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4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
ISA03 Security Information Qualifier ID 2-2 R 00, 01 ISA03 Security Information Qualifier ID 2-2 R 00, 01
ISA04 Security Information AN 10-10 R ISA04 Security Information AN 10-10 R
01, 14, 20, 27, 28, 01, 14, 20, 27, 28,
ISA05 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ ISA05 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ
ISA06 Interchange Sender ID AN 15-15 R ISA06 Interchange Sender ID AN 15-15 R
01, 14, 20, 27, 28, 01, 14, 20, 27, 28,
ISA07 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ ISA07 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ
ISA08 Interchange Receiver ID AN 15-15 R ISA08 Interchange Receiver ID AN 15-15 R
ISA09 Interchange Date DT 6-6 R YYMMDD ISA09 Interchange Date DT 6-6 R YYMMDD
ISA10 Interchange Time TM 4-4 R HHMM ISA10 Interchange Time TM 4-4 R HHMM
Interchange Control Code Change
ISA11 Standards ID ID 1-1 R U ISA11 Repetition Seperator 1-1 R Name Change
Interchange Control Version Interchange Control Version
ISA12 Number ID 5-5 R 00401 ISA12 Number ID 5-5 R 00501 Code Change
ISA13 Interchange Control Number N0 9-9 R ISA13 Interchange Control Number N0 9-9 R
GS03 Application Receiver's Code AN 2-15 R GS03 Application Receiver's Code AN 2-15 R
GS04 Date DT 8-8 R CCYYMMDD GS04 Date DT 8-8 R CCYYMMDD
GS05 Time TM 4-8 R HHMM GS05 Time TM 4-8 R HHMM
GS06 Group Control Number N0 1-9 R GS06 Group Control Number N0 1-9 R
GS07 Responsible Agency Code ID 1-2 R X GS07 Responsible Agency Code ID 1-2 R X
Version/ Release/ Industry Version/Release/ Industry
GS08 Identifier Code AN 1-12 R 004010X092 GS08 Identifier Code AN 1-12 R 005010X279 Code Change
Page 1 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
BEGINNING OF BEGINNING OF
HIERARCHICAL HIERARCHICAL
BHT TRANSACTION 1 R BHT TRANSACTION 1 R
BHT01 Hierarchical Structure Code ID 4-4 R 0022 BHT01 Hierarchical Structure Code ID 4-4 R 0022
Transaction Set Purpose Transaction Set Purpose
BHT02 Code ID 2-2 R 01,13, 36 BHT02 Code ID 2-2 R 01,13 Code deleted
BHT03 Reference Identification AN 1-30 S BHT03 Reference Identification AN 1-50 S Increase from 30 - 50
Transaction Set Creation
BHT04 Date DT 8-8 R CCYYMMDD BHT04 Date DT 8-8 R CCYYMMDD Name Change
BHT05 Time TM 4-8 R BHT05 Time TM 4-8 R
BHT06 Transaction Type Code ID 2-2 S RT, RU BHT06 Transaction Type Code ID 2-2 S RT Code deleted
Page 2 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
N402 State or Province Code ID 2-2 R N402 State or Province Code ID 2-2 S Usage change to Required
Page 3 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
INFORMATION RECEIVER
PER CONTACT INFORMATION 3 S 2100B Segment Deleted
PER01 Contact Function Code ID 2-2 R IC
PER02 Name AN 1-60 S
Communication Number
PER03 Qualifier ID 2-2 S ED, EM, FX, TE
PER04 Communication Number AN 1-80 S
Communication Number ED, EM, EX, FX,
PER05 Qualifier ID 2-2 S TE
PER06 Communication Number AN 1-80 S AAABBBCCCC
Communication Number ED, EM, EX, FX,
PER07 Qualifier ID 2-2 S TE
PER08 Communication Number AN 1-80 S AAABBBCCCC
PER09 Contact Inquiry Reference AN 1-20 N/U
PRV06 Provider Organization Code ID 3-3 N/U PRV06 Provider Organization Code ID 3-3 N/U
Page 4 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
TRN03 Originating Company Identifier AN 10-10 R TRN03 Originating Company Identifier AN 10-10 R
TRN04 Reference Identification AN 1-30 S TRN04 Reference Identification AN 1-50 S Increase from 30 - 50
N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage change to Required
N402 State or Province Name ID 2-2 S N402 State or Province Name ID 2-2 S
N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S
N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S
N405 Location Qualifier ID 1-2 N/U N405 Location Qualifier ID 1-2 N/U
N406 Location Qualifier AN 1-30 N/U N406 Location Qualifier AN 1-30 N/U
N407 Country Subdivision Code ID 1-3 S New Element
Page 5 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
PRV06 Provider Organization Code ID 3-3 N/U PRV06 Provider Organization Code ID 3-3 N/U
SUBSCRIBER SUBSCRIBER
DEMOGRAPHIC DEMOGRAPHIC
DMG INFORMATION 1 S 2100C DMG INFORMATION 1 S 2100C
Date Time Period Format Date Time Period Format
DMG01 Qualifier ID 2-3 S D8 DMG01 Qualifier ID 2-3 S D8
DMG02 Date Time Period AN 1-35 S DMG02 Date Time Period AN 1-35 S
DMG03 Gender Code ID 1-1 S F, M DMG03 Gender Code ID 1-1 S F, M
DMG04 Marital Status Code ID 1-1 N/U DMG04 Marital Status Code ID 1-1 N/U
Composite Race or Ethnicity
DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05 Information N/U
DMG06 Citizenship Status Code ID 1-2 N/U DMG06 Citizenship Status Code ID 1-2 N/U
DMG07 Country Code ID 2-3 N/U DMG07 Country Code ID 2-3 N/U
DMG08 Basis of Verification Code ID 1-2 N/U DMG08 Basis of Verification Code ID 1-2 N/U
DMG09 Quantity R 1-15 N/U DMG09 Quantity R 1-15 N/U
DMG10 Code List Qualifier Code ID 1-3 N/U New Element
DMG11 Industry Code AN 1-30 N/U New Element
INS02 Individual Relationsgip Code ID 2-2 R 18 INS02 Individual Relationsgip Code ID 2-2 R 18
INS03 Maintenance Type Code ID 3-3 N/U INS03 Maintenance Type Code ID 3-3 N/U
INS04 Maintenance Reason Code ID 2-3 N/U INS04 Maintenance Reason Code ID 2-3 N/U
INS05 Benefit Status Code ID 1-1 N/U INS05 Benefit Status Code ID 1-1 N/U
INS06 Medicare Plan Code ID 1-1 N/U INS06 MEDICARE STATUS CODE N/U Name Change
Consolidated Omnibus Consolidated Omnibus
Budget Reconcilliation Act Budget Reconcilliation Act
INS07 (COBRA) Qualifying ID 1-2 N/U INS07 (COBRA) Qualifying ID 1-2 N/U
INS08 Employment Status Code ID 2-2 N/U INS08 Employment Status Code ID 2-2 N/U
INS09 Student Status Code ID 1-1 N/U INS09 Student Status Code ID 1-1 N/U
Page 6 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
SUBSCRIBER HEALTH
HI CARE DIAGNOSIS CODE 1 S 2100C New Segment
HEALTH CARE CODE
HI01 INFORMATION R
HI01 - 1 Code List Qualifier Code ID 1-3 R ABK, BK
HI01 - 2 Industry Code AN 1-30 R
Date Time Period Format
HI01 - 3 Qualifier ID 2-3 N/U
HI01 - 4 Date Time Period AN 1-35 N/U
HI01 - 5 Monetary Amount R 1-18 N/U
HI01 - 6 Quantity R 1-15 N/U
HI01 - 7 Version Identifier AN 1-30 N/U
HI01 - 8 Industry Code AN 1-30 N/U
Yes/No Condition or
HI01 - 9 Response Code ID 1-1 N/U
HEALTH CARE CODE
HI02 INFORMATION S
HI02 - 1 Code List Qualifier Code ID 1-3 R ABF, BF
HI02 - 2 Industry Code AN 1-30 R
Date Time Period Format
HI02 - 3 Qualifier ID 2-3 N/U
HI02 - 4 Date Time Period AN 1-35 N/U
HI02 - 5 Monetary Amount R 1-18 N/U
HI02 - 6 Quantity R 1-15 N/U
HI02 - 7 Version Identifier AN 1-30 N/U
HI02 - 8 Industry Code AN 1-30 N/U
Yes/No Condition or
HI02 - 9 Response Code ID 1-1 N/U
HEALTH CARE CODE
HI03 INFORMATION S
HI03 - 1 Code List Qualifier Code ID 1-3 R ABF, BF
HI03 - 2 Industry Code AN 1-30 R
Date Time Period Format
HI03 - 3 Qualifier ID 2-3 N/U
HI03 - 4 Date Time Period AN 1-35 N/U
HI03 - 5 Monetary Amount R 1-18 N/U
HI03 - 6 Quantity R 1-15 N/U
HI03 - 7 Version Identifier AN 1-30 N/U
HI03 - 8 Industry Code AN 1-30 N/U
Page 7 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
Page 8 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
DTP01 Date/Time Qualifier ID 3-3 R 102, 307, 435, 472 DTP01 Date Time Qualifier ID 3-3 R 102, 291 Code Change
Date Time Period Format Date Time Period Format
DTP02 Qualifier ID 2-3 R D8, RD8 DTP02 Qualifier ID 2-3 R D8, RD8
CCYYMMDD, CCYYMMDD,
CCYYMMDD- CCYYMMDD-
DTP03 Date Time Period AN 1-35 R CCYYMMDD DTP03 Date Time Period AN 1-35 R CCYYMMDD
SUBSCRIBER SUBSCIBER
ELIGIBILITY/BENEFIT ELIGIBILITY/BENEFIT
EQ INQUIRY INFORMATION 1 S 2110C 99 EQ INQUIRY INFORMATION 1 S 2110C 99
Page 9 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
Page 10 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
AMT02 Monetary Amount R 1-18 N/U AMT02 Monetary Amount R 1-18 R Usage change to Required
AMT03 Credit/Debit Flag Code ID 1-1 N/U AMT03 Credit/Debit Flag Code ID 1-1 N/U
SUBSCRIBER SPEND
DOWN TOTAL BILLED
AMT AMOUNT 1 S 2110C New Segment
AMT01 Amount Qualifier Code ID 1-3 R PB
AMT02 Monetary Amount R 1-18 R
AMT03 Credit/Debit Flag Code ID 1-1 N/U
SUBSCRIBER
SUBSCRIBER ELIGIBILITY/ ELIGIBILITY/BENEFIT
BENEFIT ADDITIONAL ADDITIONAL INQUIRY
III INQUIRY INFORMATION 10 S 2110C III INFORMATION 10 S 2110C
III01 Code List Qualifier Code ID 1-3 R BF, BK, ZZ III01 Code List Qualifier Code ID 1-3 R ZZ Code Deleted
If Ill01 = BK or BF:
use diagnosis
code from code 01, 03, 04, 05, 06,
source 131; 07, 08, 11, 12, 13,
If III01 = ZZ: 11, 14, 15, 20, 21, 22,
12, 21, 22, 23, 24, 23, 24, 25, 26, 31,
25, 26, 31, 32, 33, 32, 33, 34, 41, 42,
34, 41, 42, 50, 51, 49, 50, 51, 52, 53,
52, 53, 54, 55, 56, 54, 55, 56, 57, 60,
60, 61, 62, 65, 71, 61, 62, 65, 71, 72,
III02 Industry Code AN 1-30 R 72, 81, 99 III02 Industry Code AN 1-30 R 81, 99 Code Deleted
III03 Code Category ID 2-2 N/U III03 Code Category ID 2-2 N/U
III04 Free-Form Message Text AN 1-264 N/U III04 Free-Form Message Text AN 1-264 N/U
III05 Quantity R 1-15 N/U III05 Quantity R 1-15 N/U
COMPOSITE UNIT OF COMPOSITE UNIT OF
III06 MEASURE N/U III06 MEASURE N/U
III07 Surface/Layer/Position Code ID 2-2 N/U III07 Surface/Layer/Position Code ID 2-2 N/U
Page 11 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
III09 Surface/Layer/Position Code ID 2-2 N/U III09 Surface/Layer/Position Code ID 2-2 N/U
SUBSCRIBER SUBSCRIBER
DTP ELIGIBILITY/BENEFIT DATE 1 S 2110C DTP ELIGIBILITY/BENEFIT DATE 1 S 2110C
DTP01 Date/Time Qualifier ID 3-3 R 307, 435, 472 DTP01 Date Time Qualifier ID 3-3 R 291 Code Change
Date Time Period Format Date Time Period Format
DTP02 Qualifier ID 2-3 R D8, RD8 DTP02 Qualifier ID 2-3 R D8, RD8
CCYYMMDD,
Date Time Period Format CCYYMMDD-
DTP03 Date Time Period AN 1-35 R DTP03 Qualifier AN 1-35 R CCYYMMDD Code Added
TRN03 Originating Company Identifier AN 10-10 R TRN03 Originating Company Identifier AN 10-10 R
TRN04 Reference Identification AN 1-30 S TRN04 Reference Identification AN 1-50 S Increase from 30 - 50
NM108 Identification Code Qualifier ID 1-2 N/U NM108 Identification Code Qualifier ID 1-2 N/U
Page 12 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
DEPENDENT DEPENDENT
N4 CITY/STATE/ZIP CODE 1 S 2100D N4 CITY/STATE/ZIP CODE 1 S 2100D
N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage change to Required
N402 State or Provine Code ID 2-2 S N402 State or Provine Code ID 2-2 S
N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S
N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S
N405 Location Qualifier ID 1-2 N/U N405 Location Qualifier ID 1-2 N/U
N406 Location Qualifier AN 1-30 N/U N406 Location Qualifier AN 1-30 N/U
N407 Country Subdivision Code ID 1-3 S New Element
PRV06 Provider Organization Code ID 3-3 N/U PRV06 Provider Organization Code ID 3-3 N/U
Page 13 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
DEPENDENT DEPENDENT
INS RELATIONSHIP 1 S 2100D INS RELATIONSHIP 1 S 2100D
Yes/No Condition or Yes/No Condition or
INS01 Response Code ID 1-1 R N INS01 Response Code ID 1-1 R N
INS02 Individual Relationship Code ID 2-2 R 01, 19, 34 INS02 Individual Relationship Code ID 2-2 R 01, 19, 34
INS03 Maintenance Type Code ID 3-3 N/U INS03 Maintenance Type Code ID 3-3 N/U
INS04 Maintenance Reason Code ID 2-3 N/U INS04 Maintenance Reason Code ID 2-3 N/U
INS05 Benefit Status Code ID 1-1 N/U INS05 Benefit Status Code ID 1-1 N/U
INS06 Medicare Plan Code ID 1-1 N/U INS06 MEDICARE STATUS CODE 1-1 N/U
Consolidated Omnibus Consolidated Omnibus
Budget Reconcilliation Act Budget Reconcilliation Act
INS07 (COBRA) Qualifying ID 1-2 N/U INS07 (COBRA) Qualifying ID 1-2 N/U
INS08 Employment Status Code ID 2-2 N/U INS08 Employment Status Code ID 2-2 N/U
INS09 Student Status Code ID 1-1 N/U INS09 Student Status Code ID 1-1 N/U
Yes/No Condition or Yes/No Condition or
INS10 Response Code ID 1-1 N/U INS10 Response Code ID 1-1 N/U
Date Time Period Format Date Time Period Format
INS11 Qualifier ID 2-3 N/U INS11 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 Confidentiality Code ID 1-1 N/U INS13 Confidentiality Code ID 1-1 N/U
INS14 City Name AN 2-30 N/U INS14 City Name AN 2-30 N/U
INS15 State or Province Code ID 2-2 N/U INS15 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 S INS17 Number N0 1-9 S
DEPENDENT HEALTH
HI CARE DIAGNOSIS CODE 1 S 2100D New Segment
HEALTH CARE CODE
HI01 INFORMATION R
HI01 - 1 Code List Qualifier Code ID 1-3 R ABK, BK
HI01 - 2 Industry Code AN 1-30 R
Page 14 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
Page 15 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
Page 16 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
Page 17 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
Page 18 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
If Ill01 = BK or BF,
use diagnosis
code from code 01, 03, 04, 05, 06,
source 131; 07, 08, 11, 12, 13,
If III01 = ZZ: 11, 14, 15, 20, 21, 22,
12, 21, 22, 23, 24, 23, 24, 25, 26, 31,
25, 26, 31, 32, 33, 32, 33, 34, 41, 42,
34, 41, 42, 50, 51, 49, 50, 51, 52, 53,
52, 53, 54, 55, 56, 54, 55, 56,57, 60,
60, 61, 62, 65, 71, 61, 62, 65, 71, 72,
III02 Industry Code AN 1-30 R 72, 81, 99 III02 Industry Code AN 1-30 R 81, 99 Code Deleted
III03 Code Category ID 2-2 N/U III03 Code Category ID 2-2 N/U
III04 Free-Form Message Text AN 1-264 N/U III04 Free-Form Message Text AN 1-264 N/U
III05 Quantity R 1-15 N/U III05 Quantity R 1-15 N/U
COMPOSITE UNIT OF COMPOSITE UNIT OF
III06 MEASURE N/U III06 MEASURE N/U
III07 Surface/Layer/Position Code ID 2-2 N/U III07 Surface/Layer/Position Code ID 2-2 N/U
III08 Surface/Layer/Position Code ID 2-2 N/U III08 Surface/Layer/Position Code ID 2-2 N/U
III09 Surface/Layer/Position Code ID 2-2 N/U III09 Surface/Layer/Position Code ID 2-2 N/U
Page 19 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
IEA02 Interchange Control Number N0 9-9 R IEA02 Interchange Control Number N0 9-9 R
Page 20 of 20
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
ISA03 Security Information Qualifier ID 2/2 R 00, 01 ISA03 Security Information Qualifier ID 2-2 R 00, 01
ISA04 Security Information AN 10/10 R ISA04 Security Information AN 10-10 R
01, 14, 20, 27, 28, 01, 14, 20, 27, 28,
ISA05 Interchange ID Qualifier ID 2/2 R 29, 30, 33, ZZ ISA05 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ
ISA06 Interchange Sender ID AN 15/15 R ISA06 Interchange Sender ID AN 15-15 R
01, 14, 20, 27, 28, 01, 14, 20, 27, 28,
ISA07 Interchange ID Qualifier ID 2/2 R 29, 30, 33, ZZ ISA07 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ
ISA08 Interchange Receiver ID AN 15/15 R ISA08 Interchange Receiver ID AN 15-15 R
ISA09 Interchange Date DT 6/6 R YYMMDD ISA09 Interchange Date DT 6-6 R YYMMDD
ISA10 Interchange Time TM 4/4 R HHMM ISA10 Interchange Time TM 4-4 R HHMM
Interchange Control Code Change
ISA11 Standards ID ID 1/1 R U ISA11 Repetition Seperator 1-1 R Name Change
Interchange Control Version Interchange Control Version
ISA12 Number ID 5/5 R 00401 ISA12 Number ID 5-5 R 00501 Code Change
ISA13 Interchange Control Number N0 9/9 R ISA13 Interchange Control Number N0 9-9 R
GS03 Application Receiver's Code AN 2/15 R GS03 Application Receiver's Code AN 2-15 R
GS04 Date DT 8/8 R CCYYMMDD GS04 Date DT 8-8 R CCYYMMDD
GS05 Time TM 4/8 R HHMM GS05 Time TM 4-8 R HHMM
GS06 Group Control Number N0 1/9 R GS06 Group Control Number N0 1-9 R
GS07 Responsible Agency Code ID 1/2 R X GS07 Responsible Agency Code ID 1-2 R X
Version/ Release/ Industry Version/Release/ Industry
GS08 Identifier Code AN 1/12 R 004010X092 GS08 Identifier Code AN 1-12 R 005010X279 Code Change
Page 1 of 32
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
BEGINNING OF BEGINNING OF
HIERARCHICAL HIERARCHICAL
BHT TRANSACTION 1 R BHT TRANSACTION 1 R
BHT01 Hierarchical Structure Code ID 4-4 R 0022 BHT01 Hierarchical Structure Code ID 4-4 R 0022
Transaction Set Purpose Transaction Set Purpose
BHT02 Code ID 2-2 R 11 BHT02 Code ID 2-2 R 06, 11 Code Added
BHT03 Reference Identification AN 1-30 S BHT03 Reference Identification AN 1-50 S Increase from 30 - 50
BHT04 Date DT 8-8 R CCYYMMDD BHT04 Date DT 8-8 R CCYYMMDD
BHT05 Time TM 4-8 R BHT05 Time TM 4-8 R
BHT06 Transaction Type Code ID 2-2 N/U BHT06 Transaction Type Code ID 2-2 N/U
Page 2 of 32
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
INFORMATION SOURCE
ADDITIONAL
REF IDENTIFICATION 9 S 2100A Segment Deleted
Reference Identification
REF01 Qualifier ID 2-3 R 18, 55
REF02 Reference Identification AN 1-30 R
REF03 Description AN 1-80 S
REF04 REFERENCE INDENTIFIER N/U
Page 3 of 32
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
AAA04 Follow-up Action Code ID 1-1 R C, N, R, S, W, X, Y AAA04 Follow-up Action Code ID 1-1 R C, N, R, S, W, X, Y
Page 4 of 32
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
TRN03 Originating Company Identifier AN 10-10 R TRN03 Originating Company Identifier AN 10-10 R
TRN04 Reference Identification AN 1-30 S TRN04 Reference Identification AN 1-50 S Increase form 30 - 50
Page 5 of 32
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
N405 Location Qualifier ID 1-2 S CY, FI N405 Location Qualifier ID 1-2 N/U CY, FI Usage change to Not Used
N406 Location Qualifier AN 1-30 S N406 Location Qualifier AN 1-30 N/U Usage change to Not Used
N407 Country Subdivision Code ID 1-3 S New Element
SUBSCRIBER CONTACT
PER INFORMATION 3 S 2100C Segment Deleted
PER01 Contact Function Code ID 2-2 R IC
PER02 Name AN 1-60 S
Communication Number
PER03 Qualifier ID 2-2 S HP, TE, WP
PER04 Communication Number AN 1-80 S AAABBBCCCC
Communication Number
PER05 Qualifier ID 2-2 S EX, HP, TE, WP
PER06 Communication Number AN 1-80 S AAABBBCCCC
Communication Number
PER07 Qualifier ID 2-2 S EX, HP, TE, WP
PER08 Communication Number AN 1-80 S
PER09 Contact Inquiry Reference AN 1-20 N/U
Page 6 of 32
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
AAA04 Follow-up Action Code ID 1-1 R C, N, R, S, W, X, Y AAA04 Follow-up Action Code ID 1-1 R C, N, R, S, W, X, Y
SUBSCRIBER SUBSCRIBER
DEMOGRAPHIC DEMOGRAPHIC
DMG INFORMATION 1 S 2100C DMG INFORMATION 1 S 2100C
Date Time Period Format Date Time Period Format
DMG01 Qualifier ID 2-3 S D8 DMG01 Qualifier ID 2-3 S D8
DMG02 Date Time Period AN 1-35 S DMG02 Date Time Period AN 1-35 S
DMG03 Gender Code ID 1-1 S F, M, U DMG03 Gender Code ID 1-1 S F, M, U
DMG04 Marital Status Code ID 1-1 N/U DMG04 Marital Status
COMPOSITE CodeOR
RACE ID 1-1 N/U
DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05 ETHNICITY INFORMATION ID 1-1 N/U
DMG06 Citizenship Status Code ID 1-2 N/U DMG06 Citizenship Status Code ID 1-2 N/U
DMG07 Country Code ID 2-3 N/U DMG07 Country Code ID 2-3 N/U
DMG08 Basis of Verification Code ID 1-2 N/U DMG08 Basis of Verification Code ID 1-2 N/U
DMG09 Quantity R 1-15 N/U DMG09 Quantity R 1-15 N/U
DMG10 Code List Qalifier Code ID 1-3 N/U New Element
DMG11 Industry Code AN 1-30 N/U New Element
SUBSCRIBER SUBSCRIBER
INS REALTIONSHIP 1 S 2100C INS RELATIONSHIP 1 S 2100C
Page 7 of 32
ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
SUBSCRIBER HEALTH
HI CARE DIAGNOSIS CODE 1 S 2100C New Element
HEALTH CARE CODE
HI01 INFORMATION R
HI01 - 1 Code List Qualifier Code ID 1-3 R ABK, BK
HI01 - 2 Industry Code AN 1-30 R
Date Time Period Format
HI01 - 3 Qualifier ID 2-3 N/U
HI01 - 4 Date Time Period AN 1-35 N/U
HI01 - 5 Monetary Amount R 1-18 N/U
HI01 - 6 Quantity R 1-15 N/U
HI01 - 7 Version Identifier AN 1-30 N/U
HI01 - 8 Industry Code AN 1-30 N/U
Yes/No Condition or
HI01 - 9 Response Code ID 1-1 N/U
HEALTH CARE CODE
HI02 INFORMATION S
HI02 - 1 Code List Qualifier Code ID 1-3 R ABF, BF
HI02 - 2 Industry Code AN 1-30 R
Date Time Period Format
HI02 - 3 Qualifier ID 2-3 N/U
HI02 - 4 Date Time Period AN 1-35 N/U
HI02 - 5 Monetary Amount R 1-18 N/U
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
SUBSCRIBER MILITARY
PERSONNEL
MPI INFORMATION 1 S 2100C New Element
MPI01 Information Status Code ID 1-1 R A, C, L, O, P, S, T
AE, AO, AS, AT,
AU, CC, DD, HD,
IR, LX, PE, RE,
MPI02 Employment Status Code ID 2-2 R RM, RR, RU
A, B, C, D, E, F,
G, H, I, J, K, L, M,
Government Service Affiliation N, O, Q, R, S, U,
MPI03 Code ID 1-1 R W
MPI04 Description AN 1-80 S
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
12, 13, 14, 15, 16, 12, 13, 14, 15, 16,
41, 42, 43, 47, AP, 41, 42, 43, 47, AP,
C1, CO, CP, D, C1, CO, CP, D,
DB, EP, FF, GP, DB, EP, FF, GP,
HM, HN, HS, IN, HM, HN, HS, IN,
LC, LD, LI, LT, IP, LC, LD, LI, LT,
MA, MB, MC, MH, MA, MB, MC, MH,
MI, MP, OT, PE, MI, MP, OT, PE,
PL, PP, PR, PS, PL, PP, PR, PS,
QM, RP, SP, TF, QM, RP, SP, TF,
EB04 Insurance Type Code ID 1-3 S WC, WU EB04 Insurance Type Code ID 1-3 S WC, WU
EB05 Plan Coverage Description AN 1-50 S EB05 Plan Coverage Description AN 1-50 S
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
MSG02 Printer Carriage Control Code ID 2-2 N/U MSG02 Printer Carriage Control Code ID 2-2 N/U
MSG03 Number N0 1-9 N/U MSG03 Number N0 1-9 N/U
SUBSCRIBER
SUBSCRIBER ELIGIBILITY/ ELIGIBILITY/BENEFIT
BENEFIT ADDITIONAL ADDITIONAL
III INFORMATION 1 S 2115C 10 III INFORMATION 1 S 2115C 10
Code Change
Usage change to
III01 Code List Quantifier Code ID 1-3 R BF, BK, ZZ III01 Code List Quantifier Code ID 1-3 S GR, NI, ZZ Situational
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
III07 Surface/Layer/Position Code ID 2-2 N/U III07 Surface/Layer/Position Code ID 2-2 N/U
III08 Surface/Layer/Position Code ID 2-2 N/U III08 Surface/Layer/Position Code ID 2-2 N/U
III09 Surface/Layer/Position Code ID 2-2 N/U III09 Surface/Layer/Position Code ID 2-2 N/U
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U
Name Last or Organization
NM112 Name AN 1-60 N/U New Element
SUBSCRIBER BENEFIT
SUBSCRIBER RELATED RELATED ENTITY
N3 ENTITY ADDRESS 1 S 2120C N3 ADDRESS 1 S 2120C
N301 Address Information AN 1-55 R N301 Address Information AN 1-55 R
N302 Address Information AN 1-55 S N302 Address Information AN 1-55 S
N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage change to Required
N402 State or Province Code ID 2-2 S N402 State or Province Code ID 2-2 S
N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S
N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S
N405 Location Qualifier ID 1-2 S RJ N405 Location Qualifier ID 1-2 S RJ
N406 Location Qualifier AN 1-30 S N406 Location Qualifier AN 1-30 S
N407 Country Subdivision Code ID 1-3 S Code Added
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ELIGIBILITY STATUS
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Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
PRV06 Provider Organization Code ID 3-3 N/U PRV06 Provider Organization Code ID 3-3 N/U
HL03 Hierarchical Level Code ID 1-2 R 23 HL03 Hierarchical Level Code ID 1-2 R 23
HL04 Hierarchical Child Code ID 1-1 R 0 HL04 Hierarchical Child Code ID 1-1 R 0
TRN03 Originating Company Identifier AN 10-10 R TRN03 Originating Company Identifier AN 10-10 R
TRN04 Reference Identification AN 1-30 S TRN04 Reference Identification AN 1-50 S Increase from 30 - 50
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ELIGIBILITY STATUS
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Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
Code Deleted
NM108 Identification Code Qualifier ID 1-2 S MI, ZZ NM108 Identification Code Qualifier ID 1-2 N/U Usage change to Not Used
NM109 Identification Code AN 2-80 S NM109 Identification Code AN 2-80 N/U Usage change to Not Used
NM110 Entity Relationship Code ID 2-2 N/U NM110 Entity Relationship Code ID 2-2 N/U
NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U
Name Last or Organization
NM112 Name AN 1-60 N/U New Element
DEPENDENT DEPENDENT
N4 CITY/STATE/ZIP CODE 1 S 2100D N4 CITY/STATE/ZIP CODE 1 S 2100D
N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage change to Required
N402 State or Province Code ID 2-2 S N402 State or Province Code ID 2-2 S
N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S
N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S
N405 Location Qualifier ID 1-2 N/U N405 Location Qualifier ID 1-2 N/U
N406 Location Qualifier AN 1-30 N/U N406 Location Qualifier AN 1-30 N/U
N407 Country Subdivision Code ID 1-3 New Element
DEPENDENT CONTACT
PER INFORMATION 3 S 2100D Segment Deleted
PER01 Contact Function Code ID 2-2 R IC
PER02 Name AN 1-60 S
Communication Number
PER03 Qualifier ID 2-2 S HP, TE, WP
PER04 Communication Number AN 1-80 S AAABBBCCCC
Communication Number
PER05 Qualifier ID 2-2 S EX, HP, TE, WP
PER06 Communication Number AN 1-80 S AAABBBCCCC
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
15, 42, 43, 45, 47, 15, 35, 42, 43, 45,
48, 49, 51, 52, 56, 47, 48, 49, 51, 52,
57, 58, 60, 61, 62, 56, 57, 58, 60, 61,
63, 64, 65, 66, 67, 62, 63, 64, 65, 66,
AAA03 Reject Reason Code ID 2-2 R 68, 71 AAA03 Reject Reason Code ID 2-2 R 67, 68, 71, 77 Code Added
AAA04 Follow-up Action Code ID 1-1 R C, N, R, S, W, X, Y AAA04 Follow-up Action Code ID 1-1 R C, N, R, S, W, X, Y
DEPENDENT DEPENDENT
DEMOGRAPHIC DEMOGRAPHIC
DMG INFORMATION 1 S 2100D DMG INFORMATION 1 S 2100D
Date Time Period Format Date Time Period Format
DMG01 Qualifier ID 2-3 S D8 DMG01 Qualifier ID 2-3 S D8
DMG02 Date Time Period AN 1-35 S DMG02 Date Time Period AN 1-35 S
DMG03 Gender Code ID 1-1 S F, M, U DMG03 Gender Code ID 1-1 S F, M, U
DMG04 Marital Status Code ID 1-1 N/U DMG04 Marital Status Code ID 1-1 N/U
COMPOSITE RACE OR
DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05 ETHNICITY INFORMATION N/U Name Change
DMG06 Citizenship Status Code ID 1-2 N/U DMG06 Citizenship Status Code ID 1-2 N/U
DMG07 Country Code ID 2-3 N/U DMG07 Country Code ID 2-3 N/U
DMG08 Basis of Verification Code ID 1-2 N/U DMG08 Basis of Verification Code ID 1-2 N/U
DMG09 Quantity R 1-15 N/U DMG09 Quantity R 1-15 N/U
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
DEPENDENT DEPENDENT
INS RELATIONSHIP 1 S 2100D INS RELATIONSHIP 1 S 2100D
Yes/No Condition or Yes/No Condition or
INS01 Response Code ID 1-1 R N INS01 Response Code ID 1-1 R N
01, 19, 20, 21, 39,
INS02 Individual Relationship Code ID 2-2 R 01, 19, 21, 34 INS02 Individual Relationship Code ID 2-2 R 40, 53, G8 Code Change
INS03 Maintenance Type Code ID 3-3 S 001 INS03 Maintenance Type Code ID 3-3 S 001
INS04 Maintenance Reason Code ID 2-3 S 25 INS04 Maintenance Reason Code ID 2-3 S 25
INS05 Benefit Status Code ID 1-1 N/U INS05 Benefit Status Code ID 1-1 N/U
INS06 Medicare Plan Code ID 1-1 N/U INS06 MEDICARE STATUS CODE N/U
Consolidated Omnibus Consolidated Omnibus
Budget Reconcilliation Act Budget Reconcilliation Act
INS07 (COBRA) Qualifying ID 1-2 N/U INS07 (COBRA) Qualifying ID 1-2 N/U
INS08 Employment Status Code ID 2-2 N/U INS08 Employment Status Code ID 2-2 N/U
DEPENDENT HEALTH
HI CARE DIAGNOSIS CODE 1 S 2100D New Segment
HEALTH CARE CODE
HI01 INFORMATION R
HI01 - 1 Code List Qualifier Code ID 1-3 R ABK, BK
HI01 - 2 Industry Code AN 1-30 R
Date Time Period Format
HI01 - 3 Qualifier ID 2-3 N/U
HI01 - 4 Date Time Period AN 1-35 N/U
HI01 - 5 Monetary Amount R 1-18 N/U
HI01 - 6 Quantity R 1-15 N/U
HI01 - 7 Version Identifier AN 1-30 N/U
HI01 - 8 Industry Code AN 1-30 N/U
Yes/No Condition or
HI01 - 9 Response Code ID 1-1 N/U
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
HI07 - 2 Industry
Date Time Code
Period Format AN 1-30 R
HI07 - 3 Qualifier ID 2-3 N/U
HI07 - 4 Date Time Period AN 1-35 N/U
HI07 - 5 Monetary Amount R 1-18 N/U
HI07 - 6 Quantity R 1-15 N/U
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
CCYYMMDD,
CCYYMMDD-
DTP03 Date Time Period AN 1-35 R DTP03 Date Time Period AN 1-35 R CCYYMMDD Code Deleted
DEPENDENT MILITARY
PERSONNEL
MPI INFORMATION 1 S 2100D New Segment
MPI01 Information Status Code ID 1-1 R A, C, L, O, P, S, T
AE, AO, AS, AT,
AU, CC, DD, HD,
IR, LX, PE, RE,
MPI02 Employment Status Code ID 2-2 R RM, RR, RU
A, B, C, D, E, F,
G, H, I, J, K, L, M,
Government Service Affiliation N, O, Q, R, S, U,
MPI03 Code ID 1-1 R W
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
DEPENDENT DEPENDENT
ELIGIBILITY/BENEFIT ELIGIBILITY/BENEFIT
EB INFORMATION 1 S 2110D >1 EB INFORMATION 1 2110D >1
1, 2, 3, 4, 5, 6, 7, 1, 2, 3, 4, 5, 6, 7,
8, A, B, C, CB, D, 8, A, B, C, CB, D,
E, F, G, H, I, J, K, E, F, G, H, I, J, K,
L, M, MC, N, O, P, L, M, MC, N, O, P,
Q, R, S,T, U, V, Eligibility or Benefit Q, R, S, T, U, V,
EB01 Eligibility/ Benefit Information ID 1-2 R W, X, Y EB01 Information Code ID 1-2 R W, X, Y
CHD, DEP, ECH, CHD, DEP, ECH,
ESP, FAM, IND, EMP, ESP, FAM,
EB02 Coverage Level Code ID 3-3 S SPC, SPO EB02 Coverage Level Code ID 3-3 S IND, SPC, SPO Code Added
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
12, 13, 14, 15, 16, 12, 13, 14, 15, 16,
41, 42, 43, 47, AP, 41, 42, 43, 47, AP,
C1, CO, CP, D, C1, CO, CP, D,
DB, EP, FF, GP, DB, EP, FF, GP,
HM, HN, HS, IN, HM, HN, HS, IN,
IP, LC, LD, LI, LT, IP, LC, LD, LI, LT,
MA, MB, MC, MH, MA, MB, MC, MH,
MI, MP, OT, PE, MI, MP, OT, PE,
PL, PP, PR, PS, PL, PP, PR, PS,
QM, RP, SP, TF, QM, RP, SP, TF,
EB04 Insurance Type Code ID 1-3 S WC, WU EB04 Insuarance Type Code ID 1-3 S WC, WU
EB05 Plan Coverage Description AN 1-50 S EB05 Plan Coverage Description AN 1-50 S
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
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ELIGIBILITY STATUS
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Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
DEPENDENT DEPENDENT
DTP ELIGIBILITY/BENEFIT DATE 20 S 2110D DTP ELIGIBILITY/BENEFIT DATE 20 S 2110D
096, 193, 194,
193, 194, 198, 198, 290, 291,
290, 292, 295, 292, 295, 304,
304, 307, 318, 307, 318, 346,
348, 349, 356, 348, 349, 356,
357, 435, 472, 357, 435, 472,
DTP01 Date/Time Qualifier ID 3-3 R 636, 771 DTP01 Date Time Qualifier ID 3-3 R 636, 771 Code Added
Date Time Period Format Date Time Period Format
DTP02 Qualifier ID 2-3 R D8, RD8 DTP02 Qualifier ID 2-3 R D8, RD8
CCYYMMDD,
CCYYMMDD-
DTP03 Date Time Period AN 1-35 R DTP03 Date Time Period AN 1-35 R CCYYMMDD Code Added
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
MSG02 Printer Carriage Control Code ID 2-2 N/U MSG02 Printer Carriage Control Code ID 2-2 N/U
MSG03 Number N0 1-9 N/U MSG03 Number N0 1-9 N/U
DEPENDENT DEPENDENT
ELIGIBILITY/BENEFIT ELIGIBILITY/BENEFIT
ADDITIONAL ADDITIONAL
III INFORMATION 1 S 2115D 10 III INFORMATION 1 S 2115D 10
Code Change
Usage change to
III01 Code List Qualifier Code ID 1-3 R BF, BK, ZZ III01 Code List Qualifier Code ID 1-3 S GR, NI, ZZ Situational
III07 Surface/Layer/Position Code ID 2-2 N/U III07 Surface/Layer/Position Code ID 2-2 N/U
III08 Surface/Layer/Position Code ID 2-2 N/U III08 Surface/Layer/Position Code ID 2-2 N/U
III09 Surface/Layer/Position Code ID 2-2 N/U III09 Surface/Layer/Position Code ID 2-2 N/U
DEPENDENT ELIGIBILITY/
LS BENEFIT INFORMATION 1 S 2110D LS LOOP HEADER 1 S 2115D
LS01 Loop Identifier Code AN 1-6 R 2120 LS01 Loop Identifier Code AN 1-4 R 2120 Decrease from 6 - 4
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage change to Required
N402 State or Province Code ID 2-2 S N402 State or Province Code ID 2-2 S
N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S
N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S
N405 Location Qualifier ID 1-2 S RJ N405 Location Qualifier ID 1-2 S RJ
N406 Location Qualifier AN 1-30 S N406 Location Qualifier AN 1-30 S
N407 Country Subdivision Code ID 1-3 S New Element
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
PRV06 Provider Organization Code ID 3-3 N/U PRV06 Provider Organization Code ID 3-3 N/U
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ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
IEA02 Interchange Control Number N0 9-9 R IEA02 Interchange Control Number N0 9-9 R
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