Health Care Ideas: 271–5010 Health Care Eligibility Benefit Response

Use this segment to identify an entity by name and/or identification number. Use this NM1 loop to identify the insured or subscriber

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	NM1	Subscriber Name	ID	3		R	NM1
		Element Separator	AN	1			*
	NM101	Entity Identifier Code	ID	2/3	98	R	IL
		Element Separator	AN	1			*
	NM102	Entity Type qualifier	ID	1/1	1065	R	1
		Element Separator	AN	1			*
	NM103	Name Last or Organization Name	AN	1/60	1035	R	Insured Person Last Name
		Element Separator	AN	1			*
	NM104	Name First	AN	1/35	1036	S	Insured Person First Name
		Element Separator	AN	1			*
	NM105	Name Middle	AN	1/25	1037	S	Insured Person Middle Name
		Element Separator	AN	1			*
	NM106	Name Prefix	AN	1/10	1038	Not used
		Element Separator	AN	1			*
	NM107	Name Suffix	AN	1/10	1039	S	Insured Person Suffix
		Element Separator	AN	1			*
	NM108	Identification code Qualifier	ID	1/2	66	R	MI
		Element Separator	AN	1			*
	NM109	Identification code	AN	2/80	67	R	Insured Policy No
		Segment Terminator					~

NM102 - Entity Type Qualifier

Code qualifying the type of entity

Sample
NM1*IL*1*MULLIN*DANIEL****MI*XJBH12345678~

Segment Structure

SUBSCRIBER Additional identification

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	REF	Reference Identification	ID	3		R	REF
		Element Separator	AN	1			*
	REF01	Reference Identification qualifier	ID	2/3	128	R	See below for valid values
		Element Separator	AN	1			*
	REF02	Reference Identification	AN	1/50	127	R	Identification value
		Element Separator	AN	1			*
	REF03	Description	AN	1/80	352	S	Free form description as optional

REF01- Reference Identification Type Qualifier

Code	Definition
18	Plan Number
1L	Group Policy Number
1W	Member Identification Number
3H	Case Number
49	Family Unit Number
6P	Group Number
CE	Class of Contract
CT	Contract Number
EA	Medical Record Identification Number
EJ	Patient Account Number
F6	Health Insurance Claim (HIC) Number
GH	Identification Card Serial Number
HJ	Identify Card Number
IF	Issue Number
IG	Insurance Policy Number
N6	Plan Network Identification Number
NQ	Medicaid Recipient Identification Number
Q4	Prior Identifier Number
SY	Social Security Number
Y4	Agency Claim Number

Sample
REF*6P*1111119*XXXXXXX XXXXXXXXXX XXXXXXXXX, INC.
REF*EJ*660415~

2100C Subscriber Address

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	N3	Subscriber Address	AN	2		R	N3
		Element Separator	AN	1			*
	N301	Address Line 1	AN	1/55	166	R	Insured Person Address Line 1
		Element Separator	AN	1			*
	N302	Address Line 2	AN	1/55	166	S	Insured Person Address Line 2 if exists
		Segment Terminator					~

2100C Subscriber City/State/Zip code

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	N4	Subscriber City / State / Zip Code	AN	2		R	N4
		Element Separator	AN	1			*
	N401	City Name	AN	2/30	19	R	Insured Person City Name
		Element Separator	AN	1			*
	N402	State or Province Code	ID	2/2	156	R	Insured Person State Code
		Element Separator	AN	1			*
	N403	Postal Code	ID	3/15	116	R	Insured Person Zip Code
		Segment Terminator					~

2100C Subscriber Demographic Information.

Loop	Seg ID	Segment Name	Format	Length	Ref#	Req	Value
2100C	DMG	Subscriber Demographic	ID	3		R	DMG
		Element Separator	AN	1			*
	DMG01	Date time Period Format Qualifier	ID	2/3	1250	R	D8
		Element Separator	AN	1			*
	DMG02	Date time Period	AN	1/35	1251	R	Insured Date of birth in the Format CCYYMMDD
		Element Separator	AN	1			*
	DMG03	Gender Code	ID	1	1068	R	Print M for Male Print F for Female Print U for unknown
		Segment Terminator