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April 3, 2014
Companion Guide Version 1.1
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/.
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X12N/005010/270 v1.1
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 ASCX12s 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.
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This page is intentionally left blank.
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Table of Contents
INTRODUCTION .................................................................................................................................................................. 7
Scope ................................................................................................................................................................................................. 7
Overview ........................................................................................................................................................................................... 7
References ......................................................................................................................................................................................... 7
Additional Information ...................................................................................................................................................................... 8
ACKNOWLEDGEMENTS.................................................................................................................................................... 20
TRANSACTION SPECIFIC INFORMATION ........................................................................................................................ 20
Aetna 10004 ................................................................................................................................................................................. 21
AFLAC Dental 10398 .................................................................................................................................................................. 24
Alan Sturm and Associates - Dental - 10798 .................................................................................................................................. 26
Altus Dental - 10786 ....................................................................................................................................................................... 27
BCBS of Alabama 10025 ............................................................................................................................................................. 28
BCBS of Alabama (Institutional) 10609 ...................................................................................................................................... 30
BCBS of Arizona 10027 .............................................................................................................................................................. 32
BCBS of Arkansas 10028 ............................................................................................................................................................ 34
BCBS of Central New York 10461 .............................................................................................................................................. 36
BCBS of Colorado (Wellpoint Anthem) 10029 ........................................................................................................................... 38
BCBS of Connecticut (Wellpoint Anthem) 10030 ....................................................................................................................... 40
BCBS of Georgia 10032 .............................................................................................................................................................. 42
BCBS of Indiana (Wellpoint Anthem) 10258 .............................................................................................................................. 44
BCBS of Kansas 10034 ................................................................................................................................................................ 46
BCBS of Kansas City 10473 ........................................................................................................................................................ 48
BCBS of Kentucky (Wellpoint Anthem) 10259 .......................................................................................................................... 50
BCBS of Maine (Wellpoint Anthem) 10036 ................................................................................................................................ 52
BCBS of Michigan (Institutional) 10519 ..................................................................................................................................... 54
BCBS of Michigan (Professional) 10038 ..................................................................................................................................... 56
BCBS of Missouri (Wellpoint Anthem) 10322 ............................................................................................................................ 58
BCBS of Nevada (Wellpoint Anthem) 10260 .............................................................................................................................. 60
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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.
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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 Years 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 Years Day
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Day after Thanksgiving
Christmas Day
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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 support@exchangeedi.com to receive password information for the testing accounts as well as the Testing
Functionality Guide.
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Process Flow
Trading
Partner
EDI
XML
Common
Connectivity Interface
Exchange EDI
TransUnion
Healthcare
Clearinghouse
SNA
MQSeries
HTTPS
Socket
Web Service
Payer
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Payer
Payer
Payer
X12N/005010/270 v1.1
Payer
10
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.
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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 partners 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 partners 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 payers 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.
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12
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 Methods
SubmitSync (Preferred Method)
SubmitAsync
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13
GetResponses
GetResponsesBySubmissionID
GetResponsesByTrackingID
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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.
Please contact support@exchangeedi.com to receive password information for the testing accounts as well as the Testing
Functionality Guide.
Please contact support@exchangeedi.com for web portal user name/password assistance.
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Contact Information
Exchange EDI Insurance Eligibility Support
Email: support@exchangeedi.com
Phone: (877) 732-6853
Hours of Operation: 8am to 5pm EST
Contact us for:
Applicable Websites
Exchange EDI: http://www.exchangeedi.com
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Delimiters
There are no restrictions on delimiters you can use when exchanging transactions with Exchange EDI. 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: *
that were used for the request.
Sub Element: : The response interchange will contain the same delimiters
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 Exchange EDI.
Element Name
Min
Max
Type
ISA01
ID
00
ISA02
10
10
AN
ISA03
ID
00
ISA04
10
10
AN
ISA05
ID
ZZ
ISA06
15
15
AN
User Defined
ISA07
ID
30
ISA08
15
15
AN
204202692
ISA Segment
Data Type:
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.
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17
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.
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18
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.
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19
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 members coverage.
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Aetna 10004
Search Options
Element 2
Element 3
Option
Element 1
Subscriber
Member ID (CUMB
ID)
Subscriber
Member ID (HMO)
Subscriber
Member ID (SSN)
Date of Birth
Subscriber
SSN
Date of Birth
Subscriber
Last Name
First Name
Dependent
Sub: Member ID
(CUMB ID)
Dependent
Sub: Member ID
(SSN)
Dependent
Sub: SSN
Dependent
Sub: Member ID
(CUMB ID)
10 Dependent
Element 4
Element 5
Date of Birth
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10004
2100B
NM1
Information Receiver
2100B
NM103
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21
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
2100C
XX
2
10
National Provider ID
Last Name
60
NM104
First Name
35
NM108
MI
2
Search options: #1, #6, and #10
2100C
NM109
2100C
NM108
12
MI
2
Search Option: #2
2100C
NM109
Member ID (HMO)
2100C
NM108
2100C
NM109
Member ID (SSN)
2100C
REF01
2100C
REF02
SSN
2100C
REF01
2100C
REF02
Group Number
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13
MI
2
9
SY
2
9
6P
2
17
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Search options:
2100C
DMG02
Date of Birth
CCYYMMDD
8
#1, #3, #4, and #5
Up to 2 years in the Past.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
2100D
NM1
Dependent Name
2100D
NM103
Last Name
60
2100D
NM104
First Name
35
2100D
REF01
2100D
REF02
Group Number
2100D
DMG02
Date of Birth
6P
2
17
CCYYMMDD
DTP03
Service Date
CCYYMMDD
2100D
EQ01
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Element 1
Element 2
Element 3
Element 4
1 Subscriber
Member ID
Last Name
First Name
Date of Birth
2 Dependent
Sub: Member ID
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10398
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
National Provider ID
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
20
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
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2100C
EQ01
30
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
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Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10798
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
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EQ01
30, 35
2
26
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10786
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
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EQ01
30, 35
2
27
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Codes
2100A
NM108
2100A
NM109
Payer ID
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
Information Receiver ID
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
10025
Length Notes/Comments
60
XX
10
National Provider ID
Last Name
24
Search Option: #1
NM104
First Name
24
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
24
2100C
DMG02
Date of Birth
Search Option: #1
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DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
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EQ01
35
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Option
Element 1
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
2100B
NM109
NM1
Payer ID
Information Receiver
10609
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
National Provider ID
Last Name
24
Search Option: #1
NM104
First Name
24
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
24
CCYYMMDD 8
2100C
DTP03
Service Date
CCYYMMDD 8
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2100C
EQ01
35
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
Up to 1 year in the Past is
allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
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Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10027
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
Information Receiver ID
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
10
NPI if NM108 = XX
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
12
CCYYMMDD 8
2100C
DTP03
Service Date
CCYYMMDD 8
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2100C
EQ01
35
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
Up to 14 days in the Past is allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
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X12N/005010/270 v1.1
33
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10028
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
Information Receiver ID
Qualifier
2100B
NM109
NPI, Provider ID
Notes/Comments
60
XX, SV
Provider ID if NM108 = SV
10
NPI if NM108 = XX
2100B
REF01
Reference Identification
Qualifier
2100B
REF02
Submitter ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
2100C
EO
10
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
NM108
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X12N/005010/270 v1.1
34
2100C
NM109
Member ID
20
2100C
REF01
Reference Identification
Qualifier
2100C
REF02
SSN
2100C
DMG02
Date of Birth
SY
9
CCYYMMDD 8
Search Option: #1
Up to 1 year in the Past is allowed.
2100C
DTP03
Service Date
CCYYMMDD 8
2100C
EQ01
35
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
2100D
REF02
SSN
2100D
DMG02
Date of Birth
SY
9
CCYYMMDD 8
Search Option: #2
Up to 1 year in the Past is allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
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Option
Element 1
Element 2
Search Options
Element 3
Subscriber
Member ID
Last Name
Element 4
Element 5
First Name
Date of Birth
Gender
Dep: Gender
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10461
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
Information Receiver ID
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
10
National Provider ID
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
15
CCYYMMDD 8
M = Male
2100C
DMG03
Gender
Search Option #1
F = Female
April 3, 2014
X12N/005010/270 v1.1
36
DTP03
Service Date
CCYYMMDD 8
2100C
EQ01
35
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
M = Male
2100D
DMG03
Gender
Search Option: #2
F = Female
Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
37
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10029
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
80
CCYYMMDD 8
X12N/005010/270 v1.1
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
Search Option: #1
38
DTP03
Service Date
CCYYMMDD 8
2100C
EQ01
2100D
NM1
Dependent Name
NM103
Last Name
35
Search Option: #2
2100D
NM104
First Name
25
Search Option: #2
2100D
DMG02
Date of Birth
2100D
35
CCYYMMDD 8
Search Option: #2
No Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
39
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
Reference
Element Name
2100A
NM1
Information Source
2100A
NM108
2100A
Element 3
Element 4
Codes
Length
PI
NM109
Payer ID
10030
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
80
CCYYMMDD 8
X12N/005010/270 v1.1
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
Search Option: #1
40
DTP03
Service Date
CCYYMMDD 8
2100C
EQ01
35
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
No Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
41
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10032
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
MI
80
CCYYMMDD 8
X12N/005010/270 v1.1
42
DTP03
Service Date
CCYYMMDD 8
2100C
EQ01
35
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
No Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
43
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10258
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
2100C
DMG03
Gender
MI
2
80
CCYYMMDD 8
M=Male
1
Optional
F=Female
April 3, 2014
X12N/005010/270 v1.1
44
DTP03
Service Date
CCYYMMDD 8
2100C
EQ01
35
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
M=Male
2100D
DMG03
Gender
Optional
F=Female
No Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
45
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10034
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
National Provider ID
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
20
CCYYMMDD 8
2100C
DTP03
Service Date
CCYYMMDD 8
April 3, 2014
X12N/005010/270 v1.1
46
2100C
EQ01
35
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
Up to 2 years in the Past
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
47
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10473
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
National Provider ID
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
20
CCYYMMDD 8
2100C
DTP03
Service Date
CCYYMMDD 8
April 3, 2014
X12N/005010/270 v1.1
48
2100C
EQ01
35
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
Up to 2 years in the Past
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
49
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10259
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
80
CCYYMMDD 8
X12N/005010/270 v1.1
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
Search Option: #1
50
DTP03
Service Date
CCYYMMDD 8
2100C
EQ01
35
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
No Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
51
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10036
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
80
CCYYMMDD 8
X12N/005010/270 v1.1
Alphanumeric subscriber ID as it
appears on the front of the ID
card and must include the alpha
prefix as submitted.
Search Option: #1
52
DTP03
Service Date
CCYYMMDD 8
2100C
EQ01
35
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
No Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
53
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Element 3
Element 4
Loop ID
2100A
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10519
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
Information Receiver ID
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
10
National Provider ID
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
Reference Identification
Qualifier
2100C
REF02
Group Number
April 3, 2014
MI
2
20
6P
30
X12N/005010/270 v1.1
54
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
55
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10038
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
Information Receiver ID
Qualifier
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
10
National Provider ID
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
Reference Identification
Qualifier
2100C
REF02
Group Number
April 3, 2014
MI
2
20
6P
30
X12N/005010/270 v1.1
56
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
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
2100D
REF02
Group Number
2100D
DMG02
Date of Birth
CCYYMMDD
2100D
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
35
April 3, 2014
35
6P
30
X12N/005010/270 v1.1
Search Option: #2
57
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10322
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
58
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
59
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10260
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
60
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
61
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10261
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
62
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
2100D
NM1
Dependent Name
2100D
NM103
2100D
2100D
35
Last Name
35
Search Option: #2
NM104
First Name
25
Search Option: #2
DMG02
Date of Birth
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
63
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10043
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
64
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
65
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10323
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
National Provider ID
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
80
Search Option: #1
Up to 90 days in the Past
2100C
DTP03
Service Date
CCYYMMDD
April 3, 2014
X12N/005010/270 v1.1
66
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
67
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Element 3
Element 4
Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10383
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
10
National Provider ID
Last Name
60
NM104
First Name
35
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
April 3, 2014
MI
CCYYMMDD
X12N/005010/270 v1.1
2
12
68
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #3
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
69
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10044
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
70
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
71
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
Subscriber
Member ID
Date of Birth
Dependent
Sub: Member ID
Dependent
Sub: Member ID
Element 3
Element 4
First Name
Date of Birth
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10047
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
FI, XX
10
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
60
Search Option: #1
2100C
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
MI
2
Search options:
17
#1, #2, #3, and #4
April 3, 2014
X12N/005010/270 v1.1
72
2100C
DMG02
Date of Birth
CCYYMMDD
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
73
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Last Name
First Name
Date of Birth
Gender
Dependent
Sub: Member ID
Dep: Gender
Element 4
Element 5
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10469
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
National Provider ID
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
2100C
DMG03
Gender
MI
CCYYMMDD
2
15
Search Option: #1
Search Option: #1
M=Male
F=Female
April 3, 2014
X12N/005010/270 v1.1
74
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
Search Option: #2
CCYYMMDD
M=Male
2100D
DMG03
Gender
F=Female
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
75
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Last Name
First Name
Date of Birth
Gender
Dependent
Sub: Member ID
Dep: Gender
Element 4
Element 5
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10470
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
National Provider ID
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
2100C
DMG03
Gender
MI
CCYYMMDD
2
15
Search Option: #1
Search Option: #1
M=Male
F=Female
April 3, 2014
X12N/005010/270 v1.1
76
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
Search Option: #2
CCYYMMDD
M=Male
2100D
DMG03
Gender
F=Female
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
77
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10049
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
78
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
79
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Codes
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10299
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
April 3, 2014
Member ID
80
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
80
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
35
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
Search Option: #2
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
81
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10803
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100C
NM1
Subscriber Name
2100C
NM103
2100C
Notes/Comments
60
XX
2
10
National Provider ID
Last Name
35
Search Option: #1
NM104
First Name
25
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
2
20
CCYYMMDD 8
2100C
DTP03
Service Date
CCYYMMDD 8
April 3, 2014
X12N/005010/270 v1.1
82
Last Name
35
Search Option: #2
NM104
First Name
25
Search Option: #2
DMG02
Date of Birth
2100C
EQ01
2100D
NM1
Dependent Name
2100D
NM103
2100D
2100D
35
CCYYMMDD 8
Search Option: #2
Past Dates allowed.
2100D
DTP03
Dependent Date
CCYYMMDD 8
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
83
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Element 3
Element 4
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10051
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
Notes/Comments
60
SV, XX
2
Provider ID if NM108 = SV
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
MI
2
Search options: #1 and #2
2100C
NM109
April 3, 2014
Member ID
12
X12N/005010/270 v1.1
Alphanumeric subscriber ID
as it appears on the front of
the ID card and must include
the alpha prefix as
submitted.
84
2100C
DMG02
Date of Birth
CCYYMMDD
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
Last Name
35
Search Option: #2
NM104
First Name
25
Search Option: #2
DMG02
Date of Birth
Search Option: #2
2100C
EQ01
2100D
NM1
Dependent Name
2100D
NM103
2100D
2100D
35
CCYYMMDD
DTP03
Dependent Date
CCYYMMDD
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
85
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10783
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
86
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Date of Birth
Subscriber
Member ID
Last Name
Subscriber
SSN
Date of Birth
Subscriber
SSN
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
State
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dependent
Sub: Member ID
Element 4
First Name
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10806
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
April 3, 2014
Element 5
X12N/005010/270 v1.1
Dep: State
Notes/Comments
60
XX, FI, SV
10
National Provider ID if
NM108=XX. Federal Tax
ID if NM108=FI.
Provider ID if
87
NM108=SV.
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
2100C
NM104
First Name
25
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
2100C
REF02
2100C
REF01
2100C
REF02
Group Number
Optional, but
recommended.
2100C
N402
State
Search Option #5
2100C
DMG02
Date of Birth
MI
SY
2
9
6P
CCYYMMDD
Up to 18 months in the
Past
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
2100D
NM1
Dependent Name
April 3, 2014
X12N/005010/270 v1.1
35
88
2100D
NM103
Last Name
35
Search Options #7
2100D
NM104
First Name
25
2100D
REF01
2100D
REF02
2100D
REF01
2100D
REF02
Group Number
30
Optional, but
recommended.
2100D
N402
State
Search Option #8
2100D
DMG02
Date of Birth
SY
2
9
6P
CCYYMMDD
Optional
Up to 18 months in the
Past
2100D
DTP03
Dependent Date
2100D
EQ01
April 3, 2014
X12N/005010/270 v1.1
35
89
Option
Element 1
Search Options
Element 2
Subscriber
Member ID
Last Name
First Name
Subscriber
Member ID
Last Name
Date of Birth
Subscriber
Member ID
Last Name
First Name
Subscriber
Member ID
Date of Birth
Subscriber
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dependent
Sub: Member ID
Dependent
Sub: Member ID
Dependent
Sub: Member ID
10
Dependent
Element 3
Element 4
Date of Birth
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10062
2100B
NM1
Information Receiver
2100B
NM103
April 3, 2014
X12N/005010/270 v1.1
Notes/Comments
60
90
2100B
NM108
2100B
NM109
FI, XX
NM1
Subscriber Name
2100C
NM103
Last Name
35
2100C
NM104
First Name
25
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
24
CCYYMMDD 8
2100C
DTP03
Service Date
CCYYMMDD 8
Up to 30 days in the future.
No Date Ranges allowed.
2100C
EQ01
2100D
NM1
Dependent Name
2100D
NM103
Last Name
35
2100D
NM104
First Name
25
2100D
DMG02
Date of Birth
CCYYMMDD 8
2100D
DTP03
Dependent Date
CCYYMMDD 8
April 3, 2014
35
X12N/005010/270 v1.1
stored.
Up to 30 days in the future.
No Date Ranges allowed.
2100D
EQ01
April 3, 2014
35
X12N/005010/270 v1.1
92
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10780
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
93
Delta Dental
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Payer Name
Payer ID
10709
10725
10710
10726
10711
10727
10712
10728
10713
10729
10714
10730
10715
10731
10716
10732
10717
10733
10705
10734
10718
10735
10719
10736
10720
10737
10721
10738
10722
10739
10723
10740
10724
10741
Note: Delta Dental of Minnesota includes Delta MN Capitation, Delta MN DeltaCare Claims, Delta MN National Claims,
Delta MN/Wells Fargo Claims, Delta USA Dental Claims Plan 005 MN
April 3, 2014
X12N/005010/270 v1.1
94
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length Notes/Comments
2100A
NM108
PI
2
Exchange EDI Payer ID
2100A
NM109
Payer ID
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
Reference Indentification
Qualifier
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
95
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10787
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
96
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10784
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
97
Evercare 10807
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Date of Birth
Subscriber
Member ID
Last Name
Subscriber
SSN
Date of Birth
Subscriber
SSN
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
State
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dependent
Sub: Member ID
Element 4
First Name
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10807
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
April 3, 2014
Element 5
X12N/005010/270 v1.1
Dep: State
Notes/Comments
60
XX, FI, SV
10
National Provider ID if
NM108=XX. Federal Tax
ID if NM108=FI.
Provider ID if
NM108=SV.
98
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
2100C
NM104
First Name
25
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
2100C
REF02
2100C
REF01
2100C
REF02
Group Number
Optional, but
recommended.
2100C
N402
State
Search Option #5
2100C
DMG02
Date of Birth
MI
SY
2
9
6P
CCYYMMDD
Up to 18 months in the
Past
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
2100D
NM1
Dependent Name
2100D
NM103
Last Name
April 3, 2014
35
35
X12N/005010/270 v1.1
Search Options #7
99
2100D
NM104
First Name
25
2100D
REF01
2100D
REF02
2100D
REF01
2100D
REF02
Group Number
30
Optional, but
recommended.
2100D
N402
State
Search Option #8
2100D
DMG02
Date of Birth
SY
2
9
6P
CCYYMMDD
Optional
Up to 18 months in the
Past
2100D
DTP03
Dependent Date
2100D
EQ01
April 3, 2014
X12N/005010/270 v1.1
35
100
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10799
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
101
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10811
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
102
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10781
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
103
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10788
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
104
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10785
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
105
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Date of Birth
Subscriber
Member ID
Last Name
Subscriber
SSN
Date of Birth
Subscriber
SSN
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
State
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dependent
Sub: Member ID
Element 4
First Name
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10804
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
April 3, 2014
Element 5
X12N/005010/270 v1.1
Dep: State
Notes/Comments
60
XX, FI, SV
10
National Provider ID if
NM108=XX. Federal Tax
ID if NM108=FI.
Provider ID if
NM108=SV.
106
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
2100C
NM104
First Name
25
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
2100C
REF02
2100C
REF01
2100C
REF02
Group Number
Optional, but
recommended.
2100C
N402
State
Search Option #5
2100C
DMG02
Date of Birth
MI
SY
2
9
6P
CCYYMMDD
Up to 18 months in the
Past
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
2100D
NM1
Dependent Name
2100D
NM103
Last Name
April 3, 2014
35
35
X12N/005010/270 v1.1
Search Options #7
107
2100D
NM104
First Name
25
2100D
REF01
2100D
REF02
2100D
REF01
2100D
REF02
Group Number
30
Optional, but
recommended.
2100D
N402
State
Search Option #8
2100D
DMG02
Date of Birth
SY
2
9
6P
CCYYMMDD
Optional
Up to 18 months in the
Past
2100D
DTP03
Dependent Date
2100D
EQ01
April 3, 2014
X12N/005010/270 v1.1
35
108
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10789
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
109
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10795
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
110
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10134
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
111
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10782
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
112
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10790
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
113
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10792
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
114
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10793
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
115
TennDent - 10794
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10794
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
116
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10791
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
117
Option
Element 1
Search Options
Element 2
Element 3
Subscriber
Member ID
Date of Birth
Subscriber
Member ID
Last Name
Subscriber
SSN
Date of Birth
Subscriber
SSN
Last Name
First Name
Subscriber
Last Name
First Name
Date of Birth
State
Subscriber
Member ID
Last Name
First Name
Date of Birth
Dependent
Sub: Member ID
Dependent
Sub: Member ID
Element 4
Element 5
First Name
Dep: State
Note: UHC Payer ID 10002 supports Health Plan of Nevada and SierraHealth (UHC Nevada)
Loop ID
2100A
Reference
NM1
Element Name
Information Source
Codes
Length
2100A
NM108
PI
2100A
NM109
Payer ID
10002
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
April 3, 2014
X12N/005010/270 v1.1
Notes/Comments
60
XX, FI, SV
10
National Provider ID if
NM108=XX. Federal Tax
ID if NM108=FI.
Provider ID if
NM108=SV.
118
2100C
NM1
Subscriber Name
2100C
NM103
Last Name
35
2100C
NM104
First Name
25
2100C
NM108
2100C
NM109
Member ID
2100C
REF01
2100C
REF02
2100C
REF01
2100C
REF02
Group Number
Optional, but
recommended.
2100C
N402
State
Search Option #5
2100C
DMG02
Date of Birth
MI
SY
2
9
6P
CCYYMMDD
Up to 18 months in the
Past
2100C
DTP03
Service Date
CCYYMMDD
2100C
EQ01
2100D
NM1
Dependent Name
2100D
NM103
Last Name
April 3, 2014
35
35
X12N/005010/270 v1.1
Search Options #7
119
2100D
NM104
First Name
25
2100D
REF01
2100D
REF02
2100D
REF01
2100D
REF02
Group Number
30
Optional, but
recommended.
2100D
N402
State
Search Option #8
2100D
DMG02
Date of Birth
SY
2
9
6P
CCYYMMDD
Optional
Up to 18 months in the
Past
2100D
DTP03
Dependent Date
2100D
EQ01
April 3, 2014
X12N/005010/270 v1.1
35
120
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10810
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
121
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10809
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
122
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10797
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
123
Option
Element 1
Search Options
Element 2
Element 3
Element 4
Subscriber
Member ID
Last Name
First Name
Date of Birth
Loop ID
2100A
Codes
Length Notes/Comments
2100A
NM108
PI
2100A
NM109
Payer ID
10796
2100B
NM1
Information Receiver
2100B
NM103
2100B
NM108
2100B
NM109
NPI
2100B
REF01
2100B
REF02
Provider Tax ID
2100C
NM1
Subscriber Name
2100C
NM103
2100C
60
XX
2
10
TJ
NPI if NM108 = XX
2
9
Last Name
60
Search Option: #1
NM104
First Name
35
Search Option: #1
2100C
NM108
2100C
NM109
Member ID
2100C
DMG02
Date of Birth
MI
CCYYMMDD
2
9
Search Option: #1
Search Option: #1
No Past Dates allowed.
2100C
DTP03
Service Date
CCYYMMDD
2100C
April 3, 2014
EQ01
30, 35
2
124
Payer
BCBS of Alabama
BCBS of Michigan
April 3, 2014
Enrollment Process
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.
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 EDISupport@bcbsm.com.
b.
Note: If a provider doesnt know their User
ID and password, they can contact BCBS MI at
800.542.0945, option 3 or email
EDISupport@bcbsm.com 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 = Providers NPI
c.
Source of Payment = Blue Cross Blue Shield
d.
Submitter ID = c0ina (thats 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 wont send another email. Transactions
should work in 48 hours.
X12N/005010/270 v1.1
Estimated Timeframe
2 weeks
48 hours, at discretion of
BCBS MI
125
Payer Name
Aetna
AFLAC Dental
Alan Sturm and Associates - Dental
10786
Altus Dental
10609
10027
10028
10461
10029
10030
10032
BCBS of Arizona
BCBS of Arkansas
BCBS of Central New York
BCBS of Colorado (Wellpoint)
BCBS of Connecticut (Wellpoint)
BCBS of Georgia
10258
10034
BCBS of Kansas
10473
10259
10036
10519
10038
10322
10260
No Stated Downtime
10261
No Stated Downtime
10043
10323
10302
April 3, 2014
Stated Downtime
Sunday 4:00 am 12:00 pm (Eastern)
No Stated Downtime
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Mon Fri 12:01 am 6:00 am, Sat 12:00 pm Mon
6:00 am (Central)
Sun 12:00am 12:00 pm (central)
Mon Sat 12am to 6am (Central) Sat (all day)
No Stated Downtime
No Stated Downtime
No Stated Downtime
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)
Down all day Sunday 12am 11:59pm (Eastern)
Sat 12 am - Mon 5am (Central)
Sun 6 pm 11:59 pm
Mon - Sat 12am 2am
All times Central
Down all day Sunday 12am 11:59pm (Eastern)
No Stated Downtime
Mon Sat 1:00 am 6:59 am, Sunday and Holidays
6:00 pm 7:00 am (Eastern)
Mon Sat 1:00 am 6:59 am, Sunday and Holidays
6:00 pm 7:00 am (Eastern)
X12N/005010/270 v1.1
126
ID
10044
Payer Name
BCBS of Ohio (Wellpoint)
10047
10469
No Stated Downtime
10470
No Stated Downtime
10299
10051
10803
10783
10806
10062
CIGNA
10780
10709
10710
10711
10712
10713
10714
10715
10716
10717
10705
10718
10719
10720
April 3, 2014
Stated Downtime
Down all day Sunday 12am 11:59pm (Eastern)
Sunday 3:00pm-10:00pm (Eastern)
X12N/005010/270 v1.1
No Stated Downtime
No Stated Downtime
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
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)
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)
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
127
ID
10721
Payer Name
Delta Dental of Hawaii
10722
10723
10724
10725
10726
10727
10728
10729
10730
10731
10732
10733
10734
10735
10736
10737
10738
10739
10740
10741
10787
10784
April 3, 2014
X12N/005010/270 v1.1
Stated Downtime
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
128
ID
10807
Payer Name
Evercare
10811
10781
10788
10785
10804
10789
10795
10134
10782
MetLife Dental
Patriot Dental
10790
10792
Securian Dental
10793
Securian/Patriot Dental
10794
TennDent
10791
UNICARE - Dental
10810
10809
10002
United Healthcare
10797
10796
April 3, 2014
X12N/005010/270 v1.1
Stated Downtime
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)
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
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)
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
Thursdays between 8 PM and 10 PM Pacific Time
Sundays between 12 AM and 4 AM Pacific Time
129
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>
April 3, 2014
X12N/005010/270 v1.1
130
Response Formats
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" />
April 3, 2014
X12N/005010/270 v1.1
131
<EB EB01="G" EB02="" EB03.1="30" EB04="" EB05="STANDARD" EB06="23" EB07="5000" EB08="" EB09="" EB10=""
EB11="" EB12="Y" />
<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">
April 3, 2014
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April 3, 2014
X12N/005010/270 v1.1
133
</EB>
<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=""
EB11="" EB12="Y">
<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>
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<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"
ISA03_TEXT="No Security Information Present (No Meaningful Information in I04)" ISA04="
" ISA05="ZZ" ISA05_TEXT="Mutually
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"
BHT02_TEXT="Response" BHT03="ABC123" BHT04="20130809" BHT05="131926" />
<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
Segment in This Hierarchical Structure.">
<NM1 NM101="1P" NM101_TEXT="Provider" NM102="2" NM102_TEXT="Non-Person Entity" NM103="SMITH" NM104=""
NM105="" NM106="" NM107="" NM108="XX" NM108_TEXT="Health Care Financing Administration National Provider Identifier"
NM109="ABC123">
<REF REF01="TJ" REF01_TEXT="Federal Taxpayer's ID" REF02="ABC123" />
</NM1>
<HL HL01="3" HL02="2" HL03="22" HL03_TEXT="Subscriber" HL04="0" HL04_TEXT="No Subordinate HL Segment in This
Hierarchical Structure.">
<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"
DMG03_TEXT="Male" />
<DTP DTP01="291" DTP01_TEXT="Plan" DTP02="RD8" DTP02_TEXT="Range of Dates Expressed in Format CCYYMMDDCCYYMMDD" DTP03="19900101-99991231" />
<EB EB01="1" EB01_TEXT="Active Coverage" EB02="IND" EB02_TEXT="Individual" EB03.1="30" EB03.1_TEXT="Health
Benefit Plan Coverage" EB04="PR" EB04_TEXT="Preferred Provider Organization (PPO)" EB05="STANDARD">
<DTP DTP01="291" DTP01_TEXT="Plan" DTP02="RD8" DTP02_TEXT="Range of Dates Expressed in Format CCYYMMDDCCYYMMDD" DTP03="19900101-99991231" />
</EB>
<EB EB01="P" EB01_TEXT="Benefit Disclaimer">
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<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
Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" 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="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
Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="350" 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="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
Plan Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="2281" EB08="" EB09=""
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
Plan Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" EB07="4225.4" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No" />
<EB EB01="G" EB01_TEXT="Out of Pocket (Stop Loss)" EB02="" EB02_TEXT="" EB03.1="30" EB03.1_TEXT="Health Benefit
Plan Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="5000" EB08="" EB09=""
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
Plan Coverage" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="23" EB06_TEXT="Calendar Year" EB07="7000" EB08="" EB09=""
EB09_TEXT="" EB10="" EB11="" EB11_TEXT="" EB12="N" EB12_TEXT="No" />
<EB EB01="1" EB01_TEXT="Active Coverage" EB02="" EB02_TEXT="" EB03.1="1" EB03.1_TEXT="Medical Care" EB03.2="MH"
EB03.2_TEXT="Mental Health" EB03.3="35" EB03.3_TEXT="Dental Care" EB03.4="88" EB03.4_TEXT="Pharmacy" EB04="" EB04_TEXT=""
EB05="STANDARD" />
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="33" EB03.1_TEXT="Chiropractic"
EB03.2="98" EB03.2_TEXT="Professional (Physician) Visit - Office" 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" />
<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"
EB06="27" EB06_TEXT="Visit" EB07="" EB08=".35" />
<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=""
EB04_TEXT="" EB05="STANDARD" EB06="29" EB06_TEXT="Remaining" 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>
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<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital Inpatient" 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" />
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital Inpatient" 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" />
</EB>
<EB EB01="B" EB01_TEXT="Co-Payment" EB02="IND" EB02_TEXT="Individual" EB03.1="48" EB03.1_TEXT="Hospital Inpatient" EB04="" EB04_TEXT="" EB05="STANDARD" EB06="36" EB06_TEXT="Admission" EB07="350" EB08="" EB09=""
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 Inpatient" 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" />
</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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EdiXmlExtHtml
Xml Schema of Response:
<EdiXmlExtHtml>
<EdiTransmission></EdiTransmission>
<html></html>
<ResponseResult></ResponseResult>
</EdiXmlExtHtml>
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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.
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>
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<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>
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<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>
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</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>
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</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>
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<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>
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<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>
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<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>
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<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>
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</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.
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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>
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>
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<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>
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=UTF8;action="http://services.medconnect.net/submissionportal/SubmitSync"
User-Agent: Jakarta Commons-HttpClient/3.1
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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>
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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Changes
03/21/2014
03/21/2014
03/21/2014
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03/20/2014
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03/20/2014
03/20/2014
Added New Payer: United Concordia Federal Employees Program - Dental 10809
03/20/2014
03/20/2014
3/12/2014
3/12/2014
Added New Payer: Group Health Cooperative of South Central Wisconsin - Dental - 10781
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
Added New Payer: Guardian Life Insurance Co. of America - Dental - 10788
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
3/12/2014
2/28/2014
Added Payers MetLife Dental Payer ID 10134 and AFLAC Dental payer ID 10398
2/28/2014
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2/28/2014
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02/25/2014
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