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X12 270/271 Companion Guide
and Payer List
Refers to the Implementation Guides
Based on ASC X12N version: 005010X279A1
December 30, 2013
Version 1.8
December 30, 2013 X12N/005010/270 v1.7 2
Disclosure Statement
Exchange EDI is committed to maintaining the integrity and security of health care data in accordance with applicable
laws and regulations.
This document is intended only as a supplement to and not a replacement for the ASC Guide as mandated under the
Health Insurance Portability and Accountability Act (HIPAA). If you do not have the full HIPAA implementation guide,
you can download it from the Washington Publishing Company (WPC) internet website at http://www.wpc-edi.com/.
© 2013 Exchange EDI, LLC. All rights reserved.
December 30, 2013 X12N/005010/270 v1.7 3
Preface
Companion Guides (CG) may contain two types of data, instructions for electronic communications with the publishing
entity (Communications/Connectivity Instructions) and supplemental information for creating transactions for the
publishing entity while ensuring compliance with the associated ASC X12 IG (Transaction Instructions). Either the
Communications/Connectivity component or the Transaction Instruction component must be included in every CG. The
components may be published as separate documents or as a single document.
The Communications/Connectivity component is included in the CG when the publishing entity wants to convey the
information needed to commence and maintain communication exchange.
The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG
instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited
by ASCX12’s copyrights and Fair Use statement.
CORE Preface:
This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA
clarifies and specifies the data content when exchanging electronically with Exchange EDI. Transmissions based on this
companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12
syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the
ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey
information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.
December 30, 2013 X12N/005010/270 v1.7 4
Editor’s Note:
This page is intentionally left blank.
December 30, 2013 X12N/005010/270 v1.7 5
Table of Contents
INTRODUCTION ................................................................................................................................................................ 12 Scope ............................................................................................................................................................................................... 12 Overview ......................................................................................................................................................................................... 12 References ....................................................................................................................................................................................... 12 Additional Information .................................................................................................................................................................... 13
GETTING STARTED WITH EXCHANGE EDI .................................................................................................................... 14 Working with Exchange EDI .......................................................................................................................................................... 14 Certification and Testing Overview ................................................................................................................................................ 14
CONNECTIVITY WITH THE PAYER .................................................................................................................................. 15 Process Flow ................................................................................................................................................................................... 15 Transmission Administrative Procedures ........................................................................................................................................ 16 Re-Transmission Procedure ............................................................................................................................................................ 17 Communication Protocol Specifications ......................................................................................................................................... 17 Passwords ........................................................................................................................................................................................ 20
CONTACT INFORMATION ................................................................................................................................................ 21 Exchange EDI Insurance Eligibility Support .................................................................................................................................. 21 Exchange EDI Enrollment and Customer Support .......................................................................................................................... 21 Applicable Websites ........................................................................................................................................................................ 21
CONTROL SEGMENTS AND ENVELOPES ......................................................................................................................... 22 Interchange Information .................................................................................................................................................................. 22 ISA-IEA .......................................................................................................................................................................................... 22 GS-GE ............................................................................................................................................................................................. 23 ST-SE .............................................................................................................................................................................................. 23
PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ................................................................................................. 24 Search Options ................................................................................................................................................................................ 24 Data Usage ...................................................................................................................................................................................... 24
ACKNOWLEDGEMENTS.................................................................................................................................................... 25
TRANSACTION SPECIFIC INFORMATION ........................................................................................................................ 25 AARP (A United Healthcare Insurance Company) – 10431 ........................................................................................................... 26 Absolute Total Care – 10560 .......................................................................................................................................................... 28 Advantage by Bridgeway Health Solutions – 10561....................................................................................................................... 30 Advantage by Buckeye Community Health Plan – 10562 .............................................................................................................. 32 Advantage by Managed Health Services – 10563 ........................................................................................................................... 34 Advantage by Superior Health Plan – 10564 .................................................................................................................................. 36 Aetna – 10004 ................................................................................................................................................................................. 38 Aetna Long Term Care – 10397 ...................................................................................................................................................... 42 Affinity Health Plan – 10594 .......................................................................................................................................................... 43 AFLAC Dental – 10398 .................................................................................................................................................................. 45 Alabama Medicaid – 10007 ............................................................................................................................................................ 47 Allegiance Benefit Plan Management – 10654 ............................................................................................................................... 49 American Family Insurance Group – Medicare Supplemental and PPO Policies – 10487 ............................................................. 50 American Postal Workers Union (APWU) – 10016 ....................................................................................................................... 52 American Republic Insurance Company (ARIC) – 10017 .............................................................................................................. 54 American Retirement Life Insurance Co Medicare Supp – 10538 .................................................................................................. 57 AmeriChoice of New Jersey (Commercial) – 10018 ...................................................................................................................... 59 AmeriHealth Administrators – 10416 ............................................................................................................................................. 61 AmeriHealth Mercy Health Plan – 10340 ....................................................................................................................................... 63 Ameritas Group ............................................................................................................................................................................... 65
December 30, 2013 X12N/005010/270 v1.7 6
Arbor Health Plan – 10641.............................................................................................................................................................. 67 Arkansas Medicaid – 10023 ............................................................................................................................................................ 69 Assurant Health ............................................................................................................................................................................... 71 Asuris Northwest Health – 10529 ................................................................................................................................................... 73 Aultcare – 10472 ............................................................................................................................................................................. 75 AvMed Health Plans – 10024 ......................................................................................................................................................... 77 BCBS of Alabama – 10025 ............................................................................................................................................................. 78 BCBS of Alabama (Institutional) – 10609 ...................................................................................................................................... 82 BCBS of Arizona – 10027 .............................................................................................................................................................. 84 BCBS of Arkansas – 10028 ............................................................................................................................................................ 86 BCBS of Central New York – 10461 .............................................................................................................................................. 88 BCBS of Colorado (Wellpoint Anthem) – 10029 ........................................................................................................................... 91 BCBS of Connecticut (Wellpoint Anthem) – 10030 ....................................................................................................................... 94 BCBS of Florida – 10031 ................................................................................................................................................................ 97 BCBS of Georgia – 10032 ............................................................................................................................................................ 100 BCBS of Hawaii – 10530 .............................................................................................................................................................. 103 BCBS of Illinois – 10033 .............................................................................................................................................................. 105 BCBS of Indiana (Wellpoint Anthem) – 10258 ............................................................................................................................ 107 BCBS of Iowa – 10396 ................................................................................................................................................................. 110 BCBS of Kansas – 10034 .............................................................................................................................................................. 112 BCBS of Kansas City – 10473 ...................................................................................................................................................... 114 BCBS of Kentucky (Wellpoint Anthem) – 10259 ........................................................................................................................ 116 BCBS of Louisiana – 10035.......................................................................................................................................................... 119 BCBS of Maine (Wellpoint Anthem) – 10036 .............................................................................................................................. 121 BCBS of Massachusetts – 10037 .................................................................................................................................................. 124 BCBS of Michigan (Institutional) – 10519 ................................................................................................................................... 127 BCBS of Michigan (Professional) – 10038 ................................................................................................................................... 129 BCBS of Minnesota – 10039 ........................................................................................................................................................ 131 BCBS of Mississippi – 10040 ....................................................................................................................................................... 133 BCBS of Missouri (Wellpoint Anthem) – 10322 .......................................................................................................................... 136 BCBS of Nebraska – 10384 .......................................................................................................................................................... 139 BCBS of Nevada (Wellpoint Anthem) – 10260 ............................................................................................................................ 141 BCBS of New Hampshire (Wellpoint Anthem) – 10261 .............................................................................................................. 144 BCBS of New Jersey (Horizon) – 10041 ...................................................................................................................................... 147 BCBS of New Mexico – 10042 ..................................................................................................................................................... 149 BCBS of New York (Empire) – 10043 ......................................................................................................................................... 151 BCBS of New York (Excellus) – 10323 ....................................................................................................................................... 154 BCBS of North Carolina – 10383 ................................................................................................................................................. 156 BCBS of North Dakota – 10478.................................................................................................................................................... 158 BCBS of Ohio (Wellpoint Anthem) – 10044 ................................................................................................................................ 160 BCBS of Oklahoma – 10582 ......................................................................................................................................................... 163 BCBS of Oregon (Regence) – 10045 ............................................................................................................................................ 165 BCBS of Pennsylvania (Highmark) – 10046 ................................................................................................................................ 167 BCBS of Pennsylvania (Highmark) Institutional – 10524 ............................................................................................................ 169 BCBS of Rhode Island – 10304 .................................................................................................................................................... 171 BCBS of South Carolina – 10047 ................................................................................................................................................. 173 BCBS of South Dakota (Wellmark) – 10395 ................................................................................................................................ 175 BCBS of Tennessee – 10430 ......................................................................................................................................................... 177 BCBS of Texas – 10048 ................................................................................................................................................................ 180 BCBS of the Rochester Area (NY) – 10469 ................................................................................................................................. 182 BCBS of Utica-Watertown (NY) – 10470 .................................................................................................................................... 184 BCBS of Vermont – 10624 ........................................................................................................................................................... 186 BCBS of Virginia (Wellpoint Anthem) – 10049 ........................................................................................................................... 188 BCBS of West Virginia – 10462 ................................................................................................................................................... 191
December 30, 2013 X12N/005010/270 v1.7 7
BCBS of Western New York – 10498 .......................................................................................................................................... 194 BCBS of Wisconsin (Wellpoint Anthem) – 10299 ....................................................................................................................... 197 BCBS of Wyoming – 10480 ......................................................................................................................................................... 200 Best Choice Health Plan – 10256 .................................................................................................................................................. 202 Better Health Plans (Unison Health Plan) - 10187 ........................................................................................................................ 204 Blue Cross Independence (Pennsylvania) – 10262 ....................................................................................................................... 206 Blue Cross Northeastern Pennsylvania – 10264 ........................................................................................................................... 209 Blue Cross of California – 10051 .................................................................................................................................................. 211 Blue Cross of Idaho – 10638 ......................................................................................................................................................... 214 Blue Cross of Utah (Regence) – 10618 ......................................................................................................................................... 216 Blue Cross of Washington and Alaska (Premera) – 10326 ........................................................................................................... 218 Blue Cross Pennsylvania (Capital) – 10325 .................................................................................................................................. 220 Blue Cross of Washington (Regence) – 10054 ............................................................................................................................. 222 Blue Shield of California – 10053 ................................................................................................................................................. 224 Blue Shield of Idaho (Regence) – 10052 ...................................................................................................................................... 229 Blue Shield of Northeastern New York – 10499 ........................................................................................................................... 231 BlueChoice Health Plan South Carolina Medicaid – 10504 ......................................................................................................... 234 Bluegrass Family Health – 10429 ................................................................................................................................................. 235 BMC Health Net – 10556.............................................................................................................................................................. 236 Bridgeway Arizona – 10565 ......................................................................................................................................................... 238 Buckeye Community Health – 10566 ........................................................................................................................................... 240 California Medicaid (Medi-Cal) – 10118 ...................................................................................................................................... 242 Capital District’s Physicians’ Health Plan (CDPHP) – 10458 ...................................................................................................... 244 CAPROCK – 10660 ...................................................................................................................................................................... 246 Carefirst Blue Cross Blue Shield – 10270 ..................................................................................................................................... 248 CarePlus Health Plan – 10056 ....................................................................................................................................................... 250 Celticare – 10589 .......................................................................................................................................................................... 251 Cenpatico ...................................................................................................................................................................................... 253 Central Reserve Life Insurance Company – 10450 ....................................................................................................................... 255 Central Reserve Life Ins Co. Medicare Supp- 10539 .................................................................................................................... 257 Central States Funds – 10486 ........................................................................................................................................................ 258 CHAMPVA/Spina Bifida/Children of Women Vietnam Vets - 10061 ......................................................................................... 261 CIGNA/Great West Healthcare – 10062 ....................................................................................................................................... 263 Colorado Access – 10064 .............................................................................................................................................................. 267 Colorado Medicaid – 10065 .......................................................................................................................................................... 269 Community HealthFirst Medicare (CHF Medicare Advantage) – 10421 ..................................................................................... 271 Community Health Plan of Washington (CHPW) – 10329 .......................................................................................................... 273 ConnectiCare – 10303 ................................................................................................................................................................... 275 Connecticut Medicaid – 10067 ..................................................................................................................................................... 277 Continental General Insurance Company – 10454 ........................................................................................................................ 279 Continental General Insurance Co Medicare Supp – 10540 ......................................................................................................... 281 Cook Children’s Health Plan – 10610 ........................................................................................................................................... 282 Cooperative Benefits Administrators – 10068 .............................................................................................................................. 283 CoreSource .................................................................................................................................................................................... 285 Coventry Healthcare ...................................................................................................................................................................... 287 DakotaCare – 10577 ...................................................................................................................................................................... 291 Dean Health Plan – 10653 ............................................................................................................................................................. 293 Delaware Medicaid – 10293 ......................................................................................................................................................... 294 Denver Health Medical Plan – 10331 ........................................................................................................................................... 296 Deseret Mutual (DMBA) – 10578................................................................................................................................................. 298 District of Columbia Medicaid – 10078 ........................................................................................................................................ 300 Emblem Health – 10616 ................................................................................................................................................................ 302 Essence Healthcare – 10601 .......................................................................................................................................................... 303 FamilyCare – 10427 ...................................................................................................................................................................... 305
December 30, 2013 X12N/005010/270 v1.7 8
Federated Insurance Company – 10083 ........................................................................................................................................ 306 Fidelis Care New York – 10459 .................................................................................................................................................... 308 Florida Health Care Plans – 10615................................................................................................................................................ 311 Florida Hospital Healthcare System – 10333 ................................................................................................................................ 313 Florida Medicaid – 10086 ............................................................................................................................................................. 314 Freedom Blue – 10502 .................................................................................................................................................................. 316 Fresenius Medical Care – 10602 ................................................................................................................................................... 318 Gateway Health Plan – 10629 ....................................................................................................................................................... 319 Geisinger Health Plan – 10611 ...................................................................................................................................................... 321 Geisinger Health Plan Gold – 10612 ............................................................................................................................................. 322 Generations Healthcare – 10603 ................................................................................................................................................... 323 Georgia Medicaid – 10088 ............................................................................................................................................................ 324 Gilsbar – 10509 ............................................................................................................................................................................. 326 Golden Rule Insurance – 10652 .................................................................................................................................................... 328 Government Employees Health Association (GEHA) – 10394 .................................................................................................... 331 Great American Life Insurance Co Medicare Supp – 10543 ........................................................................................................ 333 Group Health Cooperative – 10608............................................................................................................................................... 334 Harmony Health Plan – 10514 ...................................................................................................................................................... 336 Health Alliance Medical Plan (HAP) – 10308 .............................................................................................................................. 337 Healthcare Solutions Group – 10463 ............................................................................................................................................ 339 Health Choice Arizona – 10092 .................................................................................................................................................... 340 HealthEase – 10510 ....................................................................................................................................................................... 341 HealthEase Kids – 10511 .............................................................................................................................................................. 342 Health First New Jersey – 10438 .................................................................................................................................................. 343 Health First New York – 10099 .................................................................................................................................................... 344 HealthMarkets ............................................................................................................................................................................... 345 Health Net National - 10385 ......................................................................................................................................................... 348 Health New England - 10627 ........................................................................................................................................................ 350 HealthNow – 10500 ...................................................................................................................................................................... 351 Health Partners (Minnesota) – 10484 ............................................................................................................................................ 354 Health Partners of Philadelphia – 10098 ....................................................................................................................................... 356 Health Plan of San Mateo – 10362 ................................................................................................................................................ 358 Health Plan of Upper Ohio Valley – 10657 .................................................................................................................................. 359 HealthPlus of Michigan – 10309 ................................................................................................................................................... 360 HealthScope – 10621 .................................................................................................................................................................... 362 HealthSpring – 10552 ................................................................................................................................................................... 364 Hometown Health – 10335 ........................................................................................................................................................... 365 Horizon NJ Health - 10337 ........................................................................................................................................................... 366 Humana – 10100 ........................................................................................................................................................................... 368 Idaho Medicaid – 10101 ................................................................................................................................................................ 370 Illinois Medicaid – 10102 ............................................................................................................................................................. 372 Independence Administrators – 10417 .......................................................................................................................................... 374 Independent Health – 10536 ......................................................................................................................................................... 376 Indiana Medicaid – 10103 ............................................................................................................................................................. 379 Iowa Medicaid – 10107 ................................................................................................................................................................. 381 John Hopkins Health Plan – 10267 ............................................................................................................................................... 383 Kaiser Foundation Health Plan of Colorado – 10110.................................................................................................................... 384 Kaiser Foundation Health Plan of Hawaii – 10111 ....................................................................................................................... 385 Kaiser Foundation Health Plan of the Mid-Atlantic – 10113 ........................................................................................................ 387 Kaiser Foundation Health Plan of the Northwest – 10114 ............................................................................................................ 389 Kaiser Foundation Health Plan of Ohio – 10112 .......................................................................................................................... 390 Kaiser Permanente of Georgia – 10238 ........................................................................................................................................ 392 Kaiser Permanente of Northern CA – 10115 ................................................................................................................................ 394 Kaiser Permanente of Southern CA – 10239 ................................................................................................................................ 396
December 30, 2013 X12N/005010/270 v1.7 9
Kansas Medicaid – 10116 ............................................................................................................................................................. 398 Kentucky Medicaid – 10117 ......................................................................................................................................................... 400 Keystone Mercy Health – 10300 ................................................................................................................................................... 402 Kitsap Physician Services – 10341 ............................................................................................................................................... 404 LaCare – 10640 ............................................................................................................................................................................. 406 Lifewise Health Plan of Oregon – 10651 ...................................................................................................................................... 408 Lifewise Health Plan of Washington – 10650 ............................................................................................................................... 410 Louisiana Medicaid – 10118 ......................................................................................................................................................... 412 Loyal American Life Insurance Co. Medicare Supp – 10544 ....................................................................................................... 414 Maine Medicaid – 10121............................................................................................................................................................... 415 Managed Health Services Indiana – 10586 ................................................................................................................................... 416 Managed Health Services Wisconsin – 10587 .............................................................................................................................. 417 Maricopa Care Advantage (Arizona) – 10435 .............................................................................................................................. 418 Maricopa Health Plan Arizona – 10434 ........................................................................................................................................ 420 Maryland Medicaid – 10289 ......................................................................................................................................................... 422 Massachusetts Medicaid – 10124 .................................................................................................................................................. 424 MDWise Hoosier Alliance – 10598 .............................................................................................................................................. 426 Medica – 10125 ............................................................................................................................................................................. 428 Medical Mutual of Ohio - 10126 ................................................................................................................................................... 430 Medicare (Part A & B) – 10001 .................................................................................................................................................... 432 Meridian Health Plan of Illinois – 10644 ...................................................................................................................................... 434 Meritain Health – 10635 ............................................................................................................................................................... 435 Michigan Medicaid – 10136 ......................................................................................................................................................... 436 Michigan Medicaid Pending Eligibility – 10392 .......................................................................................................................... 438 Michigan MIChild – 10138 ........................................................................................................................................................... 440 Mid Atlantic Medical Services, LLC (MAMSI) – 10122 ............................................................................................................. 442 Minnesota Medicaid – 10139 ........................................................................................................................................................ 443 Mississippi Medicaid – 10141 ....................................................................................................................................................... 445 Missouri Medicaid – 10143........................................................................................................................................................... 447 MMSI (Mayo Health) – 10144 ...................................................................................................................................................... 449 Molina Healthcare ......................................................................................................................................................................... 451 Montana Medicaid – 10147 ........................................................................................................................................................... 453 Mutual of Omaha – 10382 ............................................................................................................................................................ 454 MVP Health Care (New York) – 10148 ........................................................................................................................................ 456 National Association of Letter Carriers (NALC) – 10149 ............................................................................................................ 458 NEHEN – Harvard Pilgrim Health Care – 10376 ......................................................................................................................... 460 NEHEN - Neighborhood Health Plans – 10377 ............................................................................................................................ 462 Neighborhood Health Plan – Tufts Associated Health Plan – 10379 ............................................................................................ 464 Neighborhood Health Plan (RI) – 10630 ...................................................................................................................................... 465 Network Health – 10626 ............................................................................................................................................................... 466 Nevada Medicaid – 10152............................................................................................................................................................. 467 New Hampshire Medicaid – 10153 ............................................................................................................................................... 469 New Jersey Medicaid – 10154 ...................................................................................................................................................... 471 New Mexico Medicaid – 10247 .................................................................................................................................................... 473 New York Medicaid – 10155 ........................................................................................................................................................ 475 North Carolina Medicaid – 10156 ................................................................................................................................................. 477 North Dakota Medicaid – 10157 ................................................................................................................................................... 479 Nova Healthcare Administrators – 10537 ..................................................................................................................................... 481 NovaSys Health – 10466 ............................................................................................................................................................... 484 Ohana – 10515 .............................................................................................................................................................................. 486 Ohio Medicaid – 10158 ................................................................................................................................................................. 487 Oklahoma Medicaid – 10159 ........................................................................................................................................................ 489 Optima/Sentara – 10477 ................................................................................................................................................................ 490 Oregon Medicaid – 10160 ............................................................................................................................................................. 492
December 30, 2013 X12N/005010/270 v1.7 10
Oxford Health Plans – 10161 ........................................................................................................................................................ 494 Pacific Source Health Plan – 10375 .............................................................................................................................................. 497 Passport Health Plan – 10368 ........................................................................................................................................................ 498 Pennsylvania Medicaid – 10165.................................................................................................................................................... 500 Physicians Health Plan of Northern Indiana– 10658..................................................................................................................... 502 Physicians Mutual Insurance Company – 10167 .......................................................................................................................... 503 PreferredOne – 10169 ................................................................................................................................................................... 505 Principal Financial Group (Nippon Life) - 10170 ......................................................................................................................... 507 Priority Health – 10490 ................................................................................................................................................................. 509 Providence Health Plan – 10172 ................................................................................................................................................... 510 Provident American Life & Health Ins Co Medicare Supp – 10545 ............................................................................................. 512 Public Employees Health Plan (PEHP) – 10574 ........................................................................................................................... 514 Puerto Rico Medicaid – 10173 ...................................................................................................................................................... 517 Qualcare – 10637 .......................................................................................................................................................................... 519 Recall Systems .............................................................................................................................................................................. 521 Sanford Health Plan – 10533 ........................................................................................................................................................ 523 Santa Clara Valley Health and Hospital – 10361 .......................................................................................................................... 525 Schaller Anderson Parkland Community Health Plan – 10643..................................................................................................... 527 Scott and White Health Plan – 10360 ........................................................................................................................................... 528 Select Health SC – 10520.............................................................................................................................................................. 530 Select Health Utah – 10575 ........................................................................................................................................................... 532 Significa Benefit Services – 10081 ............................................................................................................................................... 535 South Carolina Medicaid – 10179 ................................................................................................................................................. 537 South Dakota Medicaid – 10180 ................................................................................................................................................... 539 State Farm – 10645 ....................................................................................................................................................................... 540 Staywell – 10512 ........................................................................................................................................................................... 542 Staywell Kids – 10513 .................................................................................................................................................................. 543 SummaCare – 10294 ..................................................................................................................................................................... 544 Superior Health Plan Texas – 10592 ............................................................................................................................................. 546 Tennessee Medicaid – 10184 ........................................................................................................................................................ 547 TexanPlus North Texas Area – 10604 .......................................................................................................................................... 549 TexanPlus Southeast Texas Area – 10605 .................................................................................................................................... 551 Texas Medicaid – 10186 ............................................................................................................................................................... 552 Three Rivers Health Plans (Unison Health Plan) – 10318 ............................................................................................................ 554 Today’s Health – 10606 ................................................................................................................................................................ 556 Today’s Option – 10505 ................................................................................................................................................................ 557 Tribute/SelectCare of Oklahoma – 10607 ..................................................................................................................................... 558 Tricare – 10189 ............................................................................................................................................................................. 559 Trustmark – 10190 ........................................................................................................................................................................ 561 UCare of Minnesota – 10352 ........................................................................................................................................................ 563 UMR (WAUSAU) – 10501........................................................................................................................................................... 565 Unicare – 10285 ............................................................................................................................................................................ 568 United Healthcare – 10002 ............................................................................................................................................................ 571 United Healthcare Community Plan River Valley – 10192 .......................................................................................................... 574 United Healthcare SecureHorizons – 10655 ................................................................................................................................. 576 United Healthcare Student Resources – 10183 ............................................................................................................................. 578 United Teacher Associates Ins Co Medicare Supp – 10547.......................................................................................................... 580 Unity Health Plans – 10349 .......................................................................................................................................................... 581 Univera – 10535 ............................................................................................................................................................................ 582 University Family Care – 10194 ................................................................................................................................................... 585 University Physicians Care Advantage (Arizona) – 10433 ........................................................................................................... 587 University Physicians Healthcare Group (Arizona) – 10439 ........................................................................................................ 589 UPMC Health Plan (Tristate) – 10288 .......................................................................................................................................... 591 USAA Life Insurance Company – 10195 ..................................................................................................................................... 592
December 30, 2013 X12N/005010/270 v1.7 11
Utah Medicaid – 10648 ................................................................................................................................................................. 594 VA Fee Basis Program – 10196 .................................................................................................................................................... 596 Vermont Medicaid – 10197 ........................................................................................................................................................... 598 Virginia Medicaid – 10198 ........................................................................................................................................................... 599 VIVA Health – 10468 ................................................................................................................................................................... 601 VNSNY CHOICE Health Plans - 10187 ....................................................................................................................................... 603 Washington Medicaid – 10424 ..................................................................................................................................................... 605 WEA Trust – 10554 ...................................................................................................................................................................... 607 WellCare Health Plans – 10488 .................................................................................................................................................... 609 West Virginia Medicaid – 10200 .................................................................................................................................................. 610 Windsor Medicare Extra – 10576 ................................................................................................................................................. 611 Wisconsin Medicaid – 10202 ........................................................................................................................................................ 612 Wisconsin Medicaid Chronic Disease Program – 10452 .............................................................................................................. 614 Wisconsin Medicaid Well Woman Program – 10453 ................................................................................................................... 616 World Insurance (ARIC) – 10386 ................................................................................................................................................. 618 Wyoming Medicaid – 10204 ......................................................................................................................................................... 620
APPENDIX A: SPECIAL ENROLLMENT PAYERS ............................................................................................................ 622
APPENDIX B: PAYER MAINTENANCE SCHEDULE ........................................................................................................ 626
APPENDIX C: TRANSACTION EXAMPLES ..................................................................................................................... 638
APPENDIX D: CHANGE SUMMARY ................................................................................................................................ 666
December 30, 2013 X12N/005010/270 v1.7 12
Introduction
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires Exchange EDI to comply with the
electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services
(HHS). The ANSI X12N implementation guides have been established as the standards of compliance for electronic
health care transactions.
Scope
This Companion Guide (CG) is intended for use by Exchange EDI partners as a supplement to the standards set forth in
the ANSI X12N implementation guides. This Companion Guide assumes compliance with all loops, segments and data
elements contained in the 005010X279A1 implementation guide. This Companion Guide only includes the loops,
segments, and data elements that require further clarification beyond the information defined in the 005010X279A1
implementation guide.
Overview
Exchange EDI has compiled this document to expand upon the requirements set forth in the ANSI X12N 005010X279A1
implementation guide.
This CG contains the following topics
Data formats, content, codes, business rules, and characteristics of the electronic transaction
Technical requirements and transmission options
Information on testing procedures that each trading partner is recommended to complete prior to transmitting
electronic transactions
Payer-specific enrollment and downtime information
This document should be used in conjunction with the ANSI X12N 005010X279A1 Implementation Guide throughout the
process of submitting transactions through Exchange EDI to each supported payer.
References
Exchange EDI supports the ANSI X12N 5010A1 270/271. The full implementation guide, published by the Washington
Publishing Company, can be obtained at www.wpc-edi.com.
December 30, 2013 X12N/005010/270 v1.7 13
Additional Information
System Maintenance Schedule
System maintenance, when scheduled, will occur during the following time frame.
Sunday: 3:00 AM to 6:00 AM (ET)
Holidays
Real-Time system processing is still available through Exchange EDI on the following holidays, but the Service and
Support office will be closed or not available. If New Year’s Day, Independence Day, or Christmas Day falls on a
weekend day, contact Service and Support for the exact day that Exchange EDI will be closed:
New Year’s Day
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Day after Thanksgiving
Christmas Day
December 30, 2013 X12N/005010/270 v1.7 14
Getting Started with Exchange EDI
Working with Exchange EDI
Exchange EDI offers several methods to submit eligibility transactions to payers. Each has certain steps to begin the
process of submitting eligibility transactions.
Contact the Insurance Eligibility Support Team at [email protected] for steps to begin submitting eligibility
transactions.
Certification and Testing Overview
Exchange EDI does not require certification of submitters and their transactions; however we do encourage sufficient
transaction testing.
Exchange EDI offers a separate document; the Testing Functionality Guide. The Testing Functionality guide specifically
outlines the process for testing transactions through three methods:
Connectivity Testing
Performance / Load Testing
Integration / DEV Testing
Testing is controlled by the username that is used when submitting transactions. All testing functionality is available at no
cost to the trading partner.
Please contact [email protected] to receive password information for the testing accounts as well as the Testing
Functionality Guide.
December 30, 2013 X12N/005010/270 v1.7 15
Connectivity with the Payer
Exchange EDI provides an efficient and secure exchange for healthcare transactions, which links payers, providers, and
business partners together. The Connectivity Guide contains technical specifications for the various methods that
Exchange EDI supports for communicating with our trading partners. Requests for the Connectivity Guide should be sent
Exchange EDI supports multiple connectivity endpoints, as well as multiple transaction formats. This allows our trading
partners to choose communication methods which are the best fit for their particular integration needs. All available
communication methods and formats are outlined in this document.
Process Flow
TransUnion
Healthcare
Clearinghouse
PayerPayerPayer
EDI XML
SNA
HTTPS
Web Service
Payer
Socket
Payer
MQSeries
Trading
Partner
Common
Connectivity Interface
Exchange EDI
December 30, 2013 X12N/005010/270 v1.7 16
Transmission Administrative Procedures
Real time requests must include a single inquiry or submission (e.g. one eligibility inquiry to one information source for
one patient). In this model the response from the message receiver is either an error response or the corresponding
response message.
Request formats are independent of response formats. You can submit an EDI request and get back an XML response. All
request / response format combinations are allowed where supported.
Appendix C: Supplemental Connectivity Information has been included to provide examples of message formats.
Request
EDI
ANSI ASC X12N 270 as defined in the HIPAA implementation guideline. 005010X279A1
Please refer to www.wpc-edi.com to obtain information on the HIPAA implementation guidelines. Exchange EDI
and payer specific requirements can be found in the Transaction Specific Information section of this Companion
Guide.
FlatXml
A custom Xml format has been created to enable non-EDI trading partners to submit health care transactions to
Exchange EDI. The Xml structure is fairly flat which allows for easy implementation. Please refer to the
Connectivity Guide for more information on the FlatXml format.
Response
EDI
ANSI ASC X12N 271 as defined in the HIPAA implementation guideline. 005010X279A1
Please refer to www.wpc-edi.com to obtain information on the HIPAA implementation guidelines. Exchange EDI
and payer specific requirements can be found in the Transaction Specific Information section of this Companion
Guide.
EdiXml
This format is a custom Xml response format which matches the looping structures of the equivalent EDI
transaction.
EDI segments are represented as Xml elements and EDI elements are represented as Xml attributes. Please refer
to the Connectivity Guide for more information on the EdiXml format.
EdiXmlExt
This format is based on the EdiXml format with extra information added into the response. All EDI code
attributes have an additional attribute which includes the English description of the EDI code.
Example: <REF REF01="SY" REF01_TEXT="Social Security Number" REF02="123456789" />
Please refer to the Connectivity Guide for more information on the EdiXmlExt format.
December 30, 2013 X12N/005010/270 v1.7 17
EdiXmlExtHtml
There is a licensing fee that is associated with using this response type. Please contact your account manager for
more details.
This format includes the EdiXmlExt format, HTML representation of the response, and a response result code.
Please refer to the Connectivity Guide for more information on the EdiXmlExtHtml format.
VerboseXml
This format resembles the looping structure of the equivalent EDI transaction. The EDI codes are replaced with
English descriptions, all data is stored in Xml elements, and the element names are descriptive. Please refer to the
Connectivity Guide for more information on the VerboseXml format.
Re-Transmission Procedure
Authorization Errors:
If the HTTP Post Reply Message is not received within the timeout period, the trading partner’s system should
send a duplicate transaction no sooner than 90 seconds after the original attempt was sent.
If no response is received after the second attempt, the trading partner’s system should submit no more than 5
duplicate transactions within the next 15 minutes. If the additional attempts result in the same timeout
termination, the trading partner can contact Exchange EDI Insurance Eligibility Support to determine the length
and severity of the payer’s outage.
Server Errors:
It is possible that the HTTP server is not able to process a real time request. In this case, a standard HTTP 500
Internal Server Error will be returned. If a trading partner receives a response with this error code, they will need
to resubmit the request at a later time, because this indicates that Exchange EDI never processed this message.
Communication Protocol Specifications
All primary connectivity endpoints are based on the HTTP protocol. There are two different primary endpoints available;
URL get or post and Xml SOAP (web services).
In some circumstances a trading partner may not be able to make a HTTP connection. An example would be trading
partners that only support a TCP/IP sockets based connection. If a trading partner has a specific connectivity need outside
of the primary two HTTP endpoints they should contact the Exchange EDI technical support contact.
All connectivity endpoints have been tested with various integration technologies including .NET, Java EE and others.
Web Services (XML SOAP) – Submission Portal
The submission portal web service is used to submit and retrieve healthcare transactions. There are two main
communication methods the submission portal uses which are synchronous and asynchronous. The Exchange EDI
preferred method for real-time transactions is synchronous.
December 30, 2013 X12N/005010/270 v1.7 18
Synchronous Transactions
A single web method is called and the connection is kept open until a response is returned. One of the advantages
of this method of communication is you do not have to rely on unique identifiers to match up your request to the
response.
Asynchronous Transactions
Two web method calls are required to complete a transaction. The first call submits the transaction and the second
call retrieves the response, if available. Although this requires keeping track of unique identifiers for each
transaction, it does allow for automatic resubmission of transactions by Exchange EDI that timeout.
Web Service Description The web service is SOAP 1.1 and 1.2 compliant.
URL: https://services.meddatahealth.com/submissionportal/submissionportal.asmx
WSDL URL: https://services.meddatahealth.com/submissionportal/submissionportal.asmx?WSDL
Security is handled through the use of a SOAP header. This SOAP header will contain the username and password
provided to you by Exchange EDI. The WSDL provides the format for the header. It must be provided for each of the web
methods that you call.
<SecurityHeader>
<UserName>ABC</UserName>
<Password>123</Password>
</SecurityHeader>
Web Methods
SubmitSync (Preferred Method)
December 30, 2013 X12N/005010/270 v1.7 19
SubmitAsync
GetResponses
GetResponsesBySubmissionID
December 30, 2013 X12N/005010/270 v1.7 20
GetResponsesByTrackingID
URL Description
URL: https://services.meddatahealth.com/clients/default/submit.aspx
Parameters can be either posted in a form or passed in on the query string of the URL.
Passwords
If the username and/or password included in the request are not valid, an HTTP 403 Forbidden error response with no data
content will be returned.
December 30, 2013 X12N/005010/270 v1.7 21
Please contact [email protected] to receive password information for the testing accounts as well as the Testing
Functionality Guide.
Please contact [email protected] for web portal user name/password assistance.
Contact Information
Exchange EDI Insurance Eligibility Support
Email: [email protected]
Phone: (850) 656-6755
Hours of Operation: 8am to 5pm EST
Contact us for:
Questions regarding 270/271 transactions
Documentation requests
Testing process and credentials
Exchange EDI Enrollment and Customer Support
Email: [email protected]
Phone: (850) 656-6755
Hours of Operation: 8am to 5pm EST
Contact us for:
Web portal related questions
Medicare NPI validation
User name and password
Payer specific provider enrollments
Applicable Websites
Exchange EDI: http://www.exchangeedi.com
December 30, 2013 X12N/005010/270 v1.7 22
Control Segments and Envelopes
Interchange Information
Interchange requirements are not strict. As long as the interchange is properly formatted, we will accept the
transaction. Security and identification are handled by the transport method and / or any logins associated with
the communication method. For example, a web services request will be identified by the SOAP security
header that is required and not any values in the interchange.
Dates must be in the CCYYMMDD format.
Delimiters
There are no restrictions on delimiters you can use when exchanging transactions with TransUnion. Use
caution when trying to use a delimiter that might be repeated in a data element. One of the more common
choices is:
Segment: “~” Element: “*” Sub Element: “:” The response interchange will contain the same delimiters
that were used for the request.
ISA-IEA
If you need to configure your system for specific interchange values you can use the following table. These
values are not required in order to exchange transactions with TransUnion.
Element Name Min Max Type Codes and Values
ISA Segment
ISA01 2 2 ID “00”
ISA02 10 10 AN “ “
ISA03 2 2 ID “00”
ISA04 10 10 AN “ “
ISA05 2 2 ID “ZZ”
ISA06 15 15 AN User Defined
ISA07 2 2 ID “30”
ISA08 15 15 AN “204202692”
Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code
The sender ID, ISA06, is a User-Defined field. You can use this field to identify your company, or a client
code on your transactions. The sender and receiver ID values will be swapped and echoed back in the
response transmission. If you have any interchange specific requirements for ISA01-ISA04, we will
support those. The GS application sender and receiver ID values will also be swapped and echoed back in
the response.
December 30, 2013 X12N/005010/270 v1.7 23
GS-GE
Exchange EDI does not require specific information for this segment. Exchange EDI automatically populates the correct,
required information to send to each payer.
Transactions are expected to have the minimum data populated as required by the implementation guide.
ST-SE
Exchange EDI does not require specific information for this segment. Exchange EDI automatically populates the correct,
required information to send to each payer.
Transactions are expected to have the minimum data populated as required by the implementation guide.
December 30, 2013 X12N/005010/270 v1.7 24
Payer Specific Business Rules and Limitations
Search Options
The 270 transactions have the flexibility for allowing a variety of patient information. In the Transaction Specific
Information section of this Companion Guide, you will find that multiple Search Options may be defined. The data
elements are then listed in conjunction with the Loops and Segments that are required. Payer edits for specific fields are
also documented, i.e. fields that require numeric or alphanumeric elements.
Patients may be identified in either Loop 2100C or 2100D. If the Patient has a unique ID number then that person should
be considered the Subscriber. Only Loop 2100C should be sent for identification purposes.
If the Payer does not assign a unique identifier then the Subscriber and Dependents must be identified in Loops 2100C
and 2100D.
Data Usage
There are two levels in which the 270 transactions are divided:
The Header Level contains the transactions structure information; i.e. ISA and GS Segments.
The Detail Level contains specific insurer, insured, dependent and requestor information. There are four different ways in
which the Segments are utilized. Each HL is assigned a number identifying its purpose.
Loop 2000A: Information Source – Payer Level.
The Exchange EDI Payer ID should be used to properly route requests to the Payer. Download the most recent payer list
from http://www.ExchangeEDI.com
Loop 2000B: Information Receiver – Provider Level
This is where the Submitters will identify themselves to the Payer by using either their assigned National Provider
Identifier, Payer assigned Provider Identifier or Federal Tax ID Number. (This depends on the specific payer.)
Loop 2000C: Subscriber Level
This loop is used to identify the Insured Member/Subscriber data elements. Only loop 2100C must be sent for
identification if the Patient has a unique identifier.
Loop 2000D: Dependent Level
This loop is used to identify Dependent data elements. If the Payer does not assign a unique identifier then the Subscriber
and Dependents must be identified in loops 2100C and 2100D.
December 30, 2013 X12N/005010/270 v1.7 25
Acknowledgements
Submitters will receive only one of the following responses when submitting a 270 transaction:
• TA1 (X12) when the ISA-IEA envelope cannot be processed;
• 999 when submitted 270 does not pass HIPAA validation; or
• The 271 is returned in all other cases to indicate the member’s coverage.
Transaction Specific Information
The following section includes the payer sheets that describe the specific information, beyond the ASC X12
implementation guide, required by the payer.
Each payer sheet includes transaction specific information pertinent to that payer. Specific information includes the
unique Exchange EDI Payer ID, specific provider identifying information, subscriber and dependent identification
information, and specific service type codes accepted for each payer.
Exchange EDI works through various channels, partners, and direct with payers to obtain eligibility responses. We strive
to uphold all facets of regulations mandated under the Health Insurance Portability and Accountability Act (HIPAA).
Exchange EDI strives to keep this documented as changes occur and communicated by the payers or through our channel
partners. Keep in mind that each payer differs in their requirements and that Exchange EDI will update this document as
changes are received in a timely fashion.
December 30, 2013 X12N/005010/270 v1.7 26
AARP (A United Healthcare Insurance Company) – 10431
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID First Name Date of Birth
4 Subscriber Member ID Date of Birth
5 Subscriber Member ID Last Name First Name
6 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10431 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 27
2100C NM103 Last Name 35
Search options:
#1, #2, #5, and #6.
2100C NM104 First Name 25
Search options:
#1, #3, #5, and #6.
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11
Search options:
#1, #2, #3, #4 and #5.
Note: Only 11-digit
member IDs are accepted
at this time. 9 and 10
digit member IDs, though
valid, are not accessible
via EDI eligibility until
the payer completes an
internal enhancement.
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #2, #3, #4 and #6.
2100C DMG03 Gender Code
F=Female
M=Male
1 Optional
2100C DTP03 Subscriber Date
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 28
Absolute Total Care – 10560
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10560 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#2 and #3.
2100C NM104 First Name 25 Search options: #2 and
#3.
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 29
2100C NM109 Member ID 20
Search options:
#1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2 and #3.
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 30
Advantage by Bridgeway Health Solutions – 10561
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10561 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2, #3.
2100C NM104 First Name 25 Search options: #2, #3.
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1 and #3.
December 30, 2013 X12N/005010/270 v1.7 31
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2, #3.
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 32
Advantage by Buckeye Community Health Plan – 10562
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10562 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#2 and #3.
2100C NM104 First Name 25
Search options:
#2 and #3.
December 30, 2013 X12N/005010/270 v1.7 33
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1 and #3.
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2 and #3.
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 34
Advantage by Managed Health Services – 10563
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10563 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#2 and #3.
2100C NM104 First Name 25
Search options:
#2 and #3.
December 30, 2013 X12N/005010/270 v1.7 35
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1 and #3.
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2 and #3.
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 36
Advantage by Superior Health Plan – 10564
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10564 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#2 and #3.
2100C NM104 First Name 25
Search options:
#2 and #3.
December 30, 2013 X12N/005010/270 v1.7 37
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1 and #3.
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2 and #3.
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 38
Aetna – 10004
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5
1 Subscriber Member ID (CUMB
ID) Date of Birth
2 Subscriber Member ID (HMO)
3 Subscriber Member ID (SSN) Date of Birth
4 Subscriber SSN Date of Birth
5 Subscriber Last Name First Name Date of Birth
6 Dependent Sub: Member ID
(CUMB ID) Dep: Date of Birth
7 Dependent Sub: Member ID
(SSN) Dep: Date of Birth
8 Dependent Sub: SSN Dep: Date of Birth
9 Dependent Sub: Last Name Sub: First Name Dep: Last Name Dep: First Name Dep: Date of Birth
10 Dependent Sub: Member ID
(CUMB ID) Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10004 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
December 30, 2013 X12N/005010/270 v1.7 39
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #5 and #9
2100C NM104 First Name 35 Search options: #5 and #9
2100C NM108 Information Receiver ID Qualifier MI 2
2100C NM109 Member ID (CUMB ID) 12
Search options: #1, #6, and #10
Note: CUMB ID is for Non-HMO
line of business. It will be
identified on the ID card by a
leading W; i.e. W123456789-01.
Omit any dashes.
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID (HMO) 13
Search Option: #2
Note: HMO Subscriber ID is
captured via swipe, or if the ID is
8 digits with at least one alpha
character, or if the Member ID
card specifies HMO or POS.
2100C NM108 Information Receiver ID Qualifier MI 2
2100C NM109 Member ID (SSN) 9 Search options: #3 and #7
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search options: #4 and #8
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 17
December 30, 2013 X12N/005010/270 v1.7 40
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #3, #4, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past.
No Future Dates allowed.
Date Ranges are allowed
2100C EQ01 Service Type Code 2 See “Aetna (10004) - Service
Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search options: #9 and #10
2100D NM104 First Name 35 Search options: #9 and #10
2100D REF01 Reference Identification Qualifier 6P 2
2100D REF02 Group Number 17
2100D DMG02 Date of Birth CCYYMMDD 8 Search options:#6, #7, #8, #9, #10
2100D DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past.
No Future Dates allowed.
Date Ranges are allowed
2100D EQ01 Service Type Code 2 See “Aetna (10004)- Service
Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 41
Aetna (10004) - Service Type Code List
Code Description Code Description
2 Surgical 76 Dialysis
3 Consultation 78 Chemotherapy
4 Diagnostic X-ray 79 Allergy Testing
5 Diagnostic Lab 80 Immunization
6 Radiation Therapy 81 Routine Physical
8 Surgical Assistance 82 Family Planning
9 Other Medical Care 83 Infertility
10 Blood Charges 84 Abortion
12 Durable Medical Equipment Purchase 86 Emergency Services
13 Ambulatory Service Center Facility 88 Pharmacy
17 Pre-Admission Testing 89 Free-standing Prescription Drug
18 Durable Medical Equipment Rental 90 Mail Order Prescription Drug
20 Second Surgical Opinion 91 Brand Name Prescription Drug
23 Diagnostic Dental 92 Generic Prescription Drug
24 Periodontics 94 Podiatry – Office Visits
25 Restorative 97 Anesthesiologist
26 Endodontics 98 Professional (Physician) Visit - Office
30 Health Benefits Plan Coverage 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office A1 Professional (Physician) Visit – Nursing
35 Dental A2 Professional (Physician) Visit – Skilled Nursing Facility
36 Dental Crowns A4 Psychiatric
37 Dental Accident A6 Psychotherapy
38 Orthodontics A7 Psychiatric-Inpatient
CB Private Duty Nursing - Home DM Durable Medical Equipment
CC Surgical Benefits - Professional (Physician) DS Diabetic Supplies
CD Surgical Benefits - Facility GF Generic Prescription Drug - Formulary
CE Mental Health Provider - Inpatient GN Generic Prescription Drug - Non-Formulary
CF Mental Health Provider - Outpatient GY Allergy
CG Mental Health Facility - Inpatient IC Intensive Care
CH Mental Health Facility - Outpatient MH Mental Health
CI Substance Abuse Facility - Inpatient NI Neonatal Intensive Care
CK Screening X-ray ON Oncology
CL Screening Laboratory PT Physical Therapy
CM Mammogram, High Risk Patient PU Pulmonary
CN Mammogram, Low Risk Patient RN Renal
CO Flu Vaccination RT Residential Psychiatric Treatment
CP Eyewear and Eyewear Accessories UC Urgent Care
DG Dermatology
December 30, 2013 X12N/005010/270 v1.7 42
Aetna Long Term Care – 10397
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10397 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 43
Affinity Health Plan – 10594
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10594 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 20 Search options: #3 and #4
2100C NM104 First Name 12 Search options: #3 and #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 44
2100C NM109 Member ID 9 Search options: #1 and #4
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search Option: #2
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2, #3, and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 45
AFLAC Dental – 10398
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10398 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Nam 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed
December 30, 2013 X12N/005010/270 v1.7 46
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 47
Alabama Medicaid – 10007
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber SSN Date of Birth
Note: If a transaction returns a AAA*51 error this might mean the transaction needs to be submitted with the provider’s
Medicaid ID.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10007 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100B REF01 REF01 1D 2
2100B REF01 Medicaid Provider Number 50
Optional.
Including Medicaid
Provider Number with the
NPI may resolve a AAA51
errror.
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #2
December 30, 2013 X12N/005010/270 v1.7 48
2100C NM104 First Name 35 Search Option: #2
2100C NM105 Middle Name 25 Optional
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 13 Search Option: #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search Option: #3
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2 and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
90 day Date Ranges are
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 49
Allegiance Benefit Plan Management – 10654
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Last Name First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10654 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #2, #3
2100C NM104 First Name 25 Search options: #1, #3
2100C NM108 Information Receiver ID
Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1, #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
Up to end of current
month for Future Dates
Date Ranges are allowed
2100C EQ01 Service Type Code All Service type
codes supported 2
December 30, 2013 X12N/005010/270 v1.7 50
American Family Insurance Group – Medicare Supplemental and PPO
Policies – 10487
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: First Name Dep: Last Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10487 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if NM108=FI.
December 30, 2013 X12N/005010/270 v1.7 51
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#2, #3, and #4
2100C NM104 First Name 25
Search options:
#2, #3, and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1, #2, #4, #5, #6, and #8
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #3, and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35
Search options:
#6, #7, and #8
2100D NM104 First Name 35
Search options:
#6, #7, and #8
2100D DMG02 Date of Birth CCYYMMDD 8
Search options:
#5, #7, and #8
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 52
American Postal Workers Union (APWU) – 10016
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last name Dep: First name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10016 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option:#1
2100C NM104 First Name 25 Search Option:#1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 30 Optional
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option:#1
December 30, 2013 X12N/005010/270 v1.7 53
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option:#2
2100D NM104 First Name 35 Search Option:#2
2100D REF01 Reference Identification Qualifier 6P 2
2100D REF02 Group Number 30 Optional
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option:#2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 54
American Republic Insurance Company (ARIC) – 10017
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: First Name Dep: Last Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10017 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if NM108=FI.
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 55
2100C NM103 Last Name 35
Search options:
#2, #3, and #4
2100C NM104 First Name 25
Search options:
#2, #3, and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1, #2, #4, #5, #6, and #8
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 30 Optional
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #3, and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60
Search options:
#6, #7, and #8
2100D NM104 First Name 35
Search options:
#6, #7, and #8
2100D REF01 Reference Identification Qualifier 6P 2
2100D REF02 Group Number 30 Optional
December 30, 2013 X12N/005010/270 v1.7 56
2100D DMG02 Date of Birth CCYYMMDD 8
Search options:
#5, #7, and #8
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 57
American Retirement Life Insurance Co Medicare Supp – 10538
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10538 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX. Federal Tax
ID if NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
December 30, 2013 X12N/005010/270 v1.7 58
2100C DTP03 Subscriber Date CCYYMMDD 8
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 59
AmeriChoice of New Jersey (Commercial) – 10018
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10018 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #2
2100C NM104 First Name 25 Search options: #1, #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2, #3
December 30, 2013 X12N/005010/270 v1.7 60
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 1 year in the Future.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search option: #3
2100D NM104 First Name 35 Search option: #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search option: #3
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 1 year in the Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 61
AmeriHealth Administrators – 10416
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Dependent Sub: Member ID Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10416 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20
Search options:
#1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 24 months in the Past.
Up to 30 days in the Future
Date Ranges are allowed.
2100C EQ01 Service Type Code 2
See “AmeriHealth
Administrators (10416) -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 62
2100D NM1 Dependent Name
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 24 months in the Past.
Up to 30 days in the Future
Date Ranges are allowed.
2100D EQ01 Service Type Code 2
See “AmeriHealth
Administrators (10416) -
Service Type Code List” below
AmeriHealth Administrators (10416) - Service Type Code List
Code Description Code Description
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
20 Second Surgical Opinion 93 Podiatry
33 Chiropractic 98 Professional (Physician) Visit - Office
40 Medical Oral Surgery 99 Professional (Physician) Visit – Inpatient
42 Home Health Care A0 Professional (Physician) Visit – Outpatient
45 Hospice A3 Professional (Physician) Visit – Home
48 Hospital – Inpatient A6 Psychotherapy
50 Hospital – Outpatient A7 Psychiatric-Inpatient
51 Hospital – Emergency Accident A8 Psychiatric-Outpatient
52 Hospital – Emergency Medical AD Occupational Therapy
53 Hospital – Ambulatory Surgical AE Physical Medicine
61 In-vitro Fertilization AF Speech Therapy
62 MRI/CAT Scan AG Skilled Nursing Care
65 Newborn Care AI Substance Abuse
68 Well Baby Care BG Cardiac Rehabilitation
69 Maternity BH Pediatric
73 Diagnostic Medical
December 30, 2013 X12N/005010/270 v1.7 63
AmeriHealth Mercy Health Plan – 10340
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10340 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100B REF01 Reference Identification Qualifier 1J 2
2100B REF02 User ID 9 Federal Tax ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #3
2100C NM104 First Name 35 Search Option: #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 64
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search Option: #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 3 years in the Past
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 65
Ameritas Group
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last name Dep: First name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 5
Transunion Payer ID
See “Ameritas Group Payer
Codes” table above
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
Ameritas Group Payer Codes
Payer Name Payer ID
Ameritas Life Insurance Co. 10020
First Ameritas of New York 10232
First Reliance Standard Life 10233
Reliance Standard Life 10234
Standard Insurance 10236
Standard Insurance of New York 10237
December 30, 2013 X12N/005010/270 v1.7 66
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 67
Arbor Health Plan – 10641
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber SSN
Note: Area of coverage is Nebraska.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10641 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #2
2100C NM104 First Name 35 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 8 Search Option: #1
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search Option: #3
December 30, 2013 X12N/005010/270 v1.7 68
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Past search is allowed
Future searches are not allowed.
Date Ranges are not allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 69
Arkansas Medicaid – 10023
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID First Name Date of Birth
3 Subscriber Member ID Last Name First Name
4 Subscriber Member ID Date of Birth Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10023 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60
Search options:
#3, #4, and #5
2100C NM104 First Name 35
Search options:
#2, #3, #4, and #5
December 30, 2013 X12N/005010/270 v1.7 70
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12
Search options:
#1, #2, #3, and #4
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2 and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future dates allowed.
1 year Date Ranges are
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 71
Assurant Health
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last name Dep: First name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 5
Transunion Payer ID
See “Assurant Health Payer
Codes” table above
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
Assurant Health Payer Codes
Payer Name Payer ID
John Alden Insurance Company (JALIC) 10230
Time Insurance Company (FIC) 10087
Union Security Insurance Company (FBIC) 10227
December 30, 2013 X12N/005010/270 v1.7 72
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 16 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 73
Asuris Northwest Health – 10529
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last name Dep: First name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10529 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 24 months in the Past.
Up to 6 weeks in the Future.
Date Ranges are allowed.
December 30, 2013 X12N/005010/270 v1.7 74
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8
Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 24 months in the Past.
Up to 6 weeks in the Future.
Date Ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 75
Aultcare – 10472
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name
3 Subscriber Date of Birth Last Name
4 Dependent Sub: Member ID Dep: Last name Dep: First name
Note: Please note that the new Aultcare system will require all data that is supplied to be exact
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10472 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2 and #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1, #2, and
#4
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1 and #3
December 30, 2013 X12N/005010/270 v1.7 76
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates are allowed
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #4
2100D NM104 First Name 25 Search Option: #4
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #4
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates are allowed
No Future Dates allowed
No Date Ranges allowed.
2100D EQ01 Service Type Code 1,30,33,35,48,50,86,88,98,AL 2
December 30, 2013 X12N/005010/270 v1.7 77
AvMed Health Plans – 10024
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10024 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last Organization 60
2100B NM108 Information Receiver ID
Qualifier XX, SV 2
2100B NM109 NPI, Provider ID 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search options: #1, #2, and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past is
allowed.
Future search is not allowed.
Date ranges are allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 78
BCBS of Alabama – 10025
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10025 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 24 Search Option: #1
2100C NM104 First Name 24 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 24 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 79
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past is
allowed.
Future search is not allowed.
Date ranges are not allowed.
2100C EQ01 Service Type Code 2 See “BCBS of Alabama (10025) -
Service Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 24 Search Option: #2
2100D NM104 First Name 24 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past is
allowed.
Future search is not allowed.
Date ranges are not allowed.
2100D EQ01 Service Type Code 2 See “BCBS of Alabama (10025) -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 80
BCBS of Alabama (10025) - Service Type Code List
Code Description Code Description
2 Surgical 76 Dialysis
3 Consultation 78 Chemotherapy
4 Diagnostic X-ray 79 Allergy Testing
5 Diagnostic Lab 80 Immunization
6 Radiation Therapy 81 Routine Physical
8 Surgical Assistance 82 Family Planning
9 Other Medical Care 83 Infertility
10 Blood Charges 84 Abortion
12 Durable Medical Equipment Purchase 86 Emergency Services
13 Ambulatory Service Center Facility 88 Pharmacy
17 Pre-Admission Testing 89 Free-standing Prescription Drug
18 Durable Medical Equipment Rental 90 Mail Order Prescription Drug
20 Second Surgical Opinion 91 Brand Name Prescription Drug
23 Diagnostic Dental 92 Generic Prescription Drug
24 Periodontics 94 Podiatry – Office Visits
25 Restorative 97 Anesthesiologist
26 Endodontics 98 Professional (Physician) Visit - Office
30 Health Benefits Plan Coverage 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office A1 Professional (Physician) Visit – Nursing
35 Dental A2 Professional (Physician) Visit – Skilled Nursing Facility
36 Dental Crowns A4 Psychiatric
37 Dental Accident A6 Psychotherapy
38 Orthodontics A7 Psychiatric-Inpatient
39 Prosthodontics A8 Psychiatric-Outpatient
40 Medical Oral Surgery AB Rehabilitation-Inpatient
41 Routine (Preventive) Dental AC Rehabilitation-Outpatient
42 Home Health Care AD Occupational Therapy
44 Home Health Visits AE Physical Medicine
45 Hospice AF Speech Therapy
47 Hospital AG Skilled Nursing Care
48 Hospital – Inpatient AH Skilled Nursing Care – Room & Board
50 Hospital – Outpatient AI Substance Abuse
51 Hospital – Emergency Accident AL Vision (Optometry)
52 Hospital – Emergency Medical AM Frames
53 Hospital – Ambulatory Surgical AN Routine Exam
57 Air Transportation AO Lenses
59 Licensed Ambulance BG Cardiac Rehabilitation
60 General Benefits BH Pediatric
61 In-vitro Fertilization BT Gynecological
62 MRI/CAT Scan BU Obstetrical
65 Newborn Care BV Obstetrical/Gynecological
December 30, 2013 X12N/005010/270 v1.7 81
66 Pathology BW Mail Order Prescription Drug: Brand Name
68 Well Baby Care BX Mail Order Prescription Drug: Generic
69 Maternity BY Physician Visit - Office: Sick
73 Diagnostic Medical BZ Physician Visit - Office: Well
74 Private Duty Nursing CA Private Duty Nursing - Inpatient
75 Prosthetic Device CB Private Duty Nursing - Home
CB Private Duty Nursing - Home DM Durable Medical Equipment
CC Surgical Benefits - Professional (Physician) DS Diabetic Supplies
CD Surgical Benefits - Facility GF Generic Prescription Drug - Formulary
CE Mental Health Provider - Inpatient GN Generic Prescription Drug - Non-Formulary
CF Mental Health Provider - Outpatient GY Allergy
CG Mental Health Facility - Inpatient IC Intensive Care
CH Mental Health Facility - Outpatient MH Mental Health
CI Substance Abuse Facility - Inpatient NI Neonatal Intensive Care
CK Screening X-ray ON Oncology
CL Screening Laboratory PT Physical Therapy
CM Mammogram, High Risk Patient PU Pulmonary
CN Mammogram, Low Risk Patient RN Renal
CO Flu Vaccination RT Residential Psychiatric Treatment
CP Eyewear and Eyewear Accessories UC Urgent Care
DG Dermatology
December 30, 2013 X12N/005010/270 v1.7 82
BCBS of Alabama (Institutional) – 10609
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10609 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 24 Search Option: #1
2100C NM104 First Name 24 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 24 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past is
allowed.
Future search is not allowed.
Date ranges are allowed.
December 30, 2013 X12N/005010/270 v1.7 83
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 24 Search Option: #2
2100D NM104 First Name 24 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past is
allowed.
Future search is not allowed.
Date ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 84
BCBS of Arizona – 10027
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10027 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 14 days in the Past is allowed.
Future date is allowed.
Date ranges are allowed.
December 30, 2013 X12N/005010/270 v1.7 85
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 14 days in the Past is allowed.
Future date is allowed.
Date ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 86
BCBS of Arkansas – 10028
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10028 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX, SV 2
2100B NM109 NPI, Provider ID 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100B REF01
Reference Identification
Qualifier EO 2
2100B REF02 Submitter ID 10 Five character ID beginning with ‘E’
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 87
2100C NM109 Member ID 20 Search options: #1 and #2
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past is allowed.
Future search is not allowed.
Date ranges are not allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D REF01 Reference Identification
Qualifier SY 2
2100D REF02 SSN 9
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past is allowed.
Future search is not allowed.
Date ranges are not allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 88
BCBS of Central New York – 10461
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5
1 Subscriber Member ID Last Name First Name Date of Birth Gender
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Dep: Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10461 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 15 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DMG03 Gender
M = Male
F = Female
1 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 89
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates allowed.
Future Dates allowed.
No Date Ranges allowed
2100C EQ01 Service Type Code 2
See “BCBS of Central New York
(10461) – Service Type Code List”
below
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option: #2
2100D NM104 First Name 35 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DMG03 Gender
M = Male
F = Female
1 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates allowed.
Future Dates allowed.
No Date Ranges allowed
2100D EQ01 Service Type Code 2
December 30, 2013 X12N/005010/270 v1.7 90
BCBS of Central New York (10461) - Service Type Code List
Code Description Code Description
1 Medical Care 83 Infertility
2 Surgical 86 Emergency Services
4 Diagnostic X-Ray 88 Pharmacy
5 Diagnostic Lab 98 Professional (Physician) Visit - Office
6 Radiation Therapy 99 Professional (Physician) Visit - Inpatient
7 Anesthesia 51 Hospital - Emergency Accident
8 Surgical Assistance A0 Professional (Physician) Visit - Outpatient
12 Durable Medical Equipment Purchase A3 Professional (Physician) Visit - Home
13 Ambulatory Service Center Facility AD Occupational Therapy
18 Durable Medical Equipment Rental AE Physical Medicine
20 Second Surgical Opinion AF Speech Therapy
35 Dental Care AG Skilled Nursing Care
40 Oral Surgery AL Vision (Optometry)
42 Home Health Care BG Cardiac Rehabilitation
45 Hospice BH Pediatric
48 Hospital - Inpatient BT Gynecological
50 Hospital Outpatient BU Obstetrical
51 Hospital - Emergency Accident BV Obstetrical/Gynecological
52 Hospital - Emergency Medical BY Physician Visit – Office: Sick
53 Hospital - Ambulatory Surgical BZ Physician Visit – Office: Well
60 General Benefits CE MH Provider – Inpatient
61 In-vitro Fertilization CF MH Provider – Outpatient
62 MRI/CAT Scan CG MH Provider Facility – Inpatient
65 Newborn Care CH MH Provider Facility – Outpatient
68 Well Baby Care CI Substance Abuse Facility – Inpatient
69 Maternity CJ Substance Abuse Facility – Outpatient
69 Maternity CM Mammogram, HR Patient
73 Diagnostic Medical CN Mammogram, LR Patient
76 Dialysis CO Flu Vaccination
78 Chemotherapy DM Durable Medical Equipment
80 Immunizations MH Mental Health
81 Routine Physical PT Physical Therapy
82 Family Planning UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 91
BCBS of Colorado (Wellpoint Anthem) – 10029
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10029 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 92
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Colorado
(Wellpoint Anthem) (10029) -
Service Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Colorado
(Wellpoint Anthem) (10029) -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 93
BCBS of Colorado (Wellpoint Anthem) (10029) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 94
BCBS of Connecticut (Wellpoint Anthem) – 10030
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10030 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 95
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Connecticut
(Wellpoint Anthem) (10029) -
Service Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Connecticut
(Wellpoint Anthem) (10029) -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 96
BCBS of Connecticut (Wellpoint Anthem) (10029) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 97
BCBS of Florida – 10031
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Member ID First Name Date of Birth
4 Subscriber Member ID Date of Birth
5 Subscriber Last Name First Name Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
7 Dependent Sub: Member ID Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name
9 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10031 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
December 30, 2013 X12N/005010/270 v1.7 98
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#1, #2, and #5
2100C NM104 First Name 25
Search options:
#1, #2, #3, and #5
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 16
Search options:
#1, #2, #3, #4, #6, #7, and
#8
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #3, #4, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Future Dates allowed
Date Ranges allowed
2100C EQ01 Service Type Code
1, 2, 4, 5, 30, 33,
47, 50, 69, 78, 98,
A9, AG
2
2100D NM1 Dependent Name
2100D NM103 Last Name 35
Search options:
#6, #8, and #9
2100D NM104 First Name 25
Search options:
#6, #7, #8, and #9
December 30, 2013 X12N/005010/270 v1.7 99
2100D DMG02 Date of Birth CCYYMMDD 8
Search options:
#6, #7, and #9
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past
Future Dates allowed
Date Ranges allowed
2100D EQ01 Service Type Code
1, 2, 4, 5, 30, 33,
47, 50, 69, 78, 98,
A9, AG
2
December 30, 2013 X12N/005010/270 v1.7 100
BCBS of Georgia – 10032
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10032 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 101
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2 See “BCBS of Georgia (10032) -
Service Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2 See “BCBS of Georgia (10032) -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 102
BCBS of Georgia (10032) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 103
BCBS of Hawaii – 10530
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name Date of Birth
3 Subscriber Last Name First Name Date of Birth
4 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10530 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#2 and #3
2100C NM104 First Name 25
Search options:
#2 and #3
December 30, 2013 X12N/005010/270 v1.7 104
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 16
Search options:
#1, #2, and #4
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #2, and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past
Future Dates are allowed
Date Ranges are allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #4
2100D NM104 First Name 25 Search Option: #4
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #4
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past
Future Dates are allowed
Date Ranges are allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 105
BCBS of Illinois – 10033
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10033 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 16
Search options:
#1, and #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 106
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #4
2100D NM104 First Name 25 Search Option: #4
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #4
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 107
BCBS of Indiana (Wellpoint Anthem) – 10258
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10258 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DMG03 Gender
M=Male
F=Female
1 Optional
December 30, 2013 X12N/005010/270 v1.7 108
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Indiana
(Wellpoint Anthem) (10258) -
Service Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DMG03 Gender
M=Male
F=Female
1 Optional
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Indiana
(Wellpoint Anthem) (10258) -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 109
BCBS of Indiana (Wellpoint Anthem) (10258) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 110
BCBS of Iowa – 10396
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10396 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 111
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to 30 days in the Future
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past
Up to 30 days in the Future
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 112
BCBS of Kansas – 10034
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10034 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Information Receiver ID Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past
Only Current Month for Future
dates
No Date Ranges allowed
December 30, 2013 X12N/005010/270 v1.7 113
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past
Only Current Month for Future
dates
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 114
BCBS of Kansas City – 10473
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10473 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Information Receiver ID Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past
Only Current Month for Future
dates
No Date Ranges allowed
December 30, 2013 X12N/005010/270 v1.7 115
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past
Only Current Month for Future
dates
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 116
BCBS of Kentucky (Wellpoint Anthem) – 10259
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10259 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 117
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Kentucky
(Wellpoint Anthem) (10259) -
Service Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Kentucky
(Wellpoint Anthem) (10259) -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 118
BCBS of Kentucky (Wellpoint Anthem) (10259) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 119
BCBS of Louisiana – 10035
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10035 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DMG03 Gender
M=Male
F=Female
1 Optional
December 30, 2013 X12N/005010/270 v1.7 120
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DMG03 Gender
M=Male
F=Female
1 Optional
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 121
BCBS of Maine (Wellpoint Anthem) – 10036
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10036 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 122
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Maine (Wellpoint
Anthem) (10036) - Service Type
Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Maine (Wellpoint
Anthem) (10036) - Service Type
Code List” below
December 30, 2013 X12N/005010/270 v1.7 123
BCBS of Maine (Wellpoint Anthem) (10036) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 124
BCBS of Massachusetts – 10037
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10037 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 125
2100C EQ01 Service Type Code 2
See “BCBS of Massachusetts
(10037) - Service Type Code
List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Massachusetts
(10037) - Service Type Code
List” below
December 30, 2013 X12N/005010/270 v1.7 126
BCBS of Massachusetts (10037) - Service Type Code List
Code Description Code Description
1 Medical Care 66 Pathology
2 Surgical 68 Well Baby Care
4 Diagnostic X-ray 69 Maternity
5 Diagnostic Lab 71 Audiology Exam
6 Radiation Therapy 72 Inhalation Therapy
7 Anesthesia 75 Prosthetic Device
9 Other Medical 76 Dialysis
13 Ambulatory Service Center Facility 77 Otological Exam
17 Pre-Admission Testing 78 Chemotherapy
20 Second Surgical Opinion 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 86 Emergency Services
26 Endodontics 88 Pharmacy
30 Health Benefits Plan Coverage (use only if a single
category of benefits can be supported) 93 Podiatry
33 Chiropractic 98 Professional (Physician) Visit - Office
35 Dental Care 99 Professional (Physician) Visit – Inpatient
36 Dental Crowns A0 Professional (Physician) Visit – Outpatient
38 Orthodontic AB Rehabilitation-Inpatient
39 Prosthodontics AD Occupational Therapy
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AJ Alcoholism
45 Hospice AK Drug Addiction
48 Hospital – Inpatient AL Vision (Optometry)
50 Hospital – Outpatient BF Pulmonary Rehabilitation
52 Hospital – Emergency Medical BG Cardiac Rehabilitation
53 Hospital – Ambulatory Surgical BH Pediatric
56 Medically Related Transportation
62 MRI/CAT Scan
December 30, 2013 X12N/005010/270 v1.7 127
BCBS of Michigan (Institutional) – 10519
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10519 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C REF01 Reference Identification
Qualifier 6P 2
2100C REF02 Group Number 30
December 30, 2013 X12N/005010/270 v1.7 128
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 13,30,42,45,48,50,76,A8,
AC,AG,AI 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 13,30,42,45,48,50,76,A8,
AC,AG,AI 2
December 30, 2013 X12N/005010/270 v1.7 129
BCBS of Michigan (Professional) – 10038
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10038 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C REF01 Reference Identification
Qualifier 6P 2
2100C REF02 Group Number 30
December 30, 2013 X12N/005010/270 v1.7 130
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 13,30,42,45,48,50,76,A8,
AC,AG,AI 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D REF01 Reference Identification
Qualifier 6P 2
2100D REF02 Group Number 30
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
2100D EQ01 Service Type Code 13,30,42,45,48,50,76,A8,
AC,AG,AI 2
December 30, 2013 X12N/005010/270 v1.7 131
BCBS of Minnesota – 10039
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10039 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
Group NPI accepted.
Individual NPI will return
AAA43 for members of
BCBS MN.
December 30, 2013 X12N/005010/270 v1.7 132
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #2, and
#5
2100C NM104 First Name 25 Search options: #1, #2, #3,
and #5
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1, #2, #3,
#4, #6, #7, and #8
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #3, #4,
and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #6, #8, and
#9
2100D NM104 First Name 25 Search options: #6, #7, #8,
and #9
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #6, #7, and
#9
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 133
BCBS of Mississippi – 10040
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10040 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to 1 year in the Future
Date Ranges are allowed
December 30, 2013 X12N/005010/270 v1.7 134
2100C EQ01 Service Type Code 2
See “BCBS of Mississippi
(10040) - Service Type Code
List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past
Up to 1 year in the Future
Date Ranges are allowed
2100D EQ01 Service Type Code 2
See “BCBS of Mississippi
(10040) - Service Type Code
List” below
December 30, 2013 X12N/005010/270 v1.7 135
BCBS of Mississippi (10040) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 136
BCBS of Missouri (Wellpoint Anthem) – 10322
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10322 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
December 30, 2013 X12N/005010/270 v1.7 137
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Missouri
(Wellpoint Anthem) (10322)
- Service Type Code List”
below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Missouri
(Wellpoint Anthem) (10322)
- Service Type Code List”
below
December 30, 2013 X12N/005010/270 v1.7 138
BCBS of Missouri (Wellpoint Anthem) (10322) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 139
BCBS of Nebraska – 10384
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10384 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 140
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 141
BCBS of Nevada (Wellpoint Anthem) – 10260
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10260 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
December 30, 2013 X12N/005010/270 v1.7 142
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Nevada
(Wellpoint Anthem) (10260)
- Service Type Code List”
below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Nevada
(Wellpoint Anthem) (10260)
- Service Type Code List”
below
December 30, 2013 X12N/005010/270 v1.7 143
BCBS of Nevada (Wellpoint Anthem) (10260) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 144
BCBS of New Hampshire (Wellpoint Anthem) – 10261
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10261 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
December 30, 2013 X12N/005010/270 v1.7 145
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of New
Hampshire (Wellpoint
Anthem) (10261) - Service
Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of New
Hampshire (Wellpoint
Anthem) (10261) - Service
Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 146
BCBS of New Hampshire (Wellpoint Anthem) (10261) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 147
BCBS of New Jersey (Horizon) – 10041
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10041 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DMG03 Gender
M=Male
F=Female
1 Optional
December 30, 2013 X12N/005010/270 v1.7 148
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past
No Future Dates allowed.
Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DMG03 Gender
M=Male
F=Female
1 Optional
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past
No Future Dates allowed.
Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 149
BCBS of New Mexico – 10042
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10042 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 150
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 151
BCBS of New York (Empire) – 10043
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10043 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
December 30, 2013 X12N/005010/270 v1.7 152
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of New York
(Empire) (10043) - Service
Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of New York
(Empire) (10043) - Service
Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 153
BCBS of New York (Empire) (10043) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 154
BCBS of New York (Excellus) – 10323
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10323 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 90 days in the Past
No Future Dates allowed.
90 day Date Ranges allowed
December 30, 2013 X12N/005010/270 v1.7 155
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 90 days in the Past
No Future Dates allowed.
90 day Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 156
BCBS of North Carolina – 10383
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10383 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #1 and #2
2100C NM104 First Name 35 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1 and #2
December 30, 2013 X12N/005010/270 v1.7 157
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 3 years prior to the
current date in the Past
No Future Dates allowed.
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option: #3
2100D NM104 First Name 35 Search Option: #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #3
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 3 years prior to the
current date in the Past
No Future Dates allowed.
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 158
BCBS of North Dakota – 10478
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10478 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 17 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 159
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 30 days prior to
current date in the Past
For Future Dates:
If current date is 1st-15th,
inquiries allowed through
the end of current month. If
current date is 16th - 31st,
inquiry allowed through end
of the next month.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 30 days prior to
current date in the Past
For Future Dates:
If current date is 1st-15th,
inquiries allowed through
the end of current month. If
current date is 16th - 31st,
inquiry allowed through end
of the next month.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 160
BCBS of Ohio (Wellpoint Anthem) – 10044
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10044 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
December 30, 2013 X12N/005010/270 v1.7 161
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Ohio
(Wellpoint Anthem) (10044)
- Service Type Code List”
below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Ohio
(Wellpoint Anthem) (10044)
- Service Type Code List”
below
December 30, 2013 X12N/005010/270 v1.7 162
BCBS of Ohio (Wellpoint Anthem) (10044) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 163
BCBS of Oklahoma – 10582
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10582 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Provider ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 17 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 164
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 165
BCBS of Oregon (Regence) – 10045
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: This payer supports local BCBS transactions ONLY. No connectivity to the Blue Exchange.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10045 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 17 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 166
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 3 years in the Past
Up to 1 year in the Future
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 3 years in the Past
Up to 1 year in the Future
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 167
BCBS of Pennsylvania (Highmark) – 10046
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10046 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 17 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past.
Up to 6 months in the
Future.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 168
2100C EQ01 Service Type Code 2
See “BCBS of Pennsylvania
(Highmark) (10046) -
Service Type Code List”
below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past.
Up to 6 months in the
Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Pennsylvania
(Highmark) (10046) -
Service Type Code List”
below
BCBS of Pennsylvania (Highmark) (10046) - Service Type Code List
Code Description Code Description
10 Blood Charges 41 Routine (Preventive) Dental
23 Diagnostic Dental 60 General Benefits
24 Periodontics 85 AIDS
25 Restorative 87 Cancer
26 Endodontics AA Rehabilitation – Room and Board
27 Maxillofacial Prosthetics AR Substance Abuse
28 Adjunctive Dental Services BA Independent Medical Evaluation
30 Health Benefit Plan Coverage BK Orthopedics
32 Family Planning BL Cardiac
35 Dental Care BM Lymphatic
36 Dental Crowns BN Gastrointestinal
37 Dental Accident BP Endocrine
38 Orthodontics BQ Neurology
39 Prosthodontics BR Eye
December 30, 2013 X12N/005010/270 v1.7 169
BCBS of Pennsylvania (Highmark) Institutional – 10524
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10524 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 17 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past.
Up to 6 months in the
Future.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 170
2100C EQ01 Service Type Code 2
See “BCBS of Pennsylvania
(Highmark) Institutional
(10524) - Service Type Code
List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past.
Up to 6 months in the
Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Pennsylvania
(Highmark) Institutional
(10524) - Service Type Code
List” below
BCBS of Pennsylvania (Highmark) Institutional (10524) - Service Type Code List
Code Description Code Description
10 Blood Charges 41 Routine (Preventive) Dental
23 Diagnostic Dental 60 General Benefits
24 Periodontics 85 AIDS
25 Restorative 87 Cancer
26 Endodontics AA Rehabilitation – Room and Board
27 Maxillofacial Prosthetics AR Substance Abuse
28 Adjunctive Dental Services BA Independent Medical Evaluation
30 Health Benefit Plan Coverage BK Orthopedics
32 Family Planning BL Cardiac
35 Dental Care BM Lymphatic
36 Dental Crowns BN Gastrointestinal
37 Dental Accident BP Endocrine
38 Orthodontics BQ Neurology
39 Prosthodontics BR Eye
December 30, 2013 X12N/005010/270 v1.7 171
BCBS of Rhode Island – 10304
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10304 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 172
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 173
BCBS of South Carolina – 10047
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
4 Dependent Sub: Member ID Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10047 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 17
Search options:
#1, #2, #3, and #4
December 30, 2013 X12N/005010/270 v1.7 174
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1 and #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 3 years in the Past
Up to 1 year in the Future
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #3
2100D NM104 First Name 25 Search Option: #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #3 and #4
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 3 years in the Past
Up to 1 year in the Future
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 175
BCBS of South Dakota (Wellmark) – 10395
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10395 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 176
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 177
BCBS of Tennessee – 10430
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5 Element 6
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member
ID
Sub: Last
Name
Sub: First
Name
Dep: Last
Name
Dep: First
Name
Dep: Date of
Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10430 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #1 and #2
2100C NM104 First Name 35 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 178
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Tennessee
(10430) - Service Type Code
List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Tennessee
(10430) - Service Type Code
List” below
December 30, 2013 X12N/005010/270 v1.7 179
BCBS of Tennessee (10430) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 88 Pharmacy
20 Second Surgical Opinion 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
33 Chiropractic 99 Professional (Physician) Visit – Inpatient
35 Dental Care A0 Professional (Physician) Visit – Outpatient
40 Medical Oral Surgery A3 Professional (Physician) Visit – Home
42 Home Health Care A6 Psychotherapy
45 Hospice A7 Psychiatric-Inpatient
47 Hospital A8 Psychiatric-Outpatient
48 Hospital – Inpatient AD Occupational Therapy
49 Hospital – Room and Board AE Physical Medicine
50 Hospital – Outpatient AF Speech Therapy
51 Hospital – Emergency Accident AG Skilled Nursing Care
52 Hospital – Emergency Medical AI Substance Abuse
53 Hospital – Ambulatory Surgical AL Vision (Optometry)
60 General Benefits BG Cardiac Rehabilitation
61 In-vitro Fertilization BH Pediatric
62 MRI/CAT Scan DM Durable Medical Equipment
65 Newborn Care MH Mental Health
68 Well Baby Care UC Urgent Care
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 180
BCBS of Texas – 10048
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10048 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 15 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 181
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 182
BCBS of the Rochester Area (NY) – 10469
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5
1 Subscriber Member ID Last Name First Name Date of Birth Gender
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Dep: Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10469 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 15 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DMG03 Gender
M=Male
F=Female
1 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 183
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option: #2
2100D NM104 First Name 35 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DMG03 Gender
M=Male
F=Female
1 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 184
BCBS of Utica-Watertown (NY) – 10470
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5
1 Subscriber Member ID Last Name First Name Date of Birth Gender
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Dep: Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10470 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 15 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DMG03 Gender
M=Male
F=Female
1 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 185
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option: #2
2100D NM104 First Name 35 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DMG03 Gender
M=Male
F=Female
1 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 186
BCBS of Vermont – 10624
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5
1 Subscriber Member ID Last Name First Name Date of Birth Gender
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Dep: Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10624 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DMG03 Gender
M=Male
F=Female
1 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 187
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option: #2
2100D NM104 First Name 35 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DMG03 Gender
M=Male
F=Female
1 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 188
BCBS of Virginia (Wellpoint Anthem) – 10049
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10049 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
December 30, 2013 X12N/005010/270 v1.7 189
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Virginia
(Wellpoint Anthem) (10049)
- Service Type Code List”
below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Virginia
(Wellpoint Anthem) (10049)
- Service Type Code List”
below
December 30, 2013 X12N/005010/270 v1.7 190
BCBS of Virginia (Wellpoint Anthem) (10044) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 191
BCBS of West Virginia – 10462
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Member ID Last Name First Name
4 Subscriber Member ID Last Name Date of Birth
5 Subscriber Member ID First Name Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
7 Dependent Sub: Member ID Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name
9 Dependent Sub: Member ID Dep: Last Name Dep: Date of Birth
10 Dependent Sub: Member ID Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10462 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
December 30, 2013 X12N/005010/270 v1.7 192
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #3, and
#4
2100C NM104 First Name 25 Search Option: #1, #5, and
#5
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20
Search options:
#1, #2, #3, #4, #5, #6, #7,
#8, #9, and #10
Include 2-digit suffix
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #2, #4, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates are allowed.
Up to 6 months in the
Future.
No Date Ranges are
allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35
Search options:
#6, #8, and #9
2100D NM104 First Name 25
Search options:
#6, #8, and #10
2100D DMG02 Date of Birth CCYYMMDD 8
Search options:
#6, #7, #9, and #10
December 30, 2013 X12N/005010/270 v1.7 193
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates are allowed.
Up to 6 months in the
Future.
No Date Ranges are
allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 194
BCBS of Western New York – 10498
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: Please note that BCBS WNY, BS NE NY and HealthNow will require a special contractual agreement/addendum
with Exchange EDI. Please contact your Account Manager, or [email protected] for more information.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10498 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1,#2
2100C NM104 First Name 25 Search options: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9
December 30, 2013 X12N/005010/270 v1.7 195
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Past dates are allowed.
Future dates are allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Western New
York (10498) - Service Type
Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Past dates are allowed.
Future dates are allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Western New
York (10498) - Service Type
Code List” below
BCBS of Western New York (10498) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 88 Pharmacy
20 Second Surgical Opinion 91 Brand Name Prescription Drug
30 Health Benefit Plan Coverage 92 Generic Prescription Drug
December 30, 2013 X12N/005010/270 v1.7 196
33 Chiropractic 93 Podiatry
35 Dental Care 98 Professional (Physician) Visit - Office
40 Medical Oral Surgery 99 Professional (Physician) Visit – Inpatient
42 Home Health Care A0 Professional (Physician) Visit – Outpatient
45 Hospice A3 Professional (Physician) Visit – Home
47 Hospital A6 Psychotherapy
48 Hospital – Inpatient A7 Psychiatric-Inpatient
50 Hospital – Outpatient A8 Psychiatric-Outpatient
51 Hospital – Emergency Accident AD Occupational Therapy
52 Hospital – Emergency Medical AE Physical Medicine
53 Hospital – Ambulatory Surgical AF Speech Therapy
60 General Benefits AG Skilled Nursing Care
61 In-vitro Fertilization AI Substance Abuse
62 MRI/CAT Scan AL Vision (Optometry)
65 Newborn Care BG Cardiac Rehabilitation
68 Well Baby Care BH Pediatric
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 197
BCBS of Wisconsin (Wellpoint Anthem) – 10299
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10299 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1 and #2
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
December 30, 2013 X12N/005010/270 v1.7 198
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “BCBS of Wisconsin
(Wellpoint Anthem) (10299)
- Service Type Code List”
below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “BCBS of Wisconsin
(Wellpoint Anthem) (10299)
- Service Type Code List”
below
December 30, 2013 X12N/005010/270 v1.7 199
BCBS of Wisconsin (Wellpoint Anthem) (10299) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 200
BCBS of Wyoming – 10480
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10480 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 17 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 201
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 30 days prior to
current date in the Past
For Future Dates:
If current date is 1st-15th,
inquiries allowed through
the end of current month. If
current date is 16th - 31st,
inquiry allowed through end
of the next month.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 30 days prior to
current date in the Past
For Future Dates:
If current date is 1st-15th,
inquiries allowed through
the end of current month. If
current date is 16th - 31st,
inquiry allowed through end
of the next month.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 202
Best Choice Health Plan – 10256
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Last Name First Name Date of Birth
Note: For Dependent Searches, use the Employees Member ID. No dependent loops are supported by this payer.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10256 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options: #1, #4
2100C NM104 First Name 25 Search Options: #1, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options: #1, #2
2100C REF01 Reference Identification
SY 2
December 30, 2013 X12N/005010/270 v1.7 203
Qualifier
2100C REF02 SSN 9 Search Option: #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options: #1, #2, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates are not allowed.
Future Dates are not allowed.
Date ranges are not allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 204
Better Health Plans (Unison Health Plan) - 10187
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10187 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, FI 2
2100B NM109 Provider ID, Federal Tax ID 9
Provider ID if NM108 = SV
Federal Tax ID if NM108 =
FI
2100B REF01 Reference Identification Qualifier N5, N7 2
2100B REF02 Plan Network ID, Facility Network
ID 12
Plan Network ID if REF01 =
N5
Facility Network ID if
REF01 = N7
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 205
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 206
Blue Cross Independence (Pennsylvania) – 10262
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10262 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 207
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the past
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “Blue Cross
Independence
(Pennsylvania) (10262) -
Service Type Code List”
below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the past
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “Blue Cross
Independence
(Pennsylvania) (10262) -
Service Type Code List”
below
December 30, 2013 X12N/005010/270 v1.7 208
Blue Cross Independence (Pennsylvania) (10262) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 209
Blue Cross Northeastern Pennsylvania – 10264
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: 13 Counties in PA - Bradford, Carbon, Clinton, Monroe, Lackawanna, Luzerne, Lycoming, Sullivan, Susquehanna,
Tioga, Pike, Wayne and Wyoming
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10264 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
December 30, 2013 X12N/005010/270 v1.7 210
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the past
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 211
Blue Cross of California – 10051
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10051 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12
Search options: #1 and #2
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
December 30, 2013 X12N/005010/270 v1.7 212
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “Blue Cross of
California (10051) - Service
Type Code List” below
Only (1) EQ01 segment per
transaction
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “Blue Cross of
California (10051) - Service
Type Code List” below
Only (1) EQ01 segment per
transaction
December 30, 2013 X12N/005010/270 v1.7 213
Blue Cross of California (10051) - Service Type Code List
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 214
Blue Cross of Idaho – 10638
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10638 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates are allowed.
No Future Dates allowed.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 215
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates are allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 216
Blue Cross of Utah (Regence) – 10618
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber SSN Last Name First Name
3 Dependent Sub: Member ID/SSN Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10618 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options: #1 and #2
2100C NM104 First Name 25 Search Options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options: #1 and #3
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search Options: #2 and #3
December 30, 2013 X12N/005010/270 v1.7 217
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 24 months in the Past
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #3
2100D NM104 First Name 25 Search Option: #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #3
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 24 months in the Past
No Future Dates allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 218
Blue Cross of Washington and Alaska (Premera) – 10326
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10326 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #2
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 30 Optional
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 219
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code All valid service
types are supported 2
Only (1) EQ01 segment per
transaction
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 30
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code All valid service
types are supported 2
Only (1) EQ01 segment per
transaction
December 30, 2013 X12N/005010/270 v1.7 220
Blue Cross Pennsylvania (Capital) – 10325
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: 21 County area in PA - Fulton, Franklin, Adams, York, Lancaster, Cumberland, Perry, Dauphin, Lebanon, Berks,
Lehigh, Northampton, Juniata, Mifflin, Centre, Union, Snyder, Northumberland, Montour, Columbia, Schuylkill
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10325 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 221
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 6 months in the
Future.
No Date Ranges allowed.
2100C EQ01 Service Type Code All valid service
types are supported 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option: #2
2100D NM104 First Name 35 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 6 months in the
Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code All valid service
types are supported 2
December 30, 2013 X12N/005010/270 v1.7 222
Blue Cross of Washington (Regence) – 10054
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID/SSN Dep: Last Name Dep: First Name Dep: Date of Birth
Note: This payer supports local BCBS transactions ONLY. No connectivity to the Blue Exchange.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10054 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 223
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
Future Dates are allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
Future Dates are allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 224
Blue Shield of California – 10053
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10053 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 225
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code
2
See “Blue Shield of
California (10053) - Service
Type Code List” below
Blue Shield of CA only
accepts 1 service type code
per request. If multiple
Codes are received, the only
the first service type code
will be returned the on the
271 response.
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “Blue Shield of
California (10053) - Service
Type Code List” below
Blue Shield of CA only
accepts 1 service type code
per request. If multiple
Codes are received, the only
the first service type code
will be returned the on the
271 response.
December 30, 2013 X12N/005010/270 v1.7 226
Blue Shield of California (10053) - Service Type Code List
Code Description Code Description
1 Medical Care 51 Hospital - Emergency Accident
2 Surgical 52 Hospital - Emergency Medical
3 Consultation 53 Hospital - Ambulatory Surgical
4 Diagnostic X-Ray 54 Long Term Care
5 Diagnostic Lab 55 Major Medical
6 Radiation Therapy 56 Medically Related Transportation
7 Anesthesia 57 Air Transportation
8 Surgical Assistance 58 Cabulance
9 Other Medical 59 Licensed Ambulance
10 Blood Charges 60 General Benefits
11 Used Durable Medical Equipment 61 In-vitro Fertilization
12 Durable Medical Equipment Purchase 62 MRI/CAT Scan
13 Ambulatory Service Center Facility 63 Donor Procedures
14 Renal Supplies in the Home 64 Acupuncture
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 66 Pathology
17 Pre-Admission Testing 67 Smoking Cessation
18 Durable Medical Equipment Rental 68 Well Baby Care
19 Pneumonia Vaccine 69 Maternity
20 Second Surgical Opinion 70 Transplants
21 Third Surgical Opinion 71 Audiology Exam
22 Social Work 72 Inhalation Therapy
23 Diagnostic Dental 73 Diagnostic Medical
24 Periodontics 74 Private Duty Nursing
25 Restorative 75 Prosthetic Device
26 Endodontics 76 Dialysis
27 Maxillofacial Prosthetics 77 Otological Exam
28 Adjunctive Dental Services 78 Chemotherapy
30 Health Benefit Plan Coverage 79 Allergy Testing
32 Plan Waiting Period 80 Immunizations
33 Chiropractic 81 Routine Physical
34 Chiropractic Office Visits 82 Family Planning
35 Dental Care 83 Infertility
36 Dental Crowns 84 Abortion
37 Dental Accident 85 AIDS
38 Orthodontics 86 Emergency Services
39 Prosthodontics 87 Cancer
40 Oral Surgery 88 Pharmacy
41 Routine (Preventive) Dental 89 Free Standing Prescription Drug
42 Home Health Care 90 Mail Order Prescription Drug
43 Home Health Prescriptions 91 Brand Name Prescription Drug
44 Home Health Visits 92 Generic Prescription Drug
45 Hospice 93 Podiatry
46 Respite Care 94 Podiatry - Office Visits
47 Hospital 95 Podiatry - Nursing Home Visits
December 30, 2013 X12N/005010/270 v1.7 227
48 Hospital - Inpatient 96 Professional (Physician)
49 Hospital - Room and Board 97 Anesthesiologist
50 Hospital - Outpatient 98 Professional (Physician) Visit - Office
99 Professional (Physician) Visit - Inpatient BR Eye
A0 Professional (Physician) Visit - Outpatient BS Invasive Procedures
A1 Professional (Physician) Visit - Nursing Home BT Gynecological
A2 Professional (Physician) Visit - Skilled Nursing Facility BU Obstetrical
A3 Professional (Physician) Visit - Home BV Obstetrical/Gynecological
A4 Psychiatric BW Mail Order Prescription Drug: Brand Name
A5 Psychiatric - Room and Board BX Mail Order Prescription Drug: Generic
A6 Psychotherapy BY Physician Visit - Office: Sick
A7 Psychiatric - Inpatient BZ Physician Visit - Office: Well
A8 Psychiatric - Outpatient C1 Coronary Care
A9 Rehabilitation CA Private Duty Nursing - Inpatient
AA Rehabilitation - Room and Board CB Private Duty Nursing - Home
AB Rehabilitation- Inpatient CC Surgical Benefits - Professional (Physician)
AC Rehabilitation- Outpatient CD Surgical Benefits - Facility
AD Occupational Therapy CE Mental Health Provider - Inpatient
AE Physical Medicine CF Mental Health Provider - Outpatient
AF Speech Therapy CG Mental Health Facility - Inpatient
AG Skilled Nursing Care CH Mental Health Facility - Outpatient
AH Skilled Nursing Care - Room and Board CI Substance Abuse Facility - Inpatient
AI Substance Abuse CJ Substance Abuse Facility -Outpatient
AJ Alcoholism CK Screening X-ray
AK Drug Addiction CL Screening laboratory
AL Vision (Optometry) CM Mammogram, High Risk Patient
AM Frames CN Mammogram, Low Risk Patient
AN Routine Exam CO Flu Vaccination
AO Lenses CP Eyewear and Eyewear Accessories
AQ Non-medically Necessary Physical CQ Case Management
AR Experimental Drug Therapy DG Dermatology
B1 Burn Care DM Durable Medical Equipment
B2 Brand Name Prescription Drug - Formulary DS Diabetic Supplies
B3 Brand Name Prescription Drug - Non-Formulary GF Generic Prescription Drug - Formulary
BA Independent Medical Evaluation GN Generic Prescription Drug - Non- Formulary
BB Partial Hospitalization (Psychiatric) GY Allergy
BC Day Care (Psychiatric) IC Intensive Care
BD Cognitive Therapy MH Mental Health
BE Massage Therapy NI Neonatal Intensive Care
BF Pulmonary Rehabilitation ON Oncology
BG Cardiac Rehabilitation PT Physical Therapy
BH Pediatric PU Pulmonary
BI Nursery RN Renal
BJ Skin RT Residential Psychiatric Treatment
BK Orthopedic TC Transitional Care
BL Cardiac TN Transitional Nursery Care
BM Lymphatic UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 228
BN Gastrointestinal BQ Neurology
BP Endocrine
December 30, 2013 X12N/005010/270 v1.7 229
Blue Shield of Idaho (Regence) – 10052
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID/SSN Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10052 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 230
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates are allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates are allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 231
Blue Shield of Northeastern New York – 10499
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: Please note that BCBS WNY, BS NE NY and HealthNow will require a special contractual agreement/addendum
with Exchange EDI. Please contact your Account Manager, or [email protected] for more information.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10499 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1
2100C NM104 First Name 25 Search options: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1
*Including 2-digit Suffix
2100C REF01 Reference Identification Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 232
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Past dates are allowed.
Future dates are not allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “Blue Shield of
Northeastern New York
(10499) - Service Type
Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #2
2100D NM104 First Name 25 Search options: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #2
2100D DTP03 Subscriber Date CCYYMMDD 8
Past dates are allowed.
Future dates are not allowed.
No Date Ranges allowed
2100D EQ01 Service Type Code 2
See “Blue Shield of
Northeastern New York
(10499) - Service Type
Code List” below
December 30, 2013 X12N/005010/270 v1.7 233
Blue Shield of Northeastern New York (10499) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 88 Pharmacy
20 Second Surgical Opinion 91 Brand Name Prescription Drug
30 Health Benefit Plan Coverage 92 Generic Prescription Drug
33 Chiropractic 93 Podiatry
35 Dental Care 98 Professional (Physician) Visit - Office
40 Medical Oral Surgery 99 Professional (Physician) Visit – Inpatient
42 Home Health Care A0 Professional (Physician) Visit – Outpatient
45 Hospice A3 Professional (Physician) Visit – Home
47 Hospital A6 Psychotherapy
48 Hospital – Inpatient A7 Psychiatric-Inpatient
50 Hospital – Outpatient A8 Psychiatric-Outpatient
51 Hospital – Emergency Accident AD Occupational Therapy
52 Hospital – Emergency Medical AE Physical Medicine
53 Hospital – Ambulatory Surgical AF Speech Therapy
60 General Benefits AG Skilled Nursing Care
61 In-vitro Fertilization AI Substance Abuse
62 MRI/CAT Scan AL Vision (Optometry)
65 Newborn Care BG Cardiac Rehabilitation
68 Well Baby Care BH Pediatric
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 234
BlueChoice Health Plan South Carolina Medicaid – 10504
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10504 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #2
2100C NM104 First Name 35 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DMG03 Gender
M = Male
F= Female 1 Search Option: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 235
Bluegrass Family Health – 10429
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name Date of Birth
2 Subscriber Member ID Last Name First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10429 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #2
2100C NM104 First Name 25 Search options: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Past dates are allowed.
Future Dates are allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 236
BMC Health Net – 10556
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10556 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #2
2100C NM104 First Name 35 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DMG03 Gender
M = Male
F= Female
1 Search Option: #2
December 30, 2013 X12N/005010/270 v1.7 237
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 238
Bridgeway Arizona – 10565
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10565 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #2
2100C NM104 First Name 25 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
December 30, 2013 X12N/005010/270 v1.7 239
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 240
Buckeye Community Health – 10566
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10566 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #2
2100C NM104 First Name 25 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
December 30, 2013 X12N/005010/270 v1.7 241
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 242
California Medicaid (Medi-Cal) – 10118
Search Options
# Option Element 1 Element 2 Element 3
1 Subscriber Member ID Card Issue Date Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10055 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100B REF01 Reference Identification Qualifier 4A 2
2100B REF02 Provider PIN 7 CA Medicaid Provider
PIN
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 13 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP01 Date/Time Qualifier 3
DTP01= 102 for Card
Issue Date
DTP01=291 for
Subscriber/Plan Date
December 30, 2013 X12N/005010/270 v1.7 243
2100C DTP02 Date Time Period Format
Qualifier D8 3
2100C DTP03 Card Issue Date CCYYMMDD 8
Card Issue Date if
DTP01=102
Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Plan Date if DTP01=291
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 244
Capital District’s Physicians’ Health Plan (CDPHP) – 10458
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Member ID Last Name First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10458 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #2
2100C NM104 First Name 35 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Future Dates are allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “Capital District’s
Physicians’ Health Plan
(10458) - Service Type
Code List” below
December 30, 2013 X12N/005010/270 v1.7 245
Capital District’s Physicians’ Health Plan (10458) - Service Type Code List
Code Description Code Description
1 Medical Care 78 Chemotherapy
2 Surgical 80 Immunizations
4 Diagnostic X-ray 81 Routine Physical
5 Diagnostic Lab 82 Family Planning
6 Radiation Therapy 86 Emergency Services
7 Anesthesia 88 Pharmacy
8 Surgical Assistance 93 Podiatry
12 Durable Medical Equipment Purchase 98 Professional (Physician) Visit - Office
13 Ambulatory Service Center Facility 99 Professional (Physician) Visit – Inpatient
18 Durable Medical Equipment Rental A0 Professional (Physician) Visit – Outpatient
20 Second Surgical Opinion A3 Professional (Physician) Visit – Home
33 Chiropractic A6 Psychotherapy
35 Dental Care A7 Psychiatric-Inpatient
40 Medical Oral Surgery A8 Psychiatric-Outpatient
42 Home Health Care AD Occupational Therapy
45 Hospice AE Physical Medicine
47 Hospital AF Speech Therapy
48 Hospital – Inpatient AG Skilled Nursing Care
50 Hospital – Outpatient AI Substance Abuse
51 Hospital – Emergency Accident AL Vision (Optometry)
52 Hospital – Emergency Medical BG Cardiac Rehabilitation
53 Hospital – Ambulatory Surgical BH Pediatric
65 Newborn Care DM Durable Medical Equipment
68 Well Baby Care MH Mental Health
73 Diagnostic Medical UC Urgent Care
76 Dialysis
December 30, 2013 X12N/005010/270 v1.7 246
CAPROCK – 10660
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10660 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI National Provider ID if
NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1
2100C NM104 First Name 25 Search options: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1#2
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #2
2100D NM104 First Name 25 Search options: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #2
December 30, 2013 X12N/005010/270 v1.7 247
2100D DTP03 Dependent Date CCYYMMDD 8
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 248
Carefirst Blue Cross Blue Shield – 10270
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Dependent Sub: Member ID Dep: Date of Birth
Note: Maryland, DC, and Northern Virginia
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10270 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Optional
2100C NM104 First Name 25 Optional
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8
2100C DMG03 Gender
M = Male
F= Female
1 Optional
December 30, 2013 X12N/005010/270 v1.7 249
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35
2100D NM104 First Name 25
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
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CarePlus Health Plan – 10056
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Note: CPHP is limited to only the Providers who are in the following counties in Florida: Palm Beach, Broward and
Miami Dade.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10056 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #2
2100C NM104 First Name 25 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 24 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
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Celticare – 10589
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: First Name Dep: Last Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10589 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
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2100C NM103 Last Name 35 Search options: #2, #3, and #4
2100C NM104 First Name 25 Search options: #2, #3, and #4
2100C NM108 Information Receiver ID Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1, #2, #4, #5, #6, and #8
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #3, and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35
Search options:
#6, #7, and #8
2100D NM104 First Name 25
Search options:
#6, #7, and #8
2100D DMG02 Date of Birth CCYYMMDD 8
Search options:
#5, #7, and #8
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 253
Cenpatico
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 5
Transunion Payer ID
See “Cenpatico Payer Codes”
table above
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
Cenpatico Payer Codes
Payer Name Payer ID Payer Name Payer ID
Cenpatico - Arizona 10567 Cenpatico - Massachusetts 10588
Cenpatico - Florida 10568 Cenpatico - Ohio 10572
Cenpatico - Illinois 10631 Cenpatico – South Carolina 10573
Cenpatico - Indiana 10570 Cenpatico - Texas 10633
Cenpatico - Kansas 10571 Cenpatico - Wisconsin 10634
Cenpatico - Kentucky 10632
December 30, 2013 X12N/005010/270 v1.7 254
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #2
2100C NM104 First Name 25 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2 and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 255
Central Reserve Life Insurance Company – 10450
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10450 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
December 30, 2013 X12N/005010/270 v1.7 256
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2, #3, #4
2100C NM104 First Name 25 Search options: #2, #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20
Search options:
#1, #2, #4, #5, #6, and #8
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code
1,30,33,35,48,50,52,86
88,98,A4,AL
2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #6, #7, #8
2100D NM104 First Name 25 Search options: #6, #7, #8
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #5, #7, #8
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code
1,30,33,35,48,50,52,86
88,98,A4,AL
2
December 30, 2013 X12N/005010/270 v1.7 257
Central Reserve Life Ins Co. Medicare Supp- 10539
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10539 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #2
2100C NM104 First Name 25 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2 and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 258
Central States Funds – 10486
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber SSN Date of Birth
4 Subscriber Last Name First Name Date of Birth
5 Subscriber Member ID Last Name First Name Date of Birth
1 Dependent Sub: Member ID Dep: Date of Birth
2 Dependent Sub: Member ID Dep: First Name Dep: Last Name
3 Dependent Dep: SSN Dep: Date of Birth
4 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
5 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10486 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX, FI, SV 2
2100B NM109 NPI, Federal Tax ID, Provider ID
National Provider ID if
NM108 = XX
Federal Tax ID if
NM108 =FI
December 30, 2013 X12N/005010/270 v1.7 259
Provider ID if
NM108 = SV
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2,#4,#5
2100C NM104 First Name 25 Search options: #2,#4,#5
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1,#2,#5
2100C REF01 Reference Identifier Qualifier SY 2
2100C REF02 SSN 9 Search options:#3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1,#3,#4,#5
2100C DTP03 Subscriber Date CCYYMMDD 8
2100C EQ01 Service Type Code
1, 2, 4, 5, 7, 8, 9,
24, 25, 26, 27, 30,
33, 35, 36, 38, 40,
48, 49, 50, 51, 52,
53, 55, 69, 78, 86,
87, 88, 89, 90, 96,
97, 98, 99, A0, A1,
A2, A3, A4, A5,
A6, A7, A8
2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #2,#4,#5
2100D NM104 First Name 25 Search options: #2,#4,#5
2100D REF01 Reference Identifier Qualifier SY 2
2100D REF02 SSN 9 Search options:#3
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #1,#3,#4,#5
2100D DTP03 Dependent Date CCYYMMDD 8
December 30, 2013 X12N/005010/270 v1.7 260
2100D EQ01 Service Type Code
1, 2, 4, 5, 7, 8, 9,
24, 25, 26, 27, 30,
33, 35, 36, 38, 40,
48, 49, 50, 51, 52,
53, 55, 69, 78, 86,
87, 88, 89, 90, 96,
97, 98, 99, A0, A1,
A2, A3, A4, A5,
A6, A7, A8
2
December 30, 2013 X12N/005010/270 v1.7 261
CHAMPVA/Spina Bifida/Children of Women Vietnam Vets - 10061
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10061 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1, #2
2100C NM104 First Name 25 Search Option: #1, #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option: #1
2100C REF01
Reference Identification
Qualifier 6P 2
2100C REF02 Group Number 30 Optional
December 30, 2013 X12N/005010/270 v1.7 262
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1, #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 263
CIGNA/Great West Healthcare – 10062
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
NOTE: Great West Healthcare has been merged with Cigna
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10062 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 24 Search options: #1 and #2
December 30, 2013 X12N/005010/270 v1.7 264
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
There is no limit on Past date
searches. All historical data is
stored.
Up to 30 days in the future.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2 See “CIGNA/Great West (10062)
- Service Type Code List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
There is no limit on Past date
searches. All historical data is
stored.
Up to 30 days in the future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2 See “CIGNA/Great West (10062)
- Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 265
CIGNA/Great West (10062) - Service Type Code List
Code Description Code Description
1 Medical Care 79 Allergy Testing
2 Surgical 80 Immunizations
4 Diagnostic X-ray 81 Routine Physical
5 Diagnostic Lab 82 Family Planning
6 Radiation Therapy 83 Infertility
7 Anesthesia 84 Abortion
8 Surgical Assistance 86 Emergency Services
9 Other Medical 88 Pharmacy
10 Blood Charges 90 Mail Order Prescription Drug
12 Durable Medical Equipment Purchase 91 Brand Name Prescription Drug
13 Ambulatory Service Center Facility 92 Generic Prescription Drug
17 Pre-Admission Testing 93 Podiatry
19 Pneumonia Vaccine 96 Professional (Physician)
22 Social Work 97 Anesthesiologist
23 Diagnostic Dental 98 Professional (Physician) Visit – Office
24 Periodontics 99 Professional (Physician) Visit – Inpatient
25 Restorative A0 Professional (Physician) Visit – Outpatient
26 Endodontics A2 Professional (Physician) Visit - Skilled Nursing Facility
28 Adjunctive Dental Services A3 Professional (Physician) Visit – Home
30 Health Benefit Plan Coverage A4 Psychiatric
33 Chiropractic A5 Psychiatric - Room & Board
35 Diagnostic Lab A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
38 Orthodontics A8 Psychiatric-Outpatient
39 Prosthodontics A9 Rehabilitation
40 Medical Oral Surgery AA Rehabilitation – Room and Board
41 Routine (Preventive Dental) AC Rehabilitation - Outpatient
42 Home Health Care AD Occupational Therapy
45 Hospice AF Speech Therapy
46 Respite Care AG Skilled Nursing Care
47 Hospital AI Substance Abuse
48 Hospital – Inpatient AJ Alcoholism
49 Hospital – Room and Board AK Drug Addiction
50 Hospital – Outpatient AL Vision (Optometry)
51 Hospital – Emergency Accident AM Frames
52 Hospital – Emergency Medical AN Routine Exam
56 Medically Related Transportation AO Lenses
59 Licensed Ambulance AR Experimental Drug Therapy
61 In-vitro Fertilization BB Partial Hospitalization (Psychiatric)
62 MRI/CAT Scan BC Day Care (Psychiatric)
64 Acupuncture BD Cognitive Therapy
67 Smoking Cessation BF Pulmonary Rehabilitation
68 Well Baby Care BG Cardiac Rehabilitation
69 Maternity BH Pediatric
December 30, 2013 X12N/005010/270 v1.7 266
70 Transplants BK Orthopedic
71 Audiology Exam BL Cardiac
72 Inhalation Therapy BN Gastrointestinal
73 Diagnostic Medical BQ Neurology
74 Private Duty Nursing BR Eye
75 Prosthetic Device CC Surgical Benefits – Professional (Physician)
76 Dialysis MH Mental Health
78 Chemotherapy UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 267
Colorado Access – 10064
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Member ID Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10064 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108
= FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #1, #2,
#4, and #5
2100C NM104 First Name 35 Search options: #1, #4,
and #5
December 30, 2013 X12N/005010/270 v1.7 268
2100C NM108 Information Receiver ID
Qualifier MI 2
2100C NM109 Member ID 11 Search options: #1, #2,
#3, and #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2,
#3, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 60 days in the
Future.
60 day Date Ranges are
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 269
Colorado Medicaid – 10065
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10065 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #2 and #4
2100C NM104 First Name 35 Search options: #2 and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 7 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 270
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #3 and #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2,
and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 271
Community HealthFirst Medicare (CHF Medicare Advantage) – 10421
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber SSN Last Name
4 Subscriber Last Name First Name Date of Birth
5 Subscriber SSN Date of Birth
Note: Date updated Monday morning, last day of the month.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10421 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10 National Provider ID if NM108=XX
Provider ID if NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #3, #4
2100C NM104 First Name 25 Search Options #1, #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 272
2100C NM109 Member ID 20 Search Options #1, #2
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #3, #5
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1,#2, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to 60 Days in the Future
60 day Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 273
Community Health Plan of Washington (CHPW) – 10329
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber SSN Date of Birth
4 Subscriber SSN Last Name
5 Subscriber Last Name First Name Date of Birth
Note: Data updated Monday morning and last day of the month
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10329 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #4 and #5
2100C NM104 First Name 25 Search options: #1 and #5
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 274
2100C NM109 Member ID 80 Search options: #1 and #2
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #3 and #4
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2, #3, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to 60 days in the Future
Up to 60 day Date Ranges.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 275
ConnectiCare – 10303
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: **If the patient is subscriber then the Member ID must be 11 digits long and end with “01”. If the patient is
dependent Member ID must be 11 digits and NOT end with “01” otherwise a AAA*64 response will be returned.
Note: **Any 7 digit member ID that begins with the number ‘1’ is for the Medicare division of Connecticare. Our
connection does not support eligibility for these Medicare patients
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10303 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1
2100C NM104 First Name 25 Search options: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1, #2
December 30, 2013 X12N/005010/270 v1.7 276
2100C DMG02 Date of Birth CCYYMMDD 8 Search option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #2
2100D NM104 First Name 25 Search options: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 277
Connecticut Medicaid – 10067
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID SSN
2 Subscriber Member ID Date of Birth
3 Subscriber SSN Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10067 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 =
SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #3
2100C NM104 First Name 35 Search Option: #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search options: #1 and #2
December 30, 2013 X12N/005010/270 v1.7 278
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search Options:#1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
Current month Date
Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 279
Continental General Insurance Company – 10454
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10454 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 280
2100C NM103 Last Name 35 Search options: #2, #3, #4
2100C NM104 First Name 25 Search options: #2, #3, #4
2100C NM108 Information Receiver ID
Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1, #2, #4, #5, #6, and #8
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #3, and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 1,33,35,48,50,86,88,92,AL 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #6, #7, #8
2100D NM104 First Name 25 Search options: #6, #7, #8
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #5, #7, #8
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 1,33,35,48,50,86,88,92,AL 2
December 30, 2013 X12N/005010/270 v1.7 281
Continental General Insurance Co Medicare Supp – 10540
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10540 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108
= FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 282
Cook Children’s Health Plan – 10610
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10610 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #2
2100C NM104 First Name 35 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search options: #1
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search Option: #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 283
Cooperative Benefits Administrators – 10068
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10068 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
December 30, 2013 X12N/005010/270 v1.7 284
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2, #3, #4
2100C NM104 First Name 25 Search options: #2, #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1, #2, #4, #5, #6, and #8
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #3, and
#4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 1,33,35,48,50,86,88,92,AL 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35
Search options:
#6, #7, and #8
2100D NM104 First Name 25
Search options:
#6, #7, and #8
2100D DMG02 Date of Birth CCYYMMDD 8
Search options:
#5, #7, and #8
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 1,33,35,48,50,86,88,92,AL 2
December 30, 2013 X12N/005010/270 v1.7 285
CoreSource
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
CoreSource Payer Codes
Payer Name Payer ID
FMH 10311
Little Rock 10071
MD, PA, IL, NC, IN, AZ, MN 10072
OH 10074
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 5
Transunion Payer ID
See “CoreSource Payer
Codes” table above
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 286
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C REF01
Reference Identification
Qualifier 6P 2
2100C REF02 Group Number 30 Optional
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D REF01
Reference Identification
Qualifier 6P 2
2100D REF02 Group Number 30
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 287
Coventry Healthcare
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Medicaid ID
3 Subscriber SSN Date of Birth
4 Subscriber Group Number Last Name First Name
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
Coventry Healthcare Payer Codes
Payer Name Payer ID Payer Name Payer ID
Advantra (TX, NM, AZ Only) 10447 Healthcare USA(HCUSA) 10222
Altius Health Plans 10216 Iowa 10207
Advantra Freedom 10307 Kansas 10208
Coventry Health &Life - Nevada 10448 Louisiana 10210
Coventry Health and Life (Oklahoma) 10212 Missouri 10449
Coventry HealthCare Carelink (Advantra) 10214 Nebraska 10211
Coventry Health Care Carelink Medicaid 10215 OmniCare (Michigan) 10223
Coventry Health Care Carenet 10217 PersonalCare/Coventry Health of Illinois 10224
Delaware 10076 Southern Health Services (SHS) 10225
Diamond Plan (Maryland Medicaid) 10218 WellPath Select (Carolinas) 10226
Georgia 10206 Coventry Health and Life (Tenn) 10405
Group Health Plan (GHP) 10219 Advantra Savings 10419
HealthAmerica & HealthAssurance 10220 Mail Handlers Benefit Plan 10085
HealthCare Inc. (Promina) 10221 Coventry Healthcare National Network 10084
University of Missouri 10428 Coventry Health Care Federal 10481
CoventryOne 10440 Coventry Nebraska Medicaid 10548
Vista (MCD, FHK, LTC) 10483 CoventryCares 10614
Florida/Vista/Summit 10551 Coventry Cares of Kentucky 10642
MHNet Behavioral Health 10659
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 5 Transunion Payer ID
See “Coventry Healthcare Payer
December 30, 2013 X12N/005010/270 v1.7 288
Codes” table above
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C REF01 Reference Identification Qualifier NQ 2
2100C REF02 Medicaid ID 12 Search Option: #1
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search Option: #1
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 10 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 18 months in the Past
Up to 3 months in the Future.
Date Ranges are allowed.
2100C EQ01 Service Type Code 2 See “Coventry Healthcare -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 289
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D INS01 Information Receiver ID Qualifier N 2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 18 months in the Past
Up to 3 months in the Future.
Date Ranges are allowed.
2100D EQ01 Service Type Code 2 See “Coventry Healthcare -
Service Type Code List” below
December 30, 2013 X12N/005010/270 v1.7 290
Coventry Healthcare - Service Type Code List
Code Description Code Description
1 Medical Care 72 Inhalation Therapy
2 Surgical 73 Diagnostic Medical
4 Diagnostic X-ray 74 Private Duty Nursing
5 Diagnostic Lab 75 Prosthetic Device
6 Radiation Therapy 76 Dialysis
7 Anesthesia 78 Chemotherapy
9 Other Medical 79 Allergy Testing
10 Blood Charges 80 Immunizations
12 Durable Medical Equipment Purchase 81 Routine Physical
20 Diagnostic Dental 82 Family Planning
22 Social Work 83 Infertility
23 Periodontics 84 Abortion
26 Endodontic 86 Emergency Services
30 Health Benefits Plan Coverage 88 Pharmacy
33 Chiropractic 98 Professional (Physician) Visit - Office
35 Dental Care A0 Professional (Physician) Visit – Outpatient
36 Dental Crowns A3 Professional (Physician) Visit - Home
37 Dental Accident A4 Psychiatric
38 Orthodontic A7 Psychiatric-Inpatient
40 Medical Oral Surgery A8 Psychiatric-Outpatient
41 Routine (Preventive) Dental A9 Rehabilitation
42 Home Health Care AD Occupational Therapy
45 Hospice AF Speech Therapy
47 Hospital AG Skilled Nursing Care
48 Hospital – Inpatient AI Substance Abuse
49 Hospital – Room and Board AL Vision (Optometry)
50 Hospital – Outpatient AM Frames
52 Hospital – Emergency Medical AN Routine Exam
65 Newborn Care AQ Non-medically Necessary Physical
68 Well Baby Care BG Cardiac Rehabilitation
69 Maternity BQ Neurology
70 Transplants
71 Audiology Exam
December 30, 2013 X12N/005010/270 v1.7 291
DakotaCare – 10577
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name
3 Subscriber Member ID First Name
4 Subscriber Last Name First Name Date of Birth
5 Subscriber Member ID Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10577 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2, #3, #4
2100C NM104 First Name 25 Search options: #2, #3, #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 292
2100C NM109 Member ID 80
Search options:
#1, #2, #4, #5, #6, and #8
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #3, and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 1,33,35,48,50,86,88,92,AL 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35
Search options:
#6, #7, and #8
2100D NM104 First Name 25
Search options:
#6, #7, and #8
2100D DMG02 Date of Birth CCYYMMDD 8
Search options:
#5, #7, and #8
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 1,33,35,48,50,86,88,92,AL 2
December 30, 2013 X12N/005010/270 v1.7 293
Dean Health Plan – 10653
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10653 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX 2
National Provider ID
NM108=XX.
2100B NM109 NPI 10
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options 1, 2, 3
2100C NM104 First Name 25 Search Options 1, 2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Options 1,2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options 1, 2, 3
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates allowed
Future dates allowed up
to 7 days
Date ranges allowed
2100C EQ01 Service Type Code
1,2,4,5,6,7,8,12,18,20,33,3
5,40,42,45,47,48,50,51,52,
53,62,65,68,73,76,78,80,81
,82,86,88,93,98,99,A0,A3,
A6,A7,A8,AD,AE,AF,AG,
AI,AL,BG,BH,MH,UC
2 Multiple STC submission
allowed in single request.
December 30, 2013 X12N/005010/270 v1.7 294
Delaware Medicaid – 10293
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Last Name First Name
4 Subscriber Member ID SSN Date of Birth
5 Subscriber Member ID SSN
6 Subscriber Member ID Date of Birth
7 Subscriber Member ID
8 Subscriber Last Name First Name SSN Date of Birth
9 Subscriber Last Name First Name Date of Birth
10 Subscriber Last Name SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10293 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
December 30, 2013 X12N/005010/270 v1.7 295
2100B NM109 NPI 10 National Provider ID
2100B PRV01 Information Receiver ID
Qualifier LA 2
2100B PRV02 Information Receiver ID
Qualifier PXC 2
2100B PRV03 Taxonomy Code 30
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #1, #2, #3,
#8, #9, and #10
2100C NM104 First Name 35
Search options:
#1, #3, #8, and #9
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1, #2, #3, #4, #5, #6, and #7
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #4, #5, #8,
and #10
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #2, #4, #6 #8, #9, and #10
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 296
Denver Health Medical Plan – 10331
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Member ID Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10331 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#1, #2, #4, and #5
2100C NM104 First Name 25 Search options: #1, #4, #5
December 30, 2013 X12N/005010/270 v1.7 297
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11
Search options:
#1, #2, #3, and #4
Member ID must include the
dash “-” in the inquiry else
"Not Found" response will be
returned
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #2, #3, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 298
Deseret Mutual (DMBA) – 10578
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10578 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI 2
2100B NM109 Federal Tax ID 9 Federal Tax ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates allowed.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 299
2100C EQ01 Service Type Code
2, 4, 5, 7, 12, 18,
33, 35, 42, 48, 50,
52, 54, 56, 59, 69,
80, 82, 86, 88, 98,
A4, AD, AE, AI,
AL
2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code
2, 4, 5, 7, 12, 18,
33, 35, 42, 48, 50,
52, 54, 56, 59, 69,
80, 82, 86, 88, 98,
A4, AD, AE, AI,
AL
2
December 30, 2013 X12N/005010/270 v1.7 300
District of Columbia Medicaid – 10078
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10078 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #2 and #4
2100C NM104 First Name 35 Search options: #2 and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 301
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #2 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2 and #4
2100C DMG03 Gender
M = Male
F= Female
8 Search Option: #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 302
Emblem Health – 10616
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10616 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search option: #1
2100C NM104 First Name 25 Search option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 303
Essence Healthcare – 10601
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10601 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 304
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code
4, 5, 7, 11, 12, 13,
14, 15, 16, 18, 19,
30, 34, 41, 42, 45,
48, 50, 53, 56, 58,
60, 62, 70, 71, 73,
75, 76, 77, 78, 79,
80, 81, 86, 88, 90,
94, 98, A7, A8,
AD, AE, AF, AI,
AJ, AK, AM, AN,
AO
2
December 30, 2013 X12N/005010/270 v1.7 305
FamilyCare – 10427
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Last Name First Name Date of Birth
Note: Verification of benefits or eligibility is not a guarantee of payment. Payment can only be made after the claim has
been received and reviewed in regards to eligibility, benefits, medical necessity, and other limitations and/or exclusions.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10427 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10 Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #3
2100C NM104 First Name 25 Search options: #1 and #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, and
#3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 60 days in the Future.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 306
Federated Insurance Company – 10083
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: THE PROVIDED INFORMATION IS NOT A GUARANTEE OF COVERAGE. ACTUAL BENEFITS ARE
DETERMINED ONLY WHEN THE CLAIM IS RECEIVED. NOTE: CERTAON PROCEDURES MAY REQUIRE
PRE APPROVAL
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10083 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
December 30, 2013 X12N/005010/270 v1.7 307
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #2, #3, #4
2100C NM104 First Name 35 Search options: #2, #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options:
#1, #2, #4, #5, #6, and #8
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates are allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 1, 30, 33, 48, 50, 52, 86,88,
98, A4, AL 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #6, #7, #8
2100D NM104 First Name 25 Search options: #6, #7, #8
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #5, #7, #8
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past.
Future Dates are allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 1, 30, 33, 48, 50, 52, 86,88,
98, A4, AL 2
December 30, 2013 X12N/005010/270 v1.7 308
Fidelis Care New York – 10459
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Member ID Date of Birth
3 Subscriber SSN Date of Birth
4 Subscriber SSN Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10459 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #4 and #5
2100C NM104 First Name 25 Search options: #1, #4 and #5
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 309
2100C NM109 Member ID 11 Search options: #1 and #2
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #3 and #4
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2, #3, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “Fidelis Care New York
(10459) - Service Type Code
List” Below
December 30, 2013 X12N/005010/270 v1.7 310
Fidelis Care New York (10459) - Service Type Code List
Code Description Code Description
1 Medical Care 75 Prosthetic Device
2 Surgical 76 Dialysis
3 Consultation 78 Chemotherapy
4 Diagnostic X-Ray 80 Immunizations
5 Diagnostic Lab 81 Routine Physical
6 Radiation Therapy 82 Family Planning
7 Anesthesia 86 Emergency Services
8 Surgical Assistance 88 Pharmacy
12 DME Purchase 93 Podiatry
13 Ambulatory Service Center Facility 98 Physician Visit – Office
18 Durable Medical Equipment Rental 99 Physician Visit - Inpatient
20 Second Surgical Opinion A0 Physician Visit - Outpatient
33 Chiropractic A3 Physician Visit - Home
35 Dental Care A6 Psychotherapy
40 Oral Surgery A7 Psychiatric - Inpatient
42 Home Health Care A8 Psychiatric - Outpatient
45 Hospice AC Rehabilitation – Outpatient
47 Hospital AD Occupational Therapy
48 Hospital - Inpatient AE Physical Medicine
49 Hospital - Room and Board AF Speech Therapy
50 Hospital - Outpatient AG Skilled Nursing Care
51 Hospital - Emergency Accident AH SNC - Room and Board
52 Hospital - Emergency Medicine AI Substance Abuse [Inpatient/Outpatient]
53 Hospital - Ambulatory Surgical AL Vision - Optometry
59 Licensed Ambulance BG Cardiac Rehabilitation
62 MRI/CAT Scan BH Pediatric
65 Newborn Care MH Mental Health [Inpatient/Outpatient]
68 Well Baby Care UC Urgent Care
73 Diagnostic Medical
December 30, 2013 X12N/005010/270 v1.7 311
Florida Health Care Plans – 10615
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10615 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 312
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 24 months in the Past.
Up to 12 months in the
Future.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 24 months in the Past.
Up to 12 months in the
Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 313
Florida Hospital Healthcare System – 10333
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Member ID Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10333 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #1
2100C NM104 First Name 35 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
90 day Date Ranges
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 314
Florida Medicaid – 10086
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Card Number
3 Subscriber Last Name First Name Date of Birth Gender
4 Subscriber SSN Last Name First Name
5 Subscriber SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10086 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #3 and #4
2100C NM104 First Name 25 Search options: #3 and #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 315
2100C NM109 Member ID 10 Search Option: #1
2100C REF01 Reference Identification
Qualifier HJ 2
2100C REF02 Card Number 8 Search Option: #2
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #4 and #5
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #3 and #5
2100C DMG03 Gender
M = Male
F = Female
1 Search Option: #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 18 months in the Past.
No Future Dates allowed.
Date Ranges of up to 18
months allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 316
Freedom Blue – 10502
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Member ID Last Name First Name
4 Subscriber Member ID Last Name Date of Birth
5 Subscriber Member ID First Name Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
7 Dependent Sub: Member ID Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name
9 Dependent Sub: Member ID Dep: Last Name Dep: Date of Birth
10 Dependent Sub: Member ID Dep: First Name Dep: Date of Birth
Note: Freedom Blue is a Highmark Blue Shield Medicare Advantage PPO
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10502 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
December 30, 2013 X12N/005010/270 v1.7 317
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #3, and #4
2100C NM104 First Name 25 Search options: #1, #3, and #5
2100C NM108 Information Receiver ID Qualifier MI 2
2100C NM109 Member ID 20
Search options:
#1, #2, #3, #4, #5, #6, #7, #8, #9
and #10
Include 2-digit suffix
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, #4, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past.
Up to 6 months in the Future.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #6, #8, and #9
2100D NM104 First Name 25 Search options: #6, #8, and #10
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #6, #7, #9, and
#10
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past.
Up to 6 months in the Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 318
Fresenius Medical Care – 10602
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10602 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM102 Information Receiver ID Qualifier 1 or 2 1 1 = Person, 2 = Entity
2100B NM103 Name Last or Organization Name 60
2100B NM104 First Name 24 Required if NM102 = 1
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 319
Gateway Health Plan – 10629
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber SSN Date of Birth
4 Subscriber SSN Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Note: Data updated daily. Area of coverage is Pennsylvania and Ohio
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10629 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX
Provider ID if NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #3, #4
2100C NM104 First Name 25 Search Options #1, #3, #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 320
2100C NM109 Member ID 20 Search Options #1, #2
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1,#2, #3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to 60 Days in the Future
60 day Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 321
Geisinger Health Plan – 10611
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID
Note: Lines of Business are Pennsylvania / Commercial
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10611 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 322
Geisinger Health Plan Gold – 10612
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID
Note: Lines of Business are Pennsylvania / Commercial
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10612 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 323
Generations Healthcare – 10603
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10603 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM102 Information Receiver ID Qualifier 1 or 2 1 1 = Person; 2 = Entity
2100B NM103 Name Last or Organization Name 60
2100B NM104 First Name 24 Required if NM102 = 1
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code
23, 24, 25, 26, 27,
28, 35, 36, 37, 38,
39, 40, 41, 88, 89,
90, 91, 92
2
December 30, 2013 X12N/005010/270 v1.7 324
Georgia Medicaid – 10088
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Gender Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10088 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #2 and #3
2100C NM104 First Name 35 Search options: #2 and #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 325
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #2 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2 and #4
2100C DMG03 Gender
M = Male
F = Female
1 Search Option: #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to End of Current Month
in the Future.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 326
Gilsbar – 10509
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Dependent Sub: Member ID Dep: Date of Birth
3 Dependent Sub: Member ID Dep: First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10509 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 30 Search options: #1, #2, and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
December 30, 2013 X12N/005010/270 v1.7 327
2100D NM104 First Name 25 Search Option: #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 328
Golden Rule Insurance – 10652
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID First Name Date of Birth
4 Subscriber Member ID Date of Birth
5 Subscriber Member ID Last Name First Name
6 Subscriber Last Name First Name Date of Birth
7 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: Date of Birth
9 Dependent Sub: Member ID Dep: First Name Dep: Date of Birth
10 Dependent Sub: Member ID Dep: Date of Birth
11 Dependent Sub: Member ID Dep: Last Name Dep: First Name
12 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10652 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX, FI 2
December 30, 2013 X12N/005010/270 v1.7 329
2100B NM109 NPI, Federal Tax ID 10
National Provider ID if
NM108=XX
Federal Tax ID if NM108=FI
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #2, #5, and #6
2100C NM104 First Name 25 Search options: #1, #3, #5, and #6
2100C NM108 Information Receiver ID Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1, #2, #3, #4, #5,
#7, #8, #9, #10 and #11
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, #3, #4, #6
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 18 months in the Past.
Up to end of current month in the
Future.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
See “Golden Rule Insurance
(10652) - Service Type Code
List” below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #7, #8, #11, #12
2100D NM104 First Name 25 Search options: #7, #9, #11, #12
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #7, #8, #9, #10,
#12
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 18 months in the Past.
Up to end of current month in the
Future.
Date Ranges are allowed.
2100D EQ01 Service Type Code 2
See “Golden Rule Insurance
(10652) - Service Type Code
List” below
December 30, 2013 X12N/005010/270 v1.7 330
Golden Rule Insurance (10652) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 86 Emergency Services
12 Durable Medical Equipment Purchase 88 Pharmacy
13 Ambulatory Service Center Facility 93 Podiatry
18 Durable Medical Equipment Rental 98 Professional (Physician) Visit - Office
20 Second Surgical Opinion 99 Professional (Physician) Visit – Inpatient
30 Health Benefit Plan Coverage A0 Professional (Physician) Visit – Outpatient
33 Chiropractic A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
40 Medical Oral Surgery A7 Psychiatric-Inpatient
42 Home Health Care A8 Psychiatric-Outpatient
45 Hospice AD Occupational Therapy
47 Hospital AE Physical Medicine
48 Hospital – Inpatient AF Speech Therapy
50 Hospital – Outpatient AG Skilled Nursing Care
51 Hospital – Emergency Accident AI Substance Abuse
52 Hospital – Emergency Medical AL Vision (Optometry)
53 Hospital – Ambulatory Surgical BG Cardiac Rehabilitation
62 MRI/CAT Scan BH Pediatric
65 Newborn Care MH Mental Health
68 Well Baby Care UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 331
Government Employees Health Association (GEHA) – 10394
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10394 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10 Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9
Search options: #1 and #2
The Member ID can either be
the SSN (9 positions) or the
GEHA ID (8 positions). The
GEHA ID must not be zero
filled to create a 9 position ID.
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 332
2100C DMG03 Gender M = Male
F = Female 1 Optional
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DMG03 Gender M = Male
F = Female 1 Optional
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 333
Great American Life Insurance Co Medicare Supp – 10543
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10543 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108
= FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 334
Group Health Cooperative – 10608
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10608 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Nam 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed
December 30, 2013 X12N/005010/270 v1.7 335
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 336
Harmony Health Plan – 10514
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10514 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #2
2100C NM104 First Name 25 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 337
Health Alliance Medical Plan (HAP) – 10308
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber SSN Date of Birth
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
Note: This transaction does not support eligibility requests for Illinois plan members.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10308 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #3 and #4
2100C NM104 First Name 25 Search options: #3 and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search options: #1 and #4
2100C REF01 Reference Identification Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 338
2100C REF02 SSN 9 Search Option: #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates up to 1/1/1996
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 339
Healthcare Solutions Group – 10463
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
Note: This currently includes only one Healthcare Solutions Group – M8063: City Utilities. More groups may be added
in the future.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10463 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #1 and #2
2100C NM104 First Name 35 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1 and #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 340
Health Choice Arizona – 10092
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10092 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10 Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 20 Search Option: #2
2100C NM104 First Name 12 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 341
HealthEase – 10510
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10510 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #2
2100C NM104 First Name 25 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 342
HealthEase Kids – 10511
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10511 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #2
2100C NM104 First Name 25 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 343
Health First New Jersey – 10438
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10438 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 344
Health First New York – 10099
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10099 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 345
HealthMarkets
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
HealthMarkets Payer Codes
Payer Name Payer ID
Chesapeake National Life 10248
Mid-West National Life 10129
Trans America Life 10131
Mega Life and Health Insurance 10127
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
December 30, 2013 X12N/005010/270 v1.7 346
2100A NM109 Payer ID 5
Transunion Payer ID
See “HealthMarkets Payer
Codes” list above.
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2, #3, #4
2100C NM104 First Name 25 Search options: #2, #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20
Search options:
#1, #2, #4, #5, #6, and #8
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35
Search options:
#6, #8, and #9
December 30, 2013 X12N/005010/270 v1.7 347
2100D NM104 First Name 25
Search options:
#6, #8, and #9
2100D DMG02 Date of Birth CCYYMMDD 8
Search options:
#8 and #9
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past
Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 348
Health Net National - 10385
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID SSN Date of Birth
3 Subscriber Member ID
4 Subscriber SSN Last Name First Name Date of Birth
Note: *(Member ID only searches) ID’s without the suffix are 9 digits and if you send a member ID only search you must
submit the 9 digit plus the person number/suffix for commercial members. When the proper ID and person number/suffix
is sent it should return a valid response example: RXXXXXXXXMM1 or RXXXXXXXX00.
Note: For CA Medicaid members, the 9 digit Medicaid CIN (8 numbers and 1 suffix) is sufficient.
Note: For ID-only search (S3), must be 11-12 characters for commercial patient or can be 9 digits for CA Medicaid
patients
Note: HealthNet Medi-Cal members should be submitted through Health Net National effective 7/1/2013
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10385 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #1 and #4
December 30, 2013 X12N/005010/270 v1.7 349
2100C NM104 First Name 35 Search options: #1 and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search options: #1, #2, and #3
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search options: #2 and #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
To obtain future dates, submit
the date range for the full,
current month. The payer
provides the response to the
end of the current month.
Date Ranges allowed
2100C EQ01 Service Type Code
1, 2, 4, 5, 6, 7, 8,
12, 13, 18, 20,
30,33, 35, 40, 42,
45,48, 50, 51, 52,
53, 62, 65,68,73,
76, 78, 80, 81, 82,
86, 88, 93, A0,
A3, A6, A7, A8,
AD, AE, AF, AG,
AI, AL, BG, BH
2
STC 30 will return benefit
information for STC 1, 30, 33,
35, 48, 50, 86, 88, 98, AL
December 30, 2013 X12N/005010/270 v1.7 350
Health New England - 10627
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10627 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #2
2100C NM104 First Name 35 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option: #1
2100C REF01 Reference Identification Qualifier SY 2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 351
HealthNow – 10500
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Last Name First Name SSN
5 Subscriber SSN Date of Birth
6 Subscriber Member ID SSN
Note: Please note that BCBS WNY, BS NE NY and HealthNow will require a special contractual agreement/addendum
with Exchange EDI. Please contact your Account Manager, or [email protected] for more information.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10500 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#1, #2, and #4
December 30, 2013 X12N/005010/270 v1.7 352
2100C NM104 First Name 25
Search options:
#1, #2, and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1, #3, and #6
*Including 2-digit Suffix
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9
Search options:
#4, #5, and #6
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#2, #3, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates are allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “HealthNow (10500) -
Service Type Code List”
below
December 30, 2013 X12N/005010/270 v1.7 353
HealthNow (10500) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 88 Pharmacy
20 Second Surgical Opinion 91 Brand Name Prescription Drug
30 Health Benefit Plan Coverage 92 Generic Prescription Drug
33 Chiropractic 93 Podiatry
35 Dental Care 98 Professional (Physician) Visit - Office
40 Medical Oral Surgery 99 Professional (Physician) Visit – Inpatient
42 Home Health Care A0 Professional (Physician) Visit – Outpatient
45 Hospice A3 Professional (Physician) Visit – Home
47 Hospital A6 Psychotherapy
48 Hospital – Inpatient A7 Psychiatric-Inpatient
50 Hospital – Outpatient A8 Psychiatric-Outpatient
51 Hospital – Emergency Accident AD Occupational Therapy
52 Hospital – Emergency Medical AE Physical Medicine
53 Hospital – Ambulatory Surgical AF Speech Therapy
60 General Benefits AG Skilled Nursing Care
61 In-vitro Fertilization AI Substance Abuse
62 MRI/CAT Scan AL Vision (Optometry)
65 Newborn Care BG Cardiac Rehabilitation
68 Well Baby Care BH Pediatric
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 354
Health Partners (Minnesota) – 10484
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID First Name Date of Birth
4 Subscriber Member ID Date of Birth
5 Subscriber Member ID Last Name First Name
6 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10484 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#1, #2, #5, and #6
2100C NM104 First Name 25
Search options:
#1, #3, #5, and #6
December 30, 2013 X12N/005010/270 v1.7 355
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options:
#1, #2, #3, #4, and #5
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #2, #3, #4, and #6
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 60 days in the Future.
Up to 60 day Date Ranges.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 356
Health Partners of Philadelphia – 10098
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Member ID Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Note: PA Children’s Health Insurance Program, KidzPartners
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10098 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search options:
#1, #2, #4, and #5
December 30, 2013 X12N/005010/270 v1.7 357
2100C NM104 First Name 25
Search options:
#1, #4, and #5
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11
Search options:
#1, #2, #3, and #4
2100C DMG02 Date of Birth CCYYMMDD 8
Search options:
#1, #2, #3, and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 60 days in the Future.
Up to 60 day Date Ranges.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 358
Health Plan of San Mateo – 10362
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10362 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 80
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #2
2100C NM104 First Name 25 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 60 days in the Future
60 day date ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 359
Health Plan of Upper Ohio Valley – 10657
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Member ID Last Name Last Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10657 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2
2100C NM104 First Name 25 Search options: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 360
HealthPlus of Michigan – 10309
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Member ID Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10309 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108 =
FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #2, #4, #5
2100C NM104 First Name 25 Search options: #1, #4, #5
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 361
2100C NM109 Member ID 11 Search options: #1, #2, #3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, #3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 362
HealthScope – 10621
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber SSN Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: HealthScope includes the following entities: Morris Associates, Central Benefits, Employer’s Health Coalition, and
Plan Handlers.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10621 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #1 and #2
2100C NM104 First Name 35 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search options: #1 and #3
2100C REF01 Reference Identification Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 363
2100C REF02 SSN 9 Search Option: #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option: #3
2100D NM104 First Name 25 Search Option: #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #3
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 364
HealthSpring – 10552
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Note: Only the following states are supported – AL, AR, GA, MS, OK, TN, TX, and WV. States FL and IL can be
obtained through Bravo Health -10399
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10552 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 365
Hometown Health – 10335
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10335 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10 Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #3
2100C NM104 First Name 25 Search options: #1 and #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2, and
#3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to 60 days in the Future.
60 day Date Ranges are
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 366
Horizon NJ Health - 10337
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10337 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100B REF01 Reference Identification Qualifier 1J 2
2100B REF02 Facility ID 9 Federal Tax ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #3
2100C NM104 First Name 35 Search Option: #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 367
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search Option: #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to Last Day of Current
Month for Future Dates.
Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 368
Humana – 10100
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Medicare ID Date of Birth
3 Subscriber Medicaid ID Date of Birth State
Note: This is an estimate of the benefits provided under this contract. Any payment is subject to coordination of benefits
with any other insurance that may cover the services rendered and the coverage being in effect on the date of service. If
your plan requires a Primary Care Physician (PCP), your PCP would be responsible for providing or authorizing all care.
The above information is usually updated within 24 hours of being processed by Humana. The information may contain
inaccuracies or errors.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10100 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12
Search Option: #1
If is a ChoiceCare Subscriber,
please provide the Member ID
number including the two-
digit suffix.
2100C REF01 Reference Identification Qualifier F6 2
December 30, 2013 X12N/005010/270 v1.7 369
2100C REF02 Medicare ID 12 Search Option: #2
2100C REF01 Reference Identification Qualifier NQ 2
2100C REF02 Medicaid ID 15 Search Option: #3
2100C N402 State 2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1, #2, and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to 1 year in the Future
No Date Ranges allowed
2100C EQ01 Service Type Code All Service Types
accepted 2
December 30, 2013 X12N/005010/270 v1.7 370
Idaho Medicaid – 10101
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID SSN
3 Subscriber Member ID Last Name First Name
4 Subscriber SSN Last Name First Name
5 Subscriber SSN Date of Birth
6 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10101 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #3, #4, #6
2100C NM104 First Name 25 Search options: #3, #4, #6
December 30, 2013 X12N/005010/270 v1.7 371
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search options: #1, #2, #3
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #2, #4, #5
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #5, #6
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
No Future Dates allowed.
Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 372
Illinois Medicaid – 10102
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Last Name First Name
3 Subscriber SSN Date of Birth
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10102 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search options: #2 and #4
2100C NM104 First Name 35 Search options: #2 and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option: #1
2100C REF01 Reference Identification Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 373
2100C REF02 SSN 9 Search options: #2 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #3 and #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to Current Month for
Future Dates
Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 374
Independence Administrators – 10417
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Dependent Sub: Member ID Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10417 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 24 months in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “Independence Administrators
(10417) - Service Type Code List”
below
2100D NM1 Dependent Name
December 30, 2013 X12N/005010/270 v1.7 375
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 24 months in the Past.
Up to 30 days in the Future.
No Date Ranges allowed.
2100D EQ01 Service Type Code 2
See “Independence Administrators
(10417) - Service Type Code List”
below
Independence Administrators (10417) - Service Type Code List
Code Description Code Description
1 Medical Care 69 Maternity
2 Surgical 73 Diagnostic Medical
4 Diagnostic X-ray 76 Dialysis
5 Diagnostic Lab 78 Chemotherapy
6 Radiation Therapy 80 Immunizations
7 Anesthesia 81 Routine Physical
8 Surgical Assistance 82 Family Planning
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 93 Podiatry
20 Second Surgical Opinion 98 Professional (Physician) Visit - Office
30 Health Benefit Plan Coverage 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
40 Medical Oral Surgery A3 Professional (Physician) Visit – Home
42 Home Health Care A6 Psychotherapy
48 Hospital – Inpatient A7 Psychiatric-Inpatient
50 Hospital – Outpatient A8 Psychiatric-Outpatient
51 Hospital – Emergency Accident AD Occupational Therapy
52 Hospital – Emergency Medical AE Physical Medicine
53 Hospital – Ambulatory Surgical AF Speech Therapy
61 In-vitro Fertilization AG Skilled Nursing Care
62 MRI/CAT Scan AI Substance Abuse
65 Newborn Care BG Cardiac Rehabilitation
68 Well Baby Care BH Pediatric
December 30, 2013 X12N/005010/270 v1.7 376
Independent Health – 10536
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Last Name First Name SSN
5 Subscriber SSN Date of Birth
6 Subscriber Member ID SSN
Note: Please note that Independent Health, Nova, and Univera will require a special contractual agreement/addendum
with Exchange EDI. Please contact your Account Manager, or [email protected] for more information.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10536 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1, #2, #4
2100C NM104 First Name 25 Search options: #1, #2, #4
December 30, 2013 X12N/005010/270 v1.7 377
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search options: #1, #3, #6
*Including 2-digit Suffix
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 SSN 9 Search options: #4, #5, #6
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2, #3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates are allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 2
See “Independent Health
(10536) - Service Type Code
List” below
December 30, 2013 X12N/005010/270 v1.7 378
Independent Health (10536) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 88 Pharmacy
20 Second Surgical Opinion 91 Brand Name Prescription Drug
30 Health Benefit Plan Coverage 92 Generic Prescription Drug
33 Chiropractic 93 Podiatry
35 Dental Care 98 Professional (Physician) Visit - Office
40 Medical Oral Surgery 99 Professional (Physician) Visit – Inpatient
42 Home Health Care A0 Professional (Physician) Visit – Outpatient
45 Hospice A3 Professional (Physician) Visit – Home
47 Hospital A6 Psychotherapy
48 Hospital – Inpatient A7 Psychiatric-Inpatient
50 Hospital – Outpatient A8 Psychiatric-Outpatient
51 Hospital – Emergency Accident AD Occupational Therapy
52 Hospital – Emergency Medical AE Physical Medicine
53 Hospital – Ambulatory Surgical AF Speech Therapy
60 General Benefits AG Skilled Nursing Care
61 In-vitro Fertilization AI Substance Abuse
62 MRI/CAT Scan AL Vision (Optometry)
65 Newborn Care BG Cardiac Rehabilitation
68 Well Baby Care BH Pediatric
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 379
Indiana Medicaid – 10103
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Medicare ID
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10103 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option: #3
2100C NM104 First Name 35 Search Option: #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 380
2100C REF01 Reference Identification
Qualifier F6 2
2100C REF02 Medicare ID 12 Search Option: #4
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search Option: #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges allowed.
2100C EQ01 Service Type Code
4, 12, 18, 23, 24,
25, 28, 30, 33, 34,
35, 41, 56, 71, 93,
94, 98, A8, AB,
AD, AE, AF, AI,
AL, AM, AO
2
December 30, 2013 X12N/005010/270 v1.7 381
Iowa Medicaid – 10107
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10107 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search option: #3
2100C NM104 First Name 35 Search option: #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option: #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 382
2100C REF02 SSN 9 Search option: #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2 and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 3 years in the Past.
No Future dates
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 383
John Hopkins Health Plan – 10267
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
Note: Employee Health Plan
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10267 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 30 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 384
Kaiser Foundation Health Plan of Colorado – 10110
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10110 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 30 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DMG03 Gender
M = Male
F = Female
1 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 385
Kaiser Foundation Health Plan of Hawaii – 10111
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber SSN Last Name First Name Date of Birth
3 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10111 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2, #3
2100C NM104 First Name 25 Search Options #1, #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 30 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 386
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #3
2100C DMG03 Gender
M = Male
F = Female
1 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 387
Kaiser Foundation Health Plan of the Mid-Atlantic – 10113
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10113 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2, #3
2100C NM104 First Name 25 Search Options #1, #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 30 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 388
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #3
2100C DMG03 Gender M= Male
F= Female 1 Search Option#3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 389
Kaiser Foundation Health Plan of the Northwest – 10114
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10114 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2 Search Option #1
2100C NM109 Member ID 30 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DMG03 Gender 1 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 390
Kaiser Foundation Health Plan of Ohio – 10112
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber SSN Last Name First Name Date of Birth
3 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10112 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2, #3
2100C NM104 First Name 25 Search Options #1, #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 30 Search Option #1
2100C REF01 Reference Identification Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 391
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1, #2, #3
2100C DMG03 Gender
M= Male
F= Female
1 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 392
Kaiser Permanente of Georgia – 10238
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Member ID Last Name Date of Birth
4 Subscriber Member ID First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10238 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 393
2100C NM109 Member ID 30 Search Options #1, #2,
#3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #3, #4
2100C DMG03 Gender
M = Male
F= Female
1 Optional
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 394
Kaiser Permanente of Northern CA – 10115
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 395
2100C NM109 Member ID 12
Search Option #1
California Member IDs
are a total of 12 digits.
The ID numbers are left
zero filled to 10 digits
and then a prefix is added
for the region (11 for
Northern California and
00 for Southern
California members). An
ID that is 1234567 would
be 110001234567 for
Northern California and
000001234567 for
Southern California
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DMG03 Gender
M = Male
F = Female
1 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 396
Kaiser Permanente of Southern CA – 10239
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10239 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 397
2100C NM109 Member ID 30
Search Option #1
California Member IDs
are a total of 12 digits.
The ID numbers are left
zero filled to 10 digits
and then a prefix is added
for the region (11 for
Northern California and
00 for Southern
California members). An
ID that is 1234567 would
be 110001234567 for
Northern California and
000001234567 for
Southern California
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DMG03 Gender
M = Male
F = Female
1 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 398
Kansas Medicaid – 10116
Search Options
# Option Element 1 Element 2 Element 3
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber First Name Last Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10116 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Option #1
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
December 30, 2013 X12N/005010/270 v1.7 399
2100C REF01 Reference Identification Qualifier EJ 2
2100C REF02 Patient Account Number 30 Optional
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to end of current
month in the Future
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 400
Kentucky Medicaid – 10117
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Last Name First Name
3 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10117 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #2, #3
2100C NM104 First Name 35 Search Options #2, #3
2100C NM108 ID Code Qualifier MI 2
2100C NM109 Member ID 10 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 401
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100C DMG03 Gender
M = Male
F = Female
1 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
No Future Dates allowed
Date ranges are allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 402
Keystone Mercy Health – 10300
Search Options
# Option Element 1 Element 2 Element 3
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10300 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60
2100C NM104 First Name 35
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12
Search Option #1
*Do not send prefix
2100C REF01 Reference Identification Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 403
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past
No future date allowed
No date range allowed
2100C EQ01 Service Type Code 30
December 30, 2013 X12N/005010/270 v1.7 404
Kitsap Physician Services – 10341
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Member ID First Name Date of Birth
4 Subscriber Member ID Last Name Date of Birth
5 Subscriber Member ID Last Name First Name
Note: Data updated twice weekly.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10341 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX
Provider ID if NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #4, #5
2100C NM104 First Name 25 Search Options #1, #3, #5
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 405
2100C NM109 Member ID 20 Search Options #1, #2, #3, #4, #5
2100C REF01 Reference Identification
Qualifier SY 2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1,#2, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to 60 Days in the Future
60 day Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 406
LaCare – 10640
Search Options
# Option Element 1 Element 2 Element 3
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth
Note: Area of coverage is Louisiana
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10640 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 8 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 407
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 408
Lifewise Health Plan of Oregon – 10651
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10651 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #2
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 30 Optional
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 409
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code All valid service
types are supported 2
Only (1) EQ01 segment per
transaction
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 30 Optional
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code All valid service
types are supported 2
Only (1) EQ01 segment per
transaction
December 30, 2013 X12N/005010/270 v1.7 410
Lifewise Health Plan of Washington – 10650
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10650 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search options: #1 and #2
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 30 Optional
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 411
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code All valid service
types are supported 2
Only (1) EQ01 segment per
transaction
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 30 Optional
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code All valid service
types are supported 2
Only (1) EQ01 segment per
transaction
December 30, 2013 X12N/005010/270 v1.7 412
Louisiana Medicaid – 10118
Search Options
# Option Element 1 Element 2 Element 3
1 Subscriber Member ID SSN
2 Subscriber Member ID Last Name First Name
3 Subscriber Member ID Date of Birth
4 Subscriber SSN Last Name First Name
5 Subscriber SSN Date of Birth
6 Subscriber Last Name First Name Date of Birth
7 Subscriber Card Control Number Card Issue Date SSN
8 Subscriber Card Control Number Card Issue Date Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10118 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100B PRV01 Provider Code SB 2
December 30, 2013 X12N/005010/270 v1.7 413
2100B PRV02 Reference Identification Qualifier PXC 3
2100B PRV03 Taxonomy Code 30
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #2, #4, #6
2100C NM104 First Name 35 Search Options #2, #4, #6
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 13 Search Options #1, #2, #3
2100C REF01 Reference Identification Qualifier HJ 2
2100C REF02 Card Control Number Search Options #7, #8
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #4, #5
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #3, #5,
#6, #8
2100C DTP03 Card Issue Date CCYYMMDD 8
Card Issue Date if
DTP01=102
Search Options #7, #8
2100C DTP03 Subscriber Date CCYYMMDD 8
Plan Date if DTP01=291
Up to 1 year in the Past.
Up to end of the current
month in the Future
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 414
Loyal American Life Insurance Co. Medicare Supp – 10544
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10544 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Tax ID, NPI 10 Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #2
2100C NM104 First Name 25 Search options: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search options: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 415
Maine Medicaid – 10121
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10121 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
2100C NM104 First Name 25
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option: #1
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option: #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 416
Managed Health Services Indiana – 10586
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10586 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCMMYYYY 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 1,30,33,35,86,88
98,AL,MH,UC 2
December 30, 2013 X12N/005010/270 v1.7 417
Managed Health Services Wisconsin – 10587
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10587 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCMMYYYY 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 418
Maricopa Care Advantage (Arizona) – 10435
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name Date of Birth
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10435 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV 2
2100B NM109 Provider ID 10 Provider ID if NM108 = SV
2100C NM1 Subscriber Name
2100C NM103 Last Name 24 Search options: #2, #4
2100C NM104 First Name 24 Search options: #2, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search option: #1
December 30, 2013 X12N/005010/270 v1.7 419
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #2, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 420
Maricopa Health Plan Arizona – 10434
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Member ID Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
4 Subscriber Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10434 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #3, #4
December 30, 2013 X12N/005010/270 v1.7 421
2100C NM104 First Name 25 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Options #1, #2,
#3, #5, #6
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3,
#4
2100C DTP03 Subscriber Date CCMMYYYY 8
No Past Dates allowed
No Future Dates
allowed
No Date Ranges
allowed
2100C EQ01 Service Type Code 1,30,35,38,47,48,50,86,88,98,AL 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #5
2100D NM104 First Name 25 Search Option #5
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #5, #6
2100C DTP03 Dependent Date CCMMYYYY 8
No Past Dates allowed
No Future Dates
allowed
No Date Ranges
allowed
2100D EQ01 Service Type Code 1,30,35,38,47,48,50,86,88,98,AL 2
December 30, 2013 X12N/005010/270 v1.7 422
Maryland Medicaid – 10289
Search Options
# Option Element 1 Element 2 Element 3
1 Subscriber Member ID Last Name
2 Subscriber *SSN Last Name First Name
Note: If Medicaid Recipient ID Number is not available, a search can be performed using recipient SSN as the member
number, and recipient last name. However, not all recipients have SSNs in their records.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10289 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1, #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2 Search Option #1
2100C NM109 Member ID 11 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2 Search Option #2
December 30, 2013 X12N/005010/270 v1.7 423
2100C REF02 Social Security Number 9 Search Option #2
2100C DTP03 Subscriber Date CCMMYYYY 8
Up to 12 months in the Past
Up to next day in the Future
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 424
Massachusetts Medicaid – 10124
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10124 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 425
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100C DMG03 Gender
M= Male
F = Female
1 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 13 months in the
past
No future date allowed
No range allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 426
MDWise Hoosier Alliance – 10598
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10598 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Service Provider ID
(legacy) if NM108=SV
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #3, #4
2100C NM104 First Name 25 Search Options #3, #4
2100C NM108 ID Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 427
2100C NM109 Member ID 12 Search Option #1, #4
2100C REF01 Reference Identification
Qualifier SY 2 Search Option #2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 428
Medica – 10125
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber SSN Date of Birth
3 Subscriber Member ID Last Name First Name
4 Subscriber Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: First Name Dep: Last Name Dep: Date of Birth
6 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10125 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI, SV 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
Provider ID (legacy) if
NM108=SV.
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 429
2100C NM103 Last Name 35 Search Options #3, #4
2100C NM104 First Name 25 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Options #1, #3, #5
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code All services type
codes accepted 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Options #5, #6
2100D NM104 First Name 25 Search Options #5, #6
2100D REF01 Reference Identification Qualifier SY 2 Optional
2100D REF02 Social Security Number 9 Optional
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #5, #6
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100D EQ01 Service Type Code All services type
codes accepted 2
December 30, 2013 X12N/005010/270 v1.7 430
Medical Mutual of Ohio - 10126
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10126 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 30 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2
December 30, 2013 X12N/005010/270 v1.7 431
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 1, 30, 35, AL, 98,
68, 52, 81, 49, A8 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #3
2100D NM104 First Name 25 Search Option #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100D DTP03 Dependent Date 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 1, 30, 35, AL, 98,
68, 52, 81, 49, A8 2
December 30, 2013 X12N/005010/270 v1.7 432
Medicare (Part A & B) – 10001
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Last Name First Name
Note: Medicare payerId 10001 is a direct connection to the real-time CMS database. This payer includes all possible
Medicare patients. There is no separate payerID for Railroad Medicare, or any other Regional Medicare eligibility.
“10001” is the sole payerId for all Medicare eligibility at a national level.
Note: There is a special enrollment process for Medicare. Please follow the steps as required in Appendix A: Special
Enrollment Payers to ensure the provider can submit to Medicare.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10001 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options: #1, #2, #3
2100C NM104 First Name 35 Search Options: #1, #3
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 433
2100C NM109 Member ID 12 Search Options: #1, #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options: #1, and #2
2100C DMG03 Gender
M = Male
F= Female
1 Optional
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 28 months in the Past
Up to 4 months in the
Future.
Date ranges are allowed.
2100C EQ01 Service Type Code 30, 14, 15, 42,
45, 47, AG 2
December 30, 2013 X12N/005010/270 v1.7 434
Meridian Health Plan of Illinois – 10644
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Member ID Last Name First Name Date of Birth
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10644 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 435
Meritain Health – 10635
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10635 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 436
Michigan Medicaid – 10136
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Card Control Number
3 Subscriber SSN Date of Birth
4 Subscriber SSN Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10136 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier SV, XX 2
2100B NM109 Provider ID/NPI 10
Provider ID if NM108 =
SV
National Provider ID if
NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #4, #5
2100C NM104 First Name 35 Search Options #4, #5
December 30, 2013 X12N/005010/270 v1.7 437
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID/Card Control
Number 24
Search Option #1 for
Member ID (10
characters)
Search Option #2 for
Card Control number (24
characters)
2100C REF01 Reference Identification
Qualifier SY 2 Search Options #3, #4
2100C REF02 Social Security Number 9 Search Options #3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Up to the end of the
current month in the
Future
Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 438
Michigan Medicaid Pending Eligibility – 10392
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10392 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier SV, XX 2
2100B NM109 Provider ID/NPI 10
Provider ID if NM108 =
SV. Provider ID format
= First 7 digits are
Provider ID and last 2
digits are provider ID
type
National Provider ID if
NM109 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options:
#3 and #4
December 30, 2013 X12N/005010/270 v1.7 439
2100C NM104 First Name 35 Search Options:
#3 and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 8 Search Option: #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options:
#2 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options:
#2 and #4
2100C DTP03 Subscriber Date
Up to 1 year in the Past
Up to the end of the
current month in the
Future
Date Ranges allowed
2100C EQ01 Service Type Code 30
December 30, 2013 X12N/005010/270 v1.7 440
Michigan MIChild – 10138
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10138 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier SV, XX 2
2100B NM109 Provider ID/NPI 10
Provider ID if NM108 =
SV. Provider ID format
= First 7 digits are
Provider ID and last 2
digits are provider ID
type
National Provider ID if
NM108=XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options:
#3 and #4
December 30, 2013 X12N/005010/270 v1.7 441
2100C NM104 First Name 25 Search Options:
#3 and #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option: #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options:
#2 and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options:
#2 and #4
2100C DTP03 Subscriber Date
Up to 1 year in the Past
Up to the end of the
current month in the
Future
Date Ranges allowed
2100C EQ01 Service Type Code 30
December 30, 2013 X12N/005010/270 v1.7 442
Mid Atlantic Medical Services, LLC (MAMSI) – 10122
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10122 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier SV, XX 2
2100B NM109 Provider ID/NPI 10
Provider ID if NM108 =
SV
National Provider ID if
NM108 = XX
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
2100C DTP03 Subscriber Date 8
Up to 1 year in the past
No future date allowed
No date range allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 443
Minnesota Medicaid – 10139
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI
2100A NM109 Payer ID 10139 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10
National Provider ID
This payer may require
certain providers to
submit additional info
along with NPI, such as
taxonomy code, city, state
and ZIP.
2100B N401 Provider City 30
2100B N402 Provider State 2
December 30, 2013 X12N/005010/270 v1.7 444
2100B N403 Provider Zip Code 9 5 or 9 chars; no dashes
2100B PRV01 Provider Code PC 2
2100B PRV02
Reference Identification
Qualifier PXC 3
2100B PRV03 Taxonomy Code 30
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #3, #4
2100C NM104 First Name 35 Search Options #3, #4
2100C NM105 Middle Name 25 Optional
2100C NM108 Identification Code Qualifier MI 2 Search Option #1
2100C NM109 Member ID 8 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2 Search Options #2, #3
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 445
Mississippi Medicaid – 10141
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Last Name First Name
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10141 5 Transunion Payer ID
2100B NM1 Information Receiver
2100A NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 14 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 446
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100C DTP03 Subscriber Date 8 No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 447
Missouri Medicaid – 10143
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Sub: Member ID Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10143 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100B PRV01 Provider Code LA 2
2100B PRV02 Reference Identification
Qualifier PXC 3
2100B PRV03 Taxonomy Code 30
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #3
December 30, 2013 X12N/005010/270 v1.7 448
2100C NM104 First Name 25 Search Option #3
2100C NM105 Middle Name 25 Optional
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 8 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date 8
Up to 1 year in the Past
Up to end of the current
month into the Future.
Range allowed up to end
of the current month.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D DMG02 Date of Birth CCYYMMDD Search Option #4
2100D DTP03 Dependent Date
Up to 1 year in the Past
Up to end of the current
month into the Future.
Range allowed up to end
of the current month.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 449
MMSI (Mayo Health) – 10144
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10144 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX. Federal Tax ID if
NM108=FI.
Either tax ID or NPI is required
December 30, 2013 X12N/005010/270 v1.7 450
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3, #4
2100C NM104 First Name 25 Search Options #2, #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #2, #4, #5,
#6, #8
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Options #6, #7, #8
2100D NM104 First Name 25 Search Options #6, #7, #8
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #5, #7, #8
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 451
Molina Healthcare
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Molina Healthcare Payers
Payer Name Payer ID Payer Name Payer ID
Molina HealthCare of California 10145 Molina HealthCare of Ohio 10251
Molina HealthCare of Florida 10445 Molina HealthCare of Texas 10391
Molina HealthCare of Michigan 10250 Molina HealthCare of Utah 10252
Molina HealthCare of Missouri 10523 Molina HealthCare of Wisconsin 10628
Molina HealthCare of New Mexico 10146
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID
See “Molina
Healthcare
Payers” list above
5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
December 30, 2013 X12N/005010/270 v1.7 452
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if NM108=FI.
Either tax ID or NPI is required
2100C NM1 Subscriber Name
2100C NM103 Last Name 24 Search Option #1
2100C NM104 First Name 24 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C REF01 Reference Identification
Qualifier 6P 2
2100C REF02 Group Number 10
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No date ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 453
Montana Medicaid – 10147
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Card Control Number
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10147 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI/Federal Tax ID 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #3
2100C NM104 First Name 25 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option #1
2100C REF01 Reference Identification
Qualifier HJ 2
2100C REF02 Card Control Number 7 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past
Up to end of the current
month in the Future
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 454
Mutual of Omaha – 10382
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10382 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Provider ID (legacy) if
NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 455
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 456
MVP Health Care (New York) – 10148
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Last Name First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10148 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2, #3
2100C NM104 First Name 25 Search Options #1, #3
2100C NM108 Identification Code Qualifier MI 2 Search Options #1, #2, #3
2100C NM109 Member ID 11
Search Options #1, #2, #3
MVP Preferred Care is
not included and any
member ID’s not
beginning with ‘8’ is not
going to be matched or
returned.
December 30, 2013 X12N/005010/270 v1.7 457
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 458
National Association of Letter Carriers (NALC) – 10149
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10149 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option #1, #2
2100C REF01 Reference Identification
Qualifier 6P 2
December 30, 2013 X12N/005010/270 v1.7 459
2100C REF02 Group Number 30 Optional
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D REF01 Reference Identification
Qualifier 6P 2
2100D REF02 Group Number 30 Optional
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 460
NEHEN – Harvard Pilgrim Health Care – 10376
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth Gender
3 Subscriber Last Name First Name Date of Birth
Note: New England Health EDI Network. Harvard Pilgrim issues a unique member ID to each member (whether they are
subscriber or dependent). As such, all members shall be sent and returned as the subscriber. ID-only searches may fail if
more than one patient belongs to that ID in the Harvard system. Please send as much information as possible for best
results.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10376 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Code Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #2, #3
2100C NM104 First Name 35 Search Option #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 461
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2, #3
2100C DMG03 Gender
M = Male
F = Female 1 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 3 years in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 2 See “NEHEN- Harvard Pilgrim -
Service Type Code List” below
NEHEN- Harvard Pilgrim - Service Type Code List
Code Description Code Description
1 Medical Care 65 Newborn Care
2 Surgical 68 Well Baby Care
4 Diagnostic X-ray 73 Diagnostic Medical
5 Diagnostic Lab 76 Dialysis
6 Radiation Therapy 78 Chemotherapy
7 Anesthesia 80 Immunizations
8 Surgical Assistance 81 Routine Physical
11 Used Durable Medical Equipment 82 Family Planning
12 Durable Medical Equipment Purchase 86 Emergency Services
13 Ambulatory Service Center Facility 93 Podiatry
18 Durable Medical Equipment Rental 98 Professional (Physician) Visit – Office
20 Second Surgical Opinion 99 Professional (Physician) Visit – Inpatient
22 Social Work A0 Professional (Physician) Visit – Outpatient
33 Chiropractic A3 Professional (Physician) Visit – Home
40 Medical Oral Surgery AB Rehabilitation – Inpatient
42 Home Health Care AD Occupational Therapy
45 Hospice AE Physical Therapy
48 Hospital – Inpatient AF Speech Therapy
50 Hospital Outpatient AG Skilled Nursing Care
51 Hospital Emergency Accident AL Vision (Optometry)
52 Hospital Emergency Medical BG Cardiac Rehab
53 Hospital Ambulatory Surgery BH Pediatric
62 MRI/CAT Scan
December 30, 2013 X12N/005010/270 v1.7 462
NEHEN - Neighborhood Health Plans – 10377
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10377 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #2
2100C NM104 First Name 35 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
December 30, 2013 X12N/005010/270 v1.7 463
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the Past
Up to 90 days in the Future.
No range allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #3
2100D NM104 First Name 25 Search Option #3
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 2 years in the Past
Up to 90 days in the Future.
No range allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 464
Neighborhood Health Plan – Tufts Associated Health Plan – 10379
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Last Name First Name Date of Birth
Note: New England Health EDI Network
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10379 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 80 Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #2
2100C NM104 First Name 35 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DMG03 Gender M = Male
F = Female 1 Optional
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 465
Neighborhood Health Plan (RI) – 10630
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10630 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 80 Federal Tax ID if NM108 = FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #2
2100C NM104 First Name 35 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
Range cannot be longer than
60 days.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 466
Network Health – 10626
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10626 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #2
2100C NM104 First Name 35 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past
Up to 1 year in the future.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 467
Nevada Medicaid – 10152
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Card Number
3 Subscriber Last Name First Name Date of Birth
4 Subscriber SSN Last Name First Name
5 Subscriber SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10152 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier XX 2
2100B NM109 NPI 10 NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 24 Search options: #3 and #4
2100C NM104 First Name 24 Search options: #3 and #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 468
2100C NM109 Member ID 11 Search Option: #1
2100C REF01 Reference Identification
Qualifier HJ 2
2100C REF02 Card Number 5 Search Option: #2
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 SSN 9 Search options: #4 and #5
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #3 and #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past.
Up to the end of the current
month for Future
Date Ranges allowed within
the same month
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 469
New Hampshire Medicaid – 10153
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Card Control Number Date of Birth
2 Subscriber Member ID
3 Subscriber SSN Date of Birth
4 Subscriber SSN Last Name First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10153 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35
Search Options
#1, #2, and #4
2100C NM104 First Name 25
Search Options
#1, #3, and #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 470
2100C NM109 Member ID 11
Search Options
#1, #2, and #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #4
2100C DTP03 Subscriber Date 8
Up to 2 years in the Past.
No Future Dates allowed.
Range of up to 90 days
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 471
New Jersey Medicaid – 10154
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Card Control Number Date of Birth
2 Subscriber Member ID
3 Subscriber SSN Date of Birth
4 Subscriber SSN Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10154 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #4, #5
2100C NM104 First Name 35 Search Options #4, #5
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 25 Search Option #2
December 30, 2013 X12N/005010/270 v1.7 472
2100C REF01 Reference Identification
Qualifier HJ 2
2100C REF02 Card Control Number 16 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Any Past Date allowed
Up to end of current
month for future dates.
Range of up to 90 days
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 473
New Mexico Medicaid – 10247
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth Gender
3 Subscriber SSN Last Name First Name
4 Subscriber SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10247 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 19 Search Options #2, #3
2100C NM104 First Name 12 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option #1
2100C REF01 Reference Identification Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 474
2100C REF02 Social Security Number 9 Search Options #3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DMG03 Gender
M = Male
F = Female
1 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
No Future Dates allowed
Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 475
New York Medicaid – 10155
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10155 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Provider ID (Legacy) if
NM108=SV
2100B PRV01 Provider Code SB 2
2100B PRV02 Reference Identification
Qualifier PXC 3
2100B PRV03 Taxonomy Code 10
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
December 30, 2013 X12N/005010/270 v1.7 476
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 19
Search Option #1
Recipient ID = 8 digits
Access Number = 13
digits
Common Benefit ID Card
Number = 19 digits
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 477
North Carolina Medicaid – 10156
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber Last Name First Name Date of Birth
4 Subscriber SSN Last Name First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10156 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #3, #4
2100C NM104 First Name 35 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 478
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 12 months in the
past.
No future date allowed.
Range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 479
North Dakota Medicaid – 10157
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name
2 Subscriber Member ID Date of Birth
3 Subscriber Last Name First Name Date of Birth
4 Subscriber SSN Last Name First Name
5 Subscriber SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10157 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #1, #3, #4
2100C NM104 First Name 35 Search Options #1, #3, #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 480
2100C NM109 Member ID 12 Search Options #1, #2
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #4, #5
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 481
Nova Healthcare Administrators – 10537
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Last Name First Name SSN
5 Subscriber SSN Date of Birth
6 Subscriber Member ID SSN
7 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: Please note that Independent Health, Nova, and Univera will require a special contractual agreement/addendum
with Exchange EDI. Please contact your Account Manager, or [email protected] for more information.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10537 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2, #4
December 30, 2013 X12N/005010/270 v1.7 482
2100C NM104 First Name 25 Search Options #1, #2, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #3,
#6, #7
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #4, #5, #6
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
Past date allowed.
Future date not allowed.
Range not allowed.
2100C EQ01 Service Type Code 2
See “Nova Healthcare
Administrators - Service
Type Code List” below.
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #7
2100D NM104 First Name 25 Search Option #7
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #7
2100D DTP03 Dependent Date CCYYMMDD 8
Past date allowed.
Future date not allowed.
Range not allowed.
2100D EQ01 Service Type Code 2
See “Nova Healthcare
Administrators (10537) -
Service Type Code List”
below.
December 30, 2013 X12N/005010/270 v1.7 483
Nova Healthcare Administrators (10537) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 88 Pharmacy
20 Second Surgical Opinion 91 Brand Name Prescription Drug
30 Health Benefit Plan Coverage 92 Generic Prescription Drug
33 Chiropractic 93 Podiatry
35 Dental Care 98 Professional (Physician) Visit - Office
40 Medical Oral Surgery 99 Professional (Physician) Visit – Inpatient
42 Home Health Care A0 Professional (Physician) Visit – Outpatient
45 Hospice A3 Professional (Physician) Visit – Home
47 Hospital A6 Psychotherapy
48 Hospital – Inpatient A7 Psychiatric-Inpatient
50 Hospital – Outpatient A8 Psychiatric-Outpatient
51 Hospital – Emergency Accident AD Occupational Therapy
52 Hospital – Emergency Medical AE Physical Medicine
53 Hospital – Ambulatory Surgical AF Speech Therapy
60 General Benefits AG Skilled Nursing Care
61 In-vitro Fertilization AI Substance Abuse
62 MRI/CAT Scan AL Vision (Optometry)
65 Newborn Care BG Cardiac Rehabilitation
68 Well Baby Care BH Pediatric
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 484
NovaSys Health – 10466
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber SSN Date of Birth
4 Subscriber Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI
2100A NM109 Payer ID 10466 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #4
2100C NM104 First Name 25 Search Options #2, #4
December 30, 2013 X12N/005010/270 v1.7 485
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Options #1, #2,
#5, #6
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates are allowed.
Future dates are not
allowed.
Date Ranges are not
allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Options #6, #7
2100D NM104 First Name 25 Search Options #6, #7
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #5, #7
2100D DTP03 Dependent Date CCYYMMDD 8
Past Dates are allowed.
Future dates are not
allowed.
Date Ranges are not
allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 486
Ohana – 10515
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10515 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2
2100C NM104 First Name 25 Search Options #1, #2
2100C NM108 Identification Code Qualifier MI 2 Search Options #1, #3
2100C NM109 Member ID 12 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
Future date not allowed.
Range not allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 487
Ohio Medicaid – 10158
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID SSN
5 Subscriber SSN Last Name First Name
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10158 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10
Provider ID if NM108 =
SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #2, #3
and #5
2100C NM104 First Name 35 Search Options #3 and #5
December 30, 2013 X12N/005010/270 v1.7 488
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #2, #4
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #4 and #5
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1 and #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
Range allowed but it has
to be within effective
dates.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 489
Oklahoma Medicaid – 10159
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10159 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 490
Optima/Sentara – 10477
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Member ID SSN
Note: Members in the Optima Health system can uniquely be identified using their unique member number.
Note: In order to return eligibility and benefit information, the 270 eligibility requests must include the member number
or the member's Medicaid number AND the first fourteen characters of the member’s last name and the first three
characters of the member’s first name OR the date of birth that is being submitted is equal to the stored date of birth OR
the member’s social security number that is being submitted is equal to the stored social security number. If the validation
is unsuccessful, Optima Health will return a 271 response containing a AAA segment.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10477 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #1
2100C NM104 First Name 35 Search Option #1
2100C NM108 Identification Code Qualifier MI 2 Search Options #1, #2, #3
December 30, 2013 X12N/005010/270 v1.7 491
2100C NM109 Member ID 11
Search Options #1, #2, #3
Optima Health 9-11 digit
member number without
the asterisk.
2100C REF01 Reference Identification Qualifier SY 2 Search Option #3
2100C REF02 Social Security Number 9 Search Option #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date 8
Past date allowed.
Future date not allowed.
Range not allowed.
2100C EQ01 Service Type Code 30 30
December 30, 2013 X12N/005010/270 v1.7 492
Oregon Medicaid – 10160
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name
2 Subscriber Member ID Date of Birth
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10160 5 Transunion Payer ID
2100A NM103 Name Last or Organization Name 10
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 11
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #3
2100C NM104 First Name 25 Search Options #1, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 8 Search Options #1, #2
December 30, 2013 X12N/005010/270 v1.7 493
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
Range up to 90 days
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 494
Oxford Health Plans – 10161
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID First Name Date of Birth
4 Subscriber Member ID Date of Birth
5 Subscriber Member ID Last Name First Name
6 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10161 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2,
#5, #6
2100C NM104 First Name 25 Search Options #1, #3,
#5, #6
December 30, 2013 X12N/005010/270 v1.7 495
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search Options #1, #2,
#3, #4, #5
OHP has unique member
ID’s. Submit all patients
as subscribers.
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2,
#3, #4, #6
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 18 months in the
Past
Up to the end of current
month in the Future
No range allowed.
2100C EQ01 Service Type Code 2
See “Oxford Health Plan
(10161) - Service Type
Code List” below.
December 30, 2013 X12N/005010/270 v1.7 496
Oxford Health Plan (10161)- Service Type Code List
Code Description Code Description
1 Medical Care 80 Immunizations
2 Surgical 81 Routine Physical
3 Consultation 82 Family Planning
4 Diagnostic X-ray 83 Infertility
5 Diagnostic Lab 86 Emergency Services
6 Radiation Therapy 88 Pharmacy
7 Anesthesia 89 Free Standing Prescription Drug
8 Surgical Assistance 90 Mail Order Prescription Drug
12 Durable Medical Equipment Purchase 91 Brand Name Prescription Drug
13 Ambulatory Service Center Facility 92 Generic Prescription Drug
18 Durable Medical Equipment Rental 93 Podiatry
20 Second Surgical Opinion 98 Professional (Physician) Visit - Office
23 Diagnostic Dental 99 Professional (Physician) Visit – Inpatient
24 Periodontics A0 Professional (Physician) Visit – Outpatient
25 Restorative A3 Professional (Physician) Visit – Home
26 Endodontics A4 Psychiatric
27 Maxillofacial Prosthetics A5 Psychiatric - Room and Board
28 Adjunctive Dental Services A6 Psychotherapy
30 Health Benefit Plan Coverage A7 Psychiatric-Inpatient
33 Chiropractic A8 Psychiatric-Outpatient
35 Dental Care AD Occupational Therapy
36 Dental Crowns AE Physical Medicine
37 Dental Accident AF Speech Therapy
38 Orthodontics AG Skilled Nursing Care
39 Prosthodontics AI Substance Abuse
40 Medical Oral Surgery AJ Alcoholism
41 Routine (Preventive) Dental AK Drug Addiction
42 Home Health Care AL Vision (Optometry)
45 Hospice BG Cardiac Rehabilitation
47 Hospital BH Pediatric
48 Hospital – Inpatient BT Gynecological
49 Hospital - Room and Board BU Vision (Optometry)
50 Hospital – Outpatient BV Cardiac Rehabilitation
51 Hospital – Emergency Accident BW Pediatric
52 Hospital – Emergency Medical BX Mail Order Prescription Drug: Generic
53 Hospital – Ambulatory Surgical BY Physician Visit - Office: Sick
62 MRI/CAT Scan BZ Physician Visit - Office: Well
65 Newborn Care DM Durable Medical Equipment
68 Well Baby Care GF Generic Prescription Drug - Formulary
73 Diagnostic Medical GN Generic Prescription Drug - Non-Formulary
76 Dialysis MH Mental Health
78 Chemotherapy UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 497
Pacific Source Health Plan – 10375
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10375 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #3
2100C NM104 First Name 25 Search Options #1, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
Up to 60 days in the
future.
Range allowed up to 60
days.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 498
Passport Health Plan – 10368
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10368 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 499
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 500
Pennsylvania Medicaid – 10165
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10165 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2 Search Option #1
2100C NM109 Member ID 12
Search Option #1
10-digit Medicaid
Recipient ID plus 2-digit
Access Card Number
December 30, 2013 X12N/005010/270 v1.7 501
2100C REF01 Reference Identification
Qualifier SY 2 Search Option #2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 10 years in the Past.
(Payer will return basic
info for searches of 2 years
or more in the past, if
available)
No Future Dates allowed.
Range up to 31 days.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 502
Physicians Health Plan of Northern Indiana– 10658
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Note: If no response is received after the second attempt, the provider’s system should submit no more than 5 duplicate
transactions within the next 15 minutes.
Since PHP has unique Member Identification Numbers then the patient is considered to be the subscriber and is to be
identified in the Subscriber Level
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10658 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date 8
Past Dates 30 Days
Future Dates allowed
Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 503
Physicians Mutual Insurance Company – 10167
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10167 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option #1, #2
2100C REF01 Reference Identification
Qualifier 6P 2
2100C REF02 Group Number 30 Optional
December 30, 2013 X12N/005010/270 v1.7 504
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 505
PreferredOne – 10169
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: PreferredOne will return a positive response using member ID only if a unique match on the member is found. This
is for products were a unique member ID is assigned to each member of the family. For products that do not require
unique ID’s for each member, this search option will not work. We do NOT recommend searches using member ID only,
as a submitted member ID could be entered wrong, but still be a valid ID for another member.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 1
2100A NM109 Payer ID 10169 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 24 Search Option #2
2100C NM104 First Name 15 Search Option #2
December 30, 2013 X12N/005010/270 v1.7 506
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 24 Search Options #3
2100D NM104 First Name 15 Search Options #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #3
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 507
Principal Financial Group (Nippon Life) - 10170
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10170 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 35 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Options #1, #2
December 30, 2013 X12N/005010/270 v1.7 508
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 509
Priority Health – 10490
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Note: Priority Health Purchased Care Choices, so that plan is also a part of Priority Health Payer ID 10490
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10490 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
Future date allowed.
Range not allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 510
Providence Health Plan – 10172
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID First Name Date of Birth
3 Subscriber Member ID Date of Birth
Note: Plans are Choice Options, Health Connections, Joint Marketing, Open Options, Open Self-Funded, Oregon Opt
Medicaid, Personal Option, Personal Self-Funded, Providence Group Option, Providence Medicare Extra, Providence
Medicare Choice PPO, Providence Option, Self-Funded Option, Traditional Option and PEBB
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10172 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option #1, #2, #3
December 30, 2013 X12N/005010/270 v1.7 511
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
Up to 60 days in the
Future
60 day Date Range
allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 512
Provident American Life & Health Ins Co Medicare Supp – 10545
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10545 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 10
Federal Tax ID if NM108
= FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #3
December 30, 2013 X12N/005010/270 v1.7 513
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 514
Public Employees Health Plan (PEHP) – 10574
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10574 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
December 30, 2013 X12N/005010/270 v1.7 515
2100C EQ01 Service Type Code See list below 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code See list below 2
December 30, 2013 X12N/005010/270 v1.7 516
Public Employees Health Program (Payer ID 10574) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 75 Prosthetic Device
4 Diagnostic X-ray 77 Ontological Exam
5 Diagnostic Lab 80 Immunization
7 Anesthesia 81 Routine Physical
11 Used Durable Medical Equipment 82 Family Planning
12 Durable Medical Equipment Purchase 86 Emergency Services Professional
13 Ambulatory Service Center Facility 88 Pharmacy
18 Durable Medical Equipment Rental 94 Podiatry – Office Visits
23 Diagnostic Dental 97 Anesthesiologist
24 Periodontics 98 Professional (Physician) Visit - Office
25 Restorative A4 Psychiatric
26 Endodontics A6 Psychotherapy
27 Maxillofacial Prosthetics A8 Psychiatric-Outpatient
28 Adjunctive Dental Services AD Occupational Therapy
30 Health Benefits Plan Coverage AF Speech Therapy
33 Chiropractic AI Substance Abuse
34 Chiropractic Office AL Vision
35 Dental AM Frames
36 Dental Crowns AN Vision Routine Exam
37 Dental Accident AO Lenses
38 Orthodontics B1 Burn Care
39 Prosthodontics BT Gynecological
40 Oral Surgery BU Obstetrical
41 Routine (preventive) Dental BV Obstetrical/Gynecological
42 Homecare CC Surgical Benefits - Professional (Physician)
44 Home Health Visits CD Surgical Benefits - Facility
47 Hospital CF Mental Health Provider - Outpatient
48 Hospital - Inpatient CH Mental Health Facility - Outpatient
49 Hospital Room and Board CJ Substance Abuse Facility - Outpatient
50 Hospital Outpatient CP Eyewear and Eyewear Accessories
52 Hospital Emergency Medical (ER Benefits) DG Dermatology
53 Hospital – Ambulatory Surgical DM Durable Medical Equipment
54 Long Term Care IC Intensive Care
56 Medically Related Transportation MH Mental Health
59 Ambulance NI Neonatal Intensive Care
62 MRI/CAT Scan PT Physical Therapy
66 Pathology RT Residential Psychiatric Treatment
68 Well Baby Care UC Urgent Care
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 517
Puerto Rico Medicaid – 10173
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10173 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 10 Provider ID if NM108 = SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search option: #3
2100C NM104 First Name 25 Search option: #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search option: #1
2100C REF01 Reference Identification SY 2
2100C REF01 Social Security Number 9 Search option:#2
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1 and #3
December 30, 2013 X12N/005010/270 v1.7 518
2100C DMG03 Gender M = Male
F = Female 1 Search options:#3
2100C DTP03 Subscriber Date CCYYMMDD 8
Past dates are allowed.
No Future dates are allowed.
No Date Ranges are allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 519
Qualcare – 10637
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name
4 Dependent Sub: Member ID Dep: Date of Birth
5 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10637 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
December 30, 2013 X12N/005010/270 v1.7 520
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to the policy begin
date in the past.
Future date allowed.
Range is not allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Options #3, #5
2100D NM104 First Name 25 Search Options #3, #5
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #3, #5
2100D DTP03 Dependent Date CCYYMMDD 8
Up to the policy begin
date in the past.
Future date allowed.
Range is not allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 521
Recall Systems
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name
2 Dependent Sub: Member ID Dep: First Name Dep: Date of Birth
Recall Systems Payer Codes
Payer Name Payer ID
Boon-Chapman Benefit Admin 10414
Group & Pension Administrators 10174
Underwriters Safety & Claims 10246
Corporate Benefit Service 10411
Professional Benefits Administrators 10242
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 5
Transunion Payer ID
See “Recall Systems
Payer Codes” list above.
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
December 30, 2013 X12N/005010/270 v1.7 522
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV
2100C NM1 Subscriber Name
2100C NM103 Last Name 25 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 24 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 25 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 523
Sanford Health Plan – 10533
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10533 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 ID Code Qualifier MI 2
2100C NM109 Member ID 80
Search Options #1, #2, #3
Dependent inquiries must
always include the
subscriber ID ending with
‘02’ suffix.
December 30, 2013 X12N/005010/270 v1.7 524
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #3
2100D NM104 First Name 25 Search Option #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 525
Santa Clara Valley Health and Hospital – 10361
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Member ID Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Note: Eligibility is available only for Medi Cal Managed Care, Healthy Families, Healthy Kids, Healthy Workers as
delegated to Valley Health Plan Network – it does not include all Santa Clara Family Health Plan members.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10361 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2,
#4, #5
2100C NM104 First Name 25 Search Options #1, #4, #5
December 30, 2013 X12N/005010/270 v1.7 526
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Options #1, #2,
#3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2,
#3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 527
Schaller Anderson Parkland Community Health Plan – 10643
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10643 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #2
2100C NM104 First Name 25 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code
1,30,33,35,47,48,
50,52,86,88,98,A4,
AL,MH,UC 2
December 30, 2013 X12N/005010/270 v1.7 528
Scott and White Health Plan – 10360
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Member ID Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10360 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2,
#4, #5
2100C NM104 First Name 25 Search Options #1, #4, #5
December 30, 2013 X12N/005010/270 v1.7 529
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Options #1, #2,
#3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2,
#3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
1 year in the past.
60 days in the Future.
Date Ranges of 60 days.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 530
Select Health SC – 10520
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10520 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI/Federal Tax ID 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 14 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 531
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 4 years in the past.
Future date not allowed.
Range not allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 532
Select Health Utah – 10575
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10575 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 9
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #2
December 30, 2013 X12N/005010/270 v1.7 533
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code See list below 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code See list below 2
December 30, 2013 X12N/005010/270 v1.7 534
Select Health UTAH (Payer ID 10575) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 75 Prosthetic Device
4 Diagnostic X-ray 77 Ontological Exam
5 Diagnostic Lab 80 Immunization
7 Anesthesia 81 Routine Physical
11 Used Durable Medical Equipment 82 Family Planning
12 Durable Medical Equipment Purchase 86 Emergency Services Professional
13 Ambulatory Service Center Facility 88 Pharmacy
18 Durable Medical Equipment Rental 94 Podiatry – Office Visits
23 Diagnostic Dental 97 Anesthesiologist
24 Periodontics 98 Professional (Physician) Visit - Office
25 Restorative A4 Psychiatric
26 Endodontics A6 Psychotherapy
27 Maxillofacial Prosthetics A8 Psychiatric-Outpatient
28 Adjunctive Dental Services AD Occupational Therapy
30 Health Benefits Plan Coverage AF Speech Therapy
33 Chiropractic AI Substance Abuse
34 Chiropractic Office AL Vision
35 Dental AM Frames
36 Dental Crowns AN Vision Routine Exam
37 Dental Accident AO Lenses
38 Orthodontics B1 Burn Care
39 Prosthodontics BT Gynecological
40 Oral Surgery BU Obstetrical
41 Routine (preventive) Dental BV Obstetrical/Gynecological
42 Homecare CC Surgical Benefits - Professional (Physician)
44 Home Health Visits CD Surgical Benefits - Facility
47 Hospital CF Mental Health Provider - Outpatient
48 Hospital - Inpatient CH Mental Health Facility - Outpatient
49 Hospital Room and Board CJ Substance Abuse Facility - Outpatient
50 Hospital Outpatient CP Eyewear and Eyewear Accessories
52 Hospital Emergency Medical (ER Benefits) DG Dermatology
53 Hospital – Ambulatory Surgical DM Durable Medical Equipment
54 Long Term Care IC Intensive Care
56 Medically Related Transportation MH Mental Health
59 Ambulance NI Neonatal Intensive Care
62 MRI/CAT Scan PT Physical Therapy
66 Pathology RT Residential Psychiatric Treatment
68 Well Baby Care UC Urgent Care
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 535
Significa Benefit Services – 10081
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Dependent Sub: Member ID Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10081 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier FI 2
2100B NM109 Federal Tax ID 9 Federal Tax ID
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2 Search Options #1, #2
2100C NM109 Member ID 9 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
December 30, 2013 X12N/005010/270 v1.7 536
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
Date Ranges are allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 537
South Carolina Medicaid – 10179
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10179 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 538
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No date ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 539
South Dakota Medicaid – 10180
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10180 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name
60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
Past dates allowed.
No future dates allowed.
No date ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 540
State Farm – 10645
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Note: Auto related medical for P&C and Workers comp claims
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10645 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 541
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed.
No Date ranges allowed.
2100C EQ01 Service Type Code
2, 4, 5, 7, 12, 18,
30, 33, 35, 42, 48,
50, 52, 54, 56, 59,
69, 80, 82, 86, 88,
98, A4, AD, AE,
AI, AL
2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed.
No Date ranges allowed.
2100D EQ01 Service Type Code
2, 4, 5, 7, 12, 18,
30, 33, 35, 42, 48,
50, 52, 54, 56, 59,
69, 80, 82, 86, 88,
98, A4, AD, AE,
AI, AL
2
December 30, 2013 X12N/005010/270 v1.7 542
Staywell – 10512
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10512 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2
2100C NM104 First Name 25 Search Options #1, #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 543
Staywell Kids – 10513
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10513 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2
2100C NM104 First Name 25 Search Options #1, #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 544
SummaCare – 10294
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Member ID Last Name First Name
5 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10294 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2,
#4, #5
2100C NM104 First Name 25 Search Options #1, #4, #5
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 545
2100C NM109 Member ID 11 Search Options #1, #2,
#3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2,
#3, #5
2100C DTP03 Subscriber Date CCYYMMDD 8
No past date allowed.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 546
Superior Health Plan Texas – 10592
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10592 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future dates allowed
No Date ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 547
Tennessee Medicaid – 10184
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Last Name
3 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10184 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #2, #3
2100C NM104 First Name 35 Search Option #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 548
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to a 366 day period in
the past.
Up to end of next month
into the future.
Date Range is allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 549
TexanPlus North Texas Area – 10604
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10604 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM102 Entity Type Qualifier 1, 2 1
1 = Person
2 = Non Person Entity
2100B NM103 Name Last or Organization
Name 24
2100B NM104 First Name 24 Required if NM102 = 1
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 550
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future dates allowed
No Date ranges allowed
2100C EQ01 Service Type Code
23, 24, 25, 26, 27,
28, 35, 36, 37, 38,
39, 40, 41, 88, 89,
90, 91, 92
2
December 30, 2013 X12N/005010/270 v1.7 551
TexanPlus Southeast Texas Area – 10605
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10605 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM102 Entity Type Qualifier 1, 2 1
1 = Person
2 = Non Person Entity
2100B NM103 Last Name or Organization
Name 24
2100B NM104 First Name 24 Required if NM102 = 1
2100B NM108 Information Receiver ID
Code Qualifier XX 2
2100B NM109 NPI/Federal Tax ID 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 ID Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code
23, 24, 25, 26, 27, 28,
35, 36, 37, 38, 39, 40,
41, 88, 89, 90, 91, 92
2
December 30, 2013 X12N/005010/270 v1.7 552
Texas Medicaid – 10186
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Last Name First Name Date of Birth
2 Subscriber SSN Last Name
3 Subscriber SSN Date of Birth
4 Subscriber Member ID
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10186 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #1, #2
2100C NM104 First Name 35 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option #4
December 30, 2013 X12N/005010/270 v1.7 553
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 years in the past
Up to the end of current
month in the Future
Date range is allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 554
Three Rivers Health Plans (Unison Health Plan) – 10318
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10318 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier FI, SV 2
2100B NM109 Provider ID/Federal Tax ID 13
Federal Tax ID if
NM108=FI. Provider ID
if NM108=SV
Either Provider ID or Fed
Tax ID is required.
2100B REF01 Reference Identification
Qualifier N5, N7 2
2100B REF02 Facility Network ID /Plan
Network ID 12
Plan Network ID if
REF01=N5. Facility
Network ID if
REF01=N7
Either Plan Network ID
or Facility Network ID is
required.
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 555
2100C NM103 Last Name 35 Search Option: #1
2100C NM104 First Name 25 Search Option: #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Option: #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 556
Today’s Health – 10606
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10606 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM102 Entity Type Qualifier 1, 2 1 1 = Person
2 = Non Person Entity
2100B NM103 Name Last or Organization
Name 24
2100B NM104 First Name 24 Required if NM102 = 1
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code
23, 24, 25, 26, 27,
28, 35, 36, 37, 38,
39, 40, 41, 88, 89,
90, 91, 92
2
December 30, 2013 X12N/005010/270 v1.7 557
Today’s Option – 10505
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10505 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM102 Entity Type Qualifier 1, 2 1 1 = Person
2 = Non Person Entity
2100B NM103 Name Last or Organization
Name 24
2100B NM104 First Name 24 Required if NM102 = 1
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code
23, 24, 25, 26, 27,
28, 35, 36, 37, 38,
39, 40, 41, 88, 89,
90, 91, 92
2
December 30, 2013 X12N/005010/270 v1.7 558
Tribute/SelectCare of Oklahoma – 10607
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10607 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM102 Entity Type Qualifier 1, 2 1 1 = Person
2 = Non Person Entity
2100B NM103 Name Last or Organization Name 24
2100B NM104 First Name 24 Required if NM102 = 1
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code
23, 24, 25, 26, 27,
28, 35, 36, 37, 38,
39, 40, 41, 88, 89,
90, 91, 92
2
December 30, 2013 X12N/005010/270 v1.7 559
Tricare – 10189
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10189 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #1
2100C NM104 First Name 35 Search Option #1
2100C NM108 ID Code Qualifier MI 2
2100C NM109 Member ID 80
Search Options #1, #2
Member ID is the SSN or
First 9 digits of DoD ID
number and (DBN if
applicable)
December 30, 2013 X12N/005010/270 v1.7 560
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DMG03 Gender M = Male
F = Female 1 Optional
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
Date Ranges are allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 60 Search Option #2
2100D NM104 First Name 35 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DMG03 Gender M, F 1 Optional
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
Date Ranges are allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 561
Trustmark – 10190
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10190 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
December 30, 2013 X12N/005010/270 v1.7 562
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 563
UCare of Minnesota – 10352
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
3 Subscriber Member ID Date of Birth
Note: UCARE COMPLETE, PREPAID MEDICAL ASSIST PROGRAM, MINNESOTA CARE, MINNESOTA
SENIOR HEALTH OPTIONS, UCare FOR SENIORS, SOUTH COUNTY HEALTH ALLIANCE, UCARE SENIOR
SELECT, SCHA MINNESOTACARE
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10352 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI
2100C NM109 Member ID 11 Search Options #1, #2, #3
December 30, 2013 X12N/005010/270 v1.7 564
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 12 months in the past
Up to 60 days in the future.
No date ranges allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 565
UMR (WAUSAU) – 10501
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber SSN Date of Birth
4 Subscriber Last Name First Name Date of Birth
6 Dependent Sub: Member ID Dep: Date of Birth
7 Dependent Sub: Member ID Dep: Last Name Dep: First Name
8 Dependent Dep: SSN Dep: Date of Birth
9 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI
2100A NM109 Payer ID 10501 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier FI, XX 2
2100B NM109 Federal Tax ID, NPI 80
Federal Tax ID if NM108
= FI
NPI if NM108 = XX
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 566
2100C NM103 Last Name 35 Search Options #2, #4
2100C NM104 First Name 25 Search Options #2, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Options #1, #2,
#5, #6
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #3, #8
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #3, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code
1, 11, 12, 18,
23, 30, 33, 35,
38, 41, 42, 47,
48, 50, 52, 86,
88, 98, 99, A0,
A4, A7, A8,
AG, AL, AM,
AN, AO, BB,
CI, CJ, MH,
UC
2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Options #6, #9
2100D NM104 First Name 25 Search Options #6, #9
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #5, #7, #8
2100D REF01 Reference Identification Qualifier SY 2
December 30, 2013 X12N/005010/270 v1.7 567
2100D REF02 Social Security Number 9 Search Option #7
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code
1, 11, 12, 18,
23, 30, 33, 35,
38, 41, 42, 47,
48, 50, 52, 86,
88, 98, 99, A0,
A4, A7, A8,
AG, AL, AM,
AN, AO, BB,
CI, CJ, MH,
UC
2
December 30, 2013 X12N/005010/270 v1.7 568
Unicare – 10285
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10285 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #1
2100C NM104 First Name 35 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 20 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No past date allowed.
No future date allowed.
No range allowed.
December 30, 2013 X12N/005010/270 v1.7 569
2100C EQ01 Service Type Code 2
See “ Unicare (10285)-
Service Type Codes” list
below
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Options #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #2
2100D DTP03 Dependent Date 8
No past date allowed.
No future date allowed.
No range allowed.
2100D EQ01 Service Type Code 2
See “ Unicare (10285)-
Service Type Codes” list
below
December 30, 2013 X12N/005010/270 v1.7 570
Unicare (10285)- Service Type Codes
Code Description Code Description
1 Medical Care 48 Hospital – Inpatient
2 Surgical 49 Hospital – Room and Board
4 Diagnostic X-ray 50 Hospital – Outpatient
5 Diagnostic Lab 51 Hospital – Emergency Accident
6 Radiation Therapy 52 Hospital – Emergency Medical
7 Anesthesia 53 Hospital – Ambulatory Surgical
8 Surgical Assistance 54 Long Term Care
9 Other Medical 55 Major Medical
10 Blood Charges 56 Medically Related Transportation
11 Used Durable Medical Equipment 57 Air Transportation
12 Durable Medical Equipment Purchase 60 General Benefits
13 Ambulatory Service Center Facility 61 In-vitro Fertilization
14 Renal Supplies in the Home 62 MRI/CAT Scan
15 Alternate Method Dialysis 65 Newborn Care
16 Chronic Renal Disease (CRD) Equipment 68 Well Baby Care
17 Pre-Admission Testing 69 Maternity
18 Durable Medical Equipment Rental 73 Diagnostic Medical
19 Pneumonia Vaccine 76 Dialysis
20 Second Surgical Opinion 78 Chemotherapy
21 Third Surgical Opinion 80 Immunizations
22 Social Work 81 Routine Physical
23 Diagnostic Dental 82 Family Planning
24 Periodontics 83 Infertility
25 Restorative 84 Abortion
26 Endodontics 86 Emergency Services
27 Maxillofacial Prosthetics 88 Pharmacy
28 Adjunctive Dental Services 93 Podiatry
30 Health Benefit Plan Coverage 98 Professional (Physician) Visit - Office
32 Plan Waiting Period 99 Professional (Physician) Visit – Inpatient
33 Chiropractic A0 Professional (Physician) Visit – Outpatient
34 Chiropractic Office Visits A3 Professional (Physician) Visit – Home
35 Dental Care A6 Psychotherapy
36 Dental Crowns A7 Psychiatric-Inpatient
37 Dental Accident A8 Psychiatric-Outpatient
38 Orthodontic AD Occupational Therapy
39 Prosthodontics AE Physical Medicine
40 Medical Oral Surgery AF Speech Therapy
41 Routine (Preventive) Dental AG Skilled Nursing Care
42 Home Health Care AI Substance Abuse
43 Home Health Prescriptions AL Vision (Optometry)
44 Home Health Visits BG Cardiac Rehabilitation
45 Hospice BH Pediatric
46 Respite Care MH Mental Health
47 Hospital UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 571
United Healthcare – 10002
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber SSN Date of Birth
4 Subscriber SSN Last Name First Name
5 Subscriber Last Name First Name Date of Birth State
6 Subscriber Member ID Last Name First Name Date of Birth
7 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth Dep: State
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10002 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Code Qualifier XX, FI, SV 2
2100B NM109 NPI/Federal Tax ID/Provider ID 10
National Provider ID if
NM108=XX. Federal Tax
ID if NM108=FI.
Provider ID if
NM108=SV.
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 572
2100C NM103 Last Name 35 Search Options #2, #3,
#5, #6
2100C NM104 First Name 25 Search Options #2, #4,
#5, #6
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Options #1, #2,
#3, #6, #7
2100C REF01 Reference Identification Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #3, #4
2100C REF01 Reference Identification Qualifier 6P 2
2100C REF02 Group Number 7 Optional, but
recommended.
2100C N402 State 2 Search Option #5
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2,
#4, #6
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 18 months in the
Past
Up to the end of the
current month in the
Future
Date Ranges allowed
2100C EQ01 Service Type Code All Codes
accepted. 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Options #7
December 30, 2013 X12N/005010/270 v1.7 573
2100D NM104 First Name 25 Search Options #7, #8
2100D REF01 Reference Identification Qualifier SY 2
2100D REF02 Social Security Number 9 Optional
2100D REF01 Reference Identification Qualifier 6P 2
2100D REF02 Group Number 30 Optional, but
recommended.
2100D N402 State 2 Search Option #8
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #7, #8
2100D DTP03 Dependent Date 8
Up to 18 months in the
Past
Up to the end of the
current month in the
Future
Date Ranges allowed
2100D EQ01 Service Type Code All Codes
accepted. 2
December 30, 2013 X12N/005010/270 v1.7 574
United Healthcare Community Plan River Valley – 10192
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10192 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 575
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
Up to 1 year in the Past
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 576
United Healthcare SecureHorizons – 10655
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Dependent Sub: Member ID Dep: Date of Birth
4 Dependent Sub: Member ID Dep: Last Name Dep: First Name
5 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10655 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX, FI 2
2100B NM109 NPI, Federal Tax ID 10
National Provider ID if
NM108=XX
Federal Tax ID if NM108=FI
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search option: #1
2100C NM104 First Name 25 Search option: #1
2100C NM108 Information Receiver ID Qualifier MI 2
2100C NM109 Member ID 20 Search options: #1, #3, #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search options: #1, #2
December 30, 2013 X12N/005010/270 v1.7 577
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100C EQ01 Service Type Code
1, 2, 3, 30, 33,
35, 47, 48, 50,
51, 52, 53, 73,
76, 86, 88, 98,
AL, BV, BY,
DM, MH, UC
2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search options: #4, #5
2100D NM104 First Name 25 Search options: #4, #5
2100D DMG02 Date of Birth CCYYMMDD 8 Search options: #3, #5
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code
1, 2, 3, 30, 33,
35, 47, 48, 50,
51, 52, 53, 73,
76, 86, 88, 98,
AL, BV, BY,
DM, MH, UC
2
December 30, 2013 X12N/005010/270 v1.7 578
United Healthcare Student Resources – 10183
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10183 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Options #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 579
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #2
2100D NM104 First Name 25 Search Option #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 580
United Teacher Associates Ins Co Medicare Supp – 10547
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10547 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID/Provider
ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #2, #3
2100C NM104 First Name 25 Search Options #2, #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future dates allowed
No Date ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 581
Unity Health Plans – 10349
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Last Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10349 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2
2100C NM104 First Name 25 Search Option #1
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Option #1, #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 12 months in the
past
Up to 60 days in the
future.
Up to 60 day date ranges
allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 582
Univera – 10535
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
4 Subscriber Last Name First Name SSN
5 Subscriber SSN Date of Birth
6 Subscriber Member ID SSN
Note: Please note that Independent Health, Nova, and Univera will require a special contractual agreement/addendum
with Exchange EDI. Please contact your Account Manager, or [email protected] for more information.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10535 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2, #4
2100C NM104 First Name 25 Search Options #1, #2, #4
December 30, 2013 X12N/005010/270 v1.7 583
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID
80
Search Options #1, #3, #6
*Including 2-digit Suffix
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #4, #5, #6
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3, #5
2100C DTP03 Subscriber Date 8
No Past Dates allowed
No Future dates allowed
No Date ranges allowed
2100C EQ01 Service Type Code 2
See “Univera (10535) -
Service Type Code List”
below
December 30, 2013 X12N/005010/270 v1.7 584
Univera (10535) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 88 Pharmacy
20 Second Surgical Opinion 91 Brand Name Prescription Drug
30 Health Benefit Plan Coverage 92 Generic Prescription Drug
33 Chiropractic 93 Podiatry
35 Dental Care 98 Professional (Physician) Visit - Office
40 Medical Oral Surgery 99 Professional (Physician) Visit – Inpatient
42 Home Health Care A0 Professional (Physician) Visit – Outpatient
45 Hospice A3 Professional (Physician) Visit – Home
47 Hospital A6 Psychotherapy
48 Hospital – Inpatient A7 Psychiatric-Inpatient
50 Hospital – Outpatient A8 Psychiatric-Outpatient
51 Hospital – Emergency Accident AD Occupational Therapy
52 Hospital – Emergency Medical AE Physical Medicine
53 Hospital – Ambulatory Surgical AF Speech Therapy
60 General Benefits AG Skilled Nursing Care
61 In-vitro Fertilization AI Substance Abuse
62 MRI/CAT Scan AL Vision (Optometry)
65 Newborn Care BG Cardiac Rehabilitation
68 Well Baby Care BH Pediatric
69 Maternity
December 30, 2013 X12N/005010/270 v1.7 585
University Family Care – 10194
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10194 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 16
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 24 Search Options #3, #4
2100C NM104 First Name 24 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 586
2100C NM109 Member ID 24 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 587
University Physicians Care Advantage (Arizona) – 10433
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10433 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 16
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #3, #4
2100C NM104 First Name 25 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 588
2100C NM109 Member ID 10 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to a year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 589
University Physicians Healthcare Group (Arizona) – 10439
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10439 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 16
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV
2100C NM1 Subscriber Name
2100C NM103 Last Name 24 Search Options #3, #4
2100C NM104 First Name 24 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
December 30, 2013 X12N/005010/270 v1.7 590
2100C NM109 Member ID 24 Search Options #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
Range not allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 591
UPMC Health Plan (Tristate) – 10288
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
Note: For the Name/DOB only search, UPMC requires the member name to be submitted exactly as it is on file with the
payer.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10288 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #1, #2
2100C NM104 First Name 35 Search Options #1, #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Any date or date range
within the current active
span is allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 592
USAA Life Insurance Company – 10195
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Member ID Date of Birth
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Medicare HIC Number Date of Birth
1 Dependent Member ID Dep; Last Name Dep; First Name
2 Dependent Member ID Dep: Date of Birth
3 Dependent Dep; Last Name Dep; First Name
Dep: Date of
Birth
Note: Always assume current date regardless of DTP date.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10195 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109 NPI/Federal Tax ID 10
National Provider ID if
NM108=XX.
Federal Tax ID if
NM108=FI.
December 30, 2013 X12N/005010/270 v1.7 593
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1 and #3
2100C NM104 First Name 25 Search Option #1 and #3
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option #1 and #2
2100C REF01 Reference Identification
Qualifier F6 2
2100C REF02 HIC# 12 Search Option #4
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1,
#2,#3,#4
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future dates allowed
No Date ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option #1 and #3
2100D NM104 First Name 25 Search Option #1 and #3
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option #2 and #3
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 594
Utah Medicaid – 10648
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Last Name First Name Date of Birth
2 Subscriber Member ID Last Name First Name Date of Birth
NOTE: Utah Medicaid is a Special Enrollment Payer. Please see Appendix A for further instructions
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10648 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
National Provider ID
NM108=XX.
Atypical Provider ID
NM108=SV
2100B NM109 NPI/Atypical Provider ID 10/12 Atypical Provider ID is
12 digits long
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2
2100C NM104 First Name 25 Search Options #1, #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Options #2,
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2,
2100C DTP03 Subscriber Date CCYYMMDD 8
Past Dates allowed up to
36 months in the Past
Future dates allowed up
to end of current month
No Date ranges allowed
2100C EQ01 Service Type Code 2 Multiple STC submission
allowed in single request.
December 30, 2013 X12N/005010/270 v1.7 595
Utah Medicaid (10648) - Service Type Code List
Code Description Code Description
1 Medical Care 73 Diagnostic Medical
2 Surgical 76 Dialysis
4 Diagnostic X-ray 78 Chemotherapy
5 Diagnostic Lab 80 Immunizations
6 Radiation Therapy 81 Routine Physical
7 Anesthesia 82 Family Planning
8 Surgical Assistance 83 Infertility
12 Durable Medical Equipment Purchase 84 Abortion
13 Ambulatory Service Center Facility 86 Emergency Services
18 Durable Medical Equipment Rental 88 Pharmacy
20 Second Surgical Opinion 91 Brand Name Prescription Drug
30 Health Benefit Plan Coverage 92 Generic Prescription Drug
33 Chiropractic 93 Podiatry
35 Dental Care 98 Professional (Physician) Visit - Office
40 Medical Oral Surgery 99 Professional (Physician) Visit – Inpatient
42 Home Health Care A0 Professional (Physician) Visit – Outpatient
45 Hospice A3 Professional (Physician) Visit – Home
47 Hospital A6 Psychotherapy
48 Hospital – Inpatient A7 Psychiatric-Inpatient
50 Hospital – Outpatient A8 Psychiatric-Outpatient
51 Hospital – Emergency Accident AD Occupational Therapy
52 Hospital – Emergency Medical AE Physical Medicine
53 Hospital – Ambulatory Surgical AF Speech Therapy
60 General Benefits AG Skilled Nursing Care
61 In-vitro Fertilization AI Substance Abuse
62 MRI/CAT Scan AL Vision (Optometry)
65 Newborn Care BG Cardiac Rehabilitation
68 Well Baby Care BH Pediatric
69 Maternity UC Urgent Care
December 30, 2013 X12N/005010/270 v1.7 596
VA Fee Basis Program – 10196
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
Note: The Department of Veterans Affairs Fee Basis Program is not a health insurance plan. The Fee Basis Program is
designed to assist veterans who cannot easily receive care at a VA Medical Center. Each individual veteran’s eligibility
status and medical care needs are legally and medically reviewed for each episode of care. Each local Fee site determines
whether non-VA treatment can be approved. For these reasons, all Fee Basis Program eligibility responses will return an
Inactive status along with contact information for the local Fee office.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10196 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100B N401 Provider City 30 Optional
2100B N402 Provider State 2 Optional
2100B N403 Provider Zip Code 9 Optional
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option #1
2100C NM104 First Name 25 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 597
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future dates allowed
No Date ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 598
Vermont Medicaid – 10197
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Member ID Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10197 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV.
2100C NM1 Subscriber Name
2100C NM103 Last Name 20 Search Option #2
2100C NM104 First Name 20 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Options #1, #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
Up to 9 days in the future.
Range is allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 599
Virginia Medicaid – 10198
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10198 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 19 Search Option #3, #4
2100C NM104 First Name 12 Search Option #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 600
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past
Up to 5 days in the future.
Up to 1 month date ranges
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 601
VIVA Health – 10468
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
Note: Drummond Plan Member ID format is Alpha prefix + 9 digits
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10468 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #1, #2
2100C NM104 First Name 35 Search Options #1, #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Options #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future dates allowed
No Date ranges allowed
December 30, 2013 X12N/005010/270 v1.7 602
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 603
VNSNY CHOICE Health Plans - 10187
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10600 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX, FI 2
2100B NM109 NPI, Federal Tax ID 9
NPI if NM108 = XX
Federal Tax ID if NM108 =
FI
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Option: #2
2100C NM104 First Name 25 Search Option: #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Option: #1
December 30, 2013 X12N/005010/270 v1.7 604
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 2 year in the past
Future Dates allowed.
No Date Ranges are
allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 605
Washington Medicaid – 10424
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Note: Washington Medicaid does not validate the SSN, if an invalid SSN is sent that is what will be returned regardless of
eligibility
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10424 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, SV 2
2100B NM109 NPI/Provider ID 10
National Provider ID if
NM108=XX.
Provider ID if
NM108=SV
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #3, #4
2100C NM104 First Name 35 Search Options #3, #4
December 30, 2013 X12N/005010/270 v1.7 606
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 14 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9
Search Options #2, #3
Washington Medicaid
does not necessarily
validate Social Security
Number. If an invalid
SSN is sent, that is what
will be returned
irrespective of eligibility.
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to a year in the past.
No Future Dates allowed
Date Range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 607
WEA Trust – 10554
Search Options
# Option Element 1 Element 2 Element 3 Element 4 Element 5 Element 6
1 Subscriber Member ID Last Name First Name Date of Birth
2 Dependent Sub: Member
ID
Sub: Last
Name
Sub: First
Name
Dep: Last
Name
Dep: First
Name
Dep: Date of
Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10554 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization Name 60
2100B NM108 Information Receiver ID Qualifier XX 2
2100B NM109 NPI 10 NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search options: #1 and #2
2100C NM104 First Name 25 Search options: #1 and #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search options: #1 and #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option: #1
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
December 30, 2013 X12N/005010/270 v1.7 608
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Option: #2
2100D NM104 First Name 25 Search Option: #2
2100D DMG02 Date of Birth CCYYMMDD 8 Search Option: #2
2100D DTP03 Dependent Date CCYYMMDD 8
No Past Dates allowed.
No Future Dates allowed.
No Date Ranges allowed.
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 609
WellCare Health Plans – 10488
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Last Name First Name Date of Birth
2 Subscriber Last Name First Name Date of Birth
3 Subscriber Member ID Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10488 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #1, #2
2100C NM104 First Name 25 Search Options #1, #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 12 Search Options #1, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #2, #3
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 610
West Virginia Medicaid – 10200
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10200 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 11 Search Option #1
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Option #2
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 611
Windsor Medicare Extra – 10576
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber Last Name First Name Date of Birth
Note: Medicare Part A and B. Termination date of service is a valid day of member eligibility
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10576 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID.
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Option #2
2100C NM104 First Name 35 Search Option #2
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 9 Search Option #1
2100C DMG02 Date of Birth CCYYMMDD 8 Search Option #2
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the Past
No Future dates allowed
Date ranges are allowed
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 612
Wisconsin Medicaid – 10202
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth Gender
Note: Cascading logic is performed by Wisconsin Medicaid for this inquiry. The only exception is to this rule is when an
invalid Recipient ID number is used in a search.
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10202 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #3, #4
2100C NM104 First Name 35 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 613
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DMG03 Gender M = Male
F = Female 1 Search Option #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
Range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 614
Wisconsin Medicaid Chronic Disease Program – 10452
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10452 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 80
Provider ID if NM108 =
SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #3, #4
2100C NM104 First Name 25 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 14 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 615
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
Range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 616
Wisconsin Medicaid Well Woman Program – 10453
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10453 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID
Qualifier SV, XX 2
2100B NM109 Provider ID, NPI 80
Provider ID if NM108 =
SV
NPI if NM108 = XX
2100C NM1 Subscriber Name
2100C NM103 Last Name 35 Search Options #3, #4
2100C NM104 First Name 25 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 14 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 617
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
Range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 618
World Insurance (ARIC) – 10386
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID Date of Birth
2 Subscriber Member ID Last Name First Name
3 Subscriber Last Name First Name Date of Birth
4 Subscriber Member ID Last Name First Name Date of Birth
5 Dependent Sub: Member ID Dep: Date of Birth
6 Dependent Sub: Member ID Dep: Last Name Dep: First Name
7 Dependent Dep: Last Name Dep: First Name Dep: Date of Birth
8 Dependent Sub: Member ID Dep: Last Name Dep: First Name Dep: Date of Birth
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10386 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX, FI 2
2100B NM109
NPI/Federal Tax ID 10
National Provider ID if
NM108=XX. Federal Tax ID if
NM108=FI.
2100C NM1 Subscriber Name
December 30, 2013 X12N/005010/270 v1.7 619
2100C NM103 Last Name 35 Search Options #2, #3, #4
2100C NM104 First Name 25 Search Options #2, #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 80
Search Options #1, #2, #4, #5,
#6, #8
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #1, #3, #4
2100C DTP03
Subscriber Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100C EQ01 Service Type Code 30 2
2100D NM1 Dependent Name
2100D NM103 Last Name 35 Search Options #6, #7, #8
2100D NM104 First Name 35 Search Options #6, #7, #8
2100D DMG02 Date of Birth CCYYMMDD 8 Search Options #5, #7, #8
2100D DTP03
Dependent Date CCYYMMDD 8
No Past Dates allowed
No Future Dates allowed
No Date Ranges allowed
2100D EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 620
Wyoming Medicaid – 10204
Search Options
# Option Element 1 Element 2 Element 3 Element 4
1 Subscriber Member ID
2 Subscriber SSN Date of Birth
3 Subscriber SSN Last Name First Name
4 Subscriber Last Name First Name Date of Birth Gender
Loop ID Reference Element Name Codes Length Notes/Comments
2100A NM1 Information Source
2100A NM108 Identification Code Qualifier PI 2
2100A NM109 Payer ID 10204 5 Transunion Payer ID
2100B NM1 Information Receiver
2100B NM103 Name Last or Organization
Name 60
2100B NM108 Information Receiver ID Code
Qualifier XX 2
2100B NM109 NPI 10 National Provider ID
2100C NM1 Subscriber Name
2100C NM103 Last Name 60 Search Options #3, #4
2100C NM104 First Name 35 Search Options #3, #4
2100C NM108 Identification Code Qualifier MI 2
2100C NM109 Member ID 10 Search Option #1
December 30, 2013 X12N/005010/270 v1.7 621
2100C REF01 Reference Identification
Qualifier SY 2
2100C REF02 Social Security Number 9 Search Options #2, #3
2100C DMG02 Date of Birth CCYYMMDD 8 Search Options #2, #4
2100C DMG03 Gender M = Male
F = Female 1 Search Options #4
2100C DTP03 Subscriber Date CCYYMMDD 8
Up to 1 year in the past.
No future date allowed.
No range allowed.
2100C EQ01 Service Type Code 30 2
December 30, 2013 X12N/005010/270 v1.7 622
Appendix A: Special Enrollment Payers
The payers listed below require Special Enrollment, and are not immediately available to providers. Special enrollment
includes a registration process with the particular payer as outlined below.
TransUnion Healthcare
ATTN: Enrollment
2100 Rexford Road Suite 225
Charlotte, NC 28211
Email: [email protected] Fax: 704-970-1436
Payer Enrollment Process Estimated Timeframe
BCBS of Alabama
Enrollment form must be completed and submitted to
TransUnion Healthcare.
Note: Once enrollment is completed, non-institutional
providers must send a taxonomy segment (PRV01=PC) for
their transactions to route correctly.
2 weeks
BCBS of Arkansas
Providers can send Enrollment form to
Or
Providers can send enrollment directly to payer.
Email: [email protected]
Fax: 501-378-2265
2 weeks
BCBS of Kansas
Please provide the following fields to
Organization (Legal) Name:
Physical Address:
Billing NPI:
Contact Name:
Contact Phone:
Contact Fax:
Contact Email:
3-5 Business Days
December 30, 2013 X12N/005010/270 v1.7 623
Payer Enrollment Process Estimated Timeframe
BCBS of Michigan
1) Go to https://editest.bcbsm.com/tpalogon.html
2) Enter your TPA User ID and password.
a. Note: If a provider is unable to login, that
means the user ID and password are invalid.
Provider should call BCBS MI to obtain their
correct user ID and password – 800.542.0945,
option 3 or email [email protected].
b. Note: If a provider doesn’t know their User
ID and password, they can contact BCBS MI at
800.542.0945, option 3 or email
[email protected] to obtain their TPA
User ID and PW.
3) Once you are logged in, choose Professional Provider
Authorization or Institutional Provider Authorization.
4) Then enter the following information:
a. Provider ID (PIN) = LEAVE THIS FIELD
BLANK b. NPI = Provider’s NPI
c. Source of Payment = Blue Cross Blue Shield
d. Submitter ID = c0ina (that’s a zero in there)
for Professional Providers. 204202692 for
Institutional Providers.
e. Unique Receiver ID = LEAVE THIS
FIELD BLANK f. Provider email address = email address that
BCBS MI can send confirmation to.
g. Click Submit
After doing all of the steps above, BCBS MI will send a
confirmation email that the enrollment will effective in 48
hours. The payer won’t send another email. Transactions
should work in 48 hours.
48 hours, at discretion of
BCBS MI
BCBS of North Dakota Enrollment form must be completed and submitted to
TransUnion Healthcare.
2 weeks
Blue Cross of
Pennsylvania (Capital)
Enrollment form must be completed and submitted to
TransUnion Healthcare.
2 weeks
BCBS of Pennsylvania
(Highmark)
Please provide the following fields via email to
NPI:
Billing provider ID:
Provider Name:
Professional or Institutional designation.
Professional: 1-3 weeks
Institutional: 1-3 weeks
December 30, 2013 X12N/005010/270 v1.7 624
Payer Enrollment Process Estimated Timeframe
BCBS of West Virginia
Please provide the following fields via email to
Provider Name:
Physical Address:
NPI:
Legacy Provider ID:
Tax ID:
Contact Phone:
5 Business Days
BCBS of Wyoming Enrollment form must be completed and submitted to
TransUnion Healthcare. 2 weeks
California Medicaid
No special enrollment, but a 7-digit PIN must be sent on
ALL transactions. You can validate the NPI/PIN
combination by entering them as User ID and password, at
https://www.medi-cal.ca.gov/Eligibility/Login.asp
N/A
Freedom Blue
Please provide the following fields via email to
Provider Name:
Physical Address:
NPI:
Tax ID:
Contact Phone:
3-5 Business Days
Health Partners
Please provide the following fields via email to
Provider Name (group)
NPI (Group level)
TIN Group Level
Effective Date (when they wish to go live
with eligibility)
Physical Address
48 hours
Kaiser (All)
New Providers Only must be enrolled. Providers that are
already submitting are exempt.
Please provide the following fields via email to
Name:
Physical Address:
City, State, Zip:
Contact Name:
Contact Phone:
Contact Email:
Provider ID/NPI:
Tax ID:
2 weeks
Medicare
Provider NPI must be sent to
[email protected]. We will verify the
NPI is registered with CMS, and enroll for eligibility.
1 to 3 Business Days
December 30, 2013 X12N/005010/270 v1.7 625
Payer Enrollment Process Estimated Timeframe
Michigan Medicaid
Providers will need to logon to Michigan Medicaid’s
CHAMPS system and associate Billing Agent ID 2243495
with your group level NPI.
CHAMPS website: https://sso.state.mi.us/
How to Questions for the website should be referred to
Michigan Medicaid, Provider Enrollment Support, 800-292-
2550 option #5.
48 hours
Michigan Medicaid
Pending Eligibility
Providers will need to logon to Michigan Medicaid’s
CHAMPS system and associate Billing Agent ID 2243495
with your group level NPI.
CHAMPS website: https://sso.state.mi.us/
How to Questions for the website should be referred to
Michigan Medicaid, Provider Enrollment Support, 800-292-
2550 option #5.
48 hours
Rocky Mountain
Health Plan
Please provide the following fields via email to
Facility name
Address
Phone Number
Federal Tax ID
NPI
5-10 business days
Notes: Only Colorado
Facilities can be
considered for enrollment
Utah Medicaid
Providers will need to logon to Utah’s Department of Health
EDI Enrollment website and associate our Submitter ID
(HT006748-001) under your provider UT Medicaid NPI and
Tax ID record for 270 Transactions.
Utah Medicaid Website: https://mmcslive.health.utah.gov/hcfenroll2/index.jsp
24 hours
December 30, 2013 X12N/005010/270 v1.7 626
Appendix B: Payer Maintenance Schedule
Use the following table to determine the payers’ time windows for maintenance.
ID Payer Name Stated Downtime
10431 AARP Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm
(MT)
10560 Absolute Total Care No Stated Downtime
10619 Administrative Services, Inc. No Stated Downtime
10561 Advantage by Bridgeway Health Solutions No Stated Downtime
10562 Advantage by Buckeye Community Health Plan No Stated Downtime
10563 Advantage by Managed Health Services No Stated Downtime
10564 Advantage by Superior HealthPlan No Stated Downtime
10004 Aetna Sunday 4:00 am – 12:00 pm (Eastern)
10397 Aetna Long Term Care Sunday 4:00 am – 12:00 pm (Eastern)
10594 Affinity Health Plan No Stated Downtime
10398 AFLAC – Dental No Stated Downtime
10006 Aftra Health Fund No Stated Downtime
10007 Alabama Medicaid Mon – Sun 2:00 am – 5:00 am (Central)
10639 Alameda Alliance Health Plan No Stated Downtime
10008 AMC – Alaska Electrical Health & Welfare Fund No Stated Downtime
10009 AMC – American General Life and Accident No Stated Downtime
10010 AMC – Health Future No Stated Downtime
10012 AMC – Poly America No Stated Downtime
10013 AMC – Touchstone No Stated Downtime
10014 AMC – Touchstone PSO No Stated Downtime
10015 American Community Mutual No Stated Downtime
10487 American Family Insurance Group-Medicare
Supplemental and PPO Policies No Stated Downtime
10595 American National Insurance Company No Stated Downtime
10596 American National Life Insurance Company TX No Stated Downtime
10016 American Postal Workers Union (APWU) No Stated Downtime
10017 American Republic Insurance Company (ARIC) No Stated Downtime
10538 American Retirement Life Ins Co Mcare Supp No Stated Downtime
10018 AmericChoice of New Jersey (Commercial) No Stated Downtime
10019 Amerigroup Corporation No Stated Downtime
10416 AmeriHealth Administrators Sat 11:45pm – Sun 12pm (Eastern)
10340 AmeriHealth Mercy Health Plan 2nd weekend of every month where unavailability
will be between 1 hour and 2 days
10020 Ameritas Group – Ameritas Life Insurance Co. 1:30 am – 6:30am, daily
10232 Ameritas Group – First Ameritas of New York 1:30 am – 6:30am, daily
10233 Ameritas Group – First Reliance Standard Life 1:30 am – 6:30am, daily
10234 Ameritas Group – Reliance Standard Life 1:30 am – 6:30am, daily
10236 Ameritas Group – Standard Insurance 1:30 am – 6:30am, daily
10237 Ameritas Group – Standard Insurance of New York 1:30 am – 6:30am, daily
10559 Antares No Stated Downtime
10641 Arbor Health Plan No Stated Downtime
10021 Arizona Medicaid (AHCCCS) Sat 1am – Sat 2 am, Sun 1am –Sun 8am (Central) see
December 30, 2013 X12N/005010/270 v1.7 627
ID Payer Name Stated Downtime
also:
ftp://www.ahcccs.state.az.us/content/notice/hplan/hpla
n.htm#downtime
10022 Arizona Physicians IPA (APIPA) Mon – Sun 3am – 3:15am (Central)
10023 Arkansas Medicaid Sun 12:01am –Sun 10am (Central)
10230 Assurant Health – John Alden Insurance Company
(JALIC) Mon- Fri 9pm – 5:45am (Central)
10087 Assurant Health – Time Insurance Company (FIC) Mon- Fri 12am – 5:00 am (Central)
10227 Assurant Health – Union Security Insurance Company
(FBIC) Mon- Fri 12am – 5:00 am (Central)
10472 AultCare 12:00 AM Friday to 12:00 AM Saturday of the third
weekend every month
10024 AvMed Health Plans Mon 7pm – Tue 6am, Tue 7pm – Wed 6am (Central)
10025 BCBS of Alabama Mon – Fri 12:01 am – 6:00 am, Sat 12:00 pm – Mon
6:00 am (Central)
10609 BCBS of Alabama (Institutional) Mon – Fri 12:01 am – 6:00 am, Sat 12:00 pm – Mon
6:00 am (Central)
10027 BCBS of Arizona Sun 12:00am – 12:00 pm (central)
10028 BCBS of Arkansas Mon – Sat 12am to 6am (Central) Sat (all day)
10461 BCBS of Central New York No Stated Downtime
10029 BCBS of Colorado (Wellpoint) No Stated Downtime
10030 BCBS of Connecticut (Wellpoint) No Stated Downtime
10031 BCBS of Florida
Scheduled maintenance on Thursdays and Saturday;
When this differs, a specific email notification will be
provided
10032 BCBS of Georgia
Mon-Friday (4:45am-5:15am and 10:30pm-11pm);
Sat (4:45am-5:15am and 5:30pm-6pm); Sunday
(10am-10:30am and 5pm-5:30pm)
10530 BCBS of Hawaii No Stated Downtime
10033 BCBS of Illinois Mon – Sat 12:00 am – 6:30am, Sat 3:00pm – Mon
6:30 am (Central)
10258 BCBS of Indiana (Wellpoint) Down all day Sunday 12am –11:59pm (Eastern)
10396 BCBS of Iowa No Stated Downtime
10034 BCBS of Kansas Sat 12 am - Mon 5am (Central)
10473 BCBS of Kansas City
Sun 6 pm – 11:59 pm
Mon - Sat 12am – 2am
All times Central
10259 BCBS of Kentucky (Wellpoint) Down all day Sunday 12am –11:59pm (Eastern)
10035 BCBS of Louisiana Sundays, all holidays
10036 BCBS of Maine (Wellpoint) No Stated Downtime
10037 BCBS of Massachusetts No Stated Downtime
10519 BCBS of Michigan (Institutional) Mon – Sat 1:00 am – 6:59 am, Sunday and Holidays
6:00 pm – 7:00 am (Eastern)
10038 BCBS of Michigan (Professional) Mon – Sat 1:00 am – 6:59 am, Sunday and Holidays
6:00 pm – 7:00 am (Eastern)
10039 BCBS of Minnesota BCBMN will be available 24 – 7 with exception of
December 30, 2013 X12N/005010/270 v1.7 628
ID Payer Name Stated Downtime
scheduled maintenance on Thursdays 8:00 P.M. to
midnight and Sundays 2 AM to 7 AM CDT. BCSMN
maintenance periods are utilized only if necessary.
10040 BCBS of Mississippi Mon 2am – 4am (Central) All Day Sunday
10322 BCBS of Missouri (Wellpoint) Down all day Sunday 12am –11:59pm (Eastern)
10384 BCBS of Nebraska Mon – Sat 12am – 6am, Sunday (Central)
10260 BCBS of Nevada (Wellpoint) No Stated Downtime
10261 BCBS of New Hampshire (Wellpoint) No Stated Downtime
10041 BCBS of New Jersey (Horizon)
Sun 2am – Sun 5am Sun 12am – Sun 5:40am Sun
7pm – Sun 10pm Mon 2am – Mon 5am Tue 2am –
Tue 5am Wed 2am – Wed 5am Thu 2am – Thu 5am
Fri 2am – Fri 5am Sat 2am – Sat 5am (Central)
10042 BCBS of New Mexico Sun 5pm – Sun 11pm (Eastern)
10043 BCBS of New York (Empire)
Sun 12am – Sun 9pm Mon 12am – Tue 3am Tue
12am – Tue 12:45am Wed 12am – Wed 12:45am Thu
12am – 12:45 am Fri 12am – Fri 12:45 am Sat 12 am
– Sat 12:45 am and Sat 4pm – 10:59 pm (Central)
10323 BCBS of New York (Excellus) Mon – Sat 5am – 6am, Sun 4pm – Mon 6am (Eastern)
10302 BCBS of North Carolina Mon – Sun 1am – 4am (Eastern)
10478 BCBS of North Dakota Sunday 6am – 12pm
10044 BCBS of Ohio (Wellpoint) Down all day Sunday 12am –11:59pm (Eastern)
10582 BCBS of Oklahoma 12:00am to 6:00am any day - All Day Sunday
10045 BCBS of Oregon (Regence) 12:00am to 6:00am any day - All Day Sunday
10524 BCBS of Pennsylvania (Highmark) Institutional No Stated Downtime
10046 BCBS of Pennsylvania (Highmark) Professional No Stated Downtime
10304 BCBS of Rhode Island Sun 2am – 8 am (Central)
10047 BCBS of South Carolina No Stated Downtime
10395 BCBS of South Dakota (Wellpoint) No Stated Downtime
10430 BCBS of Tennessee Mon – Sun 2:01am – 2:59am; Thu 7pm-10pm
(Eastern)
10048 BCBS of Texas 12:00am to 6:00am any day - All Day Sunday
10469 BCBS of the Rochester Area (NY) No Stated Downtime
10470 BCBS of Utica-Watertown (NY) No Stated Downtime
10049 BCBS of Virginia (Wellpoint)
Tue – Sat 1am – 4am
Sun 6am – 9am
Sun 1:30pm – 8pm (Eastern)
10498 BCBS of Western New York Sat evening 6pm until Sunday evening 6pm
10462 BCBS of West Virginia No Stated Downtime
10299 BCBS of Wisconsin (Wellpoint) Down all day Sunday 12am –11:59pm (Eastern)
10480 BCBS of Wyoming Sunday 6am – 12pm
10256 Best Choice Health Plan No Stated Downtime
10050 Best Life and Health No Stated Downtime
10187 Better Health Plans (Unison Health Plans) No Stated Downtime
10262 Blue Cross Independence (Pennsylvania) No Stated Downtime
10264 Blue Cross Northeastern Pennsylvania 3rd Sunday of the month, 8am – 12pm (Eastern)
10051 Blue Cross of California (Wellpoint) No Stated Downtime
December 30, 2013 X12N/005010/270 v1.7 629
ID Payer Name Stated Downtime
10638 Blue Cross of Idaho No Stated Downtime
10326 Blue Cross of Washington and Alaska (Premera) Sunday 12am –11:59pm (Eastern)
10325 Blue Cross Pennsylvania (Capital) Mon – Sun 5am – 6am (Eastern)
10053 Blue Shield of California Mon – Sat 1am – 7 am, Sunday
10052 Blue Shield of Idaho (Regence) Mon 9pm – Fri 7am (Mountain)
10499 Blue Shield of North Eastern New York Sat evening 6pm until Sunday evening 6pm
10053 Blue Shield of California Mon – Sat 10pm – 4am, Sunday (Pacific)
10054 Blue Shield of Washington (Regence) 12:00am to 6:00am any day - All Day Sunday
10429 Bluegrass Family Health No Stated Downtimes
10556 BMC HealthNet Plan No Stated Downtime
10399 Bravo Health No Stated Downtime
10565 Bridgeway Arizona No Stated Downtime
10566 Buckeye Community Health No Stated Downtime
10055 California Medicaid (Medi-Cal) Mon – Sun 12am – 2am (Pacific)
10458 Capital District Physicians’ Health Plan (CDPHP) No Stated Downtime
10270 Carefirst Blue Cross Blue Shield Mon – Fri 9pm – 7am, Sat 4pm – Mon 7am (Pacific)
10057 CareSource Health Mon – Sun 3am – 3:15am (Central)
10058 Cariten Healthcare No Stated Downtime
10555 Carpenter’s Health and Welfare Trust Fund of St. Louis No Stated Downtime
10589 Celticare No Stated Downtime
10567 Cenpatico - Arizona No Stated Downtime
10568 Cenpatico – Georgia No Stated Downtime
10569 Cenpatico – Florida No Stated Downtime
10570 Cenpatico – Kansas No Stated Downtime
10571 Cenpatico – Indiana No Stated Downtime
10572 Cenpatico – Ohio No Stated Downtime
10588 Cenpatico - Massachusetts No Stated Downtime
10573 Cenpatico – South Carolina No Stated Downtime
10450 Central Reserve Insurance Company No Stated Downtime
10539 Central Reserve Life Ins Co Medicare Supp No Stated Downtime
10486 Central States Funds No Stated Downtime
10061 CHAMPVA/Spina Bifida/Children of Women Vietnam
Vets No Stated Downtime
10447 CHC – Advantra (TX, NM, AZ Only) No Stated Downtime
10216 CHC – Altius Health Plans No Stated Downtime
10307 CHC – Advantra Freedom No Stated Downtime
10448 CHC – Coventry Health and Life (Nevada) No Stated Downtime
10212 CHC – Coventry Health and Life (Oklahoma) No Stated Downtime
10214 CHC – Coventry Health Care Carelink (Advantra) No Stated Downtime
10215 CHC – Coventry Health Care Carelink Medicaid No Stated Downtime
10217 CHC – Coventry Health Care Carenet No Stated Downtime
10449 CHC – Coventry Missouri No Stated Downtime
10614 CHC - CoventryCares No Stated Downtime
10440 CHC – CoventryOne No Stated Downtime
10076 CHC – Delaware No Stated Downtime
10218 CHC – Diamond Plan (Maryland Medicaid) No Stated Downtime
December 30, 2013 X12N/005010/270 v1.7 630
ID Payer Name Stated Downtime
10551 CHC – Florida/Vista/Summit No Stated Downtime
10206 CHC – Georgia No Stated Downtime
10219 CHC – Group Health Plan (GHP) No Stated Downtime
10220 CHC – HealthAmerica & HealthAssurance No Stated Downtime
10221 CHC – HealthCare Inc. (Promina) No Stated Downtime
10481 CHC - Coventry Health Care Federal No Stated Downtime
10428 CHC – University of Missouri No Stated Downtime
10222 CHC – HealthCare USA (HCUSA) No Stated Downtime
10207 CHC – Iowa No Stated Downtime
10208 CHC – Kansas No Stated Downtime
10210 CHC – Louisiana No Stated Downtime
10211 CHC – Nebraska No Stated Downtime
10223 CHC – OmniCare (Michigan) No Stated Downtime
10224 CHC – PersonalCare/Coventry Health of Illinois No Stated Downtime
10225 CHC – Southern Health Services (SHS) No Stated Downtime
10226 CHC – WellPath Select (Carolinas) No Stated Downtime
10405 CHC – Coventry Health and Life (Tenn) No Stated Downtime
10419 CHC - Advantra Savings No Stated Downtime
10483 CHC – Vista (MCD, FHK, LTC) No Stated Downtime
10062 CIGNA
Mon – Fri: 10pm – 7am, Sat 8pm – Sun 2pm, Sun
8pm – Mon 7am (Eastern), Thurs 5:30am-8:00am
(MT),Sun 9:00am-12:00pm (MT)
10064 Colorado Access No Stated Downtime
10065 Colorado Medicaid Sun 12am – Sun 1am (Mountain)
10066 Community Care of Oklahoma No Stated Downtime
10421 Community HealthFirst Medicare Advantage No Stated Downtime
10329 Community Health Plan of Washington (CHPW) No Stated Downtime
10303 Connecticare No Stated Downtime
10067 Connecticut Medicaid
Mon 12am – 1am Tue 12am – 2:30am Wed 12am –
7am Thu 12am – 1am Fri 12 am – 1am Sat 12am –
1am Sun 4:55am – 7:10am, Every 2nd Sunday 1am –
8:10am, Every 3rd Saturday 12am – 3am (Eastern)
10540 Continental General Ins Co Medicare Supp No Stated Downtime
10610 Cook Children’s Health Plan No Stated Downtime
10068 Cooperative Benefit Administrators (CBA) No Stated Downtime
10311 CoreSource (FMH) No Stated Downtime
10071 CoreSource (Little Rock) No Stated Downtime
10072 CoreSource (MD,PA,IL,NC,IN,AZ,MN) No Stated Downtime
10074 CoreSource (OH) No Stated Downtime
10084 Coventry Healthcare National Network No Stated Downtime
10548 Coventry Nebraska Medicaid No Stated Downtime
10541 CSA Fraternal Live Medicare Supp No Stated Downtime
10577 DakotaCare No Stated Downtime
10293 Delaware Medicaid No Stated Downtime
10331 Denver Health Medical Plan No Stated Downtime
10578 Deseret Mutual (DMBA) No Stated Downtime
December 30, 2013 X12N/005010/270 v1.7 631
ID Payer Name Stated Downtime
10077 Director’s Guild No Stated Downtime
10078 District of Columbia Medicaid Sat 12am – 2am, occasionally 12am – 5am (Eastern)
10616 Emblem Health No Stated Downtime
10601 Essence Healthcare No Stated Downtime
10082 Fallon Community Health Plan No Stated Downtime
10427 FamilyCare No Stated Downtime
10083 Federated Insurance Company No Stated Downtime
10459 Fidelis Care New York No Stated Downtime
10615 Florida Care Health Plans No Stated Downtime
10333 Florida Hospital Healthcare System No Stated Downtime
10086 Florida Medicaid Bi-Weekly, Friday 1:00 am – 4:00 am (Eastern)
10502 Freedom Blue No Stated Downtime
10602 Fresenius Medical Care No Stated Downtime
10611 Geisinger Health Plan No Stated Downtime
10612 Geisinger Health Plan Gold (Medicare) No Stated Downtime
10603 Generations Healthcare No Stated Downtime
10088 Georgia Medicaid Thu 3:30am – Thu 4:30am Fri 1:00am – Fri 1:30am
Sat 11:30pm – Sun 6am (Eastern)
10509 Gilsbar Mon-Sun 11:30pm-2:30am (CST)
10394 Government Employees Hospital Association GEHA
Mon - Fri 5:20am-6am, 5:25pm-6:55pm, Sat 5:20am-
6:35am,
Sun 12:15pm-2:30pm, 6pm-10:00pm (Central)
Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm
(MT)
10542 Great American Life Assurance Co Mcare Supp No Stated Downtime
10543 Great American Life Insurance Co Mcare Supp No Stated Downtime
10608 Group Health Cooperative No Stated Downtime
10583 Group Practice Affiliates No Stated Downtime
10514 Harmony Health Plan No Stated Downtime
10091 Hawaii Medicaid Mon – Sun 4am – 6am (Central)
10308 Health Alliance Medical Plans (HAP) No Stated Downtime
10092 Health Choice Arizona Mon 3am – Sun 3:15am (Central)
10094 Health Net Medi-Cal No Stated Downtime
10385 Health Net National 4th Thursday of every month 5pm – 9pm (Pacific)
10484 Health Partners No Stated Downtime
10098 Health Partners of Philadelphia No Stated Downtime
10362 Health Plan of San Mateo No Stated Downtime
10463 Healthcare Solutions Group No Stated Downtime
10597 HEALTHe Exchange No Stated Downtime
10510 HealthEase No Stated Downtime
10511 HealthEase Kids No Stated Downtime
10438 Healthfirst New Jersey No Stated Downtime
10099 Healthfirst New York No Stated Downtime
10248 HealthMarkets (Chesapeake National Life) No Stated Downtime
10129 HealthMarkets (Mid-West National Life) No Stated Downtime
10131 HealthMarkets (TransAmerica Life) No Stated Downtime
December 30, 2013 X12N/005010/270 v1.7 632
ID Payer Name Stated Downtime
10127 HealthMarkets (Mega Life and Health Insurance) No Stated Downtime
10500 HealthNow Sat evening 6pm until Sunday evening 6pm
10309 HealthPlus of Michigan No Stated Downtime
10621 HealthScope One Sunday per month.
10463 HealthSpring No Stated Downtime
10335 Hometown Health No Stated Downtime
10337 Horizon New Jersey Health 2nd weekend of every month where unavailability will
be between 1 hour and 2 days
10100 Humana Sun 2am – Sun 3am (Central)
10338 Humana of Florida No Information Available
10101 Idaho Medicaid Sun 12am - Mon 1am (Central)
10102 Illinois Medicaid Mon - Sun 3am – 4am (Central)
10417 Independence Administrators Sat 11:45pm – Sun 12pm (Eastern)
10536 Independent Health No Stated Downtime
10103 Indiana Medicaid Sun 7pm – 10pm (Eastern)
10104 Inland Empire Health No Stated Downtime
10585 Integrated Mental Health Services No Stated Downtime
10105 Inter Valley Health Plan No Stated Downtime
10107 Iowa Medicaid Thurs 12am – 2am. Sun 6am – 12pm (Central)
10108 Jackson Memorial Hospital Health Plan Mon – Sun 3am – 3:15am (Central)
10267 John Hopkins Health Plan No Stated Downtime
10110 Kaiser Foundation Health Plan of Colorado Mon-Fri 11:30pm – 2:00am (PST). Sat-Sun 12:00am
– 4:00am (PST)
10111 Kaiser Foundation Health Plan of Hawaii Mon-Fri 11:30pm – 2:00am (PST). Sat-Sun 12:00am
– 4:00am (PST)
10112 Kaiser Foundation Health Plan of Ohio Mon-Fri 11:30pm – 2:00am (PST). Sat-Sun 12:00am
– 4:00am (PST)
10113 Kaiser Foundation Health Plan of the Mid-Atlantic Mon-Fri 11:30pm – 2:00am (PST). Sat-Sun 12:00am
– 4:00am (PST)
10114 Kaiser Foundation Health Plan of the Northwest Mon-Fri 11:30pm – 2:00am (PST). Sat-Sun 12:00am
– 4:00am (PST)
10238 Kaiser Permanente of Georgia Mon-Fri 11:30pm – 2:00am (PST). Sat-Sun 12:00am
– 4:00am (PST)
10115 Kaiser Permanente of Northern CA Mon-Fri 11:30pm – 2:00am (PST). Sat-Sun 12:00am
– 4:00am (PST)
10239 Kaiser Permanente of Southern CA Mon-Fri 11:30pm – 2:00am (PST). Sat-Sun 12:00am
– 4:00am (PST)
10116 Kansas Medicaid Tue - Sat 12am – 2am, Sun 6pm – 11:49pm (Central)
10117 Kentucky Medicaid Sun 12am – Sun 4am (Eastern)
10300 Keystone Mercy Health 2nd weekend of every month where unavailability will
be between 1 hour and 2 days
10341 Kitsap Physician Services No Stated Downtime
10640 LaCare No Stated Downtime
10651 Lifewise Health Plan of Oregon Sunday 12am –11:59pm (Eastern)
10650 Lifewise Health Plan of Washington Sunday 12am –11:59pm (Eastern)
10118 Louisiana Medicaid Sat 7pm – Sat 9pm (Central)
December 30, 2013 X12N/005010/270 v1.7 633
ID Payer Name Stated Downtime
10119 Lovelace Health Plan No Stated Downtime
10544 Loyal American Life Ins Co Medicare Supp No Stated Downtime
10649 Magellan Behavioral Health No Stated Downtime
10085 Mail Handlers Benefit Plan No Stated Downtime
10121 Maine Medicaid Mon – Sun 3am – 3:15am (Central)
10586 Managed Health Services Indiana No Stated Downtime
10587 Managed Health Services Wisconsin No Stated Downtime
10122 Mid Atlantic Medical Services-MAMSI Health Plan
Mon – Sun 3am – 3:15am (Central)
Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm
(MT)
10435 Maricopa Care Advantage (Arizona) No Stated Downtime
10434 Maricopa Health Plan (Arizona) No Stated Downtime
10289 Maryland Medicaid No Stated Downtime
10124 Massachusetts Medicaid Tue – 5am – 7am Fri 5am – 7am (Eastern)
10598 MDWise Hoosier Alliance
Available 24/7 with regular maintenance scheduled
the 2nd Sat of each month; outage may last from late
Fri - Sun afternoon.
10125 Medica Thurs 5:30am-8:00am (MT) ,Sun 9:00am-12:00pm
(MT)
10126 Medical Mutual of Ohio No Stated Downtime
10001 Medicare (Part A & B) Sun 10pm – Mon 3am (Eastern)
10130 Mega Life (Oklahoma City) No Stated Downtime
10133 Mercy Care Plan (Arizona) No Stated Downtime
10134 MetLife Dental Family Mon 11pm – 12am, Tue – Fri 11am -3a, Sat 4pm-
5:30pm, Sun 2am – 9am, holiday times vary
10135 Metropolitan Health Plan (MHP) No Stated Downtime
10136 Michigan Medicaid Every Second Saturday of the Month at 6:00pm to
6:00am the following day
10137 Michigan Medicaid Pending Eligibility No Stated Downtime
10138 Michigan MIChild No Stated Downtime
10139 Minnesota Medicaid No Stated Downtime
10141 Mississippi Medicaid Sun 12am – 1am (Central)
10142 Mississippi State Employees and Teachers Mon 2am – 4am (Central)
10143 Missouri Medicaid Fri 12am – Sat 2am, Sun 12am – Mon 2am,
occasionally Mon – Fri 5:10 am – 5:30 am (Eastern)
10144 MMSI (Mayo Health) No Stated Downtime
10145 Molina Healthcare of California No Stated Downtime
10445 Molina Healthcare of Florida No Stated Downtime
10249 Molina Healthcare of Indiana No Stated Downtime
10250 Molina Healthcare of Michigan No Stated Downtime
10523 Molina Healthcare of Missouri No Stated Downtime
10146 Molina Healthcare of New Mexico No Stated Downtime
10251 Molina Healthcare of Ohio No Stated Downtime
10391 Molina Healthcare of Texas No Stated Downtime
10252 Molina Healthcare of Utah No Stated Downtime
10253 Molina Healthcare of Washington No Stated Downtime
December 30, 2013 X12N/005010/270 v1.7 634
ID Payer Name Stated Downtime
10147 Montana Medicaid No Stated Downtime
10382 Mutual of Omaha Sat 9pm – Mon 2:15am. (Central)
10148 MVP Health Care (New York) Mon thru Fri 11pm – 6am (Central)
10149 National Association of Letter Carriers (NALC) No Stated Downtime
10150 Nationwide Health Plans No Stated Downtime
10376 NEHEN – Harvard Pilgrim Health Care No Stated Downtime
10377 NEHEN – Neighborhood Health Plans No Stated Downtime
10379 NEHEN – Tufts Associated Health Plan Wed 9pm – Thu 2am (Eastern)
10630 Neighborhood Health Plan (RI) No Stated Downtime
10626 Network Health No Stated Downtime
10152 Nevada Medicaid
Scheduled maintenance time starting at 11pm every
Sunday evening. This lasts for as long as necessary,
usually less than two hours but it could last until 6am
if necessary. (Eastern)
10153 New Hampshire Medicaid Occasionally on Sundays 12am – 5am
10154 New Jersey Medicaid Sun 12 am – 5am (Eastern) – DHS systems
updated/unavailable until Sunday at 5pm.
10247 New Mexico Medicaid Mon 1am – Mon 1:30am Sat 11pm – Sun 4am
(Mountain)
10155 New York Medicaid Mon – Sun 12am – 2am (Eastern)
10156 North Carolina Medicaid
1:00 a.m. to 5:00 a.m. on the first, second, fourth, and
fifth Sundays of the month
1:00 a.m. to 7:00 a.m. on the third Sunday of the
month. (Eastern)
10157 North Dakota Medicaid Wed 4am – Wed 7am (Central)
10537 Nova Healthcare Administrators No Stated Downtime
10466 NovaSys Health No Stated Downtime
10515 Ohana Health Plan No Stated Downtime
10158 Ohio Medicaid Mon – Sat 6pm – 3am; Sun 2pm – Mon 12am
(Eastern)
10159 Oklahoma Medicaid
Mon –Fri 1am – 5am; Sat 1am – Sat 5am Sat 7pm –
Sat 9pm Sat 10pm – Sun 12am Sun 1am – Sun 5am
(Central)
10477 Optima/Sentara Sun 4am – 6am (Eastern)
10161 Oxford Health Plans
Mon – Fri 2am – 4am Sat 11pm – 6am (Eastern)
Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm
(MT)
10375 Pacific Source Health Plan No Stated Downtime
10369 Partners National Health Plans of NC No Stated Downtime
10164 Partnership Health Plan of California No Stated Downtime
10368 Passport Health Plan 2nd weekend of every month where unavailability will
be between 1 hour and 2 days
10590 Peach State Health Plan No Stated Downtime
10165 Pennsylvania Medicaid Thu 10pm – Fri 2am (Eastern)
10166 Phoenix Health Plan Sun 3am to 3:15am (Central)
10471 PHCS Savility Payers No Stated Downtime
10167 Physicians Mutual Insurance Company No Stated Downtime
December 30, 2013 X12N/005010/270 v1.7 635
ID Payer Name Stated Downtime
10408 Pittman and Associates No Stated Downtime
10168 Preferred Health Systems No Stated Downtime
10169 PreferredOne No Stated Downtime
10494 PrimeWest Health No Stated Downtime
10170 Principal Financial Group (Nippon Life) 11pm- 5:45 am Mon-Fri 7pm – 5:45 am weekends
(Central)
10171 Principal Financial Group (Principal Life) 11pm- 5:45 am Mon-Fri 7pm – 5:45 am weekends
(Central)
10490 Priority Health No Stated Downtime
10172 Providence Health Plan Mon – Sun 3am to 3:15am (Central)
10545 Provident American Life & Health Mcare Supp No Stated Downtime
10574 Public Employees Health Plan No Stated Downtime
10173 Puerto Rico Medicaid No Stated Downtime
10637 Qualcare No Stated Downtime
10553 Qualchoice
Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST)
Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm
(MT)
10508 QuikTrip Corporation No Stated Downtime
10414 Recall Systems – Boon-Chapman Benefit Admin No Stated Downtime
10411 Recall Systems – Corporate Benefit Service No Stated Downtime
10174 Recall Systems – Group & Pension Administrators No Stated Downtime
10240 Recall Systems – JP Farley Corporation No Stated Downtime
10241 Recall Systems – Mississippi Admin Services No Stated Downtime
10242 Recall Systems – Professional Benefits Administrators No Stated Downtime
10246 Recall Systems – Underwriters Safety & Claims No Stated Downtime
10618 Regence Blue Cross (UTAH) No Stated Downtime
10175 Rocky Mountain Health Plan Mon – Sun 3am – 3:15am (Central)
10533 Sanford Health Plan No Stated Downtime
10176 San Francisco Health Plan No Stated Downtime
10177 San Joaquin Health Plan No Stated Downtime
10361 Santa Clara Valley Health and Hospital No Stated Downtime
10360 Scott & White Health Plan No Stated Downtime
10520 Select Health SC Every second weekend of the month from 1 hour to 2
days.
10575 Select Health Utah No Stated Downtime
10178 Senior Care Action Network (SCAN) HMO No Stated Downtime
10081 Significa Benefit Services
Sun 11:30pm – Mon 4am Mon 11:30pm – Tue 4am
Tue 11:30pm – Wed 4am Wed 11:30pm – Thu 4am
Thu 11:30pm – Fri 4am Fri 11:30pm – Sat 4am Sat
11:30pm – Sun 4am
10179 South Carolina Medicaid No Stated Downtime
10180 South Dakota Medicaid Sun 12am- Sun 1am (Central)
10591 Special Agents Mutual Benefit Association No Stated Downtime
10546 SPJST Medicare Supplement No Stated Downtime
10593 Standard Life and Accident Insurance Company No Stated Downtime
10512 StayWell No Stated Downtime
December 30, 2013 X12N/005010/270 v1.7 636
ID Payer Name Stated Downtime
10513 StayWell Kids No Stated Downtime
10183 Student Insurance No Stated Downtime
10294 SummaCare Health Plan No Stated Downtime
10451 Sunshine State No Stated Downtime
10592 Superior HealthPlan Texas No Stated Downtime
10184 Tennessee Medicaid
Sundays at the following times (Central):
12:00am - 1:00am
5:00am – 9:00am
4:30pm – 6:30pm
Every 1st of the month at the following time (Central):
5:00am – 6:00am
10186 Texas Medicaid No Information Available
10604 TexanPlus North Texas Area No Stated Downtime
10605 TexanPlus Southeast Texas Area No Stated Downtime
10318 Three Rivers Health Plans (Unison Health Plan) No Stated Downtime
10606 Today’s Health No Stated Downtime
10505 Today’s Options No Stated Downtime
10607 Tribute/SelectCare of Oklahoma No Stated Downtime
10189 TRICARE Sun 3pm – 10pm (Eastern)
10190 Trustmark Insurance No Stated Downtime
10352 Ucare of Minnesota No Stated Downtime
10501 UMR No Stated Downtime
10285 Unicare(Wellpoint) No Stated Downtime
10599 Union Pacific Railroad Employees Health Systems No Stated Downtime
10002 United Healthcare
Tues - Fri: 2:00 a.m. until 5:59 a.m., 6:00pm Sat until
6:00am Mon ET
Thurs 5:30am-8:00am (MT),Sun 9:00am-12:00pm
(MT)
10192 United Healthcare Plan of River Valley No Stated Downtime
10547 United Teachers Associates Ins Co Mcare Supp No Stated Downtime
10349 Unity Health Plans No Stated Downtime
10535 Univera No Stated Downtime
10193 Universal Care of California No Stated Downtime
10194 University Family Care No Stated Downtime
10433 Univeristy Physicians Care Advantage (AZ) No Stated Downtime
10439 Univeristy Physicians Healthcare Group (AZ) No Stated Downtime
10288 UPMC Health Plan (Tristate) 2nd Friday of the month – brief outage at 4am
10195 USAA Life Insurance Company No Stated Downtime
10648 Utah Medicaid Mon-Saturday 1:00am-5:59am & Sunday 12:00am -
11:59pm Mountain Time
10196 VA Fee Basis Program No Stated Downtime
10197 Vermont Medicaid Sun 12am- Sun 1am (Central)
10198 Virginia Medicaid Sun 11pm – Mon 2am (Eastern)
10468 VIVA Health No Stated Downtime
10600 VNS CHOICE No Stated Downtime
December 30, 2013 X12N/005010/270 v1.7 637
ID Payer Name Stated Downtime
10424 Washington Medicaid No Stated Downtime
10554 WEA Trust Sun 4:00p-5:00p, occasionally 8:00p-8:30p (EST)
10532 WEB-TPA, Inc. No Stated Downtime
10488 Wellcare Health Plan No Stated Downtime
10003 Wells Fargo Third Party Administrators, Inc. (CHIP and
PEIA) No Stated Downtime
10200 West Virginia Medicaid Mon 1am - Mon 1:30am Sat 11pm - Sun 4am
(Eastern)
10201 Western Health Advantage No Stated Downtime
10202 Wisconsin Medicaid Sunday 12am – 4am (Central)
10576 Windsor Medicare Extra Thursdays 10-11pm Central
10452 Wisconsin Medicaid Chronic Disease Program Mon-Thurs 4am-5am, Thurs 11:59pm-4am, Fri 4am-
5am, 3rd Sat 11:30p-6am
10453 Wisconsin Medicaid Well Woman Program Mon-Thurs 4am-5am, Thurs 11:59pm-4am, Fri 4am-
5am, 3rd Sat 11:30p-6am
10386 World Insurance (ARIC) No Stated Downtime
10203 Writer's Guild No Stated Downtime
10204 Wyoming Medicaid Sat 12am – 2am, occasionally 12am – 5am (Eastern)
December 30, 2013 X12N/005010/270 v1.7 638
Appendix C: Transaction Examples
Request Formats EDI
ANSI ASC X12N 270 as defined in the HIPAA implementation guideline. 005010X279A1
FlatXml This format is a relatively flat xml format to provide easier access to Exchange EDI transaction processing. A listing of
the most commonly available elements are provided in the example request below. If there is a search field that is not
contained in the sample that is required, then please contact Exchange EDI and we will provide you with the name of the
field to use when submitting the request.
Some payers require provider specific information like PIN numbers or legacy provider numbers. That information must
be submitted in provider specific fields, a listed of payers and the required elements can be obtained by contacting
support.
Date of service should be in the format of CCYYMMDD-CCYYMMDD. If this is a single date you can use the same date
value for both. All other dates, like date of births, should be in the format of CCYYMMDD.
We can provide provider id lookup services for your providers. If you are accessing a payer that requires multiple ids we
will perform the look up for you if you provide us that information ahead of time. Otherwise you can submit them
yourself by requesting the names of the fields to supply the data in. If you do not supply a service type code a default of
30 is used.
Example FlatXml eligibility request:
<?xml version="1.0" encoding="UTF-8"?>
<requests>
<request requestType="Eligibility">
<trackingId>123456789</trackingId> [Alpha-numeric, max 30 characters]
<dateOfService>19900101-19900101</dateOfService> [numeric, min 8/max 17 characters]
<payerId>10000</payerId> [numeric, 5 characters]
<providerId>123456789</providerId> [Alpha-numeric, max 80 characters]
<requestVersion>X12_005010</requestVersion> [Alpha-numeric, max 10 characters]
<responseVersion>X12_005010</responseVersion> [Alpha-numeric, max 10 characters]
<providerLastNameOrgName>ProviderLastName</providerLastNameOrgName> [Alpha-numeric, max 35 characters]
<subscriberId>123456789ABC</subscriberId> [Alpha-numeric, max 80 characters]
<subscriberSSN>123456789</subscriberSSN> [Alpha-numeric, 9 characters]
<subscriberGroupNumber>12345</subscriberGroupNumber> [Alpha-numeric, max 30 characters]
<subscriberFirstName>JOHN</subscriberFirstName> [Alpha-numeric, max 25 characters]
<subscriberMiddleName>J</subscriberMiddleName> [Alpha-numeric, max 25 characters]
<subscriberLastName>SMITH</subscriberLastName> [Alpha-numeric, max 35 characters]
<subscriberSuffixName>JR</subscriberSuffixName> [Alpha-numeric, max 10 characters]
<subscriberGender>M</subscriberGender> [Alpha, 1 characters]
<subscriberDOB>19900101</subscriberDOB> [numeric, 8 characters]
<patientRelationCode>01</patientRelationCode> [numeric, max 2 characters]
<dependentSSN>123456789</dependentSSN> [numeric, 9 characters]
<dependentGroupNumber>12345</dependentGroupNumber> [Alpha-numeric, max 30 characters]
<dependentFirstName>MARY</dependentFirstName> [Alpha-numeric, max 25 characters]
<dependentMiddleName>J</dependentMiddleName> [Alpha-numeric, max 25 characters]
<dependentLastName>SMITH</dependentLastName> [Alpha-numeric, max 35 characters]
<dependentSuffixName>JR</dependentSuffixName> [Alpha-numeric, max 10 characters]
<dependentGender>F</dependentGender> [Alpha, 1 characters]
<dependentDOB>19900101</dependentDOB> [numeric, 8 characters]
<serviceTypeCode>30</serviceTypeCode> [numeric, max 2 characters]
</request>
</requests>
Response Formats
December 30, 2013 X12N/005010/270 v1.7 639
EDI ANSI ASC X12N 270 as defined in the HIPAA implementation guideline 005010X279A1.
EdiXml EdiXml is a custom MedData xml representation of an EDI transmission. Current there is no xml schema available for
this response. Sample responses can be requested.
It follows the looping structure of health care EDI responses. EDI segments are presented as xml elements and EDI
elements are represented by XML attributes.
Sample Response:
<EdiTransmission>
<Interchange SegmentDelimiter="~" ElementDelimiter="*" SubElementDelimiter=">" RepeatingElementDelimiter="{">
<ISA ISA01="00" ISA02=" " ISA03="00" ISA04=" " ISA05="ZZ" ISA06="MEDDATA " ISA07="ZZ" ISA08="MEDDATA
" ISA09="130809" ISA10="1219" ISA11="{" ISA12="00501" ISA13="000000001" ISA14="0" ISA15="P" ISA16=">">
<GS GS01="HB" GS02="MEDDATA" GS03="MEDDATA" GS04="20130809" GS05="121926" GS06="1" GS07="X"
GS08="005010X279A1">
<ST ST01="271" ST02="0001" ST03="005010X279A1">
<BHT BHT01="0022" BHT02="11" BHT03="ABC123" BHT04="20130809" BHT05="131926" />
<HL HL01="1" HL02="" HL03="20" HL04="1">
<NM1 NM101="PR" NM102="2" NM103="PAYER NAME" NM104="" NM105="" NM106="" NM107="" NM108="PI"
NM109="ABC123" />
<HL HL01="2" HL02="1" HL03="21" HL04="1">
<NM1 NM101="1P" NM102="2" NM103="SMITH" NM104="" NM105="" NM106="" NM107="" NM108="XX" NM109="ABC123">
<REF REF01="TJ" REF02="ABC123" />
</NM1>
<HL HL01="3" HL02="2" HL03="22" HL04="0">
<TRN TRN01="2" TRN02="ABC123" TRN03="9MEDDATACO" />
<NM1 NM101="IL" NM102="1" NM103="SMITH" NM104="JOHN" NM105="" NM106="" NM107="" NM108="MI"
NM109="ABC123">
<REF REF01="6P" REF02="ABC123" />
<N3 N301="123 RIDGE WAY" />
<N4 N401="CHARLOTTE" N402="NC" N403="28211" />
<DMG DMG01="D8" DMG02="19900101" DMG03="M" />
<DTP DTP01="291" DTP02="RD8" DTP03="19900101-99991231" />
<EB EB01="1" EB02="IND" EB03.1="30" EB04="PR" EB05="STANDARD">
<DTP DTP01="291" DTP02="RD8" DTP03="19900101-99991231" />
</EB>
<EB EB01="P">
<MSG MSG01="UNLESS OTHERWISE REQUIRED BY APPROPRIATE LAW, THIS NOTICE IS NOT A GUARANTEE OF
PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITATIONS AND THE MEMBER'S ELIGIBILITY STATUS ON THE DATE
OF SERVICE. PAID-TO-DATE AMOUNTS REFLECT ONLY FINALIZED CLAIMS." />
</EB>
<EB EB01="C" EB02="IND" EB03.1="30" EB04="" EB05="STANDARD" EB06="29" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="W" />
<EB EB01="C" EB02="FAM" EB03.1="30" EB04="" EB05="STANDARD" EB06="29" EB07="350" EB08="" EB09="" EB10=""
EB11="" EB12="W" />
<EB EB01="C" EB02="IND" EB03.1="30" EB04="" EB05="STANDARD" EB06="23" EB07="350" EB08="" EB09="" EB10=""
EB11="" EB12="W">
<MSG MSG01="DOES NOT ACCUMULATE TOWARDS THE CATASTROPHIC OUT-OF-POCKET MAXIMUM" />
</EB>
<EB EB01="C" EB02="FAM" EB03.1="30" EB04="" EB05="STANDARD" EB06="23" EB07="700" EB08="" EB09="" EB10=""
EB11="" EB12="W">
<MSG MSG01="DOES NOT ACCUMULATE TOWARDS THE CATASTROPHIC OUT-OF-POCKET MAXIMUM" />
</EB>
<EB EB01="G" EB02="" EB03.1="30" EB04="" EB05="STANDARD" EB06="29" EB07="2281" EB08="" EB09="" EB10=""
EB11="" EB12="Y" />
<EB EB01="G" EB02="" EB03.1="30" EB04="" EB05="STANDARD" EB06="29" EB07="4225.4" EB08="" EB09="" EB10=""
EB11="" EB12="N" />
<EB EB01="G" EB02="" EB03.1="30" EB04="" EB05="STANDARD" EB06="23" EB07="5000" EB08="" EB09="" EB10=""
EB11="" EB12="Y" />
December 30, 2013 X12N/005010/270 v1.7 640
<EB EB01="G" EB02="" EB03.1="30" EB04="" EB05="STANDARD" EB06="23" EB07="7000" EB08="" EB09="" EB10=""
EB11="" EB12="N" />
<EB EB01="1" EB02="" EB03.1="1" EB03.2="MH" EB03.3="35" EB03.4="88" EB04="" EB05="STANDARD" />
<EB EB01="B" EB02="IND" EB03.1="33" EB03.2="98" EB04="" EB05="STANDARD" EB06="27" EB07="20" EB08="" EB09=""
EB10="" EB11="" EB12="Y" />
<EB EB01="A" EB02="IND" EB03.1="33" EB03.2="50" EB03.3="52" EB03.4="86" EB03.5="98" EB03.6="BZ" EB03.7="UC"
EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35" EB09="" EB10="" EB11="" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="33" EB03.2="50" EB03.3="52" EB03.4="86" EB03.5="98" EB03.6="BZ" EB03.7="UC"
EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35" />
<EB EB01="C" EB02="IND" EB03.1="33" EB03.2="98" EB03.3="BZ" EB03.4="UC" EB04="" EB05="STANDARD" EB06="23"
EB07="0" EB08="" EB09="" EB10="" EB11="" EB12="Y" />
<EB EB01="C" EB02="FAM" EB03.1="33" EB03.2="98" EB03.3="BZ" EB03.4="UC" EB04="" EB05="STANDARD" EB06="23"
EB07="0" EB08="" EB09="" EB10="" EB11="" EB12="Y" />
<EB EB01="F" EB02="" EB03.1="33" EB04="" EB05="STANDARD" EB06="23" EB07="" EB08="" EB09="P6" EB10="1" EB11=""
EB12="W">
<MSG MSG01="SET OF X-RAYS" />
</EB>
<EB EB01="F" EB02="" EB03.1="33" EB04="" EB05="STANDARD" EB06="29" EB07="" EB08="" EB09="P6" EB10="1" EB11=""
EB12="W">
<MSG MSG01="SET OF X-RAYS" />
</EB>
<EB EB01="F" EB02="" EB03.1="33" EB04="" EB05="STANDARD" EB06="23" EB07="" EB08="" EB09="VS" EB10="12"
EB11="" EB12="W">
<MSG MSG01="MANIPULATIVE TREATMENT" />
</EB>
<EB EB01="F" EB02="" EB03.1="33" EB04="" EB05="STANDARD" EB06="29" EB07="" EB08="" EB09="VS" EB10="12"
EB11="" EB12="W">
<MSG MSG01="MANIPULATIVE TREATMENT" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="47" EB03.2="51" EB03.3="52" EB03.4="86" EB04="" EB05="STANDARD" EB06="36"
EB07="250" EB08="" EB09="" EB10="" EB11="Y" EB12="Y">
<III III01="ZZ" III02="21" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="47" EB03.2="51" EB03.3="52" EB03.4="86" EB04="" EB05="STANDARD" EB06="36"
EB07="350" EB08="" EB09="" EB10="" EB11="Y" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III02="21" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="47" EB03.2="51" EB03.3="52" EB03.4="86" EB04="" EB05="STANDARD" EB06="36"
EB07="350" EB08="" EB09="" EB10="" EB11="Y">
<III III01="ZZ" III02="21" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="47" EB04="" EB05="STANDARD" EB06="36" EB07="" EB08=".35" EB09="" EB10=""
EB11="Y" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III02="21" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="47" EB04="" EB05="STANDARD" EB06="36" EB07="" EB08=".35" EB09="" EB10=""
EB11="Y">
<III III01="ZZ" III02="21" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="47" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".15" EB09="" EB10=""
EB11="" EB12="Y">
<III III01="ZZ" III02="22" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="47" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35" EB09="" EB10=""
EB11="" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III02="22" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="47" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35">
<III III01="ZZ" III02="22" />
</EB>
<EB EB01="C" EB02="IND" EB03.1="47" EB03.2="52" EB03.3="86" EB04="" EB05="STANDARD" EB06="23" EB07="0"
EB08="" EB09="" EB10="" EB11="Y" EB12="W">
<III III01="ZZ" III02="21" />
</EB>
December 30, 2013 X12N/005010/270 v1.7 641
<EB EB01="C" EB02="FAM" EB03.1="47" EB03.2="52" EB03.3="86" EB04="" EB05="STANDARD" EB06="23" EB07="0"
EB08="" EB09="" EB10="" EB11="Y" EB12="W">
<III III01="ZZ" III02="21" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="48" EB04="" EB05="STANDARD" EB06="36" EB07="250" EB08="" EB09="" EB10=""
EB11="Y" EB12="Y" />
<EB EB01="B" EB02="IND" EB03.1="48" EB04="" EB05="STANDARD" EB06="36" EB07="350" EB08="" EB09="" EB10=""
EB11="Y" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="48" EB04="" EB05="STANDARD" EB06="36" EB07="350" EB08="" EB09="" EB10=""
EB11="Y" />
<EB EB01="A" EB02="IND" EB03.1="48" EB04="" EB05="STANDARD" EB06="36" EB07="" EB08=".35" EB09="" EB10=""
EB11="Y" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="48" EB04="" EB05="STANDARD" EB06="36" EB07="" EB08=".35" EB09="" EB10=""
EB11="Y" />
<EB EB01="C" EB02="IND" EB03.1="48" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="Y" EB12="W" />
<EB EB01="C" EB02="FAM" EB03.1="48" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="Y" EB12="W" />
<EB EB01="A" EB02="IND" EB03.1="50" EB03.2="52" EB03.3="86" EB04="" EB05="STANDARD" EB06="27" EB07=""
EB08=".15" EB09="" EB10="" EB11="" EB12="Y" />
<EB EB01="A" EB02="IND" EB03.1="51" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0" EB09="" EB10=""
EB11="" EB12="Y" />
<EB EB01="A" EB02="IND" EB03.1="51" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0" EB09="" EB10=""
EB11="" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="51" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0" />
<EB EB01="C" EB02="IND" EB03.1="51" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="W" />
<EB EB01="C" EB02="FAM" EB03.1="51" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="W" />
<EB EB01="F" EB02="" EB03.1="51" EB04="" EB05="STANDARD" EB06="" EB07="" EB08="" EB09="HS" EB10="72" EB11=""
EB12="W" />
<EB EB01="A" EB02="IND" EB03.1="52" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".15" EB09="" EB10=""
EB11="" EB12="Y">
<III III01="ZZ" III02="23" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="52" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".15" EB09="" EB10=""
EB11="" EB12="N">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III02="23" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="52" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".15">
<III III01="ZZ" III02="23" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0" EB09="" EB10=""
EB11="" EB12="N">
<MSG MSG01="ACCIDENTALINJURY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08="0">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
<EB EB01="C" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="W">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
<EB EB01="C" EB02="FAM" EB03.1="86" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="W">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
December 30, 2013 X12N/005010/270 v1.7 642
<EB EB01="F" EB02="" EB03.1="86" EB04="" EB05="STANDARD" EB06="" EB07="" EB08="" EB09="HS" EB10="72" EB11=""
EB12="W">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".15" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III02="23" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".15" EB09="" EB10=""
EB11="" EB12="N">
<MSG MSG01="MEDICAL EMERGENCY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III02="23" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".15">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III02="23" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".15" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35" EB09="" EB10=""
EB11="" EB12="N">
<MSG MSG01="MEDICAL EMERGENCY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="" EB08=".35">
<MSG MSG01="MEDICAL EMERGENCY" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="20" EB08="" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III02="11" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="27" EB07="30" EB08="" EB09="" EB10=""
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<MSG MSG01="MEDICAL EMERGENCY SPECIALIST" />
<III III01="ZZ" III02="11" />
</EB>
<EB EB01="A" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="" EB07="" EB08=".15" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY OTHER SERVICES" />
<III III01="ZZ" III02="11" />
</EB>
<EB EB01="C" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III02="11" />
</EB>
<EB EB01="C" EB02="FAM" EB03.1="86" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III02="11" />
</EB>
<EB EB01="C" EB02="IND" EB03.1="86" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY SPECIALIST" />
<III III01="ZZ" III02="11" />
</EB>
<EB EB01="C" EB02="FAM" EB03.1="86" EB04="" EB05="STANDARD" EB06="23" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="MEDICAL EMERGENCY SPECIALIST" />
<III III01="ZZ" III02="11" />
</EB>
<EB EB01="B" EB02="IND" EB03.1="98" EB04="" EB05="STANDARD" EB06="27" EB07="30" EB08="" EB09="" EB10=""
EB11="" EB12="Y">
<MSG MSG01="SPECIALIST" />
</EB>
December 30, 2013 X12N/005010/270 v1.7 643
<EB EB01="B" EB02="IND" EB03.1="BZ" EB04="" EB05="STANDARD" EB06="27" EB07="0" EB08="" EB09="" EB10=""
EB11="" EB12="Y" />
<EB EB01="B" EB02="IND" EB03.1="UC" EB04="" EB05="STANDARD" EB06="27" EB07="40" EB08="" EB09="" EB10=""
EB11="" EB12="Y" />
</NM1>
</HL>
</HL>
</HL>
<SE SE01="144" SE02="0001" />
</ST>
<GE GE01="1" GE02="1" />
</GS>
<IEA IEA01="1" IEA02="000000001" />
</ISA>
</Interchange>
</EdiTransmission>
EdiXmlExt This format is identical to the EdiXml format with the addition of English text descriptions of EDI codes. Those English
descriptions are in _TEXT attributes.
Sample Response: <EdiTransmission>
<Interchange SegmentDelimiter="~" ElementDelimiter="*" SubElementDelimiter=">" RepeatingElementDelimiter="{">
<ISA ISA01="00" ISA01_TEXT="No Authorization Information Present (No Meaningful Information in I02)" ISA02=" " ISA03="00"
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Defined" ISA06="MEDDATA " ISA07="ZZ" ISA07_TEXT="Mutually Defined" ISA08="MEDDATA " ISA09="130809" ISA10="1219"
ISA11="{" ISA12="00501" ISA12_TEXT="Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003"
ISA13="000000001" ISA14="0" ISA14_TEXT="No Interchange Acknowledgment Requested" ISA15="P" ISA15_TEXT="Production Data"
ISA16=">">
<GS GS01="HB" GS01_TEXT="Eligibility, Coverage or Benefit Information (271)" GS02="MEDDATA" GS03="MEDDATA"
GS04="20130809" GS05="121926" GS06="1" GS07="X" GS07_TEXT="Accredited Standards Committee X12" GS08="005010X279A1">
<ST ST01="271" ST01_TEXT="Eligibility, Coverage or Benefit Information" ST02="0001" ST03="005010X279A1">
<BHT BHT01="0022" BHT01_TEXT="Information Source, Information Receiver, Subscriber, Dependent" BHT02="11"
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<HL HL01="1" HL02="" HL03="20" HL03_TEXT="Information Source" HL04="1" HL04_TEXT="Additional Subordinate HL Data
Segment in This Hierarchical Structure.">
<NM1 NM101="PR" NM101_TEXT="Payer" NM102="2" NM102_TEXT="Non-Person Entity" NM103="PAYER NAME" NM104=""
NM105="" NM106="" NM107="" NM108="PI" NM108_TEXT="Payor ID" NM109="ABC123" />
<HL HL01="2" HL02="1" HL03="21" HL03_TEXT="Information Receiver" HL04="1" HL04_TEXT="Additional Subordinate HL Data
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<NM1 NM101="1P" NM101_TEXT="Provider" NM102="2" NM102_TEXT="Non-Person Entity" NM103="SMITH" NM104=""
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<REF REF01="TJ" REF01_TEXT="Federal Taxpayer's ID" REF02="ABC123" />
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<HL HL01="3" HL02="2" HL03="22" HL03_TEXT="Subscriber" HL04="0" HL04_TEXT="No Subordinate HL Segment in This
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<TRN TRN01="2" TRN01_TEXT="Referenced Transaction Trace Numbers" TRN02="ABC123" TRN03="9MEDDATACO" />
<NM1 NM101="IL" NM101_TEXT="Insured or Subscriber" NM102="1" NM102_TEXT="Person" NM103="SMITH" NM104="JOHN"
NM105="" NM106="" NM107="" NM108="MI" NM108_TEXT="Member ID" NM109="ABC123">
<REF REF01="6P" REF01_TEXT="Group Number" REF02="ABC123" />
<N3 N301="123 RIDGE WAY" />
<N4 N401="CHARLOTTE" N402="NC" N403="28211" />
<DMG DMG01="D8" DMG01_TEXT="Date Expressed in Format CCYYMMDD" DMG02="19900101" DMG03="M"
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<DTP DTP01="291" DTP01_TEXT="Plan" DTP02="RD8" DTP02_TEXT="Range of Dates Expressed in Format CCYYMMDD-
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<EB EB01="1" EB01_TEXT="Active Coverage" EB02="IND" EB02_TEXT="Individual" EB03.1="30" EB03.1_TEXT="Health
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<DTP DTP01="291" DTP01_TEXT="Plan" DTP02="RD8" DTP02_TEXT="Range of Dates Expressed in Format CCYYMMDD-
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<EB EB01="P" EB01_TEXT="Benefit Disclaimer">
December 30, 2013 X12N/005010/270 v1.7 644
<MSG MSG01="UNLESS OTHERWISE REQUIRED BY APPROPRIATE LAW, THIS NOTICE IS NOT A GUARANTEE OF
PAYMENT. BENEFITS ARE SUBJECT TO ALL CONTRACT LIMITATIONS AND THE MEMBER'S ELIGIBILITY STATUS ON THE DATE
OF SERVICE. PAID-TO-DATE AMOUNTS REFLECT ONLY FINALIZED CLAIMS." />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="30" EB03.1_TEXT="Health Benefit Plan
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EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="30" EB03.1_TEXT="Health Benefit Plan
Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="350" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="30" EB03.1_TEXT="Health Benefit Plan
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EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
<MSG MSG01="DOES NOT ACCUMULATE TOWARDS THE CATASTROPHIC OUT-OF-POCKET MAXIMUM" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="30" EB03.1_TEXT="Health Benefit Plan
Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="700" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
<MSG MSG01="DOES NOT ACCUMULATE TOWARDS THE CATASTROPHIC OUT-OF-POCKET MAXIMUM" />
</EB>
<EB EB01="G" EB01_TEXT="Out of Pocket (Stop Loss)" EB02="" EB02_TEXT="" EB03.1="30" EB03.1_TEXT="Health Benefit
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EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="G" EB01_TEXT="Out of Pocket (Stop Loss)" EB02="" EB02_TEXT="" EB03.1="30" EB03.1_TEXT="Health Benefit
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<EB EB01="G" EB01_TEXT="Out of Pocket (Stop Loss)" EB02="" EB02_TEXT="" EB03.1="30" EB03.1_TEXT="Health Benefit
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<EB EB01="G" EB01_TEXT="Out of Pocket (Stop Loss)" EB02="" EB02_TEXT="" EB03.1="30" EB03.1_TEXT="Health Benefit
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<EB EB01="1" EB01_TEXT="Active Coverage" EB02="" EB02_TEXT="" EB03.1="1" EB03.1_TEXT="Medical Care" EB03.2="MH"
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EB05="STANDARD" />
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
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<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="50" EB03.2_TEXT="Hospital - Outpatient" EB03.3="52" EB03.3_TEXT="Hospital - Emergency Medical" EB03.4="86"
EB03.4_TEXT="Emergency Services" EB03.5="98" EB03.5_TEXT="Professional (Physician) Visit - Office" EB03.6="BZ"
EB03.6_TEXT="Physician Visit - Office: Well" EB03.7="UC" EB03.7_TEXT="Urgent Care" EB04="" EB04_TEXT="" EB05="STANDARD"
EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35" EB09="" EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N"
EB12_TEXT="No">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="50" EB03.2_TEXT="Hospital - Outpatient" EB03.3="52" EB03.3_TEXT="Hospital - Emergency Medical" EB03.4="86"
EB03.4_TEXT="Emergency Services" EB03.5="98" EB03.5_TEXT="Professional (Physician) Visit - Office" EB03.6="BZ"
EB03.6_TEXT="Physician Visit - Office: Well" EB03.7="UC" EB03.7_TEXT="Urgent Care" EB04="" EB04_TEXT="" EB05="STANDARD"
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<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="98" EB03.2_TEXT="Professional (Physician) Visit - Office" EB03.3="BZ" EB03.3_TEXT="Physician Visit - Office: Well"
EB03.4="UC" EB03.4_TEXT="Urgent Care" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year"
EB07="0" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="98" EB03.2_TEXT="Professional (Physician) Visit - Office" EB03.3="BZ" EB03.3_TEXT="Physician Visit - Office: Well"
EB03.4="UC" EB03.4_TEXT="Urgent Care" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year"
EB07="0" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="33" EB03.1_TEXT="Chiropractic" EB04=""
EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="" EB08="" EB09="P6" EB09_TEXT="Number of
Services or Procedures" EB10="1" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
<MSG MSG01="SET OF X-RAYS" />
</EB>
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="33" EB03.1_TEXT="Chiropractic" EB04=""
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<MSG MSG01="SET OF X-RAYS" />
</EB>
December 30, 2013 X12N/005010/270 v1.7 645
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="33" EB03.1_TEXT="Chiropractic" EB04=""
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EB10="12" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
<MSG MSG01="MANIPULATIVE TREATMENT" />
</EB>
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="33" EB03.1_TEXT="Chiropractic" EB04=""
EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="" EB08="" EB09="VS" EB09_TEXT="Visits" EB10="12"
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<MSG MSG01="MANIPULATIVE TREATMENT" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB03.2="51" EB03.2_TEXT="Hospital - Emergency Accident" EB03.3="52" EB03.3_TEXT="Hospital - Emergency Medical" EB03.4="86"
EB03.4_TEXT="Emergency Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="250"
EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="Y" EB12_TEXT="Yes">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="21" III02_TEXT="Inpatient Hospital" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB03.2="51" EB03.2_TEXT="Hospital - Emergency Accident" EB03.3="52" EB03.3_TEXT="Hospital - Emergency Medical" EB03.4="86"
EB03.4_TEXT="Emergency Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="350"
EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="N" EB12_TEXT="No">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="21" III02_TEXT="Inpatient Hospital" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB03.2="51" EB03.2_TEXT="Hospital - Emergency Accident" EB03.3="52" EB03.3_TEXT="Hospital - Emergency Medical" EB03.4="86"
EB03.4_TEXT="Emergency Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="350"
EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="21" III02_TEXT="Inpatient Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="" EB08=".35" EB09="" EB09_TEXT=""
EB10="" EB11="Y" EB11_TEXT="Yes" EB12="N" EB12_TEXT="No">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="21" III02_TEXT="Inpatient Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="" EB08=".35" EB09="" EB09_TEXT=""
EB10="" EB11="Y" EB11_TEXT="Yes">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="21" III02_TEXT="Inpatient Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09="" EB09_TEXT="" EB10=""
EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="22" III02_TEXT="Outpatient Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35" EB09="" EB09_TEXT="" EB10=""
EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="22" III02_TEXT="Outpatient Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="22" III02_TEXT="Outpatient Hospital" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="47" EB03.1_TEXT="Hospital"
EB03.2="52" EB03.2_TEXT="Hospital - Emergency Medical" EB03.3="86" EB03.3_TEXT="Emergency Services" EB04="" EB04_TEXT=""
EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y"
EB11_TEXT="Yes" EB12="W" EB12_TEXT="Not Applicable">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="21" III02_TEXT="Inpatient Hospital" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="47" EB03.1_TEXT="Hospital"
EB03.2="52" EB03.2_TEXT="Hospital - Emergency Medical" EB03.3="86" EB03.3_TEXT="Emergency Services" EB04="" EB04_TEXT=""
EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT="" EB10="" EB11="Y"
EB11_TEXT="Yes" EB12="W" EB12_TEXT="Not Applicable">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="21" III02_TEXT="Inpatient Hospital" />
</EB>
December 30, 2013 X12N/005010/270 v1.7 646
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital -
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EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital -
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EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="N" EB12_TEXT="No">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital -
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EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital -
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EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="N" EB12_TEXT="No">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital -
Inpatient" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="" EB08=".35" EB09=""
EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital -
Inpatient" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="Y" EB11_TEXT="Yes" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="48" EB03.1_TEXT="Hospital - Inpatient"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="Y" EB11_TEXT="Yes" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="50" EB03.1_TEXT="Hospital -
Outpatient" EB03.2="52" EB03.2_TEXT="Hospital - Emergency Medical" EB03.3="86" EB03.3_TEXT="Emergency Services" EB04=""
EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09="" EB09_TEXT="" EB10="" EB11=""
EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="51" EB03.1_TEXT="Hospital -
Emergency Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="51" EB03.1_TEXT="Hospital -
Emergency Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="51" EB03.1_TEXT="Hospital -
Emergency Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="51" EB03.1_TEXT="Hospital -
Emergency Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="51" EB03.1_TEXT="Hospital - Emergency
Accident" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="51" EB03.1_TEXT="Hospital - Emergency Accident"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="" EB06_TEXT="" EB07="" EB08="" EB09="HS" EB09_TEXT="Hours" EB10="72"
EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable" />
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="52" EB03.1_TEXT="Hospital -
Emergency Medical" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="23" III02_TEXT="Emergency Room - Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="52" EB03.1_TEXT="Hospital -
Emergency Medical" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
<MSG MSG01="PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="23" III02_TEXT="Emergency Room - Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="52" EB03.1_TEXT="Hospital -
Emergency Medical" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15">
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="23" III02_TEXT="Emergency Room - Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
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<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
<MSG MSG01="ACCIDENTALINJURY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08="0">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="86" EB03.1_TEXT="Emergency Services"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
<EB EB01="F" EB01_TEXT="Limitations" EB02="" EB02_TEXT="" EB03.1="86" EB03.1_TEXT="Emergency Services" EB04=""
EB04_TEXT="" EB05="STANDARD" EB06="" EB06_TEXT="" EB07="" EB08="" EB09="HS" EB09_TEXT="Hours" EB10="72" EB11=""
EB11_TEXT="" EB12="W" EB12_TEXT="Not Applicable">
<MSG MSG01="ACCIDENTAL INJURY" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="23" III02_TEXT="Emergency Room - Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
<MSG MSG01="MEDICAL EMERGENCY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="23" III02_TEXT="Emergency Room - Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="23" III02_TEXT="Emergency Room - Hospital" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".15" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No">
<MSG MSG01="MEDICAL EMERGENCY PLUS ANY DIFFERENCE BETWEEN ALLOWED AND BILLED AMOUNTS" />
</EB>
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35">
<MSG MSG01="MEDICAL EMERGENCY" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="20" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="11" III02_TEXT="Office" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="30" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY SPECIALIST" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="11" III02_TEXT="Office" />
</EB>
December 30, 2013 X12N/005010/270 v1.7 648
<EB EB01="A" EB01_TEXT="Co-Insurance" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="" EB06_TEXT="" EB07="" EB08=".15" EB09="" EB09_TEXT="" EB10=""
EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY OTHER SERVICES" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="11" III02_TEXT="Office" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="11" III02_TEXT="Office" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="86" EB03.1_TEXT="Emergency Services"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="11" III02_TEXT="Office" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="IND" EB02_TEXT="Individual" EB03.1="86" EB03.1_TEXT="Emergency
Services" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY SPECIALIST" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="11" III02_TEXT="Office" />
</EB>
<EB EB01="C" EB01_TEXT="Deductible" EB02="FAM" EB02_TEXT="Family" EB03.1="86" EB03.1_TEXT="Emergency Services"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="0" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="MEDICAL EMERGENCY SPECIALIST" />
<III III01="ZZ" III01_TEXT="Mutually Defined" III02="11" III02_TEXT="Office" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="98" EB03.1_TEXT="Professional
(Physician) Visit - Office" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="30" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes">
<MSG MSG01="SPECIALIST" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="BZ" EB03.1_TEXT="Physician Visit -
Office: Well" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="0" EB08="" EB09="" EB09_TEXT=""
EB10="" EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="UC" EB03.1_TEXT="Urgent Care"
EB04="" EB04_TEXT="" EB05="STANDARD" EB06="27" EB06_TEXT="Visit" EB07="40" EB08="" EB09="" EB09_TEXT="" EB10=""
EB11="" EB11_TEXT="" EB12="Y" EB12_TEXT="Yes" />
</NM1>
</HL>
</HL>
</HL>
<SE SE01="144" SE02="0001" />
</ST>
<GE GE01="1" GE02="1" />
</GS>
<IEA IEA01="1" IEA02="000000001" />
</ISA>
</Interchange>
</EdiTransmission>
EdiXmlExtHtml Xml Schema of Response:
<EdiXmlExtHtml>
<EdiTransmission></EdiTransmission>
<html></html>
<ResponseResult></ResponseResult>
</EdiXmlExtHtml>
EdiTransmission - element contains what would be returned in an EdiXmlExt response
html - contains the html markup
December 30, 2013 X12N/005010/270 v1.7 649
o The html markup utilizes a cascading style sheet which can be obtained upon request from the Exchange
EDI Insurance Eligibility support team.
o The contents of the html element are encoded as the value of the html element.
ResponseResult - an integer value that defines type of response, Eligible, Inactive, etc.
o This element is only populated on a single inquiry, not batch.
Response Result Eligibility values:
Response Result Description 0 Unknown
1 Eligible
2 Inactive
3 Not found
4 Payer Not Responding
5 Provider Validation
6 Other Eligible
7 Validation Error
10 Insufficient Application Data
11 997
12 TA1
15 Invalid Request
VerboseXml VerboseXml is a custom Exchange EDI xml representation of an EDI transmission. EDI codes are replaced with English
descriptions and element names are descriptive. All data is contained in xml elements. An xml schema for the response
can be provided upon request.
<TransactionResponse>
<RequestorTrackingID>ABC123</RequestorTrackingID>
<ResponseResult>1</ResponseResult>
<InterchangeControlHeader>
<AuthorInfoQualifier>00</AuthorInfoQualifier>
<SecurityInfoQual>00</SecurityInfoQual>
<InterchangeSenderIDQual>ZZ</InterchangeSenderIDQual>
<InterchangeSenderID>MEDDATA </InterchangeSenderID>
<InterchangeReceiverIDQual>ZZ</InterchangeReceiverIDQual>
<InterchangeReceiverID>MEDDATA </InterchangeReceiverID>
<InterchangeDate>080821</InterchangeDate>
<InterchangeTime>0936</InterchangeTime>
<InterCtrlStandIdent>U</InterCtrlStandIdent>
<InterCtrlVersionNum>00401</InterCtrlVersionNum>
<InterCtrlNumber>065451189</InterCtrlNumber>
<AckRequested>0</AckRequested>
<UsageIndicator>P</UsageIndicator>
<ComponentElemSeparator>.</ComponentElemSeparator>
</InterchangeControlHeader>
<FunctionalGroupHeader>
<FunctionalIDCode>HB</FunctionalIDCode>
<ApplicationSenderCode>MEDDATA</ApplicationSenderCode>
<ApplicationReceiverCode>MEDDATA</ApplicationReceiverCode>
<Date>20080821</Date>
<Time>09364209</Time>
<GroupCtrlNumber>1</GroupCtrlNumber>
<ResponsibleAgencyCode>X</ResponsibleAgencyCode>
<VerReleaseIDCode>005010X279A1</VerReleaseIDCode>
</FunctionalGroupHeader>
<TransactionSetHeader>
<TSIDCode>271</TSIDCode>
<TSControlNumber>0001</TSControlNumber>
<ImplConventionReference>005010X279A1</ImplConventionReference>
</TransactionSetHeader>
<BeginningOfHierarchicalTransaction>
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<HierarchStructCode>0022</HierarchStructCode>
<TSPurposeCode>11</TSPurposeCode>
<ReferenceIdent>ABC123</ReferenceIdent>
<Date>20080821</Date>
<Time>09364209</Time>
</BeginningOfHierarchicalTransaction>
<InformationSourceLevelLoop>
<InformationSourceLevel>
<HierarchIDNumber>1</HierarchIDNumber>
<HierarchLevelCode>20</HierarchLevelCode>
<HierarchChildCode>1</HierarchChildCode>
</InformationSourceLevel>
<InformationSourceNameLoop>
<InformationSourceName>
<EntityIDCode>Payer</EntityIDCode>
<EntityTypeQualifier>Non-Person Entity</EntityTypeQualifier>
<NameLastOrgName>AETNA INC</NameLastOrgName>
<IDCodeQualifier>Payor Identification</IDCodeQualifier>
<IDCode>ABC123</IDCode>
</InformationSourceName>
</InformationSourceNameLoop>
</InformationSourceLevelLoop>
<InformationReceiverLevelLoop>
<InformationReceiverLevel>
<HierarchIDNumber>2</HierarchIDNumber>
<HierarchParentID>1</HierarchParentID>
<HierarchLevelCode>21</HierarchLevelCode>
<HierarchChildCode>1</HierarchChildCode>
</InformationReceiverLevel>
<InformationReceiverNameLoop>
<InformationReceiverName>
<EntityIDCode>Provider</EntityIDCode>
<EntityTypeQualifier>Non-Person Entity</EntityTypeQualifier>
<NameLastOrgName>SMITH</NameLastOrgName>
<IDCodeQualifier>Health Care Financing Administration National Provider Identifier</IDCodeQualifier>
<IDCode>ABC123</IDCode>
</InformationReceiverName>
</InformationReceiverNameLoop>
</InformationReceiverLevelLoop>
<SubscriberLevelLoop>
<SubscriberLevel>
<HierarchIDNumber>3</HierarchIDNumber>
<HierarchParentID>2</HierarchParentID>
<HierarchLevelCode>22</HierarchLevelCode>
<HierarchChildCode>0</HierarchChildCode>
</SubscriberLevel>
<SubscriberNameLoop>
<SubscriberName>
<EntityIDCode>Insured or Subscriber</EntityIDCode>
<EntityTypeQualifier>Person</EntityTypeQualifier>
<NameLastOrgName>SMITH</NameLastOrgName>
<NameFirst>JOHN</NameFirst>
<NameMiddle>S</NameMiddle>
<IDCodeQualifier>Member Identification Number</IDCodeQualifier>
<IDCode>ABC123</IDCode>
</SubscriberName>
<SubscriberAdditionalIdentification>
<ReferenceIdentQual>Group Number</ReferenceIdentQual>
<ReferenceIdent>ABC123</ReferenceIdent>
<Description>ABC</Description>
</SubscriberAdditionalIdentification>
<SubscriberAdditionalIdentification>
<ReferenceIdentQual>Plan Number</ReferenceIdentQual>
<ReferenceIdent>ABC123</ReferenceIdent>
<Description>ABC</Description>
</SubscriberAdditionalIdentification>
<SubscriberAddress>
<AddressInformation>123 RIDGE WAY</AddressInformation>
</SubscriberAddress>
December 30, 2013 X12N/005010/270 v1.7 651
<SubscriberCityStateZipCode>
<CityName>CHARLOTTE</CityName>
<StateOrProvCode>NC</StateOrProvCode>
<PostalCode>28211</PostalCode>
</SubscriberCityStateZipCode>
<SubscriberDemographicInformation>
<DateTimeFormatQual>D8</DateTimeFormatQual>
<DateTimePeriod>19900101</DateTimePeriod>
<GenderCode>Male</GenderCode>
</SubscriberDemographicInformation>
<SubscriberRelationship>
<YesNoCondRespCode>Yes</YesNoCondRespCode>
<IndividualRelatCode>Self</IndividualRelatCode>
<MaintenanceTypeCode>Change</MaintenanceTypeCode>
<MaintainReasonCode>Change in Identifying Data Elements</MaintainReasonCode>
</SubscriberRelationship>
<SubscriberDate>
<DateTimeQualifier>Eligibility</DateTimeQualifier>
<DateTimeFormatQual>D8</DateTimeFormatQual>
<DateTimePeriod>19900101</DateTimePeriod>
</SubscriberDate>
<SubscriberDate>
<DateTimeQualifier>Service</DateTimeQualifier>
<DateTimeFormatQual>RD8</DateTimeFormatQual>
<DateTimePeriod>19900101-99991231</DateTimePeriod>
</SubscriberDate>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Primary Care Provider</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Health Benefit Plan Coverage</ServiceTypeCode>
<InsuranceTypeCode>Point of Service (POS)</InsuranceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberEligibilityBenefitDate>
<DateTimeQualifier>Period Start</DateTimeQualifier>
<DateTimeFormatQual>D8</DateTimeFormatQual>
<DateTimePeriod>19900101</DateTimePeriod>
</SubscriberEligibilityBenefitDate>
<SubscriberBenefitRelatedEntityNameLoop>
<SubscriberBenefitRelatedEntityName>
<EntityIDCode>Primary Care Provider</EntityIDCode>
<EntityTypeQualifier>Person</EntityTypeQualifier>
<NameLastOrgName>SMITH</NameLastOrgName>
<NameFirst>JOHN</NameFirst>
<NameMiddle>S</NameMiddle>
</SubscriberBenefitRelatedEntityName>
</SubscriberBenefitRelatedEntityNameLoop>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Primary Care Provider</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Health Benefit Plan Coverage</ServiceTypeCode>
<InsuranceTypeCode>Point of Service (POS)</InsuranceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberBenefitRelatedEntityNameLoop>
<SubscriberBenefitRelatedEntityName>
<EntityIDCode>Gateway Provider</EntityIDCode>
<EntityTypeQualifier>Non-Person Entity</EntityTypeQualifier>
</SubscriberBenefitRelatedEntityName>
</SubscriberBenefitRelatedEntityNameLoop>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Other Source of Data</EligibilityBenefitInf>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberBenefitRelatedEntityNameLoop>
<SubscriberBenefitRelatedEntityName>
<EntityIDCode>Facility</EntityIDCode>
December 30, 2013 X12N/005010/270 v1.7 652
<EntityTypeQualifier>Non-Person Entity</EntityTypeQualifier>
<NameLastOrgName>SMITH</NameLastOrgName>
<IDCodeQualifier>Facility Identification</IDCodeQualifier>
<IDCode>ABC123</IDCode>
</SubscriberBenefitRelatedEntityName>
</SubscriberBenefitRelatedEntityNameLoop>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Active Coverage</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Health Benefit Plan Coverage</ServiceTypeCode>
<InsuranceTypeCode>Point of Service (POS)</InsuranceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Health Benefit Plan Coverage</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Plan Requires PreCert</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Benefit Description</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Health Benefit Plan Coverage</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Active Coverage</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>UNLIMITED</FreeFormMessageTxt>
</SubscriberMessageText>
December 30, 2013 X12N/005010/270 v1.7 653
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO VST/EVAL</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>MANPULATN CHRO</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Payment</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<MonetaryAmount>35</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO VST/EVAL</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Payment</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<MonetaryAmount>35</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>MANPULATN CHRO</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO VST/EVAL/DED WAIVED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>MANPULATN CHRO/DED WAIVED</FreeFormMessageTxt>
December 30, 2013 X12N/005010/270 v1.7 654
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Plan includes NAP</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Unlimited Lifetime Benefits</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Benefit Description</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Chiropractic</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Active Coverage</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>UNLIMITED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
December 30, 2013 X12N/005010/270 v1.7 655
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>RM & BOARD</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Payment</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
<MonetaryAmount>100</MonetaryAmount>
<AuthorizationIndicator>Yes</AuthorizationIndicator>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>RM & BOARD</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>RM & BOARD /DED WAIVED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Plan includes NAP</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Unlimited Lifetime Benefits</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Benefit Description</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Inpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Active Coverage</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
December 30, 2013 X12N/005010/270 v1.7 656
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>UNLIMITED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>OP HOSPITAL</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>OP SURG FAC</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Individual</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberHealthCareServicesDelivery>
<QuantityQualifier>Visits</QuantityQualifier>
<Quantity>30</Quantity>
<UnitBasisMeasCode>Years</UnitBasisMeasCode>
<SampleSelModulus>1</SampleSelModulus>
</SubscriberHealthCareServicesDelivery>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
December 30, 2013 X12N/005010/270 v1.7 657
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Individual</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberHealthCareServicesDelivery>
<QuantityQualifier>Visits</QuantityQualifier>
<Quantity>30</Quantity>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
</SubscriberHealthCareServicesDelivery>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Plan includes NAP</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Unlimited Lifetime Benefits</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Benefit Description</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Hospital - Outpatient</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Active Coverage</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
December 30, 2013 X12N/005010/270 v1.7 658
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>UNLIMITED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>ER PHYSICIAN</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>ER FACILITY</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>URGENT CARE</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Payment</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<MonetaryAmount>35</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>ER FACILITY</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Payment</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<MonetaryAmount>25</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>URGENT CARE</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
December 30, 2013 X12N/005010/270 v1.7 659
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>ER PHYSICIAN /DED WAIVED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>ER FACILITY /DED WAIVED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>URGENT CARE /DED WAIVED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Individual</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberHealthCareServicesDelivery>
<QuantityQualifier>Visits</QuantityQualifier>
<Quantity>30</Quantity>
<UnitBasisMeasCode>Years</UnitBasisMeasCode>
<SampleSelModulus>1</SampleSelModulus>
</SubscriberHealthCareServicesDelivery>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Individual</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberHealthCareServicesDelivery>
<QuantityQualifier>Visits</QuantityQualifier>
<Quantity>30</Quantity>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
</SubscriberHealthCareServicesDelivery>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
December 30, 2013 X12N/005010/270 v1.7 660
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Plan includes NAP</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Unlimited Lifetime Benefits</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Benefit Description</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Emergency Services</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Active Coverage</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Deductible</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
<MonetaryAmount>500</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Family</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>UNLIMITED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>SPEC OFF VST</FreeFormMessageTxt>
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</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Insurance</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<Percent>0</Percent>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>PHYS OFFICE VS</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Payment</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<MonetaryAmount>35</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>SPEC OFF VST</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Co-Payment</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<MonetaryAmount>25</MonetaryAmount>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>PHYS OFFICE VS</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>SPEC OFF VST /DED WAIVED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
<InPlanNetworkIndicator>Yes</InPlanNetworkIndicator>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>PHYS OFFICE VS/DED WAIVED</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Individual</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberHealthCareServicesDelivery>
<QuantityQualifier>Visits</QuantityQualifier>
<Quantity>30</Quantity>
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<UnitBasisMeasCode>Years</UnitBasisMeasCode>
<SampleSelModulus>1</SampleSelModulus>
</SubscriberHealthCareServicesDelivery>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Individual</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberHealthCareServicesDelivery>
<QuantityQualifier>Visits</QuantityQualifier>
<Quantity>30</Quantity>
<TimePeriodQualifier>Remaining</TimePeriodQualifier>
</SubscriberHealthCareServicesDelivery>
<SubscriberMessageText>
<FreeFormMessageTxt>CHIRO</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Plan includes NAP</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Limitations</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
<SubscriberMessageText>
<FreeFormMessageTxt>Unlimited Lifetime Benefits</FreeFormMessageTxt>
</SubscriberMessageText>
</SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformationLoop>
<SubscriberEligibilityOrBenefitInformation>
<EligibilityBenefitInf>Benefit Description</EligibilityBenefitInf>
<CoverageLevelCode>Employee and Spouse</CoverageLevelCode>
<ServiceTypeCode>Professional (Physician) Visit - Office</ServiceTypeCode>
</SubscriberEligibilityOrBenefitInformation>
</SubscriberEligibilityOrBenefitInformationLoop>
</SubscriberNameLoop>
</SubscriberLevelLoop>
<FunctionalGroupTrailer>
<FunctionalIDCode>1</FunctionalIDCode>
<NumberOfInclTS>1</NumberOfInclTS>
</FunctionalGroupTrailer>
<InterchangeControlTrailer>
<NumberOfInclGS>1</NumberOfInclGS>
<InterCtrlNumber>065451189</InterCtrlNumber>
</InterchangeControlTrailer>
</TransactionResponse>
Example Requests Examples are shown using EDI as the request and response formats. For security purposes the EDI has been replaced with
a placeholder.
December 30, 2013 X12N/005010/270 v1.7 663
SubmitSync SOAP (Version 1.2) <soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:sub="http://services.medconnect.net/submissionportal">
<soap:Header>
<sub:SecurityHeader>
<sub:UserName>username</sub:UserName>
<sub:Password>password</sub:Password>
</sub:SecurityHeader>
</soap:Header>
<soap:Body>
<sub:SubmitSync>
<sub:request>ISA*...place X12 here...IEA</sub:request>
<sub:requestFormat>EDI</sub:requestFormat>
<sub:responseFormat>EDI</sub:responseFormat>
<sub:synchronousTimeout>00:01:00</sub:synchronousTimeout>
<sub:submissionTimeout>00:01:00</sub:submissionTimeout>
</sub:SubmitSync>
</soap:Body>
</soap:Envelope>
Response:
<soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema">
<soap:Body>
<SubmitSyncResponse xmlns="http://services.medconnect.net/submissionportal">
<SubmitSyncResult>ISA...IEA...~<SubmitSyncResult>
</SubmitSyncResponse>
</soap:Body>
</soap:Envelope>
SubmitASync SOAP (Version 1.2) <soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:sub="http://services.medconnect.net/submissionportal">
<soap:Header>
<sub:SecurityHeader>
<sub:UserName>username</sub:UserName>
<sub:Password>password</sub:Password>
</sub:SecurityHeader>
</soap:Header>
<soap:Body>
<sub:SubmitASync>
<sub:request>ISA*...place X12 here...IEA</sub:request>
<sub:requestFormat>EDI</sub:requestFormat>
<sub:submissionTimeout>1.00:00:00</sub:submissionTimeout>
</sub:SubmitASync>
</soap:Body>
</soap:Envelope>
Response:
<soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema">
<soap:Body>
<SubmitASyncResponse xmlns="http://services.medconnect.net/submissionportal">
<SubmitASyncResult>665a3d9c-0000-0000-0000-f2d949f90f70</SubmitASyncResult>
</SubmitASyncResponse>
</soap:Body>
</soap:Envelope>
GetResponses SOAP (Version 1.2)
December 30, 2013 X12N/005010/270 v1.7 664
<soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:sub="http://services.medconnect.net/submissionportal">
<soap:Header>
<sub:SecurityHeader>
<sub:UserName>username</sub:UserName>
<sub:Password>password</sub:Password>
</sub:SecurityHeader>
</soap:Header>
<soap:Body>
<sub:GetResponses>
<sub:responseFormat>EDI</sub:responseFormat>
</sub:GetResponses>
</soap:Body>
</soap:Envelope>
Response:
<soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema">
<soap:Body>
<GetResponsesResponse xmlns="http://services.medconnect.net/submissionportal">
<GetResponsesResult>ISA...IEA...~</GetResponsesResult>
</GetResponsesResponse>
</soap:Body>
</soap:Envelope>
GetResponsesBySubmissionId SOAP (Version 1.2) <soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:sub="http://services.medconnect.net/submissionportal">
<soap:Header>
<sub:SecurityHeader>
<sub:UserName>username</sub:UserName>
<sub:Password>password</sub:Password>
</sub:SecurityHeader>
</soap:Header>
<soap:Body>
<sub:GetResponsesBySubmissionId>
<sub:submissionId>665a3d9c-0000-0000-0000-f2d949f90f70</sub:submissionId>
<sub:responseFormat>EDI</sub:responseFormat>
<sub:overrideSent>0</sub:overrideSent>
</sub:GetResponsesBySubmissionId>
</soap:Body>
</soap:Envelope>
Response:
<soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:xsd="http://www.w3.org/2001/XMLSchema">
<soap:Body>
<GetResponsesBySubmissionIdResponse xmlns="http://services.medconnect.net/submissionportal">
<GetResponsesBySubmissionIdResult>ISA...IEA...~</GetResponsesBySubmissionIdResult>
</GetResponsesBySubmissionIdResponse>
</soap:Body>
</soap:Envelope>
HTTP Message Full HTTP message example:
POST https://services.medconnect.net/submissionportal/submissionportal.asmx HTTP/1.1
Content-Type: application/soap+xml;charset=UTF-
8;action="http://services.medconnect.net/submissionportal/SubmitSync"
User-Agent: Jakarta Commons-HttpClient/3.1
December 30, 2013 X12N/005010/270 v1.7 665
Host: services.medconnect.net
Content-Length: 888
<soap:Envelope xmlns:soap="http://www.w3.org/2003/05/soap-envelope"
xmlns:sub="http://services.medconnect.net/submissionportal">
<soap:Header>
<sub:SecurityHeader>
<sub:UserName>username</sub:UserName>
<sub:Password>password</sub:Password>
</sub:SecurityHeader>
</soap:Header>
<soap:Body>
<sub:SubmitSync>
<sub:request> ISA...IEA...~</sub:request>
<sub:requestFormat>EDI</sub:requestFormat>
<sub:responseFormat>EDI</sub:responseFormat>
<sub:synchronousTimeout>01:01:00</sub:synchronousTimeout>
<sub:submissionTimeout>01:01:00</sub:submissionTimeout>
</sub:SubmitSync>
</soap:Body>
</soap:Envelope>
URL Get / Post https://services.meddatahealth.com/clients/default/submit.aspx?userId=username&userPwd=password&requestType
=EDI&responseType=EDI&timeout=00:01:00&request=ISA...IEA&requestTime=12301000&requestDate=20090101
Full HTTP GET message example:
GET
/clients/default/submit.aspx?userId=username&userPwd=password&requestType=EDI&responseType=EDI&timeout=00:01:00&request=IS A…IEA…~&requestTime=12301000&requestDate=20090101 HTTP/1.1
Accept: image/jpeg, application/x-ms-application, image/gif, application/xaml+xml, image/pjpeg, application/x-ms-xbap, application/msword, application/vnd.ms-excel, application/vnd.ms-powerpoint, application/x-silverlight, application/xsilverlight-
2-b2, application/x-shockwave-flash, application/vnd.ms-xpsdocument, */*
Accept-Language: en-US
User-Agent: Mozilla/4.0 (compatible; MSIE 8.0; Windows NT 6.1; Trident/4.0; SLCC2; .NET CLR 2.0.50727; .NET CLR 3.5.30729;
.NET CLR 3.0.30729; Media Center PC 6.0; .NET CLR 1.1.4322; .NET CLR 3.5.20404; .NET CLR 3.5.21022;
OfficeLiveConnector.1.3; OfficeLivePatch.0.0; SLCC1) Accept-Encoding: gzip, deflate
Host: localhost:10000
Sample Code The sample code provided was created using Visual Studio .NET 2008 in the VB.NET language.
Add a new “Service Reference” (name is portal) using the URL:
https://services.medconnect.net/submissionportal/submissionportal.asmx”
Code:
Dim portal As New portal.MedDataExternalSubmissionPortalSoapClient()
Dim securityHdr As New portal.SecurityHeader() With {.UserName = "UserName", .Password = "Password"}
Dim responseEdi As String = String.Empty
responseEdi = portal.SubmitSync(securityHdr, _
"ISA...", _
"EDI", _
"EDI", _
"00:01:00", _
"00:01:00")
Debug.Print(responseEdi)
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Appendix D: Change Summary
Date Changes
12/18/2013 Modified search options for Kitsap Physician Services 10341
12/17/2013 Added search option #2 to ChampVA payer ID 10061
12/13/2013 Added new payer PHPNI-10658
12/13/2013 Updated AARP search option # 6- payer ID 10431
12/09/2013 Added note Viva Health payer ID 10468
12/6/2013 Added new payer MHNet Behavioral Health – Payer ID 10659
12/6/2013 Added New Payer CAPROCK - 10660
12/4/2013 Updated search option for NEHEN Harvard Pilgrim Health Care 10376
11/20/2013 Added New Payer Health Plan of Upper Ohio Valley Payer ID 10657
11/15/2013 Updates Scott and White-10360 date limitations
11/15/2013 Updated note for HealthSpring -10552
11/1/2013 Updated service type codes for Select Health UTAH – Payer 10575
11/1/2013 Updated service type codes for Public Employees Health Program – Payer 10574
10/28/2013 Added New Payer United Healthcare SecureHorizons 10655
10/24/2013 Added updated search options for USAA – Life Insurance Co. 10195
10/23/2013 Added Central States Funds Payer ID 10486
10/15/2013 Modified search options for Payer ID 10498 Blue Cross Blue Shield of Western New York
10/11/2013 Added New Payer Allegiance Benefit Plan Management 10654
10/11/2013 Modified search options for Payer ID 10499 Blue Shield North Eastern New York
10/11/2013 Modified search options for Payer ID 10417 Independence Administrators
10/11/2013 Added New Payer Golden Rule Insurance 10652
10/04/2013 Added New Payer Dean Health payer ID 10653
09/25/2013 Added New Payer Utah Medicaid Payer ID 10648
09/20/2013 Correction: removed DOB/SSN Search option for Best Choice Health Plan-10256
09/18/2013
Updated Healthspring-10552 Notes to reflect supported states TN, AL, MS, TX, AR, OK, WV &
GA
09/18/2013 Updated Payer name Blue Shield Idaho-10052
09/13/2013 Added VNSNY Choice Health Plan 10187
09/13/2013 Added Loyal American Life Insurance Co. Medicare Supp 10544
09/13/2013 Added Bluegrass Family Health 10429
09/13/2013 Added Puerto Rico Medicaid 10173
09/09/2013 Deactivated Kentucky Spirit Health Plan 10620
08/07/2013 Added new payer Lifewise Health Plan of Oregon 10651
08/07/2013 Added new payer Lifewise Health Plan of Washington 10650
07/08/2013 Added AmeriChoice of New Jersey (Commercial) 10018
07/03/2013
Added Kitsap Physician Services 10341, Health Plan of San Mateo 10362, NEHEN Tufts
Associated Health Plan 10379, Community HealthFirst Medicare Advantage 10421, and Gateway
Health Plan 10629
06/21/2013 Added UHC River Valley 10192
06/19/2013 Removed Presbyterian Health Plan 10646 – temporary deactivation
05/31/2013 Updated Montana Medicaid 10147 search options
05/21/2013 Added ConnectiCare Payer ID 10303
05/20/2013 Added New Payer Presbyterian Health Plan 10646
December 30, 2013 X12N/005010/270 v1.7 667
Date Changes
05/20/2013 Added Payer United Healthcare Student Resources Payer 10183 (Formerly) Student Insurance
05/17/2013 Added Michigan MIChild Payer ID 10138
05/17/2013 Added Aflac Dental Insurance Payer ID 10398
05/17/2013 Added Central Reserve Life Insurance Company Payer ID 10450
05/17/2013 Added NovaSys Health Payer ID 10466
05/17/2013 Added American Retirement Life Insurance Co Medicare Supp Payer ID 10538
05/17/2013 Added Continental General Life Insurance Co Medicare Supp Payer ID 10540
05/17/2013 Added Great American Life Insurance Co Medicare Payer ID 10543
05/17/2013 Added Provident American Life & Health Insurance Co Payer ID 10545
05/17/2013 Added United Teachers Assoc. Insurance Co Medicare Supp Payer ID 10547
05/17/2013 Added CHC - COVENTRYCARES OF KENTUCKY Payer ID 10642
05/16/2013 Removed New Hampshire Medicaid – 10153 Special Enrollment Instructions
05/16/2013 Added New Mexico Medicaid Payer -10247 please note search option change
05/16/2013 Added Providence Health Plan Payer ID -10172 please note search option change
05/13/2013 Updated Ohio Medicaid Search options-payer ID 10158
05/13/2013 Deactivated Universal Healthcare payer ID 10625
05/13/2013 Added Payer ID 10645 State Farm
05/13/2013 Added Payer ID10552 HealthSpring
05/13/2013 Updated Search option for 10626 – Network Health (added Gender as Optional)
05/10/2013 Added Payer ID 10644 Meridian Health Plan of Illinois
05/10/2013 Added Payer Id 10643 Schaller Anderson Parkland Community Health Plan
05/10/2013 Added Payer ID 10586 Managed Health Services Indiana
05/10/2013 Added Payer ID 10616 Emblem Health
05/10/2013 Updated search options to include Gender - BCBS of the Rochester Area (NY) – 10469
05/09/2013 Updated search options to removed DOB requirement – AvMed Health Plans – 10024
05/09/2013 Updated search options to allow Optional Group Number – Blue Cross WA/AK (Premera) – 10326
05/09/2013 Add new search options for Kaiser Permanente of Georgia - 10238
05/09/2013 Add payer sheet for Iowa Medicaid - 10107
03/19/2013 Deactivated Great West Healthcare-10089 and merged with Cigna-10062
03/12/2013 Kaiser Permanente of GA, CA, CO, MidAtlantic, NorthWest - search options have been modified
02/28/2013
Effective 2/22/13 CORE CAQH changes Kaiser Plans no longer support SSN searches; exception
Hawaii
02/08/2013 Added Public Employees Health Plan (PEHP) 10574
01/14/2013 Added BCBS Iowa-10396
01/14/2013 Updated: Geisinger Health Plan-10611 search options
01/14/2013 Updated: Geisinger Health Plan Gold-10612 search options
01/10/2013 Added Tricare-10189
01/03/2013 Removed future date support for BCBS Arkansas (10028)
01/03/2013 Adjusted search types for payer Arkansas Medicaid (10023)
12/19/2012 Added Core Source (MD,OA,IL,NC, IN) 10072
12/19/2012 Added Core Source OH 10074
12/19/2012 Added Essence Healthcare 10601
12/19/2012 Added MDWise Hoosier Alliance 10598
12/12/2012 Added BCBS Mississippi-10040
12/5/2012 Updated Dependent search option for BCBS MI (Professional) – 10038 to include Optional Group
Number
December 30, 2013 X12N/005010/270 v1.7 668
Date Changes
11/09/2012 Added DakotaCare 10577
11/02/2012 Added NEW payer –Arbor Health Plan-10641
11/02/2012 Added NEW payer- LaCare-10640
11/02/2012 Added Ohio Medicaid-10158
11/02/2012 Updated search options sequence-Texas Medicaid-10186
11/01/2012 Added note to Subscriber ID section-Sanford 10533
10/30/2012 Updated Search options Qualcare-10637
10/30/2012 Added New payer Alameda Alliance Health Plan-10639
10/29/2012 Added New payer Blue Cross of Idaho 10638
10/23/2012 Updated Service type codes for BCBS MA - 10037
10/22/2012 Updated date option Ucare Monnesota-10352
10/19/2012 Added Mamsi Health Plan - 10122
10/19/2012 Added Maine Medicaid - 10121
10/19/2012 Added Missouri Medicaid - 10143
10/19/2012 Added Harmony Health Plan - 10514
10/8/2012 Added the Enrollment details in Appendix A for HealthPartners MN - 10484
10/04/2012 Added Superior Health Plan Texas 10592
10/04/2012 Removed Payer 10569 Cenpatico - Georgia Database no longer available
10/04/2012 Added new payer Qualcare-10637
09/28/2012 Added Scott and White Health Plan-10360
9/06/2012 Principal Financial Group (Nippon Life) 10170 is now a parent plan under Nippon Life Benefits
8/31/2012 Added Maricopa Health Plan Arizona 10434
8/31/2012 Added University Care Advantage Arizona 10433
8/31/2012 Added University Family Care Arizona 10194
8/31/2012 Added University Physicians Healthcare Group Arizona 10439
08/30/2012 Added Great-West 10089
08/30/2012 Added Fidelis Care New York-10459
08/23/2012 Added CarePlus Health Plan 10056
08/23/2012 Added New Payer Meritain Health 10635
08/20/2012 Added Absolute Total Care 10560
08/20/2012 Added Advantage by Bridgeway Health Solutions 10561
08/20/2012 Added Advantage by Buckeye Community Health Plan 10562
08/20/2012 Added Advantage by Managed Health Services 10563
08/20/2012 Added Advantage by Superior Health Plan 10564
08/20/2012 Added Bridgeway Arizona 10565
08/20/2012 Added Buckeye Community Health 10566
08/20/2012 Added CeltiCare 10589
08/20/2012 Added Cenpatico - Arizona 10567
08/20/2012 Added Cenpatico - Florida 10568
08/20/2012 Added Cenpatico - Georgia 10569
08/20/2012 Added Cenpatico - Illinois 10631
08/20/2012 Added Cenpatico - Indiana 10570
08/20/2012 Added Cenpatico - Kansas 10571
08/20/2012 Added Cenpatico - Kentucky 10632
08/20/2012 Added Cenpatico - Massachusetts 10588
08/20/2012 Added Cenpatico - Ohio 10572
December 30, 2013 X12N/005010/270 v1.7 669
Date Changes
08/20/2012 Added Cenpatico - South Carolina 10573
08/20/2012 Added Cenpatico - Texas 10633
08/20/2012 Added Cenpatico - Wisconsin 10634
08/20/2012 Added Kentucky Spirit Health Plan 10620
08/20/2012 Added Managed Health Services Wisconsin 10587
08/17/2012 Added BCBS Wyoming 10480
08/15/2012 Added New Payer Neighborhood Health Plan (RI) 10630
07/25/2012 Updated Date Restrictions for UPMC (Tristate) - 10288
07/24/2012 Removed Tax ID requirement from Aetna 10004 – NPI only
07/24/2012 Removed Tax ID requirement from UMR 10501 – NPI only
07/24/2012 Added Affinity Health Plan - 10594
07/24/2012 Added Priority Health Payer ID 10490
07/20/2012 Updated downtimes for GEHA – 10394, Medica – 10125, Cigna – 10063, UHC – 10002, Oxford –
10161, Qualchoice – 10553, Mamsi – 10122, AARP – 10431, Great West - 10089
07/19/2012 Updated search option for BCBS North Carolina - 10383
07/18/2012 Added Idaho Medicaid - 10101
07/18/2012 Added Oregon Medicaid - 10160
07/18/2012 Added Significa Benefit Services -10081
07/18/2012 Added USAA Life Insurance Company - 10195
07/17/2012 Updated Maintenance times for UPMC (Tristate) - 10288
07/17/2012 Updated Past Dates Options for BCBS IL – 10033, BCBS TX – 10048, BCBS OK - 10582
07/10/2012 Added notes for UPMC 10288
07/06/2012 Added Texas Medicaid 10186
07/06/2012 Added Independence Administrators-10417
07/06/2012 Added Blue Cross Independence (Pennsylvania)-10262
07/06/2012 Added AmeriHealth Administrators-10416
07/05/2012 Added UPMC Health Plan (Tristate) - 10288
07/03/2012 Added Group Health Cooperative Payer Sheet - 10608
07/02/2012 Added Better Health Plans 10187
07/02/2012 Added Deseret Mutual (DMBA) 10578
07/02/2012 Added Select Health Utah 10575
07/02/2012 Added Three Rivers Health Plan (Unison Health Plan) 10318
07/02/2012 Added: NEHEN - Neighborhood Health Plans-10377
07/02/2012 Added: HealthPlus of Michigan-10309
07/02/2012 Added: Santa Clara Valley Health and Hospital-10361
07/02/2012 Added-SummaCare Health Plan-10294
07/02/2012 Added: UCare of Minnesota-10352
07/02/2012 Added: Unity Health Plans-10349
06/29/2012 Updated search option for Mutual of Omaha 10382 – SSN search no longer valid Member ID only
06/28/2012 Added BCBS of North Dakota 10478
06/28/2012 Added Sanford Health Plan-10533
06/26/2012 Corrected/Updated Cigna Search options - 10062
06/26/2012 Added Molina Healthcare CA 10145
06/26/2012 Added Molina Healthcare FL 10445
06/26/2012 Added Molina Healthcare MI 10250
06/26/2012 Added Molina Healthcare MO 10523
December 30, 2013 X12N/005010/270 v1.7 670
Date Changes
06/26/2012 Added Molina Healthcare NM 10146
06/26/2012 Added Molina Healthcare OH 10251
06/26/2012 Added Molina Healthcare TX 10391
06/26/2012 Added Molina Healthcare UT 10252
06/26/2012 Added Molina Healthcare WI 10628
06/26/2012 Added World Insurance (ARIC) 10386
06/26/2012 Added Cooperative Benefit Administrators 10068
06/26/2012 Added American Republic Insurance Company 10017
06/26/2012 Added American Family Insurance Group – Medicare Supplement and PPO Polices 10487
06/26/2012 Added Central Reserve Life Insurance Company 10539
06/26/2012 Added Continental General Insurance Company 10454
06/26/2012 Added Regence Blue Cross (UTAH) 10618
06/25/2012 Added SC Medicaid-10179
06/18/2012 Denver Health Medical plan-10331 Added Note to Member Id field
05/31/2012 Updated Search Option Payer Connecticut Medicaid - 10067
05/25/2012 Added CoreSource FMH - 10311
05/25/2012 Added CoreSource Little Rock - 10071
05/25/2012 Added Principal Financial Group (Nippon Life) 10170
05/25/2012 Added payer BCBS Hawaii-10530
05/25/2012 Added New Search Options for Medicare - 10001
05/24/2012 Added Denver Health Medical Plan-10331
05/24/2012 Added Colorado Access-10064
05/24/2012 Added Health Partners of Philadelphia-10098
05/23/2012 Added New Payer Health New England 10627
05/23/2012 Updated search options Payer AARP-10431
05/22/2012 Updated Payer Maintenance times for BCBSKS 10034 and BCBS KC 10473
05/22/2012 Added BCBS of Kansas City - 10473
05/17/2012 Added Payer South Dakota Medicaid 10180
05/17/2012 Added Ameritas Life Insurance Co. 10020
05/17/2012 Added First Ameritas of New York 10232
05/17/2012 Added First Reliance Standard Life 10233
05/17/2012 Added Reliance Standard Life 10234
05/17/2012 Added Standard Insurance 10236
05/17/2012 Added Standard Insurance of New York 10237
05/11/2012 Added New Payer : Network Health-10626
05/09/2012 Added search type list BCBS AL-10025
05/08/2012 Modified search types for BCBS FL 10031
05/07/2012 Added Fresenius Medical Care 10602
05/07/2012 Added North Dakota Medicaid -10157
05/03/2012 Added and modified search options Delaware Medicaid 10293
05/02/2012 Removed Johns Hopkins search option 2-10267
04/30/2012 Added AARP - 10431
04/30/2012 Added CIGNA - 10062
04/30/2012 Added Medica - 10125
04/25/2012 Added Maryland Medicaid -10289
04/25/2012 Added MMSI (Mayo Health) 10144
December 30, 2013 X12N/005010/270 v1.7 671
Date Changes
04/25/2012 Added BCBS of Kansas - 10034
04/23/2012 Added BMC Health Net 10556
04/19/2012 Added United HealthCare 10002
04/19/2012 Added NEHEN-Harvard Pilgrim-10376
04/17/2012 Added payer HealthNet National 10385
04/16/2012 Updated Future Date criteria for Medicare - 10001
04/12/2012 Added Recall – Professional Benefit Administrators 10242
04/12/2012 Updated requirements for MN Medicaid - 10139
04/12/2012 Updated Payer: 10461, 10469, 10470 - Subscriber ID max from 12 to 15
04/11/2012 Added UMR (Wausau) 10501
04/11/2012 Added Aultcare - 10472
04/10/2012 Added New payer Universal Healthcare-10625
04/05/2012 Added Health Choice Arizona 10092
04/05/2012 Added National Association of Letter Carriers (NALC) 10149
04/03/2012 Deactivated Payer Mercy Care Health Plan-10465 (split into payerID 10219 and 10449)
04/02/2012 Added IL Medicaid-10102
04/02/2012 Added CO Medicaid -10065
04/02/2012 Added WV Medicaid-10200
04/02/2012 Added Select Health SC-10520
03/27/2012 Added BCBS of Louisiana 10035
03/23/2012 Added Physicians Mutual Insurance Company 10167
03/23/2012 Add Trustmark 10190
03/19/2012 Added BCBS of Vermont - 10624
03/19/2012 Added additional search option for Aetna - 10004
03/16/2012 Deactivated Recall – JP Farley Corporation – 10240 payer no longer supports EDI
03/12/2012 Added AvMed - 10024
03/09/2012 Added AmeriHealth Mercy Care-10340
03/09/2012 Added Horizon NJ Health-10337
03/09/2012 Added Keystone Mercy Health Plan (KMHP)-10300
03/09/2012 Added Pacific Source Health Plan-10375
03/09/2012 Added Passport Health Plan
03/09/2012 Added MVP-10148
03/08/2012 Added Blue Cross of Washington and Alaska -10326
03/07/2012 Added Nova Healthcare Administrators - 10537
03/07/2012 Added Recall – JP Farley Corporation - 10240
03/06/2012 Added BCBS of West Virginia – 10462
03/06/2012 Added Freedom Blue - 10502
03/02/2012 Added BCBS of New Jersey (Horizon) 10041
03/02/2012 Added Chesapeake National Life 10248
03/02/2012 Added Mid-West National Life 10129
03/02/2012 Added TransAmerica Life 10131
03/02/2012 Added Mega Life and Health Insurance 10127
02/29/2012 Added HealthNow (10500)
02/29/2012 Added Univera (10535)
02/29/2012 Added Independent Health (10536)
02/29/2012 Added Blue Shield of Northeastern New York (10499)
December 30, 2013 X12N/005010/270 v1.7 672
Date Changes
02/29/2012 Added BCBS of Western New York (10498)
02/27/2012 Added additional Service type codes-Aetna 10004
02/22/2012 Added Humana 10100
02/22/2012 Added Generations HealthCare
02/09/2012 Added Member ID comment to Wellpoint payers
02/08/2012 Added American Postal Workers Union Health Plan 10016
02/08/2012 Added Montana Medicaid 10147
02/08/2012 Added TexanPlus – North Texas Area 10604
02/08/2012 Added TexanPlus – Southeast Texas Area 10605
02/08/2012 Added Today’s Health 10606
02/08/2012 Added Today’s Options 10505
02/08/2012 Added Tribute/SelectCare of Oklahoma 10607
02/07/2012 Added payer HealthEase Kids 10511
02/07/2012 Added payer HealthEase 10510
02/07/2012 Added payer Ohana 10515
02/07/2012 Added payer Wellcare 10488
02/07/2012 Added payer Staywell Kids 10513
02/07/2012 Added payer StayWell 10512
02/01/2012 Removed Group Health Cooperative 10608 until later date
01/30/2012 Added BCBS of Oregon-10045
01/30/2012 Added Blue Cross of California-10051
01/30/2012 Added BCBS of Georgia-10032
01/30/2012 Added BCBS of Wisconsin-10299
01/30/2012 Added BCBS of Virginia-10049
01/30/2012 Added BCBS of Ohio-10044
01/30/2012 Added BCBS of New York (empire)-10043
01/30/2012 Added BCBS of New Hampshire-10261
01/30/2012 Added BCBS of Nevada-10260
01/30/2012 Added BCBS of Missouri-10322
01/30/2012 Added BCBS of Maine-10036
01/30/2012 Added BCBS of Kentucky-10259
01/30/2012 Added BCBS of Indiana-10258
01/30/2012 Added BCBS of Connecticut -10030
01/30/2012 Added BCBS of Colorado-10029
01/30/2012 Added Asuris Northwest Health-10529
01/30/2012 Added Delaware Medicaid, 10293
01/30/2012 Added Indiana Medicaid, 10103
01/30/2012 Added Kentucky Medicaid, 10117
01/30/2012 Added Minnesota Medicaid, 10139
01/30/2012 Added Oklahoma Medicaid, 10159
01/30/2012 Added Pennsylvania Medicaid, 10165
01/30/2012 Added North Carolina Medicaid, 10156
01/30/2012 Added New Jersey Medicaid, 10154
01/30/2012 Added Michigan Medicaid, 10136
01/30/2012 Added Wisconsin Medicaid, 10202
01/30/2012 Added Massachusetts Medicaid, 10124
December 30, 2013 X12N/005010/270 v1.7 673
Date Changes
02/22/2012 Added Humana 10100
01/30/2012 Added Louisiana Medicaid, 10118
01/30/2012 Added Arkansas Medicaid, 10023
01/30/2012 Added Washington Medicaid, 10424
01/30/2012 Added Unicare, 10285
01/30/2012 Added Carefirst BCBS, 10270
01/30/2012 Added BCBS of Tennessee, 10430
01/30/2012 Added payer Medicare, 10001
01/30/2012 Added payer Michigan Medicaid Pending Eligibility, 10392
01/30/2012 Added BCBS South Carolina, 10047
2/3/2012 Added Oxford Health Plan, 10161
01/30/2012 Added BCBS Alabama, 10025
01/30/2012 Added payer DC Medicaid, 10078
01/30/2012 Added payer Wyoming Medicaid, 10204
01/30/2012 Added new payer HealthScope, 10621
01/30/2012 Added Mississippi Medicaid, 10141
01/26/2012 Added Enrollment for BCBS KS 10034
01/26/2012 Added Recall Systems – Corporate Benefit Service 10411
01/26/2012 Added Group Health Cooperative 10608
01/22/2012 Added Gilsbar 10509
01/22/2012 Added Recall Group & Pension Administrators 10174
01/22/2012 Added Recall Underwriters Safety & Claims 10246
01/22/2012 Added Recall Boon-Chapman Benefit Admin 10414
01/22/2012 Added BCBS Nebraska 10384
01/22/2012 Added NY Medicaid 10155
01/18/2012 Added HealthFirst New Jersey 10438 and HealthFirst New York 10099
01/18/2012 Added Vermont Medicaid 10197
01/16/2012 Added VA Fee Basis Program 10196
01/16/2012 Added Assurant Health Time Insurance Company (FIC) 10087
01/16/2012 Added Assurant Health - Union Security Insurance Company (FBIC) 10227
01/16/2012 Added Assurant Health - John Alden Insurance Company (JALIC) 10230
01/13/2012 Corrected the Dep search option for BCBS of Utica – Watertown 10470
01/13/2012 Added BCBS of Alabama (Institutional) 10609
01/12/2012 Added PreferredOne 10169
01/12/2012 Added Medical Mutual of Ohio 10126
01/12/2012 Added Mutual of Omaha 10382
01/12/2012 Added BCBS of Massachusetts 10037
01/12/2012 Added Kaiser Foundation Health Plan of Colorado 10110
01/12/2012 Added Kaiser Foundation Health Plan of Hawaii 10111
01/12/2012 Added Kaiser Permanente of Georgia 10238
01/12/2012 Added Kaiser Foundation Health Plan of Ohio 10112
01/12/2012 Added Kaiser Foundation Health Plan of the Mid-Atlantic 10113
01/12/2012 Added Kaiser Foundation Health Plan of the Northwest 10114
01/12/2012 Added Kaiser Permanente of Northern CA 10115 and Kaiser Permanente of Southern CA 10239
01/05/2012 Deleted Employee ID search option for Aetna 10004; 5010 guide no longer supports qualifier of A6
REF segment. Therefore, this ID would need to be sent in the NM109 segment with an MI qualifier
December 30, 2013 X12N/005010/270 v1.7 674
Date Changes
in NM108
12/27/2011 Added BCBS Arkansas 10028
12/27/2011 Added Florida Medicaid 10086
12/27/2011 Added BCBS of Florida 10031
12/27/2011 Added BCBS of Illinois 10033
12/27/2011 Added BCBS of Minnesota 10039
12/27/2011 Added BCBS of New Mexico 10042
12/27/2011 Added BCBS of Texas 10048
12/27/2011 Added BCBS of Oklahoma 10582
12/27/2011 Added FamilyCare 10427
12/27/2011 Added Blue Cross Northeastern Pennsylvania 10264
12/27/2011 Added John Hopkins Health Plan 10267
12/27/2011 Added Health Alliance Medical Plans (HAP) 10308
12/27/2011 Added BCBS of New York (Excellus) 10323
12/27/2011 Added Virginia Medicaid 10198
12/19/2011 Added Federated Insurance Company - 10083
12/16/2011 Added Blue Cross Pennsylvania (Capital) - 10325
12/15/2011 Updated Optima/Sentara Member ID length min/max to 9-11
12/14/2011 Updated Optima/Sentara Member ID length from 12 to 9 char
12/7/2011 Added Blue Shield of California - 10053
12/7/2011 Added Connecticut Medicaid - 10067
12/7/2011 Added BCBS of Utica-Watertown (NY) - 10470
12/7/2011 Added BCBS of the Rochester Area - 10469
12/7/2011 Added BCBS of Central New York - 10461
12/7/2011 Added Florida Hospital Healthcare System - 10333
12/7/2011 Added Healthcare Solutions Group - 10463
12/7/2011 Added Mercy Health Care Plan - 10465
12/7/2011 Added Capital District Physicians’ Health Plan (CDPHP) - 10458
12/7/2011 Added Viva Health Plan - 10468
12/7/2011 Added Geisinger Health Plan – 10611, 10612
12/7/2011 Added Cook Children’s Health Plan - 10610
12/7/2011 Added Windsor Medicare Extra - 10576
12/06/2011 Added Health Partners-10484
11/25/2011 Created
