Loop Qualifiersxx - Loop Iteration Prefix
xxyy - Outer Loop Iteration and Inner Loop Iteration
yy /
yyy - Loop Value Qualifier
xxyy /
xxyyy - Loop Iteration and Value Qualifier
Segment Modifiers:X - Distinguishing Identifier Suffix
nn - Segment Iteration (only after first iterartion)
nn - Element Repeat Iteration (only after first iterartion)
ISA | ISA | Interchange Control Header | | |
02 | | ISA_ISA02_NO_AUTH_NFO | String | No Authorization Information Present |
02 | | ISA_ISA02_ADDL_DATA_ID | String | Additional Data Identification |
04 | | ISA_ISA04_NO_SEC_NFO | String | No Security Information Present |
04 | | ISA_ISA04_PSSWD | String | Password |
06 | | ISA_ISA06_DUN_BRDST | String | Dun and Brandstreet |
06 | | ISA_ISA06_DUN_BRDST_SFX | String | Duns Plus Suffix |
06 | | ISA_ISA06_HIN | String | Health Industry Number |
06 | | ISA_ISA06_CARR_ID | String | Carrier Identification Number as assigned by Health Care Financing Administration |
06 | | ISA_ISA06_HCFA_FIIN | String | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration |
06 | | ISA_ISA06_HCFA_ID | String | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration |
06 | | ISA_ISA06_TAX_ID | String | US Federal Tax Identification Number |
06 | | ISA_ISA06_NAIC_CD | String | National Association of Insurance Commissioners Company Code |
06 | | ISA_ISA06_MUTLY_DEF | String | Mutually Defined |
08 | | ISA_ISA08_DUN_BRDST | String | Dun and Brandstreet |
08 | | ISA_ISA08_DUN_BRDST_SFX | String | Duns Plus Suffix |
08 | | ISA_ISA08_HIN | String | Health Industry Number |
08 | | ISA_ISA08_CARR_ID | String | Carrier Identification Number as assigned by Health Care Financing Administration |
08 | | ISA_ISA08_HCFA_FIIN | String | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration |
08 | | ISA_ISA08_HCFA_ID | String | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration |
08 | | ISA_ISA08_TAX_ID | String | US Federal Tax Identification Number |
08 | | ISA_ISA08_NAIC_CD | String | National Association of Insurance Commissioners Company Code |
08 | | ISA_ISA08_MUTLY_DEF | String | Mutually Defined |
09 | | ISA_ISA09_INTCHG_DT | Date (YYMMDD) | Interchange Date |
10 | | ISA_ISA10_INTCHG_TM | Time (HHMM) | Interchange Time |
11 | | ISA_ISA11_REPTN_SEP | String | Repetition Separator |
12 | | ISA_ISA12_ICN_VERS_NR | String | Interchang Control Version Number |
13 | | ISA_ISA13_ICN | Integer | Interchange Control Number |
14 | | ISA_ISA14_ACK_REQ | String | Acknowledgment Requested |
15 | | ISA_ISA15_ICN_USG_IND | String | Interchange Usage Indicator |
16 | | ISA_ISA16_COMP_ELE_SEP | String | Component Element Separator |
GSHDR | GS | Functional Group Header | | |
02 | | GSHDR_GS02_APP_SNDR_CD | String | Application Senders Code |
03 | | GSHDR_GS03_APP_RCV_CD | String | Application Receivers Code |
04 | | GSHDR_GS04_D8 | Date (YYYYMMDD) | Date |
05 | | GSHDR_GS05_TM | Time (HHMM) | Time |
05 | | GSHDR_GS05_TM8 | Time (HHMMSSCC) | Time |
06 | | GSHDR_GS06_GCN | Integer | Group Control Number |
STHDR - TRANSACTION SET HEADER |
STHDR | ST | Transaction Set Header | | |
02 | | STHDR_ST02_TCN | String | Transaction Set Control Number |
03 | | STHDR_ST03_IMP_CONV_REF | String | Implementation Convention Reference |
STHDR | BHT | Beginning of Hierarchical Transaction | | |
01 | | STHDR_BHT01_HIER_STRUC_CD | String | Hierarchical Structure Code |
02 | | STHDR_BHT02_TS_PURP_CD | String | Transaction Set Purpose Code |
03 | | STHDR_BHT03_SBM_TRANS_ID | String | Submitter Transaction Identifier |
04 | | STHDR_BHT04_TS_CRTN_D8 | Date (YYYYMMDD) | Transaction Set Creation Date |
05 | | STHDR_BHT05_TS_CRTN_TM | Time (HHMM) | Transaction Set Creation Time |
05 | | STHDR_BHT05_TS_CRTN_TM8 | Time (HHMMSSCC) | Transaction Set Creation Time |
06 | | STHDR_BHT06_TRANS_TYP_CD | String | Transaction Type Code |
L2000A - INFORMATION SOURCE LEVEL |
L2000A | HL | Information Source Level | | |
01 | | L2000A_HL01_HIER_ID_NR | String | Hierarchical ID Number |
L2100A - INFORMATION SOURCE NAME (Value Qualified) |
Mapping Prefix: L2100A_2B - Third-Party Administrator |
Mapping Prefix: L2100A_36 - Employer |
Mapping Prefix: L2100A_GP - Gateway Provider |
Mapping Prefix: L2100A_P5 - Plan Sponsor |
Mapping Prefix: L2100A_PR - Payer |
L2100A | NM1 | Information Source Name | | |
03 | | L2100A_yy_NM103_PERSN_LNM | String | Person Last Name |
03 | | L2100A_yy_NM103_NONPSNENT_NM | String | Non-Person Entity Name |
04 | | L2100A_yy_NM104_NFO_SRC_FNM | String | Information Source First Name |
05 | | L2100A_yy_NM105_NFO_SRC_MNM | String | Information Source Middle Name |
07 | | L2100A_yy_NM107_NFO_SRC_SFX | String | Information Source Name Suffix |
09 | | L2100A_yy_NM109_EMPLYR_ID | String | Employer's Identification Number |
09 | | L2100A_yy_NM109_ETN_NR | String | Electronic Transmitter Identification Number (ETIN) |
09 | | L2100A_yy_NM109_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2100A_yy_NM109_NAIC_ID | String | National Association of Insurance Commissioners (NAIC) Identification |
09 | | L2100A_yy_NM109_PAYR_ID | String | Payor Identification |
09 | | L2100A_yy_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
09 | | L2100A_yy_NM109_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
L2000B - INFORMATION RECEIVER LEVEL |
L2000B | HL | Information Receiver Level | | |
01 | | L2000B_HL01_HIER_ID_NR | String | Hierarchical ID Number |
02 | | L2000B_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
L2100B - INFORMATION RECEIVER NAME (Value Qualified) |
Mapping Prefix: L2100B_1P - Provider |
Mapping Prefix: L2100B_2B - Third-Party Administrator |
Mapping Prefix: L2100B_36 - Employer |
Mapping Prefix: L2100B_80 - Hospital |
Mapping Prefix: L2100B_FA - Facility |
Mapping Prefix: L2100B_GP - Gateway Provider |
Mapping Prefix: L2100B_P5 - Plan Sponsor |
Mapping Prefix: L2100B_PR - Payer |
L2100B | NM1 | Information Receiver Name | | |
03 | | L2100B_yy_NM103_PERSN_LNM | String | Person Last Name |
03 | | L2100B_yy_NM103_NONPSNENT_NM | String | Non-Person Entity Name |
04 | | L2100B_yy_NM104_NFO_REC_FNM | String | Information Receiver First Name |
05 | | L2100B_yy_NM105_NFO_REC_MNM | String | Information Receiver Middle Name |
07 | | L2100B_yy_NM107_NFO_RCV_SFX | String | Information Receiver Name Suffix |
09 | | L2100B_yy_NM109_EMPLYR_ID | String | Employer's Identification Number |
09 | | L2100B_yy_NM109_SSN | String | Social Security Number |
09 | | L2100B_yy_NM109_TAX_ID | String | Federal Taxpayer's Identification Number |
09 | | L2100B_yy_NM109_PAYR_ID | String | Payor Identification |
09 | | L2100B_yy_NM109_PHM_PRCSR_NR | String | Pharmacy Processor Number |
09 | | L2100B_yy_NM109_SVC_PROV_NR | String | Service Provider Number |
09 | | L2100B_yy_NM109_HCFA_PLAN_ID | String | Centers for Medicare and Medicaid Services PlanID |
09 | | L2100B_yy_NM109_NPI | String | Centers for Medicare and Medicaid Services |
L2100B | REF | Information Receiver Additional Identification | | |
02 | | L2100B_yy_REF_DUN_BRDST | String | Dun and Brandstreet |
02 | | L2100B_yy_REF_DUN_BRDST_SFX | String | Duns Plus Suffix |
02 | | L2100B_yy_REF_HIN | String | Health Industry Number |
02 | | L2100B_yy_REF_CARR_ID | String | Carrier Identification Number as assigned by Health Care Financing Administration |
02 | | L2100B_yy_REF_HCFA_FIIN | String | Fiscal Intermediary Identification Number as assigned by Health Care Financing Administration |
02 | | L2100B_yy_REF_HCFA_ID | String | Medicare Provider and Supplier Identification Number as assigned by Health Care Financing Administration |
02 | | L2100B_yy_REF_TAX_ID | String | US Federal Tax Identification Number |
02 | | L2100B_yy_REF_NAIC_CD | String | National Association of Insurance Commissioners Company Code |
02 | | L2100B_yy_REF_MUTLY_DEF | String | Mutually Defined |
03 | | L2100B_yy_REF03_NFORCV_AD_ID | String | |
L2100B | N3 | Information Receiver Address | | |
01 | | L2100B_yy_N301_NFO_RCVR_ADDR | String | Information Receiver Address Line |
02 | | L2100B_yy_N302_NFO_RCV_ADDR | String | Information Receiver Additional Address Line |
L2100B | N4 | Information Receiver City, State, ZIP Code | | |
01 | | L2100B_yy_N401_NFO_RCV_CITY_NM | String | Information Receiver City Name |
02 | | L2100B_yy_N402_NFO_RCV_STAT | String | Information Receiver State Code |
03 | | L2100B_yy_N403_NFO_RCV_ZIP | String | Information Receiver Postal Zone or ZIP Code |
04 | | L2100B_yy_N404_CNTRY_CD | String | Country Code |
07 | | L2100B_yy_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100B | PRV | Information Receiver Provider Information | | |
01 | | L2100B_yy_PRV01_PVD_CD | String | Provider Code |
03 | | L2100B_yy_PRV03_PVD_TAXNMY_CD | String | Health Care Provider Taxonomy Code |
L2000C - SUBSCRIBER LEVEL |
01 | | L2000C_HL01_HIER_ID_NR | String | Hierarchical ID Number |
02 | | L2000C_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
04 | | L2000C_HL04_HL_CHLD_CD | String | Hierarchical Child Code |
L2000C | TRN | Subscriber Trace Number | | |
02 | | L2000C_nnTRN02_TRAC_NR | String | Trace Number |
03 | | L2000C_nnTRN03_TRAC_ASS_ID | String | Trace Assigning Entity Identifier |
04 | | L2000C_nnTRN04_TRC_ASS_ADDL_ID | String | Trace Assigning Entity Additional Identifier |
03 | | L2100C_NM103_SBR_LNM | String | Subscriber Last Name |
04 | | L2100C_NM104_SBR_FNM | String | Subscriber First Name |
05 | | L2100C_NM105_SBR_MNM | String | Subscriber Middle Name or Initial |
07 | | L2100C_NM107_SBR_SFX | String | Subscriber Name Suffix |
09 | | L2100C_NM109_UNQ_HLTH_ID | String | Standard Unique Health Identifier for each Individual in the United States |
09 | | L2100C_NM109_MEM_ID_NR | String | Member Identification Number |
L2100C | REF | Subscriber Additional Identification | | |
02 | | L2100C_nnREF_PLAN_NR | String | Plan Number |
02 | | L2100C_nnREF_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2100C_nnREF_MEM_ID | String | Member Identification Number |
02 | | L2100C_nnREF_CASE_NR | String | Case Number |
02 | | L2100C_nnREF_GRP_NR | String | Group Number |
02 | | L2100C_nnREF_CNTRCT_NR | String | Contract Number |
02 | | L2100C_nnREF_MED_REC_ID | String | Medical Record Identification Number |
02 | | L2100C_nnREF_PATNT_ACCT_NR | String | Patient Account Number |
02 | | L2100C_nnREF_HIC_NR | String | Health Insurance Claim (HIC) Number |
02 | | L2100C_nnREF_ID_SERL_NR | String | Identification Card Serial Number |
02 | | L2100C_nnREF_ID_CRD_NR | String | Identity Card Number |
02 | | L2100C_nnREF_INS_PLCY_NR | String | Insurance Policy Number |
02 | | L2100C_nnREF_PLN_NET_ID | String | Plan Network Identification Number |
02 | | L2100C_nnREF_MDCD_ID_NR | String | Medicaid Recipient Identification Number |
02 | | L2100C_nnREF_SSN | String | Social Security Number |
02 | | L2100C_nnREF_AGNCY_CLM_NR | String | Agency Claim Number |
L2100C | N3 | Subscriber Address | | |
01 | | L2100C_N301_SBR_ADDR | String | Subscriber Address Line |
02 | | L2100C_N302_SBR_ADDR | String | Subscriber Address Line |
L2100C | N4 | Subscriber City, State, ZIP Code | | |
01 | | L2100C_N401_SBR_CITY | String | Subscriber City Name |
02 | | L2100C_N402_SBR_STAT | String | Subscriber State Code |
03 | | L2100C_N403_SBR_ZIP | String | Subscriber Postal Zone or ZIP Code |
04 | | L2100C_N404_CNTRY_CD | String | Country Code |
07 | | L2100C_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100C | PRV | Provider Information | | |
01 | | L2100C_PRV01_PVD_CD | String | Provider Code |
03 | | L2100C_PRV03_SERVCR | String | Servicer |
03 | | L2100C_PRV03_NCPDP_PHARM_NR | String | National Council for Prescription Drug Programs Pharmacy Number |
03 | | L2100C_PRV03_EMP_ID_NR | String | Employer's Identification Number |
03 | | L2100C_PRV03_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
03 | | L2100C_PRV03_PVD_TAXNMY_CD | String | Health Care Provider Taxonomy Code |
03 | | L2100C_PRV03_SSN | String | Social Security Number |
03 | | L2100C_PRV03_TAX_ID | String | Federal Taxpayer's Identification Number |
L2100C | DMG | Subscriber Demographic Information | | |
02 | | L2100C_DMG02_D8 | DateTime | Subscriber Birth Date |
03 | | L2100C_DMG03_SUB_GENDR_CD | String | Subscriber Gender Code |
L2100C | INS | Multiple Birth Sequence Number | | |
17 | | L2100C_INS17_BRTH_SEQ_NR | String | Birth Sequence Number |
L2100C | HI | Subscriber Health Care Diagnosis Code | | |
01 | 02 | L2100C_HI0102_ICD10_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis |
01 | 02 | L2100C_HI0102_ICD9_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis |
02 | 02 | L2100C_HI0202_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
02 | 02 | L2100C_HI0202_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
03 | 02 | L2100C_HI0302_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
03 | 02 | L2100C_HI0302_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
04 | 02 | L2100C_HI0402_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
04 | 02 | L2100C_HI0402_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
05 | 02 | L2100C_HI0502_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
05 | 02 | L2100C_HI0502_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
06 | 02 | L2100C_HI0602_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
06 | 02 | L2100C_HI0602_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
07 | 02 | L2100C_HI0702_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
07 | 02 | L2100C_HI0702_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
08 | 02 | L2100C_HI0802_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
08 | 02 | L2100C_HI0802_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
03 | | L2100C_DTP_ISSU_D8 | Date (YYYYMMDD) | Issue Date |
03 | | L2100C_DTP_ISSU_RD8_1 | Start Date (YYYYMMDD) | Issue Date |
03 | | L2100C_DTP_ISSU_RD8_2 | End Date (YYYYMMDD) | Issue Date |
03 | | L2100C_DTP_PLAN_D8 | Date (YYYYMMDD) | Plan Date |
03 | | L2100C_DTP_PLAN_RD8_1 | Start Date (YYYYMMDD) | Plan Date |
03 | | L2100C_DTP_PLAN_RD8_2 | End Date (YYYYMMDD) | Plan Date |
L2110C - SUBSCRIBER ELIGIBILITY OR BENEFIT INQUIRY |
L2110C | EQ | Subscriber Eligibility or Benefit Inquiry | | |
01 | | L2110C_EQ01_Enn_SVC_TYP_CD | String | Service Type Code |
02 | 02 | L2110C_EQ0202_ADA_CD | String | American Dental Association Codes |
02 | 02 | L2110C_EQ0202_CPT_CD | String | Current Procedural Terminology (CPT) Codes |
02 | 02 | L2110C_EQ0202_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
02 | 02 | L2110C_EQ0202_ICD9_PROC | String | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure |
02 | 02 | L2110C_EQ0202_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
02 | 02 | L2110C_EQ0202_NDC542 | String | National Drug Code in 5-4-2 Format |
02 | 02 | L2110C_EQ0202_MUTLY_DEF | String | Mutually Defined |
02 | 03 | L2110C_EQ0203_PROC_MOD | String | Procedure Modifier |
02 | 04 | L2110C_EQ0204_PROC_MOD | String | Procedure Modifier |
02 | 05 | L2110C_EQ0205_PROC_MOD | String | Procedure Modifier |
02 | 06 | L2110C_EQ0206_PROC_MOD | String | Procedure Modifier |
03 | | L2110C_EQ03_COVG_LVL_CD | String | Coverage Level Code |
05 | 01 | L2110C_EQ0501_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
05 | 02 | L2110C_EQ0502_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
05 | 03 | L2110C_EQ0503_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
05 | 04 | L2110C_EQ0504_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
L2110C | AMT | Subscriber Spend Down Amount | | |
02 | | L2110C_AMT02_SPENDOWN | Number | Spend Down |
L2110C | AMT | Subscriber Spend Down Total Billed Amount | | |
02 | | L2110C_AMT02_BILL_AMT | Number | Billed Amount |
L2110C | III | Subscriber Eligibility or Benefit Additional Inquiry Information | | |
02 | | L2110C_III02_MUTLY_DEF | String | Mutually Defined |
L2110C | REF | Subscriber Additional Information | | |
02 | | L2110C_REF_REFRL_NR | String | Referral Number |
02 | | L2110C_REF_PRIOR_AUTH | String | Prior Authorization Number |
L2110C | DTP | Subscriber Eligibility/Benefit Date | | |
03 | | L2110C_DTP_PLAN_D8 | Date (YYYYMMDD) | Plan Date |
03 | | L2110C_DTP_PLAN_RD8_1 | Start Date (YYYYMMDD) | Plan Date |
03 | | L2110C_DTP_PLAN_RD8_2 | End Date (YYYYMMDD) | Plan Date |
01 | | L2000D_HL01_HIER_ID_NR | String | Hierarchical ID Number |
02 | | L2000D_HL02_HIER_PARNT_ID_NR | String | Hierarchical Parent ID Number |
L2000D | TRN | Dependent Trace Number | | |
02 | | L2000D_nnTRN02_TRAC_NR | String | Trace Number |
03 | | L2000D_nnTRN03_TRAC_ASS_ID | String | Trace Assigning Entity Identifier |
04 | | L2000D_nnTRN04_TRC_ASS_ADDL_ID | String | Trace Assigning Entity Additional Identifier |
03 | | L2100D_NM103_DEP_LNM | String | Dependent Last Name |
04 | | L2100D_NM104_DEP_FNM | String | Dependent First Name |
05 | | L2100D_NM105_DEP_MNM | String | Dependent Middle Name |
07 | | L2100D_NM107_DEP_SFX | String | Dependent Name Suffix |
L2100D | REF | Dependent Additional Identification | | |
02 | | L2100D_nnREF_PLAN_NR | String | Plan Number |
02 | | L2100D_nnREF_GRP_POLCY_NR | String | Group or Policy Number |
02 | | L2100D_nnREF_GRP_NR | String | Group Number |
02 | | L2100D_nnREF_CNTRCT_NR | String | Contract Number |
02 | | L2100D_nnREF_MED_REC_ID | String | Medical Record Identification Number |
02 | | L2100D_nnREF_PATNT_ACCT_NR | String | Patient Account Number |
02 | | L2100D_nnREF_HIC_NR | String | Health Insurance Claim (HIC) Number |
02 | | L2100D_nnREF_ID_SERL_NR | String | Identification Card Serial Number |
02 | | L2100D_nnREF_ID_CRD_NR | String | Identity Card Number |
02 | | L2100D_nnREF_ISSU_NR | String | Issue Number |
02 | | L2100D_nnREF_INS_PLCY_NR | String | Insurance Policy Number |
02 | | L2100D_nnREF_ELIG_CAT | String | Eligibility Category |
02 | | L2100D_nnREF_PLN_NET_ID | String | Plan Network Identification Number |
02 | | L2100D_nnREF_SSN | String | Social Security Number |
02 | | L2100D_nnREF_AGNCY_CLM_NR | String | Agency Claim Number |
L2100D | N3 | Dependent Address | | |
01 | | L2100D_N301_DEP_ADDR | String | Dependent Address Line |
02 | | L2100D_N302_DEP_ADDR | String | Dependent Address Line |
L2100D | N4 | Dependent City, State, ZIP Code | | |
01 | | L2100D_N401_DEP_CITY | String | Dependent City Name |
02 | | L2100D_N402_DEP_STAT | String | Dependent State Code |
03 | | L2100D_N403_DEP_POSTL_ZIP | String | Dependent Postal Zone or ZIP Code |
04 | | L2100D_N404_CNTRY_CD | String | Country Code |
07 | | L2100D_N407_CNTRY_SUBDV_CD | String | Country Subdivision Code |
L2100D | PRV | Provider Information | | |
01 | | L2100D_PRV01_PVD_CD | String | Provider Code |
03 | | L2100D_PRV03_SERVCR | String | Servicer |
03 | | L2100D_PRV03_NCPDP_PHARM_NR | String | National Council for Prescription Drug Programs Pharmacy Number |
03 | | L2100D_PRV03_EMP_ID_NR | String | Employer's Identification Number |
03 | | L2100D_PRV03_NPI | String | Centers for Medicare and Medicaid Services National Provider Identifier |
03 | | L2100D_PRV03_PVD_TAXNMY_CD | String | Health Care Provider Taxonomy Code |
03 | | L2100D_PRV03_SSN | String | Social Security Number |
03 | | L2100D_PRV03_TAX_ID | String | Federal Taxpayer's Identification Number |
L2100D | DMG | Dependent Demographic Information | | |
02 | | L2100D_DMG02_D8 | DateTime | Dependent Birth Date |
03 | | L2100D_DMG03_DEP_GNDR_CD | String | Dependent Gender Code |
L2100D | INS | Dependent Relationship | | |
02 | | L2100D_INS02_IND_RELAT_CD | String | Individual Relationship Code |
17 | | L2100D_INS17_BRTH_SEQ_NR | String | Birth Sequence Number |
L2100D | HI | Dependent Health Care Diagnosis Code | | |
01 | 02 | L2100D_HI0102_ICD10_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis |
01 | 02 | L2100D_HI0102_ICD9_PRIN_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis |
02 | 02 | L2100D_HI0202_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
02 | 02 | L2100D_HI0202_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
03 | 02 | L2100D_HI0302_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
03 | 02 | L2100D_HI0302_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
04 | 02 | L2100D_HI0402_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
04 | 02 | L2100D_HI0402_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
05 | 02 | L2100D_HI0502_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
05 | 02 | L2100D_HI0502_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
06 | 02 | L2100D_HI0602_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
06 | 02 | L2100D_HI0602_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
07 | 02 | L2100D_HI0702_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
07 | 02 | L2100D_HI0702_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
08 | 02 | L2100D_HI0802_ICD10_DIAG | String | International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis |
08 | 02 | L2100D_HI0802_ICD9_DIAG | String | International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis |
03 | | L2100D_DTP_ISSU_D8 | Date (YYYYMMDD) | Issue Date |
03 | | L2100D_DTP_ISSU_RD8_1 | Start Date (YYYYMMDD) | Issue Date |
03 | | L2100D_DTP_ISSU_RD8_2 | End Date (YYYYMMDD) | Issue Date |
03 | | L2100D_DTP_PLAN_D8 | Date (YYYYMMDD) | Plan Date |
03 | | L2100D_DTP_PLAN_RD8_1 | Start Date (YYYYMMDD) | Plan Date |
03 | | L2100D_DTP_PLAN_RD8_2 | End Date (YYYYMMDD) | Plan Date |
L2110D - DEPENDENT ELIGIBILITY OR BENEFIT INQUIRY |
L2110D | EQ | Dependent Eligibility or Benefit Inquiry | | |
01 | | L2110D_EQ01_Enn_SVC_TYP_CD | String | Service Type Code |
02 | 02 | L2110D_EQ0202_ADA_CD | String | American Dental Association Codes |
02 | 02 | L2110D_EQ0202_CPT_CD | String | Current Procedural Terminology (CPT) Codes |
02 | 02 | L2110D_EQ0202_HCPCS_CD | String | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
02 | 02 | L2110D_EQ0202_ICD9_PROC | String | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure |
02 | 02 | L2110D_EQ0202_HIC_PRD_SVCCD | String | Home Infusion EDI Coalition (HIEC) Product/Service Code |
02 | 02 | L2110D_EQ0202_NDC542 | String | National Drug Code in 5-4-2 Format |
02 | 02 | L2110D_EQ0202_MUTLY_DEF | String | Mutually Defined |
02 | 03 | L2110D_EQ0203_PROC_MOD | String | Procedure Modifier |
02 | 04 | L2110D_EQ0204_PROC_MOD | String | Procedure Modifier |
02 | 05 | L2110D_EQ0205_PROC_MOD | String | Procedure Modifier |
02 | 06 | L2110D_EQ0206_PROC_MOD | String | Procedure Modifier |
05 | 01 | L2110D_EQ0501_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
05 | 02 | L2110D_EQ0502_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
05 | 03 | L2110D_EQ0503_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
05 | 04 | L2110D_EQ0504_DIAG_CD_PTR | Integer | Diagnosis Code Pointer |
L2110D | III | Dependent Eligibility or Benefit Additional Inquiry Information | | |
02 | | L2110D_III02_MUTLY_DEF | String | Mutually Defined |
L2110D | REF | Dependent Additional Information | | |
02 | | L2110D_REF_REFRL_NR | String | Referral Number |
02 | | L2110D_REF_PRIOR_AUTH | String | Prior Authorization Number |
L2110D | DTP | Dependent Eligibility/Benefit Date | | |
03 | | L2110D_DTP_PLAN_D8 | Date (YYYYMMDD) | Plan Date |
03 | | L2110D_DTP_PLAN_RD8_1 | Start Date (YYYYMMDD) | Plan Date |
03 | | L2110D_DTP_PLAN_RD8_2 | End Date (YYYYMMDD) | Plan Date |
STHDR | SE | Transaction Set Trailer | | |
01 | | STHDR_SE01_TS_SEG_CT | Integer | Transaction Segment Count |
02 | | STHDR_SE02_TCN | String | Transaction Set Control Number |
GSHDR | GE | Functional Group Trailer | | |
01 | | GSHDR_GE01_NR_TS_INCLUDED | Integer | Number of Transaction Sets Included |
02 | | GSHDR_GE02_GCN | Integer | Group Control Number |
ISA | IEA | Interchange Control Trailer | | |
01 | | ISA_IEA01_NR_INC_FUNC_GRP | Integer | Number of Included Functional Groups |
02 | | ISA_IEA02_ICN | Integer | Interchange Control Number |