/35 R

    address2

N302

2100C

Subscriber’s
address line 2
1/35 S

    city

N401

2100C

Subscriber’s
city
1/60 R

    state

N402

2100C

Subscriber’s
state
1/35 S

    postalCodeN403

2100C

Subscriber’s
postal code
3/15 S

Provider Information
  providerCode






PRV01






2100C/D






Identifies the
provider type.
Ex: AD=Admitting
R if Ref Id PRV03 is
provided.
See annotation in OpenAPI spec.
1/3 R






  referenceIdentificationQualifier


PRV02


2100C/D


Reference
Identification
Qualifier.
2/3 S


  providerIdentifier



PRV03



2100C/D



Reference
Identification.
See annotation in OpenAPI spec.
1/50 S



Subscriber Demographic InformationS
  dateOfBirth




DMG02




2100C/D




Subscriber's birth
date as specified
on their policy.
Format:
YYYYMMDD
1/35 S




  gender




DMG03




2100C/D




Subscriber's
gender as
specified
on their policy.
Value: M or F
1/1 S




Multiple Birth Sequence NumberS
  birthSequenceNumber



INS17



2100C



Birth Sequence
Number
INS01=Y
INS02=18
1/9 R



Subscriber Health Care Code InformationS
  healthCareCodeInformation (Array of objects)








DTP03









2100C/D









Use to send health
care codes with
dates, quantities
and amounts.
If used, specific
attributes are
required.
HI01 to HI08
use same segments.
R









  healthCareDiagnosisCode (Object)S
    diagnosisTypeCode

HI01-1

2100D

Diagnosis
Type Code
1/3 R

    diagnosisCodeHI01-22100DDiagnosis Code1/30 R
Subscriber Dates
DTP03; one date
is required.
R
  idCardIssueDate




DTP03




2100C/D




ID issue date.
Format:
YYYYMMDD
DTP01=102
DTP02=D8
1/35




  beginningCardIssueDate






DTP03






2100C/D






Beginning Card
Issue Date
Format:
YYYYMMDD-
YYYYMMDD
DTP01=102
DTP02=RD8
1/35






  endCardIssueDate






DTP03






2100C/D






End Card
Issue Date
Format: YYYYMMDD-
YYYYMMDD
DTP01=102
DTP02=RD8
1/35






  planIssueDate




DTP03




2100C/D




Plan issue date.
Format:
YYYMMDD
DTP01=291
DTP02=D8
1/35




  beginningPlanIssueDate






DTP03






2100C/D






Beginning Plan
Issue Date,
Format:
YYYYMMDD-
YYYYMMDD
DTP01=291
DTP02=RD8
1/35






  endPlanIssueDate






DTP03






2100C/D






End Plan
Issue Date
Format: YYYYMMDD-
YYYYMMDD
DTP01=291
DTP02=RD8
1/35






Subscriber’s Military Personal InformationUse only when necessaryS
  informationStatusCode

MPI01

2000C/D
2100C/D
Information
Status Code
1/1 R

  employmentStatusCode

MPI02

2000C/D
2100C/D
Employment
Status Code
2/2 R

  governmentServiceAffiliationCode

MPI03

2000C/D
2100C/D
Government Service
Affiliation Code
1/1 R

  description

MPI04

2000C/D
2100C/D
Description field

1/80 S

  militaryServiceRankCode

MPI05

2000C/D
2100C/D
Military Service
Rank Code
2/2 S

  dateTimeFormatQualifier



MPI06



2000C/D
2100C/D


Date Time
Format Qualifier
MPI106=D8,
MPI106=RD8
2/3 S



  dateTimePeriod



MPI07



2000C/D
2100C/D


Date Time
Period Format
CCYYMMDD
MPI106=D8
1/35 S



  startDateTimePeriod




MPI08




2000C/D
2100C/D



Date Time
Period Format
CCYYMMDD-
CCYYMMDD
MPI106=RD8
1/35 S




  endDateTimePeriod




MPI08




2000C/D
2100C/D



Date Time
Period Format
CCYYMMDD-
CCYYMMDD
MPI106=RD8
1/35 S




2110C - Subscriber Eligibility
and Benefit Inquiry
See 270/271 Implementation Guide,
p. 138 for details
  spendDownAmount


AMT02


2100C


Spend Down
Amount
AMT01=R
1/18 S


  spendDownTotalBilledAmount


AMT02


2100C


Spend Down Total
Billed Amount
AMT01=PB
1/18 S


NameElementLoopDescriptionConstraints
dependents (Object)

Use only
when necessary
S
  individualRelationshipCode





INS02





2100D





INS01=N
Identifies the
relationship to
subscriber.
Ex: INS02 = 01
(Spouse)
2/2 R





  birthSequenceNumber



INS17



2100D



Birth Sequence
Number.
9 digit positive
integer value
1/9 R



  issueNumber

REF02

2100D

Issue Number
REF01=IF
1/50

  eligibilityCategory

REF02

2100D

Eligibility Category
REF01=MRC
1/50 R

  firstName

NM104

2100C/D

Dependent’s
first name.
1/35 S

  lastName

NM103

2100C/D

Dependent’s
last name.
1/60 S

  middleNameNM1052100C/D1/60 S
  suffix

NM107

2100C/D

Dep. gender code.
Options: F or M
1/1 S

  dateOfBirth

DMG02

2100C/D

Dependent’s
birth date.
1/35 S

  gender

DMG03

2100C/D

Dependent’s gender
code. F or M
1/1 S

  ssn

REF02

2100D

Social Security value
REF01=SY
1/50 S

  groupNumber






REF02






2100D






Group Number value:
the subscriber’s
group or policy
number as specified
on their
insurance policy.
REF01=6P
1/50 R






  idCard

REF02

2100D

Identity Card value
REF01=HJ
1/50 R

Provider Information
  providerCode





PRV01





2100C/D





Identifies provider
type. AD = Admitting
R if Ref Id PRV03
is provided.
See annotation in OpenAPI spec.
1/3 S





  referenceIdentificationQualifier





PRV02





2100C/D





Reference
Identification
Qualifier. Ex:
PXC = Health
Care Provider
Taxonomy Code
2/3 S





  providerIdentifier


PRV03


2100C/D


Reference ID.
See annotation in OpenAPI spec.
1/50 S


  beginningCardIssueDate





DTP03





2100C/D





Beginning Card
Issue Date
DTP01=102
DTP02=RD8
YYYYMMDD-
YYYYMMDD
1/35





  endCardIssueDate





DTP03





2100C/D





End Card Issue
Date Format
DTP01=102
DTP02=RD8
YYYYMMDD-
YYYYMMDD
1/35





  idCardIssueDate



DTP03



2100C/D



ID issue date.
Format: YYYYMMDD
DTP01=102
DTP02=D8
1/35 S



  planIssueDate



DTP03



2100C/D



Plan issue date.
Format: YYYYMMDD
DTP01=291 DTP02=D8
1/35



  beginningPlanIssueDate





DTP03





2100C/D





Beginning Plan
Issue Date Format:
YYYYMMDD-
YYYYMMDD
DTP01=291
DTP02=RD8
1/35





  endPlanIssueDateDTP032100C/DEnd Plan Issue Date1/35
  healthCareCodeInformation
(Array of Objects)






Send health care
codes with dates,
quantities and
amounts. If used,
some attributes
are required.
HI01 to HI08 have
the same segments.
S







    diagnosisTypeCode






HI01-1






2100C/D






Diagnosis Type Code
Ex: ABK.
The listed diagnosis
is the patient diagnosis.
See annotation in OpenAPI spec
1/3 R






    diagnosisCode





HI01-2





2100C/D





Diagnosis Code,
indicates a code from
a specific industry
code list.
See annotation in OpenAPI spec
1/30 R





  address (object)
    address1

N301

2100C/D

Dependent’s
address line 1
1/35 R*

    address2

N302

2100C/D

Dependent’s
address line 2
1/35 S

    cityN4012100C/DDependent’s city1/60 R*
    stateN4022100C/DDependent’s state1/35 S
    postalCode

N403

2100C/D

Dependent’s
postal code
3/15 S

For dependents, one of the following REF02 ID’s is required.
  additionalIdentification (Object)
    planNumber

REF02

2100C/D

Plan Number.
REF01=18
1/50

    policyNumber


REF02


2100C/D


Group or Policy
Number.
REF01=1L
1/50


    memberIdentificationNumber


REF02


2100C/D


Member Identification
Number.
REF01=1W
1/50

    contractNumber

REF02

2100C

Contract Number.
REF01=CT
1/50

    medicalRecordIdentificationNumber



REF02



2100C/D



Medical Record
Identification
Number.
REF01=EA
1/50



    patientAccountNumber


REF02


2100C/D


Patient Account
Number.
REF01=EJ
1/50


    healthInsuranceClaimNumber


REF02


2100C/D


Health Insurance
Claim (HIC) Number.
REF01=F6
1/50


    identificationCardSerialNumber


REF02


2100C/D


Identification Card
Serial Number.
REF01=GH
1/50

    insurancePolicyNumber


REF02


2100C/D


Insurance Policy
Number.
REF01=IG
1/50


    planNetworkIdentificationNumber


REF02


2100C/D


Plan Network
Identification Number.
REF01=N6
1/50


    agencyClaimNumber


REF02


2100C/D


Agency Claim
Number.
REF01=Y4
1/50


Information applies to either Subscriber (2100C) or Dependent (2100D).

NameElementLoopDescriptionConstraints
encounter (Object)









NOTE: 1st time encounter and
any additional encounters.
Contains claim/encounter
information. Ex: doctor visit.
Depending on the request,
will be for subscriber or
dependent. Generic for:
2100C - Subscriber
2100D - Dependent
DTP01=291
R









  dateOfService


DTP03


2100C/D


Single date of service.
Format: YYYYMMDD
DTP02 = D8
1/35 S


  beginningDateOfService


DTP03


2100C/D


Date Time Period: Start Date
Format: YYYYMMDD
DTP02 = RD8
1/35 S


  endDateOfService


DTP03


2100C/D


Date Time Period: End Date
Format: YYYYMMDD
DTP02 = RD8
1/35 S


  serviceTypeCodes




EQ01




2110C/D




Subscriber or dependent
eligibility service type code.
EQ01 not Used if EQ02 is used.
EQ02 – 1 and EQ02 – 2 are
REQUIRED if using EQ02.
1/2 S




  productOrServiceIDQualifier


EQ02-1


2110C/D


Product/ServiceID Qualifier
code. Ex: AD (American
Dental Association Codes)
2/2 S


  procedureCodeEQ02-22110C/DProducer Code1/48 S
  procedureModifiers




List of
EQ02–3
EQ02–4
EQ02–5
EQ02–6
2110C/D




Producer Modifier




2/2




  diagnosisCodePointer




List of
EQ05–1
EQ05–2
EQ05–3
EQ05–4
2110C/D




Diagnosis Code Pointer




1/2




  industryCode



III02



2110C/D



Industry Code identifying
a place of service. Examples
on p. 142, Consolidated 270/271
Guide
1/30 R



  referenceIdentificationQualifier


REF01


2110C/D


Reference Identification
Qualifier Ex: 9F
(Referral Number)
2/3 R


  priorAuthorizationOrReferralNumberREF022110C/DReference Identification1/50

NameDescription
controlNumberProvided by the submitter in the 270 Request. Transaction Set Control Number.
reassociationKeyReassociates the response to the original transaction.
tradingPartnerServiceIdID used by Clearing House for the trading partner.

See Page 252 of the 270/271 Implementation Guide for further detail.

NameElementLoopDescriptionConstraints
subscriberTraceNumber (Object)Identify a transaction to the payer.S
  traceTypeCodeTRN012000C/DDefines the referenced transaction.1/2 R
  traceTypeTRN022000C/DDescribes the trace number type.1/50 R
  referenceIdentification



TRN04



2000C/D



Trace number used in the
270 TRN segment, or used by payer
for more-specific identification.
Based on value in TRN01.
10/10 S



  originatingCompanyIdentifier



TRN03



2000C/D



Identifies the company that
assigned the trace number, or
shows the value from the 270 request.
Based on value in TRN01.
10/10 R



NameElementLoopDescriptionConstraints
Payer

Requires one of the
following NM101 IDs.
entityIdentifier





NM101





2100A





Third-Party Administrator:
NM101=2B
Employer: NM101=36
Gateway Provider NM101=GP
Plan Sponsor NM101=P5
Payer NM101=PR
2/3 S





Entity Identifier Code

Requires one of the
following NM102 IDs:
entityType

NM102

2100A

Person: NM102=1
Non-Person Entity: NM102=2
1/1 R

name


NM103


2100A


Payer’s organization name.
Can use organization
or last name.
1/60 R


lastName


NM103


2100A


Payer’s last name.
Can use organization
or last name.
1/60 R


firstNameNM1042100APayer first name1/35 S
middleNameNM1052100APayer Middle Name1/25 S
suffixNM1072100APayer Name Suffix1/10 S
Identification Code

One of the following
NM109 ID’s is required.
employersId
ETIN
federalTaxpayersIdNumber
NAIC
payorIdentification
centersForMedicareAndMedicaidPlanId
npi
NM109






2100A






NM108=24
NM108=46
NM108=FI
NM108=NI
NM108=PI
NM108=XV
NM108=XX
2/80 S






Information Receiver Provider Information
informationContact

PER01

2100A

Information Contact
PER01=IC
2/2 R

namePER022100AInformation Source Contact Name1/60 S

Information Receiver Detail

NameElementLoopDescriptionConstraints
Provider
entityIdentifier











NM101











2100C/D











One of the following
NM101 ID’s is required:
Provider: NM101=1P
Third-Party Administrator: NM101=2B
Employer: NM101=36
Hospital: NM101=80
Facility: NM101=FA
Gateway Provider:
NM101=GP
Plan Sponsor: NM101=P5
Payer: NM101=PR
2/3 S











Entity Identifier CodeOne of the following NM102 ID’s is required.
entityType


NM102


2100C/D


Person - NM102=1
Non-Person Entity - NM102=2
1/1 R


name


NM103


2100C/D


Payer’s organization name.
Can use organization
or last name.
1/60 R


lastName


NM103


2100C/D


Payer’s last name.
Can use organization
or last name.
1/60 R


firstNameNM1042100C/DPayer first name.1/35 S
middleNameNM1052100C/DPayer Middle Name1/25 S
suffixNM1072100C/DPayer Name Suffix1/10 S
Identification Code

Requires one of the
following NM109 ID’s:
employersId
ssn
federalTaxpayersIdNumber
payorIdentification
pharmacyProcessorNumber
serviceProviderNumber
servicesPlanId
npi












NM109



















2100C/D



















Employer’s Ident'n
Number: NM108=24
Electronic Transmitter
Ident'n Number (ETIN): NM108=34
Federal Taxpayer’s
Ident'n Number: NM108=FI
Payer Ident'n Number: NM108=PI
Pharmacy Processor Number: NM108=PP
Service Provider Number: NM108=SV
Centers for Medicare and
Medicaid Svc's PlanID:
NM108=XV
Centers for Medicare
and Medicaid Services
National Provider ID:
NM108=XX
2/80 R



















Information Receiver AddressS
address1N3012100C/DProvider address line 11/35 R
address2N3022100C/DProvider address line 21/35 S
cityN4012100C/DProvider city1/60 R
stateN4022100C/DProvider’s state1/35 S
postalCodeN4032100C/DProvider’s postal code1/1 S
Information Receiver Additional IdentificationS
providerCodePRV012100C/DProvider Code identifies the provider type1/3 R
referenceIdentificationQualifier

PRV02

2100C/D

Reference Identification
Qualifier. PRV02=PXC
2/3 S

referenceIdentificationPRV032100C/DProvider Identifier1/50 S

NameElementLoopDescriptionConstraints
subscriber (Object)R
  memberId


NM109


2100C


Member ID for
the subscriber.
NM108=MI
2/80 S


  firstName

NM104

2100C

Subscriber’s first name
as shown on their policy
1/35 R

  lastName

NM103

2100C

Subscriber’s last name
as shown on their policy
1/60 S

  suffixNM1072100CSubscriber’s Name Suffix1/10 S
Subscriber Additional Identification

One of the following
REF02 ID’s is required.
R
  groupNumber

REF02

2100C

The subscriber group
or policy number. REF01=6P
1/50

  idCard

REF02

2100C

Identity Card value.
REF01=HJ
1/50

  ssn

REF02

2100C

Social Security value.
REF01=SY
1/50

  caseNumber

REF02

2100C

Case Number.
REF01=3H
1/50

  medicaidRecipientIdentificationNumber


REF02


2100C


Medicaid Recipient
Identification
Number. REF01=NQ
1/50


  planNumber

REF02

2100C

Plan Number.
REF01=18
1/50

  policyNumber

REF02

2100C

Group or Policy Number.
REF01=1L
1/50

  memberIdentificationNumber

REF02

2100C

Member Identification
Number. REF01=1W
1/50

  contractNumberREF022100CContract Number. REF01=CT1/50
  medicalRecordIdentificationNumber


REF02


2100C


Medical Record
Identification Number.
REF01=EA
1/50


  patientAccountNumber

REF02

2100C

Patient Account Number.
REF01=EJ
1/50

  healthInsuranceClaimNumber


REF02


2100C


Health Insurance Claim
(HIC) Number.
REF01=F6
1/50


  identificationCardSerialNumber


REF02


2100C


Identification Card
Serial Number.
REF01=GH
1/50


  insurancePolicyNumber

REF02

2100C

Insurance Policy Number.
REF01=IG
1/50

  planNetworkIdentificationNumber


REF02


2100C


Plan Network
Identification Number. REF01=N6
1/50


  agencyClaimNumber

REF02

2100C

Agency Claim Number.
REF01=Y4
1/50

  subscriberAddress (Object)
    address1N3012100CSubscriber’s address line 11/35 R
    address2N3022100CSubscriber’s address line 21/35 S
    cityN4012100CSubscriber’s city1/60 R
    stateN4022100CSubscriber’s state1/35 S
    postalCodeN4032100CSubscriber’s postal code3/15 S
Provider InformationS
  providerCode






PRV01






2100C/D






Identifies the
type of provider.
Ex: AD = Admitting
Required if Ref Id PRV03
is provided.
See annotation in OpenAPI spec.
1/3 R






  referenceIdentificationQualifier


PRV02


2100C/D


Reference
Identification
Qualifier.
2/3 S


  providerIdentifier


PRV03


2100C/D


Reference
Identification. See annotation in OpenAPI spec.
1/50 S


Subscriber Demographic InformationS
  dateOfBirth



DMG02



2100C/D



Subscriber’s birth
date as specified
on their policy.
Format: YYYYMMDD
1/35 S



  gender

DMG03

2100C/D

Subscriber’s gender as specified
on their policy. Value: M or F
1/1 S

Subscriber Health Care Code InformationS
  healthCareCodeInformation
(Array of objects)






DTP03







2100C/D







Use to send
health care codes
with dates, quantities and
amounts as needed.
If used, requires specific
attributes.
HI01 to HI08
have same segments.
R







  healthCareDiagnosisCode (Object)S
    diagnosisTypeCodeHI01-12100DDiagnosis Type Code1/3 R
    diagnosisCodeHI01-22100DDiagnosis Code1/30 R
Subscriber RelationshipS
  insuredIndicator

INS01

2000C/D
2100C/D
Insurance Indicator
INS01=Y
1/1 R

   RelationToSubscriber

INS02

2000C/D
2100C/D
Individual Relationship
Code INS02=18
2/2 R

  maintenanceTypeCode

INS03

2000C/D
2100C/D
Maintenance Type
Code. INS03=001
3/3 S

  maintenanceReasonCode

INS04

2000C/D
2100C/D
Maintenance Reason
Code INS04=25
2/3 S

  birthSequenceNumber

INS17

2000C/D
2100C/D
Subscriber’s
Birth Sequence Number
1/9 S

Subscriber’s Military
Personal Information
S

  informationStatusCode

MPI01

2000C/D
2100C/D
Information
Status Code
1/1 R

  employmentStatusCode

MPI02

2000C/D
2100C/D
Employment Status Code

2/2 R

  governmentServiceAffiliationCode

MPI03

2000C/D
2100C/D
Government Service
Affiliation Code
1/1 R

  description

MPI04

2000C/D
2100C/D
Description field

1/80 S

  militaryServiceRankCode

MPI05

2000C/D
2100C/D
Military Service Rank Code

2/2 S

  dateTimeFormatQualifier

MPI06

2000C/D
2100C/D
Date Time Format Qualifier
MPI106=D8, MPI106=RD8
2/3 S

  dateTimePeriod


MPI07


2000C/D
2100C/D

Date Time Period Format CCYYMMDD
MPI106=D8
1/35 S


  startDateTimePeriod


MPI08


2000C/D
2100C/D

Date Time Period Format
CCYYMMDD-CCYYMMDD
MPI106=RD8
1/35 S


  endDateTimePeriod


MPI08


2000C/D
2100C/D

Date Time Period Format
CCYYMMDD-CCYYMMDD
MPI106=RD8
1/35 S


NameElementLoopDescriptionConstraints
For all attributes,
also see annotations in our OpenAPI spec.
S

dependents (Object)
  firstName

NM104

2100C/D

Dependent’s
first name.
1/35 S

  lastName

NM103

2100C/D

Dependent’s
last name.
1/60 S

  middleName

NM105

2100C/D

Dependent’s
Middle Name
1/25 S

  suffix

NM107

2100C/D

Dependent’s
Name Suffix
1/10 S

  groupNumber




REF02




2100C/D




Subscriber's group
or policy number
as specified
on their policy.
REF01=6P
1/50 R




  idCard

REF02

2100C/D

Identity Card value.
REF01=HJ
1/50 S

  ssn

REF02

2100C/D

Social Security
value. REF01=SY
1/50 S

  dateOfBirth




DMG02




2100C/D




Dependent’s birth
date as specified
on their policy.
Format:
YYYYMMDD
1/35




  gender



DMG03



2100C/D



Dependent’s gender
as specified
on their policy.
Value: M or F
1/1



  address (Object)S
    address1

N301

2100C/D

Dependent’s
address line 1
1/35 R

    address2

N302

2100C/D

Dependent’s
address line 2
1/35 S

    cityN4012100C/DDependent’s city1/60 R
    stateN4022100C/DDependent’s state1/35 S
    postalCode

N403

2100C/D

Dependent’s
postal code
3/15 S

Provider InformationS
  providerCode



PRV01



2100C/D



Provider Code:
Identifies the
provider type.
See OpenAPI spec
1/3 R



  referenceIdentificationQualifierPRV02PRV02=PXC2/3 S
  ReferenceIdentification

PRV03

Provider
Identifier
1/50 S

Dependent’s RelationshipS
  insuredIndicator

INS01

2000C/D
2100C/D
Insurance Indicator
INS01=Y
1/1 R

  relationToSubscriber

INS02

2000C/D
2100C/D
Relationship Code
INS02=18
2/2 R

  maintenanceTypeCode

INS03

2000C/D
2100C/D
Maintenance Type
Code INS03=001
3/3 S

  maintenanceReasonCode


INS04


2000C/D
2100C/D

Maintenance
Reason Code
INS04=25
2/3 S


  birthSequenceNumber


INS17


2000C/D
2100C/D

Subscriber’s
Birth Sequence
Number
1/9 S


Dependent’s Health Care Diagnosis Code
  healthCareCodeInformation (Object)


HI01-08


HI01-HI08
have same
segments
R


    diagnosisTypeCode

HI01-1

2100C/D

Diagnosis
Type Code
1/3 R

    diagnosisCodeHI01-22100C/DDiagnosis Code1/30 R
Dependent’s Military
Personal Information
Use only
when necessary
S

  informationStatusCode

MPI01

2000C/D
2100C/D
Information
Status Code
1/1 R

  employmentStatusCode

MPI02

2000C/D
2100C/D
Employment
Status Code
2/2

  governmentServiceAffiliationCode

MPI03

2000C/D
2100C/D
Government Service
Affiliation Code
1/1 R

  description

MPI04

2000C/D
2100C/D
Description field

1/80 S

  militaryServiceRankCode

MPI05

2000C/D
2100C/D
Military Service
Rank Code
2/2 S

  dateTimeFormatQualifier



MPI06



2000C/D
2100C/D


Date Time
Format Qualifier
MPI106=D8,
MPI106=RD8
2/3 S



  dateTimePeriod



MPI07



2000C/D
2100C/D


Date-Time
Period Format
CCYYMMDD
MPI106=D8
1/35 S



  startDateTimePeriod




MPI08




2000C/D
2100C/D



Date Time
Period Format
CCYYMMDD-CCYYMMDD
MPI106=RD8
1/35 S




  endDateTimePeriod




MPI08




2000C/D
2100C/D



Date Time
Period Format
CCYYMMDD-
CCYYMMDD
MPI106=RD8
1/35 S




NameElementLoopDescriptionConstraints
planInformation (Object)








This field states the
reference number type
that follows in Element REF02.
Depending on eligibility,
it will be for the subscriber
or the dependent.
Subscriber = Loop 2100C;
Dependent = Loop 2100D.
Maps to REF02.
1-50 R








  planNumberREF022100C/DREF01=181-50
  policyNumberREF022100C/DREF01=1L1-50
  memberIdREF022100C/DREF01=1W1-50
  caseNumberREF022100C/DREF01=3H1-50
  familyUnitNumberREF022100C/DREF01=491-50
  groupNumberREF022100C/DREF01=6P1-50
  classOfContractCodeREF022100C/DREF01=CE1-50
  contractNumberREF022100C/DREF01=CT1-50
  medicalRecordIdentificationNumberREF022100C/DREF01=EA1-50
  patientAccountNumberREF022100C/DREF01=EJ1-50
  hicNumberREF022100C/DREF01=F61-50
  idCardSerialNumberREF022100C/DREF01=GH1-50
  idCardNumberREF022100C/DREF01=HJ1-50
  issueNumberREF022100C/DREF01=IF1-50

NameElementLoopDescriptionConstraints
planDateInformation (Object)




This field describes the date or
range of dates for the medical plan.
Depending on eligibility,
will be for subscriber or dependent.
Subscriber = Loop 2100C;
Dependent = Loop 2100D. Maps to DTP03. This information is also used in the benefitsDateInformation segment.
All dates are in YYYYMMDD format
  dischargeDTP032100CDTP01=0961-50 R
  issueDTP032100CDTP01=1021-50
  effectiveDateOfChangeDTP032100CDTP01=1521-50
  planDTP032100CDTP01=2911-50
  eligibilityDTP032100CDTP01=3071-50
  addedDTP032100CDTP01=3181-50
  cobraBeginDTP032100CDTP01=3401-50
  cobraEndDTP032100CDTP01=3411-50
  premiumPaidtoDateBeginDTP032100CDTP01=3421-50
  premiumPaidToDateEndDTP032100CDTP01=3431-50
  planBeginDTP032100CDTP01=3461-50
  planEndDTP032100CDTP01=3471-50
  eligibilityBeginDTP032100CDTP01=3561-50
  eligibilityEndDTP032100CDTP01=3571-50
  enrollmentDTP032100CDTP01=3821-50
  admissionDTP032100CDTP01=4351-50
  dateOfDeathDTP032100CDTP01=4421-50
  certificationDTP032100CDTP01=4581-50
  serviceDTP032100CDTP01=4721-50
  policyEffectiveDTP032100CDTP01=5391-50
  policyExpirationDTP032100CDTP01=5401-50
  dateOfLastUpdateDTP032100CDTP01=6361-50
  statusDTP032100CDTP01=7711-50

NameElementLoopDescriptionConstraints
planStatus (Object)



Depending on eligibility,
will be for subscriber or dependent.
Subscriber = Loop 2110C;
Dependent = Loop 2110D
R



  statusCodeEB012110C/DValues can be 1 through 8.1/2 R
  status


EB01


2110C/D


The value of the status code.
Ex: statusCode = 1,
then status = Active Coverage.
1/50


  planDetails


EB05


2110C/D


Description or number that
identifies the plan or coverage.
Value from EB05
1/50 S


Applies for Subscriber (2110C) or Dependent (2110D). Date formats are YYYYMMDD for singular and YYYYMMDD-YYYYMMDD for range, qualified by the definition in DTP02. Benefits dating information, when needed, appears for each serviceTypes entry in a more-detailed benefits response. Dating applications for eligibility benefits are similarly structured for a series of benefitsDateInformation types, to support requests for more complex benefits information including medical plan content (plan), deductibles, co-insurance, co-pays, exclusions, limitations, and other information. See Page 289-324 (Subscriber) and Page 393-398 of the
270/271 Implementation
Guide for the full list of
related codes.

NameElementDescriptionConstraints
  benefitsDateInformation
(Object)

Required for describing dates for
eligibility or benefits. Appears
under each Benefit Description.
S


     dischargeDTP03



Singular date entry. DTP=096 The singular discharge is deprecated;
you will only receive the last occurrence of the 2110C/D loop.
1/35 S



     discharges (Array)



DTP03



Discharge records appear
when the Payer returns more
than one discharge date.
DTP01=096
1/35 S



       dateDTP02Singular date for a facility discharge. DTP02=D88/17 S
       startDate

DTP02

Starting date for active
service benefit.
DTP02=RD8
8/8 S

       endDate

DTP02

Ending date for active service benefit.
DTP02=RD8
8/8 S

     admission



DTP03



Singular date entry. The singular admission is deprecated;
you will only receive the last occurrence of the 2110C/D loop.
DTP01=435
1/35 S



     admissions (Array)



DTP03



Admissions records appear
when the Payer returns more
than one facility admissions date.
DTP01=435
1/35 S



       date

DTP02

Singular date for an admission.
DTP02=D8
8/17 S

       startDate


DTP02


Starting date for benefits
if a range applies.
DTP02=RD8
8/8 S


       endDate


DTP02


Ending date for benefits for
the service if a range applies.
DTP02=RD8
8/8 S


Dates are listed in the order received from the payer.

NameDTP01 ValueDTP03 Displays...
benefitsDateInformation (Object)Date format: YYYYMMDD
  discharges096Discharge dates information, will return a singular discharge date or date range, or all dates or date ranges in a list where applicable.
  plan291Plan date
  benefit292Benefit date
  eligibility307Eligibility date
  added318Added date
  planBegin346Plan start date
  eligibilityBegin356Eligibility start date
  eligibilityEnd357Eligibility end date
  admissions435Admission date(s)
  service472Service date
  dateOfLastUpdate636Date of last update
  status771Status date

NameElementLoopDescriptionConstraints
benefitsInformation (Object)


See the OpenAPI spec for more on the attributes and values for this object.S


  code

EB01

2110C/D

Code that identifies
eligibility or benefits.
1/2 R

  name








EB01








2110C/D








Name of the benefit.
Ex: For code B,
benefit is Co-Payment.
Some codes indicate
patient responsibility.
See Pages 295-98 of the
270/271 Implementation
Guide for the list of
codes.
1/50 R








  coverageLevelCode


EB02


2110C/D


Code showing the
coverage level for
the insured. Ex: CHD
3/3 S


  coverageLevel
(Object)


EB02



2110C/D



Description of the
insurance coverage.
Ex: for code CHD,
it displays Children Only
1/50



    serviceTypeCodes



EB03



2110C/D



Identifies classification
of service. Ex: 1.
Unused if element EB13
is used in response
1/2 S



    serviceTypes

EB03

2110C/D

Describes service type.
Ex: 1 = Medical Care.
1/50 S

  insuranceTypeCode



EB04



2110C/D



Code that Identifies
the type of insurance
policy within a specific
insurance program.
1/3 S



  insuranceType






Definition
of EB04





2110C/D






The name of the policy type
in an insurance program.
Ex: code 12 = Medicare Secondary
Working Aged Beneficiary
or Spouse with Employer
Group Health Plan.
1/120 S






  planCoverage


EB05


2110C/D


Description or number
identifying the plan or
coverage.
1/50 S


  timeQualifierCode


EB06


2110C/D


Code that qualifies
the time period
for coverage. Ex: 6
1/2 S


  timeQualifier

Definition
of EB06
2110C/D

Description of EB06.
Ex: Code 6 = Hour.
1/20 S

  benefitAmount

EB07

2110C/D

Patient responsibility.
Ex: deductible, co-payment
1/18 S

  benefitPercent

EB08

2110C/D

Patient responsibility
as percentage.
1/10 S

  quantityQualifierCode

EB09

2110C/D

Code that specifies
quantity type.
2/2 S

  quantityQualifier






Definition
of EB09





2110C/D






Description of EB09.
Qualifies the benefits
in the 2110C loop by
quantity.
See 270/271
Implementation guide,
p. 37 for details.
1/50 S






  benefitQuantity

EB10

2110C/D

Numeric value
of the quantity.
1/15 S

  authOrCertIndicator





EB11





2110C/D





Indicates whether
authorization or
certification
is required per plan
provisions.
Value can be: Y/N/U.
1/1 S





  inplanNetworkIndicator



EB12



2110C/D



Indicates whether benefits
are In Plan Network
or Out of Plan Network.
Values: N, U, W, Y.
1/1 S



  compositeMedicalProcedureIdentifier
(Object)
EB13

2110C/D

Not Used if using EB03.

    ProductOrServiceIDQualifierCode




EB13-01




2100C/D




Identifies the type/source of
the descriptive number
used in Product/Service ID.
Ex: AD = American Dental
Association Code
2/2 R




    ProductOrServiceIDQualifier




EB13-01




2110C/D




Medical service or
medical product
qualifier. See 270/271
Implementation guide,
p. 310 for details.
R




procedureCode

EB13-02

2110C/D

Identifying Number for
a Product or Service.
1/48 R

producerModifiers



EB13-03
EB13-04
EB13-05
EB13-06
2110C/D



Identifies special
circumstances related
to service performance,
as defined by trading partners
2/2 S



productOrServiceID





EB13-08





2110C/D





For information source
to describe a range
of medical codes.
See 270/271
Implementation guide,
p. 312 for details.
1/48 S





Composite Diagnosis
Code Pointer
EB14

2110C/D

Identifies diagnosis
Code pointers.
S

diagnosisCodePointer



EB14-01
EB14-02
EB14-03
EB14-04
2110C/D



A pointer to the
diagnosis code
in order of importance
to this service.
1/2



Loop Header
headerLoopIdentifierCode






LS01






2115C/D






A loop ID number.
Indicates that the next
segment begins a new loop,
typically a nested loop.
See 270/271 Implementation Guide,
p. 334 for details.
1/4 S






Loop Trailer
trailerLoopIdentifierCode








LE01








2120C/D








States that the loop
preceding this segment
is completed.
The loop ID number must
be the same as given
in the loop header.
See 270/271 Implementation Guide,
p. 352 for details.
1/4 S








NameREF01 ValueDescriptionConstraints
See the OpenAPI spec for more about this object.
benefitsAdditionalInformation
(Object)
2110C - Subscriber;
2110D - Dependent
1/50 S

SubscriberDependentREF02 Displays…
  planNumber1818Plan Number
  policyNumber1L1LGroup or Policy Number
  memberId1W1WMember ID Number
  familyUnitNumber4949Family Unit Number
  groupNumber6P6PGroup Number
  classOfContractCode

CE

Class of Contract
Code (dependent)
  contractNumberCTContract Number
  medicalRecordIdentificationNumberEAMedical Record ID Number
  patientAccountNumberEJPatient Account Number
  hicNumber

F6

F6

Health insurance
Claim (HIC) Number
  idCardSerialNumber

GH

Identification Card
Serial Number
  idCardNumberHJIdentify Card Number
  issueNumberIFIssue Number
  insurancePolicyNumberIGIGInsurance Policy Number
  planNetworkIdNumberN6N6Plan Network ID
  medicaidRecepientIdNumber

NQ

NQ

Medicaid Recipient

ID Number
  priorIdNumberQ4Q4Prior ID Number
  socialSecurityNumberSYSocial Security Number
  agencyClaimNumberY4Agency Claim Number

NameElementDescriptionConstraints
benefitsRelatedEntity (Object)




2120C/D




Generic for:
2100A – Information Source Name;
2100B - Information Receiver Name;
2120C - Subscriber;
2120D - Dependent
  entityIdentifier


NM101


Displays the value of the
Entity Identifier code. Ex:
If code is PR, then Payer displays.
2/3


  entityType



NM102



Value is a person or organization;
mapping to 1 or 2.
1 – Person
2 – Non-Person Entity (organization)
1/1



  entityNameNM103Last name or Organization Name.1/60
  entityFirstnameNM104First name.1/35
  entityMiddlenameNM105Middle Name1/25
  entitySuffixNM106Suffix to individual name1/10
  entityIdentification


NM108


Definition of the
identification code of the entity.
Ex: if 34, ‘Social Security Number’ displays.
2/80


  entityIdentificationValue



NM109



Displays the value of the
entity identification.
Ex: if Social Security Number,
then actual SSN value is shown.
2/80



  entityRelationship

NM110

Displays the entity relationship.
Ex: if 01, ‘Parent’ displays.
2/2

  address (Object)Location of the named party.
    address1

N301

Displays the first line of
entity address information.
1/55

    address2

N302

Displays the second line of
entity address information.
1/55

    cityN401Displays the name of the city.2/30
    stateN402Displays the name of the state.2/2
    postalCodeN403Displays the postal code.3/15
NameElementDescription
benefitsRelatedEntities
(Object)




2120C/D





Array of benefitsRelatedEntity records.
Contains all 2120C/D respective loops, while benefitsRelatedEntity above
contains only the first loop.
The singular benefitsRelatedEntity is deprecated;
you will only receive the first occurrence of the 2120C/D loop.

NameValueDescriptionConstraint
eligibilityAdditionalInformation (Object)2115C - Subscriber; 2115D – Dependent
  codeListQualifierCode

III01

Identifies a specific industry code list
Ex: if code is ZZ, Mutually Defined.
1/3

  industryCode


III02


Code indicating a code from a
specific industry code list.
Ex: id code is 01, Pharmacy
1/30


  codeCategory



III03



Specifies the situation or category
where the code applies.
R when III01 and III02 aren't present.
Value: 44 (Nature of Injury)
2/2



  injuredBodyPartNameIII04R when III03 = ”44”1/264
NameDescription
eligibilityAdditionalInformationList (Object)





Array of eligibilityAdditionalInformation
records which contain
all occurrences of 2115C/D. The singular
eligibilityAdditionalInformation
object is deprecated because it contains the first
occurrence of the 2115C/D loops.

NameValueDescriptionConstraint
contactInformation (Object)


2100A - Information Source Name;
2120C - Subscriber;
2120D - Dependent
  name

PER02

Administrative communication
contact name.
1/60 S

  communicationMode

PER03

Type of communication.
Ex: TE is Telephone
S

  communicationNumber

PER04

First contact number,
e-mail or web address.
1/256 S

  communicationMode

PER05

Type of communication.
Ex: TE is Telephone.
S

  communicationNumber

PER06

Second contact number,
e-mail or web address.
1/256 S
  communicationMode

PER07

Type of communication.
Ex: TE is Telephone
S
  communicationNumber

PER08

Third contact number,
e-mail or web address.
1/256 S

NameValueDescriptionConstraint
providerInformation (Object)


2100B- Information Receiver Name;
2120C - Subscriber;
2120D – Dependent
  providerCode


PRV01


Displays the provider type.
Ex: if code is AD,
Admitting displays.
  referenceIdentification

PRV03

Healthcare Provider
Taxonomy code value.
1/50

HSD – Health Care Services Delivery

NameValueDescriptionConstraints
benefitsServiceDelivery (Object)2110C - Subscriber; 2110D - Dependent
  quantityQualifier


HSD01


Specifies the quantity type.
Ex: DY – Days, FL – Units,
VS - Visits
2/2


  quantityHSD02Numeric value of quantity.1/15
  unitForMeasurementCode



HSD03



Measurement code unit or basis.
Specifies the units that a value
is expressed or taken.
Examples: DA – Days, MO – Months
2/2



  sampleSelectionModulus




HSD04




Specify the sampling frequency
in terms of a modulus of the
unit of measure.
Examples: ever fifth bag,
every 1.5 minutes
1/6




  timePeriodQualifier


HSD05


Code defining periods.
Examples: 6 – Hours,
7 – Day, 21 - Years
1/2


  numOfPeriodsHSD06Total number of periods.1/3
  deliveryOrCalendarPatternCode




HSD07




Code specifying the routine shipments,
deliveries, or calendar pattern.
Examples: 1 – 1st Week of the Month
2 – 2nd Week of the Month
D - Monday
1/2




  deliveryPatternTimeCode



HSD08



Code that specifies the time
for routine shipments or deliveries.
Examples: B – 2nd Shift
G – Any Shift
1/1



NameValue fromDescriptionConstraint
additionalInformation2110C - Subscriber; 2110D - Dependent
descriptionMSG01Value from MSG segment.MSG011/264

NameDescription
errorResponse (Object)
  code

Code for the error.
Ex: INVALID_MISSING_INPUT_DATA
  description



Description of error code.
Value provided in payer id
should be a valid CHC-assigned
ERA payer Id.
  errors (Object)
    fieldAttribute that is bad.
    valueValue of that attribute.
    codeCode for the error. Ex: INVALID_VALUE
    location



Segment/location where error occurred.
If a network/system error,
there is no location attribute.
Ex: $.payerBenefits[0].payer
    followupAction


Any follow action required
for the error. For AAA errors,
this would be the value for AAA04.
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