Eligibility A 1 To 5010

ELIGIBILITY STATUS
4010A1 5010
Element Min. Usage Loop Element Min. Usage Loop
Identifier Description ID Max. Reg. Loop Repeat Values Identifier Description ID Max. Reg. Loop Repeat Values
270 4010A1 270 5010

INTERCHANGE CONTROL INTERCHANGE CONTROL
ISA HEADER 1 R ISA HEADER 1 R
Authorization Information Authorization Information
ISA01 Qualifier ID 2-2 R 00, 03 ISA01 Qualifier ID 2-2 R 00, 03
ISA02 Authorization Information AN 10-10 R ISA02 Authorization Information AN 10-10 R
ISA03 Security Information Qualifier ID 2-2 R 00, 01 ISA03 Security Information Qualifier ID 2-2 R 00, 01
ISA04 Security Information AN 10-10 R ISA04 Security Information AN 10-10 R
01, 14, 20, 27, 28, 01, 14, 20, 27, 28,
ISA05 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ ISA05 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ
ISA06 Interchange Sender ID AN 15-15 R ISA06 Interchange Sender ID AN 15-15 R
01, 14, 20, 27, 28, 01, 14, 20, 27, 28,
ISA07 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ ISA07 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ
ISA08 Interchange Receiver ID AN 15-15 R ISA08 Interchange Receiver ID AN 15-15 R
ISA09 Interchange Date DT 6-6 R YYMMDD ISA09 Interchange Date DT 6-6 R YYMMDD
ISA10 Interchange Time TM 4-4 R HHMM ISA10 Interchange Time TM 4-4 R HHMM
Interchange Control Code Change
ISA11 Standards ID ID 1-1 R U ISA11 Repetition Seperator 1-1 R Name Change
Interchange Control Version Interchange Control Version
ISA12 Number ID 5-5 R 00401 ISA12 Number ID 5-5 R 00501 Code Change
ISA13 Interchange Control Number N0 9-9 R ISA13 Interchange Control Number N0 9-9 R
ISA14 Acknowledgement Requested ID 1-1 R 0, 1 ISA14 Acknowledgement Requested ID 1-1 R 0, 1
ISA15 Usage Indicator ID 1-1 R P, T ISA15 Interchange Usage Indicator ID 1-1 R P, T

Component Element Component Element
ISA16 Separator 1-1 R ISA16 Separator 1-1 R
FUNCTIONAL GROUP FUNCTIONAL GROUP

GS HEADER 1 R GS HEADER 1 R
GS01 Functional Identifier Code ID 2-2 R HB, HS GS01 Functional Identifier Code ID 2-2 R Code Change
GS02 Application Sender's Code AN 2-15 R GS02 Application Sender's Code AN 2-15 R
GS03 Application Receiver's Code AN 2-15 R GS03 Application Receiver's Code AN 2-15 R
GS04 Date DT 8-8 R CCYYMMDD GS04 Date DT 8-8 R CCYYMMDD
GS05 Time TM 4-8 R HHMM GS05 Time TM 4-8 R HHMM
GS06 Group Control Number N0 1-9 R GS06 Group Control Number N0 1-9 R
GS07 Responsible Agency Code ID 1-2 R X GS07 Responsible Agency Code ID 1-2 R X
Version/ Release/ Industry Version/Release/ Industry
GS08 Identifier Code AN 1-12 R 004010X092 GS08 Identifier Code AN 1-12 R 005010X279 Code Change
Page 1 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

TRANSACTION SET TRANSACTION SET
ST HEADER 1 R ST HEADER 1 R
Transaction Set Identifier Transaction Set Identifier
ST01 Code ID 3-3 R 270 ST01 Code ID 3-3 R 270
Transaction Set Control Transaction Set Control
ST02 Number AN 4-9 R ST02 Number AN 4-9 R
Implementation Convention
ST03 Reference AN 1-35 R 005010X279 New Element
BEGINNING OF BEGINNING OF
HIERARCHICAL HIERARCHICAL
BHT TRANSACTION 1 R BHT TRANSACTION 1 R
BHT01 Hierarchical Structure Code ID 4-4 R 0022 BHT01 Hierarchical Structure Code ID 4-4 R 0022
Transaction Set Purpose Transaction Set Purpose
BHT02 Code ID 2-2 R 01,13, 36 BHT02 Code ID 2-2 R 01,13 Code deleted
BHT03 Reference Identification AN 1-30 S BHT03 Reference Identification AN 1-50 S Increase from 30 - 50
Transaction Set Creation
BHT04 Date DT 8-8 R CCYYMMDD BHT04 Date DT 8-8 R CCYYMMDD Name Change
BHT05 Time TM 4-8 R BHT05 Time TM 4-8 R
BHT06 Transaction Type Code ID 2-2 S RT, RU BHT06 Transaction Type Code ID 2-2 S RT Code deleted
INFORMATION SOURCE INFORMATION SOURCE

HL LEVEL 1 R 2000A >1 HL LEVEL 1 R 2000A >1
HL01 Hierarchical ID Number AN 1-12 R HL01 Hierarchical ID Number AN 1-12 R
Hierarchical Parent ID Hierarchical Parent ID
HL02 Number AN 1-12 N/U HL02 Number AN 1-12 N/U
HL03 Hierarchical Level Code ID 1-2 R 20 HL03 Hierarchical Level Code ID 1-2 R 20
HL04 Hierarchical Child Code ID 1-1 R 1 HL04 Hierarchical Child Code ID 1-1 R 1

NM1 NAME 1 R 2100A 1 NM1 NAME 1 R 2100A 1
2B, 36, GP, P5, 2B, 36, GP, P5,
NM101 Entity Identifier Code ID 2-3 R PR NM101 Entity Identifier Code ID 2-3 R PR
NM102 Entity Type Qualifier ID 1-1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1, 2
Name Last or Organization Name Last or Organization Increase from 35 - 60

NM103 Name AN 1-35 S NM103 Name AN 1-60 R Usage change to Required
NM104 Name First AN 1-25 S NM104 Name First AN 1-35 S Increase from 25 - 35
NM105 Name Middle AN 1-25 S NM105 Name Middle AN 1-25 S
NM106 Name Prefix AN 1-10 N/U NM106 Name Prefix AN 1-10 N/U
NM107 Name Suffix AN 1-10 S NM107 Name Suffix AN 1-10 S
24, 46, FI, NI, PI, 24, 46, FI, NI, PI,
NM108 Identification Code Qualifier ID 1-2 R XV, XX NM108 Identification Code Qualifier ID 1-2 R XV, XX
NM109 Identification Code AN 2-80 R NM109 Identification Code AN 2-80 R
NM110 Entity Relationship Code ID 2-2 N/U NM110 Entity Relationship Code ID 2-2 N/U
NM111 Entity Identifier Code ID 2-3 N/U NM111 Entity Identifier Code ID 2-3 N/U
Name Last or Organization
NM112 Name AN 1-60 N/U New Element
Page 2 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

INFORMATION RECEIVER INFORMATION RECEIVER
HL LEVEL 1 R 2000B >1 HL LEVEL 1 R 2000B >1
HL01 Hierarchical ID Number AN 1/12 R HL01 Hierarchical ID Number AN 1-12 R
HL02 Number AN 1/12 R HL02 Number AN 1-12 R
HL03 Hierarchical Level Code ID 1/2 R 21 HL03 Hierarchical Level Code ID 1-2 R 21
HL04 Hierarchical Child Code ID 1/1 R 1 HL04 Hierarchical Child Code ID 1-1 R 1

NM1 NAME 1 R 2100B 1 NM1 NAME 1 R 2100B 1
1P, 2B, 36, 80, FA, 1P, 2B, 36, 80, FA,
NM101 Entity Identifier Code ID 2/3 R GP, P5, PR NM101 Entity Identifier Code ID 2-3 R GP, P5, PR
NM102 Entity Type Qualifier ID 1/1 R 1, 2 NM102 Entity Type Qualifier ID 1-1 R 1, 2

NM103 Name AN 1/35 S NM103 Name AN 1-60 R Usage change to Required
NM104 Name First AN 1/25 S NM104 Name First AN 1-35 S Increase from 25 - 35
NM105 Name Middle AN 1/25 S NM105 Name Middle AN 1-25 S
24, 34, FI, PI, PP, 24, 34, FI, PI, PP,
NM108 Identification Code Qualifier ID 1-2 R SV, XV, XX NM108 Identification Code Qualifier ID 1-2 R SV, XV, XX

ADDITIONAL ADDITIONAL
REF IDENTIFICATION 9 S 2100B REF IDENTIFICATION 9 S 2100B
0B, 1C, 1D, 1J, 0B, 1C, 1D, 1J,
4A, CT, EL, EO, 4A, CT, EL, EO,
Reference Identification HPI, JD, N5, N7, Reference Identification HPI, JD, N5, N7,
REF01 Qualifier ID 2-3 R Q4, SY, TJ REF01 Qualifier ID 2-3 R Q4, SY, TJ
REF02 Reference Identification AN 1-30 R REF02 Reference Identification AN 1-50 R Increase from 30 - 50
REF03 Description AN 1-80 S REF03 Description AN 1-80 S
REF04 REFERENCE IDENTIFIER N/U REF04 REFERENCE IDENTIFIER N/U

N3 ADDRESS 1 S 2100B N3 ADDRESS 1 S 2100B
N301 Address Information AN 1-55 R N301 Address Information AN 1-55 R
N302 Address Information AN 1-55 S N302 Address Information AN 1-55 S

N4 CITY/ STATE/ ZIPCODE 1 S 2100B N4 CITY/STATE/ ZIP CODE 1 S 2100B
N401 City Name AN 2-30 R N401 City Name AN 2-30 R
N402 State or Province Code ID 2-2 R N402 State or Province Code ID 2-2 S Usage change to Required
Page 3 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

N403 Postal Code ID 3-15 R N403 Postal Code ID 3-15 S Usage change to Required
N404 Country Code ID 2-3 S N404 Country Code ID 2-3 S
N405 Location Qualifier ID 1-2 N/U N405 Location Qualifier ID 1-2 N/U
N406 Location Qualifier AN 1-30 N/U N406 Location Qualifier AN 1-30 N/U
N407 Country Subdivision Code ID 1-3 S New Element
INFORMATION RECEIVER
PER CONTACT INFORMATION 3 S 2100B Segment Deleted
PER01 Contact Function Code ID 2-2 R IC
PER02 Name AN 1-60 S
Communication Number
PER03 Qualifier ID 2-2 S ED, EM, FX, TE
PER04 Communication Number AN 1-80 S
Communication Number ED, EM, EX, FX,
PER05 Qualifier ID 2-2 S TE
PER06 Communication Number AN 1-80 S AAABBBCCCC
Communication Number ED, EM, EX, FX,
PER07 Qualifier ID 2-2 S TE
PER09 Contact Inquiry Reference AN 1-20 N/U

PRV PROVIDER INFORMATION 1 S 2100B PRV PROVIDER INFORMATION 1 S 2100B
AD, AT, BI, CO, AD, AT, BI, CO,
CV, H, HH, LA, CV, H, HH, LA,
OT, P1, P2, PC, OT, P1, P2, PC,
PE, R, RF, SB, PE, R, RF, SB,
PRV01 Provider Code ID 1-3 R SK, SU PRV01 Provider Code ID 1-3 R SK, SU
Code Change
Reference Identification Reference Identification Usage change to
PRV02 Qualifier ID 2-3 R ZZ PRV02 Qualifier ID 2-3 S PXC Situational
Increase from 30 - 50
Usage change to
PRV03 Reference Identification AN 1-30 R PRV03 Reference Identification AN 1-50 S Situational
PRV04 State or Province Code ID 2-2 N/U PRV04 State or Province Code ID 2-2 N/U
PROVIDER SPECIALTY PROVIDER SPECIALTY
PRV05 INFORMATION N/U PRV05 INFORMATION N/U
PRV06 Provider Organization Code ID 3-3 N/U PRV06 Provider Organization Code ID 3-3 N/U
HL SUBSCRIBER LEVEL 1 R 2000C >1 HL SUBSCRIBER LEVEL 1 R 2000C >1

HL02 Number AN 1-12 R HL02 Number AN 1-12 R
HL04 Hierarchical Child Code ID 1-1 R 0, 1 HL04 Hierarchical Child Code ID 1-1 R 0, 1
Page 4 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

SUBSCRIBER TRACE SUBSCRIBER TRACE
TRN NUMBER 2 S 2000C TRN NUMBER 2 S 2000C
TRN01 Trace Type Code ID 1-2 R 1 TRN01 Trace Type Code ID 1-2 R 1
TRN02 Reference Identification AN 1-30 R TRN02 Reference Identifier AN 1-50 R Increase from 30 - 50
TRN03 Originating Company Identifier AN 10-10 R TRN03 Originating Company Identifier AN 10-10 R
TRN04 Reference Identification AN 1-30 S TRN04 Reference Identification AN 1-50 S Increase from 30 - 50
NM1 SUBSCRIBER NAME 1 R 2100C 1 NM1 SUBSCRIBER NAME 1 R 2100C 1

NM101 Entity Identifier Code ID 2-3 R IL NM101 Entity Identifier Code ID 2-3 R IL
NM102 Entity Type Qualifier ID 1-1 R 1 NM102 Entity Type Qualifier ID 1-1 R 1
Name Last or Organization Name Last or Organization
NM103 Name AN 1-35 S NM103 Name AN 1-60 S Increase from 35 - 60
NM108 Identification Code Qualifier ID 1-2 S MI, ZZ NM108 Identification Code Qualifier ID 1-2 S II, MI Code Change
NM109 Identification Code AN 2-80 S NM109 Identification Code AN 2-80 S
SUBSCRIBER ADDITIONAL SUBSCRIBER ADDITIONAL

REF IDENTIFICATION 9 S 2100C REF IDENTIFICATION 9 S 2100C
18, 1L, 1W, 3H,
18, 1L, 1W, 3H, 6P, CT, EA, EJ,
Reference Identification 49, 6P, A6, CT, Reference Identification F6, GH, HJ, IG,
REF01 Qualifier ID 2-3 R EA, EJ REF01 Qualifier ID 2-3 R N6, NQ, SY, Y4 Code Change
REF03 Description AN 1-80 N/U REF03 Description AN 1-80 N/U
N3 SUBSCRIBER ADDRESS 1 S 2100C N3 SUBSCRIBER ADDRESS 1 S 2100C

SUBSCRIBER CITY/ STATE/ SUBSCRIBER

N4 ZIPE CODE 1 S 2100C N4 CITY/STATE/ZIP CODE 1 S 2100C
N401 City Name AN 2-30 S N401 City Name AN 2-30 R Usage change to Required
N402 State or Province Name ID 2-2 S N402 State or Province Name ID 2-2 S
N403 Postal Code ID 3-15 S N403 Postal Code ID 3-15 S
Page 5 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

PRV PROVIDER INFORMATION 1 S 2100C PRV PROVIDER INFORMATION 1 S 2100C
AD, AT, BI, CO,
CV, H, HH, LA, AD, AT, BI, CO,
OT, P1, P2, PC, CV, H, HH, LA,
PE, R, RF, SB, OT, P1, P2, PC,
PRV01 Provider Code ID 1-3 R SK, SU PRV01 Provider Code ID 1-3 R PE, R, RF, SK, SU Code deleted
Reference Identification 9K, D3, EI, HPI, Reference Identification 9K, D3, EI, HPI, Usage change to
PRV02 Qualifier ID 2-3 R SY, TJ, ZZ PRV02 Qualifier ID 2-3 S PXC, SY, TJ Situational
Usage change to
SUBSCRIBER SUBSCRIBER
DEMOGRAPHIC DEMOGRAPHIC
DMG INFORMATION 1 S 2100C DMG INFORMATION 1 S 2100C
Date Time Period Format Date Time Period Format
DMG01 Qualifier ID 2-3 S D8 DMG01 Qualifier ID 2-3 S D8
DMG02 Date Time Period AN 1-35 S DMG02 Date Time Period AN 1-35 S
DMG03 Gender Code ID 1-1 S F, M DMG03 Gender Code ID 1-1 S F, M
DMG04 Marital Status Code ID 1-1 N/U DMG04 Marital Status Code ID 1-1 N/U
Composite Race or Ethnicity
DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05 Information N/U
DMG06 Citizenship Status Code ID 1-2 N/U DMG06 Citizenship Status Code ID 1-2 N/U
DMG07 Country Code ID 2-3 N/U DMG07 Country Code ID 2-3 N/U
DMG08 Basis of Verification Code ID 1-2 N/U DMG08 Basis of Verification Code ID 1-2 N/U
DMG09 Quantity R 1-15 N/U DMG09 Quantity R 1-15 N/U
DMG10 Code List Qualifier Code ID 1-3 N/U New Element
DMG11 Industry Code AN 1-30 N/U New Element
SUBSCRIBER MULTIPLE BIRTH

INS RELATIONSHIP 1 S 2100C INS SEQUENCE NUMBER 1 S 2100C Name Change
Yes/No Condition or Yes/No Condition or
INS01 Response Code ID 1-1 R Y INS01 Response Code ID 1-1 R Y
INS02 Individual Relationsgip Code ID 2-2 R 18 INS02 Individual Relationsgip Code ID 2-2 R 18
INS03 Maintenance Type Code ID 3-3 N/U INS03 Maintenance Type Code ID 3-3 N/U
INS04 Maintenance Reason Code ID 2-3 N/U INS04 Maintenance Reason Code ID 2-3 N/U
INS05 Benefit Status Code ID 1-1 N/U INS05 Benefit Status Code ID 1-1 N/U
INS06 Medicare Plan Code ID 1-1 N/U INS06 MEDICARE STATUS CODE N/U Name Change
Consolidated Omnibus Consolidated Omnibus
Budget Reconcilliation Act Budget Reconcilliation Act
INS07 (COBRA) Qualifying ID 1-2 N/U INS07 (COBRA) Qualifying ID 1-2 N/U
INS08 Employment Status Code ID 2-2 N/U INS08 Employment Status Code ID 2-2 N/U
INS09 Student Status Code ID 1-1 N/U INS09 Student Status Code ID 1-1 N/U
Page 6 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

INS10 Response Code ID 1-1 N/U INS10 Response Code ID 1-1 N/U
INS11 Qualifier ID 2-3 N/U INS11 Qualifier ID 2-3 N/U
INS12 Date Time Period AN 1-35 N/U INS12 Date Time Period AN 1-35 N/U
INS13 Confidentiality Code ID 1-1 N/U INS13 Confidentiality Code ID 1-1 N/U
INS14 City Name AN 2-30 N/U INS14 City Name AN 2-30 N/U
INS15 State or Province Code ID 2-2 N/U INS15 State or Province Code ID 2-2 N/U
INS16 Country Code ID 2-3 N/U INS16 Country Code ID 2-3 N/U
INS17 Number N0 1-9 R INS17 Number N0 1-9 R
SUBSCRIBER HEALTH
HI CARE DIAGNOSIS CODE 1 S 2100C New Segment
HEALTH CARE CODE
HI01 INFORMATION R
HI01 - 1 Code List Qualifier Code ID 1-3 R ABK, BK
HI01 - 2 Industry Code AN 1-30 R
Date Time Period Format
HI01 - 3 Qualifier ID 2-3 N/U
HI01 - 4 Date Time Period AN 1-35 N/U
HI01 - 5 Monetary Amount R 1-18 N/U
HI01 - 6 Quantity R 1-15 N/U
HI01 - 7 Version Identifier AN 1-30 N/U
HI01 - 8 Industry Code AN 1-30 N/U
Yes/No Condition or
HI01 - 9 Response Code ID 1-1 N/U
HEALTH CARE CODE
HI02 INFORMATION S
HI02 - 1 Code List Qualifier Code ID 1-3 R ABF, BF
Yes/No Condition or
HEALTH CARE CODE
HI03 INFORMATION S
Page 7 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

Yes/No Condition or
HEALTH CARE CODE
HI04 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI05 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI06 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI07 INFORMATION S
Page 8 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

Yes/No Condition or
HEALTH CARE CODE
HI08 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI09 INFORMATION N/U
HEALTH CARE CODE
HEALTH CARE CODE
HEALTH CARE CODE
DTP SUBSCRIBER DATE 2 S 2100C DTP SUBSCRIBER DATE 2 S 2100C
DTP01 Date/Time Qualifier ID 3-3 R 102, 307, 435, 472 DTP01 Date Time Qualifier ID 3-3 R 102, 291 Code Change
DTP02 Qualifier ID 2-3 R D8, RD8 DTP02 Qualifier ID 2-3 R D8, RD8
CCYYMMDD, CCYYMMDD,
CCYYMMDD- CCYYMMDD-
DTP03 Date Time Period AN 1-35 R CCYYMMDD DTP03 Date Time Period AN 1-35 R CCYYMMDD
SUBSCRIBER SUBSCIBER
ELIGIBILITY/BENEFIT ELIGIBILITY/BENEFIT
EQ INQUIRY INFORMATION 1 S 2110C 99 EQ INQUIRY INFORMATION 1 S 2110C 99
Page 9 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

1, 2, 3, 4, 5, 6, 7,
8, 9,10, 11,12,13,
14, 15, 16, 17, 18,
19, 20, 21, 22, 23,
24, 25, 26, 27, 28,
30, 32, 33, 34, 35,
36, 37, 38, 39, 40,
41, 42, 43, 44, 45,
46, 47, 48, 49, 50,
1, 2, 3, 4, 5, 6, 7, 51, 52, 53, 54, 55,
8, 9,10, 11,12,13, 56, 57, 58, 59, 60,
14, 15, 16, 17, 18, 61, 62, 63, 64, 65,
19, 20, 21, 22, 23, 66, 67, 68, 69, 70,
24, 25, 26, 27, 28, 71, 72, 73, 74, 75,
30, 32, 33, 34, 35, 76, 77, 78, 79, 80,
36, 37, 38, 39, 40, 81, 82, 83, 84, 85,
41, 42, 43, 44, 45, 86, 87, 88, 89, 90,
46, 47, 48, 49, 50, 91, 92, 93, 94, 95,
51, 52, 53, 54, 55, 96, 97, 98, 99, A0,
56, 57, 58, 59, 60, A1, A2, A3, A4,
61, 62, 63, 64, 65, A5, A6, A7, A8,
66, 67, 68, 69, 70, A9, AA, AB, AC,
71, 72, 73, 74, 75, AD, AE, AF, AG,
76, 77, 78, 79, 80, AH, AI , AJ, AK,
81, 82, 83, 84, 85, AL, AM, AN ,AO,
86, 87, 88, 89, 90, AQ, AR, B1, B2,
91, 92, 93, 94, 95, B3, BA,BB, BC,
96, 97, 98, 99, A0, BD, BE, BF, BG,
A1, A2, A3, A4, BH, BI, BJ, BK,
A5, A6, A7, A8, BL, BM, BN, BP,
A9, AA, AB, AC, BQ, BR, BS, BT,
AD, AE, AF, AG, BU, BV, BW, BX,
AH, AI , AJ, AK, BY, BZ, C1, CA,
AL, AM, AN ,AO, CB, CC, CD, CE,
AQ, AR, BA,BB, CF, CG, CH, CI,
BC, BD, BE, BF, CJ, CK, CL, CM,
BG, BH, BI, BJ, CN, CO, CP, CQ,
BK, BL, BM, BN, DG, DM, DS, GF,
EQ01 Service Type Code ID 1-2 S BP, BQ, BR, BS EQ01 Service Type Code ID 1-2 S GN, GY, IC, MH, Code Change
COMPOSITE MEDICAL COMPOSITE MEDICAL
EQ02 PROCEDURE IDENTIFIER S EQ02 PROCEDURE IDENTIFIER S
AD, CJ, HC, ID, AD, CJ, HC, ID,
EQ02 - 1 Product/Service ID Qualifier ID 2-2 R IV, N4, ZZ EQ02 - 1 Product/Service ID Qualifier ID 2-2 R IV, N4, ZZ
EQ02 - 2 Product/Service ID AN 1-48 R EQ02 - 2 Product/Service ID AN 1-48 R
EQ02 - 3 Procedure Modifier AN 2-2 S EQ02 - 3 Procedure Modifier AN 2-2 S
EQ02 - 7 Description AN 1-80 N/U EQ02 - 7 Description AN 1-80 N/U
EQ02 - 8 Product/Service ID AN 1-48 N/U New Element
CHD, DEP, ECH,
EMP, ESP, FAM,
EQ03 Coverage Level Code ID 3-3 S IND, SPC, SPO EQ03 Coverage Level Code ID 3-3 S FAM Code Deleted
Page 10 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

AP, C1, CO, GP,
HM, HN, IP, MA,
MB, MC, PR, PS, Usage change to Not Used
EQ04 Insurance Type Code ID 1-3 S SP, WC EQ04 Insurance Type Code ID 1-3 N/U Code Deleted
COMPOSITE DIAGNOSIS
EQ05 CODE POINTER S New Element
EQ05 - 1 Diagnosis Code Pointer N0 1-2 R New Element
EQ05 - 2 Diagnosis Code Pointer N0 1-2 S New Element
SUBSCRIBER SPEND SUBSCRIBER SPEND

AMT DOWN AMOUNT 1 S 2110C AMT DOWN AMOUNT 1 S 2110C
AMT01 Amount Qualifier Code ID 1-3 R R AMT01 Amount Qualifier Code ID 1-3 R R
AMT02 Monetary Amount R 1-18 N/U AMT02 Monetary Amount R 1-18 R Usage change to Required
AMT03 Credit/Debit Flag Code ID 1-1 N/U AMT03 Credit/Debit Flag Code ID 1-1 N/U
SUBSCRIBER SPEND
DOWN TOTAL BILLED
AMT AMOUNT 1 S 2110C New Segment
AMT01 Amount Qualifier Code ID 1-3 R PB
AMT02 Monetary Amount R 1-18 R
AMT03 Credit/Debit Flag Code ID 1-1 N/U
SUBSCRIBER
SUBSCRIBER ELIGIBILITY/ ELIGIBILITY/BENEFIT
BENEFIT ADDITIONAL ADDITIONAL INQUIRY
III INQUIRY INFORMATION 10 S 2110C III INFORMATION 10 S 2110C
III01 Code List Qualifier Code ID 1-3 R BF, BK, ZZ III01 Code List Qualifier Code ID 1-3 R ZZ Code Deleted
If Ill01 = BK or BF:
use diagnosis
code from code 01, 03, 04, 05, 06,
source 131; 07, 08, 11, 12, 13,
If III01 = ZZ: 11, 14, 15, 20, 21, 22,
12, 21, 22, 23, 24, 23, 24, 25, 26, 31,
25, 26, 31, 32, 33, 32, 33, 34, 41, 42,
34, 41, 42, 50, 51, 49, 50, 51, 52, 53,
52, 53, 54, 55, 56, 54, 55, 56, 57, 60,
60, 61, 62, 65, 71, 61, 62, 65, 71, 72,
III02 Industry Code AN 1-30 R 72, 81, 99 III02 Industry Code AN 1-30 R 81, 99 Code Deleted
III03 Code Category ID 2-2 N/U III03 Code Category ID 2-2 N/U
III04 Free-Form Message Text AN 1-264 N/U III04 Free-Form Message Text AN 1-264 N/U
III05 Quantity R 1-15 N/U III05 Quantity R 1-15 N/U
COMPOSITE UNIT OF COMPOSITE UNIT OF
III06 MEASURE N/U III06 MEASURE N/U
III07 Surface/Layer/Position Code ID 2-2 N/U III07 Surface/Layer/Position Code ID 2-2 N/U
Page 11 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

SUBSRIBER ADDITIONAL SUBSCRIBER ADDITIONAL

REF INFORMATION 1 S 2110C REF INFORMATION 1 S 2110C
Reference Identification Reference Identification
REF01 Qualifier ID 2-3 R 9F,G1 REF01 Qualifier ID 2-3 R 9F, G1
DTP ELIGIBILITY/BENEFIT DATE 1 S 2110C DTP ELIGIBILITY/BENEFIT DATE 1 S 2110C
DTP01 Date/Time Qualifier ID 3-3 R 307, 435, 472 DTP01 Date Time Qualifier ID 3-3 R 291 Code Change
CCYYMMDD,
Date Time Period Format CCYYMMDD-
DTP03 Date Time Period AN 1-35 R DTP03 Qualifier AN 1-35 R CCYYMMDD Code Added
HL DEPENDENT LEVEL 1 S 2000D >1 HL DEPENDENT LEVEL 1 S 2000D >1

DEPENDENT TRACE DEPENDENT TRACE

TRN NUMBER 2 S 2000D TRN NUMBER 2 S 2000D
TRN01 Trace Type Code ID 1-2 R 1 TRN01 Trace Type Code ID 1-2 R 1
TRN02 Reference Identification AN 1-30 R TRN02 Reference Identification AN 1-50 R Increase from 30 - 50
NM1 DEPENDENT NAME 1 R 2100D 1 NM1 DEPENDENT NAME 1 R 2100D 1

NM101 Entity Identifier Code ID 2-3 R 03 NM101 Entity Identifier Code ID 2-3 R 03
NM108 Identification Code Qualifier ID 1-2 N/U NM108 Identification Code Qualifier ID 1-2 N/U
Page 12 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

NM109 Identification Code AN 2-80 N/U NM109 Identification Code AN 2-80 N/U
DEPENDENT ADDITIONAL DEPENDENT ADDITIONAL

REF IDENTIFICATION 9 S 2100D REF IDENTIFICATION 9 S 2100D
18, 1L, 1W, 49, 18, 1L, 6P, CT,
6P, A6, CT, EA, EA, EJ, F6, GH,
Reference Identification EJ, F6, CJ, HC, Reference Identification HJ, IF, IG, MRC,
REF01 Qualifier ID 2-3 R ID, IV, N4, ZZ REF01 Qualifier ID 2-3 R N6, SY, Y4 Code Change
N3 DEPENDENT ADDRESS 1 S 2100D N3 DEPENDENT ADDRESS 1 S 2100D

DEPENDENT DEPENDENT
N4 CITY/STATE/ZIP CODE 1 S 2100D N4 CITY/STATE/ZIP CODE 1 S 2100D
N402 State or Provine Code ID 2-2 S N402 State or Provine Code ID 2-2 S
PRV PROVIDER INFORMATION 1 S 2100D PRV PROVIDER INFORMATION 1 S 2100D

AD, AT, BI, CO,
CV, H, HH, LA, AD, AT, BI, CO,
OT, P1, P2, PC, CV, H, HH, LA,
PE, R, RF, SB, OT, P1, P2, PC, Code Deleted
PRV01 Provider Code ID 1-3 R SK, SU PRV01 Provider Code ID 1-3 R PE, R, RF, SK, SU Usage change to Required
Code Change
Reference Identification 9K, D3, EI, HPI, Reference Identification 9K, D3, EI, HPI, Usage change to
PRV02 Qualifier ID 2-3 R SY, TJ, ZZ PRV02 Qualifier ID 2-3 S PXC, SY, TJ Situational
Usage change to
PROVIDER SPECIALITY PROVIDER SPECIALITY
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ELIGIBILITY STATUS
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270 4010A1 270 5010

DEPENDENT DEPENDENT
DMG INFORMATION 1 S 2100D DMG INFORMATION 1 S 2100D
DMG02 Date Time Period AN 1-35 S CCYYMMDD DMG02 Date Time Period AN 1-35 S CCYYMMDD
DMG03 Gender Code ID 1-1 S F, M DMG03 Gender Code ID 1-1 S F, M
Composite Race or Ethnicity
DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05 Code N/U
DMG10 Code List Qualifier Code ID 1-3 N/U New Element
DEPENDENT DEPENDENT
INS RELATIONSHIP 1 S 2100D INS RELATIONSHIP 1 S 2100D
INS01 Response Code ID 1-1 R N INS01 Response Code ID 1-1 R N
INS02 Individual Relationship Code ID 2-2 R 01, 19, 34 INS02 Individual Relationship Code ID 2-2 R 01, 19, 34
INS03 Maintenance Type Code ID 3-3 N/U INS03 Maintenance Type Code ID 3-3 N/U
INS04 Maintenance Reason Code ID 2-3 N/U INS04 Maintenance Reason Code ID 2-3 N/U
INS06 Medicare Plan Code ID 1-1 N/U INS06 MEDICARE STATUS CODE 1-1 N/U
INS09 Student Status Code ID 1-1 N/U INS09 Student Status Code ID 1-1 N/U
INS10 Response Code ID 1-1 N/U INS10 Response Code ID 1-1 N/U
INS17 Number N0 1-9 S INS17 Number N0 1-9 S
DEPENDENT HEALTH
HI CARE DIAGNOSIS CODE 1 S 2100D New Segment
HEALTH CARE CODE
HI01 INFORMATION R
Page 14 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

Yes/No Condition or
HEALTH CARE CODE
HI02 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI03 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI04 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI05 INFORMATION S
Page 15 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

Yes/No Condition or
HEALTH CARE CODE
HI06 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI07 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI08 INFORMATION S
Yes/No Condition or
Page 16 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

HEALTH CARE CODE
HEALTH CARE CODE
HEALTH CARE CODE
HEALTH CARE CODE
DTP DEPENDENT DATE 2 S 2100D DTP DEPENDENT DATE 2 S 2100D

DTP01 Date/Time Qualifier ID 3-3 R 102,307,435,472 DTP01 Date Time Qualifier ID 3-3 R 102, 291 Code Change
CCYYMMDD, CCYYMMDD,
CCYYMMDD- CCYYMMDD-
DTP03 Date Time Period AN 1-35 R CCYYMMDD DTP03 Date Time Period AN 1-35 R CCYYMMDD
DEPENDENT ELIGIBILITY/ DEPENDENT

BENEFIT INQUIRY ELIGIBILITY/BENEFIT
EQ INFORMATION 1 R 2110D 99 EQ INQUIRY 1 R 2110D 99
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270 4010A1 270 5010

1, 2, 3, 4, 5, 6, 7,
8, 9,10, 11,12,13,
14, 15, 16, 17, 18,
19, 20,
21,22,23,24,25,26,
27,28,30,32,33,34,
35,36,37,38,39,40,
41, 42, 43, 44, 45,
46, 47, 48, 49, 50,
1, 2, 3, 4, 5, 6, 7, 51, 52, 53, 54, 55,
8, 9,10, 11,12, 13, 56, 57, 58, 59, 60,
14, 15, 16, 17, 18, 61, 62, 63, 64, 65,
19, 20, 21, 22, 23, 66, 67, 68, 69, 70,
24, 25, 26, 27, 28, 71, 72, 73, 74, 75,
30, 32, 33, 34, 35, 76, 77, 78, 79, 80,
36, 37, 38, 39, 40, 81, 82, 83, 84, 85,
41, 42, 43, 44, 45, 86, 87, 88, 89, 90,
46, 47, 48, 49, 50, 91, 92, 93, 94, 95,
51, 52, 53, 54, 55, 96, 97, 98, 99, A0,
56, 57, 58, 59, 60, A1, A2, A3, A4,
61, 62, 63, 64, 65, A5, A6, A7, A8,
66, 67, 68, 69, 70, A9, AA, AB, AC,
71, 72, 73, 74, 75, AD, AE, AF, AG,
76, 77, 78, 79, 80, AH, AI , AJ, AK,
81, 82, 83, 84, 85, AL, AM, AN ,AO,
86, 87, 88, 89, 90, AQ, AR, B1, B2,
91, 92, 93, 94, 95, B3, BA,BB, BC,
96, 97, 98, 99, A0, BD, BE, BF, BG,
A1, A2, A3, A4, BH, BI, BJ, BK,
A5, A6, A7, A8, BL, BM, BN, BP,
A9, AA, AB, AC, BQ, BR, BS, BT,
AD, AE, AF, AG, BU, BV, BW, BX,
AH, AI , AJ, AK, BY, BZ, C1, CA,
AL, AM, AN ,AO, CB, CC, CD, CE,
AQ, AR, BA,BB, CF, CG, CH, CI,
BC, BD, BE, BF, CJ, CK, CL, CM,
BG, BH, BI, BJ, CN ,CO, CP, CQ,
BK, BL, BM, BN, DG, DM, DS, GF,
EQ01 Service Type Code ID 1-2 S BP, BQ, BR, BS EQ01 Service Type Code ID 1-2 S GN, GY, IC, MH, Code Added
EQ02 PROCEDURE IDENTIFIER S EQ02 PROCEDURE IDENTIFIER S
EQ02 - 1 Product/Service ID Qualifier ID 2-2 R IV, N4, ZZ EQ02 - 1 Product/Service ID Qualifier ID 2-2 R IV, N4, ZZ
EQ02 - 2 Product/Service ID AN 1-48 R EQ02 - 2 Product/Service ID AN 1-48 R
EQ02 - 3 Procdeure Modifier AN 2-2 S EQ02 - 3 Procdeure Modifier AN 2-2 S
EQ02 - 7 Description AN 1-80 N/U EQ02 - 7 Description AN 1-80 N/U
EQ02 - 8 Product/Service ID AN 1-48 N/U New Element
CHD, DEP, ECH,
EMP, ESP, FAM, Code Deleted
EQ03 Coverage Level Code ID 3-3 S IND, SPC, SPO EQ03 Coverage Level Code ID 3-3 N/U Usage Change to Not Used
Page 18 of 20
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4010A1 5010
270 4010A1 270 5010

AP, C1, CO, GP,
HM, IP, OT, PR, Code Deleted
EQ04 Insurance Type Code ID 1-3 S PS, SP, WC EQ04 Insurance Type Code ID 1-3 N/U Usage Change to Not Used
COMPOSITE DIAGNOSIS
EQ05 CODE POINTER S New Element
EQ05 - 1 Diagnosis Code Pointer N0 1-2 R New Element
DEPENDENT ELIGIBILITY/ DEPENDENT

BENEFIT ADDITIONAL ELIGIBILITY/BENEFIT
III INQUIRY INFORMATION 10 S 2110D III ADDITIONAL INQUIRY 10 S 2110D
III01 Code List Qualifier Code ID 1-3 R BF, BK, ZZ III01 Code List Qualifier Code ID 1-3 R ZZ Code Deleted
If Ill01 = BK or BF,
use diagnosis
code from code 01, 03, 04, 05, 06,
source 131; 07, 08, 11, 12, 13,
If III01 = ZZ: 11, 14, 15, 20, 21, 22,
12, 21, 22, 23, 24, 23, 24, 25, 26, 31,
25, 26, 31, 32, 33, 32, 33, 34, 41, 42,
34, 41, 42, 50, 51, 49, 50, 51, 52, 53,
52, 53, 54, 55, 56, 54, 55, 56,57, 60,
60, 61, 62, 65, 71, 61, 62, 65, 71, 72,
III02 Industry Code AN 1-30 R 72, 81, 99 III02 Industry Code AN 1-30 R 81, 99 Code Deleted
III03 Code Category ID 2-2 N/U III03 Code Category ID 2-2 N/U

REF INFORMATION 1 S 2110D REF INFORMATION 1 S 2110D
Reference Identification Reference Identification
REF01 Qualifier ID 2-3 R 9F,G1 REF01 Qualifier ID 2-3 R 9F, G1
REF04 REFERENCE IDENTIFIER N/U REF04 REFRENCE IDENTIFIER N/U
DEPENDENT ELIGIBILITY/ DEPENDENT ELIGIBILITY/

DTP BENEFIT DATE 1 S 2110D DTP BENEFIT DATE 1 S 2110D
DTP01 Date/Time Qualifier ID 3-3 R 307,435,472 DTP01 Date Time Qualifier ID 3-3 R 291 Code Deleted
Page 19 of 20
ELIGIBILITY STATUS
4010A1 5010
270 4010A1 270 5010

CCYYMMDD,
CCYYMMDD-
DTP03 Date Time Period AN 1-35 R CCYYMMDD DTP03 Date Time Period AN 1-35 R Code Added

SE TRAILER 1 R SE TRAILER 1 R
Number of Included Number of Included
SE01 Segments N0 1-10 R SE01 Segments N0 1-10 R
SE02 Number AN 4-9 R SE02 Number AN 4-9 R

GE TRAILER GE TRAILER 1 R
Number of Transaction Sets Number of Transaction Sets
GE01 Included N0 1-6 R GE01 Included N0 1-6 R
GE02 Group Control Number N0 1-9 R Must=GS06 GE02 Group Control Number N0 1-9 R Must=GS06

IEA TRAILER 1 R IEA TRAILER 1 R
IEA01 Functional Groups N0 1-5 R IEA01 Functional Groups N0 1-5 R
IEA02 Interchange Control Number N0 9-9 R IEA02 Interchange Control Number N0 9-9 R
Page 20 of 20
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

ISA HEADER 1 R ISA HEADER 1 R
Authorization Information Authorization Information
ISA01 Qualifier ID 2/2 R 00, 03 ISA01 Qualifier ID 2-2 R 00, 03
ISA02 Authorization Information AN 10/10 R ISA02 Authorization Information AN 10-10 R
ISA03 Security Information Qualifier ID 2/2 R 00, 01 ISA03 Security Information Qualifier ID 2-2 R 00, 01
ISA04 Security Information AN 10/10 R ISA04 Security Information AN 10-10 R
01, 14, 20, 27, 28, 01, 14, 20, 27, 28,
ISA05 Interchange ID Qualifier ID 2/2 R 29, 30, 33, ZZ ISA05 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ
ISA06 Interchange Sender ID AN 15/15 R ISA06 Interchange Sender ID AN 15-15 R
01, 14, 20, 27, 28, 01, 14, 20, 27, 28,
ISA07 Interchange ID Qualifier ID 2/2 R 29, 30, 33, ZZ ISA07 Interchange ID Qualifier ID 2-2 R 29, 30, 33, ZZ
ISA08 Interchange Receiver ID AN 15/15 R ISA08 Interchange Receiver ID AN 15-15 R
ISA09 Interchange Date DT 6/6 R YYMMDD ISA09 Interchange Date DT 6-6 R YYMMDD
ISA10 Interchange Time TM 4/4 R HHMM ISA10 Interchange Time TM 4-4 R HHMM
Interchange Control Code Change
ISA11 Standards ID ID 1/1 R U ISA11 Repetition Seperator 1-1 R Name Change
Interchange Control Version Interchange Control Version
ISA12 Number ID 5/5 R 00401 ISA12 Number ID 5-5 R 00501 Code Change
ISA13 Interchange Control Number N0 9/9 R ISA13 Interchange Control Number N0 9-9 R
ISA14 Acknowledgement Requested ID 1/1 R 0, 1 ISA14 Acknowledgement Requested ID 1-1 R 0, 1

ISA15 Usage Indicator ID 1/1 R P, T ISA15 Interchange Usage Indicator ID 1-1 R P, T
Component Element Component Element
ISA16 Separator 1/1 R ISA16 Separator 1-1 R

GS HEADER 1 R GS HEADER 1 R
GS01 Functional Identifier Code ID 2/2 R HB, HS GS01 Functional Identifier Code ID 2-2 R Code Deleted
GS02 Application Sender's Code AN 2/15 R GS02 Application Sender's Code AN 2-15 R
GS03 Application Receiver's Code AN 2/15 R GS03 Application Receiver's Code AN 2-15 R
GS04 Date DT 8/8 R CCYYMMDD GS04 Date DT 8-8 R CCYYMMDD
GS05 Time TM 4/8 R HHMM GS05 Time TM 4-8 R HHMM
GS06 Group Control Number N0 1/9 R GS06 Group Control Number N0 1-9 R
GS07 Responsible Agency Code ID 1/2 R X GS07 Responsible Agency Code ID 1-2 R X
Version/ Release/ Industry Version/Release/ Industry
GS08 Identifier Code AN 1/12 R 004010X092 GS08 Identifier Code AN 1-12 R 005010X279 Code Change
Page 1 of 32
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271 4010A1 271 5010

ST HEADER 1 R ST HEADER 1 R
Transaction Set Identifier Transaction Set Identifier
ST01 Code ID 3-3 R 271 ST01 Code ID 3-3 R 271
ST02 Number AN 4-9 R ST02 Number AN 4-9 R
Implementation Convention
ST03 Reference AN 1-35 R 005010X279 New Element
BEGINNING OF BEGINNING OF
HIERARCHICAL HIERARCHICAL
BHT TRANSACTION 1 R BHT TRANSACTION 1 R
BHT01 Hierarchical Structure Code ID 4-4 R 0022 BHT01 Hierarchical Structure Code ID 4-4 R 0022
Transaction Set Purpose Transaction Set Purpose
BHT02 Code ID 2-2 R 11 BHT02 Code ID 2-2 R 06, 11 Code Added
BHT03 Reference Identification AN 1-30 S BHT03 Reference Identification AN 1-50 S Increase from 30 - 50
BHT04 Date DT 8-8 R CCYYMMDD BHT04 Date DT 8-8 R CCYYMMDD
BHT05 Time TM 4-8 R BHT05 Time TM 4-8 R
BHT06 Transaction Type Code ID 2-2 N/U BHT06 Transaction Type Code ID 2-2 N/U

HL LEVEL 1 R 2000A >1 HL LEVEL 1 R 2000A >1
HL02 Number AN 1-12 N/U HL02 Number AN 1-12 N/U
AAA REQUEST VALIDATION 9 S 2000A AAA REQUEST VALIDATION 9 S 2000A

AAA01 Response Code ID 1-1 R N, Y AAA01 Response Code ID 1-1 R N, Y
AAA02 Agency Qualifier Code ID 2-2 N/U AAA02 Agency Qualifier Code ID 2-2 N/U
AAA03 Reject Reason Code ID 2-2 R 04, 41, 42, 79 AAA03 Reject Reason Code ID 2-2 R 04, 41, 42, 79
AAA04 Follow-up Action Code ID 1-1 R C, N, P, R, S, Y AAA04 Follow-up Action Code ID 1-1 R C, N, P, R, S, Y

NM1 NAME 1 R 2100A 1 NM1 NAME 1 R 2100A 1
2B, 36, GP, P5, 2B, 36, GP, P5,
NM101 Entity Identifier Code ID 2-3 R PR NM101 Entity Identifier Code ID 2-3 R PR

NM103 Name AN 1-35 S NM103 Name AN 1-60 R Usage change to Required
NM104 Name First AN 1-25 S NM104 Name First AN 1-35 S Incrase from 25 - 35
Page 2 of 32
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271 4010A1 271 5010

24, 46, FI, NI, PI, 24, 46, FI, NI, PI,
NM108 Identification Code Qualifier ID 1-2 R XV, XX NM108 Identification Code Qualifier ID 1-2 R XV, XX
INFORMATION SOURCE
ADDITIONAL
REF IDENTIFICATION 9 S 2100A Segment Deleted
Reference Identification
REF01 Qualifier ID 2-3 R 18, 55
REF02 Reference Identification AN 1-30 R
REF03 Description AN 1-80 S
REF04 REFERENCE INDENTIFIER N/U
INFORMATION SOURCE PAYER CONTACT

PER CONTACT INFORMATION 3 S 2100A PER INFORMATION 3 S 2100A
PER01 Contact Function Code ID 2-2 R IC PER01 Contact Function Code ID 2-2 R IC
PER02 Name AN 1-60 S PER02 Name AN 1-60 S
Communication Number Communication Number ED, EM, TE, FX,
PER03 Qualifier ID 2-2 S ED, EM, FX, TE PER03 Qualifier ID 2-2 S UR Code Added
PER04 Communication Number AN 1-80 S AAABBBCCCC PER04 Communication Number AN 1-256 S AAABBBCCCC Increase from 80 - 256
Communication Number ED, EM, EX, FX, Communication Number ED, EM, TE, FX,
PER05 Qualifier ID 2-2 S TE PER05 Qualifier ID 2-2 S EX, UR Code Added
Communication Number ED, EM, EX, FX, Communication Number ED, EM, TE, FX,
PER07 Qualifier ID 2-2 S TE PER07 Qualifier ID 2-2 S EX, UR Code Added
PER09 Contact Inquiry Reference AN 1-20 N/U PER09 Contact Inquiry Reference AN 1-20 N/U
AAA REQUEST VALIDATION 9 S 2100A AAA REQUEST VALIDATION 9 S 2100A

04, 41, 42, 79, 80, 04, 41, 42, 79, 80,
AAA03 Reject Reason Code ID 2-2 R T4 AAA03 Reject Reason Code ID 2-2 R T4
C, N, P, R, S, W, C, N, P, R, S, W,
AAA04 Follow-up Action Code ID 1-1 R X, Y AAA04 Follow-up Action Code ID 1-1 R X, Y

HL LEVEL 1 S 2000B >1 HL LEVEL 1 S 2000B >1
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271 4010A1 271 5010

HL04 Hierarchical Child Code ID 1-1 R 0,1 HL04 Hierarchical Child Code ID 1-1 R 0, 1

NM1 NAME 1 R 2100B 1 NM1 NAME 1 R 2100B 1
1P, 2B, 36, 80, FA, 1P, 2B, 36, 80, FA,
NM101 Entity Identifier Code ID 2-3 R GP, P5, PR NM101 Entity Identifier Code ID 2-3 R GP, P5, PR
24, 34, FI, PI, PP, 24, 34, FI, PI, PP,
NM108 Identification Code Qualifier ID 1-2 R SV, XV, XX NM108 Identification Code Qualifier ID 1-2 R SV, XV, XX

REF IDENTIFICATION 9 S 2100B REF IDENTIFICATION 9 S 2100B
0B, 1C, 1D, 1J,
0B, 1C, 1D, 1J, 4A, CT, EL, EO,
Reference Identification 4A, CT, EL, EO, Reference Identification HPI, JD, N5, N7,
REF01 Qualifier ID 2-3 R HPI REF01 Qualifier ID 2-3 R Q4, SY, TJ Code Added

AAA REQUEST VALIDATION 9 S 2100B AAA VALIDATION REQUEST 9 S 2100B
Yes/ No Condition or Yes/ No Condition or
46, 47, 48, 50, 51, 46, 47, 48, 50, 51,
AAA03 Reject Reason Code ID 2-2 R 79, 97, T4 AAA03 Reject Reason Code ID 2-2 R 79, 97, T4
AAA04 Follow-up Action Code ID 1-1 R C, N, R, S, W, X, Y AAA04 Follow-up Action Code ID 1-1 R C, N, R, S, W, X, Y
Page 4 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

INFORMATION RECEIVER
PRV PROVIDER INFORMATION 1 S 2100B New Element
AD, AT, BI, CO,
CV, H, HH, LA,
OT, P1, P2, PC,
PE, R, RF, SB,
PRV01 Provider Code ID 1-3 R SK, SU
PRV02 Qualifier ID 2-3 S PXC
PRV03 Reference Identification AN 1-50 S
PRV04 State or Province Code ID 2-2 N/U
PROVIDER SPECIALITY
PRV05 INFORMATION N/U
PRV06 Provider Organization Code ID 3-3 N/U
HL SUBSCRIBER LEVEL 1 S 2000C >1 HL SUBSCRIBER LEVEL 1 S 2000C >1

HL01 Hierarchical
HierarchicalID Number
Parent ID AN 1-12 R HL01 Hierarchical
HierarchicalID Number
Parent ID AN 1-12 R
SUBSCRIBER TRACE SUBSCRIBER TRACE

TRN NUMBER 3 S 2000C TRN NUMBER 3 S 2000C
TRN01 Trace Type Code ID 1-2 R 1, 2 TRN01 Trace Type Code ID 1-2 R 1, 2
TRN02 Reference Identification AN 1-30 R TRN02 Reference Identification AN 1-50 R Increase form 30 - 50
TRN04 Reference Identification AN 1-30 S TRN04 Reference Identification AN 1-50 S Increase form 30 - 50
NM1 SUBSCRIBER NAME 1 R 2100C 1 NM1 SUBSCRIBER NAME 1 R 2100C 1

NM101 Entity Identifier Code ID 2-3 R IL NM101 Entity Identifier Code ID 2-3 R IL

NM106 Name Prefix AN 1-10 S NM106 Name Prefix AN 1-10 N/U
NM108 Identification Code Qualifier ID 1-2 S MI, ZZ NM108 Identification Code Qualifier ID 1-2 S II, MI Code Change
Page 5 of 32
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271 4010A1 271 5010

18, 1L, 1W, 3H, 18, 1L, 1W, 3H,
49, 6P, A6, EA, 49, 6P, CT, EA,
EJ, F6, GH, HJ, EJ, F6, GH, HJ,
Reference Identification IF, IG, ML, N6, Reference Identification IF, IG, N6, NQ,
REF01 Qualifier ID 2-3 R NQ, Q4, SY REF01 Qualifier ID 2-3 R Q4, SY, Y4 Code Change
N3 SUBSCRIBER ADDRESS 1 S 2100C N3 SUBSCRIBER ADDRESS 1 S 2100C

SUBSCRIBER CITY/ STATE/ SUBSCRIBER

N4 ZIP CODE 1 S 2100C N4 CITY/STATE/ZIP CODE 1 S 2100C
N401 City Name AN 2-30 S N401 City Name AN 2-30 R
N402 State or Province Code ID 2-2 S N402 State or Province Code ID 2-2 S
N405 Location Qualifier ID 1-2 S CY, FI N405 Location Qualifier ID 1-2 N/U CY, FI Usage change to Not Used
N406 Location Qualifier AN 1-30 S N406 Location Qualifier AN 1-30 N/U Usage change to Not Used
SUBSCRIBER CONTACT
PER INFORMATION 3 S 2100C Segment Deleted
PER03 Qualifier ID 2-2 S HP, TE, WP
PER05 Qualifier ID 2-2 S EX, HP, TE, WP
PER08 Communication Number AN 1-80 S
SUBSCRIBER REQUEST SUBSCRIBER REQUEST

AAA VALIDATION 9 S 2100C AAA VALIDATION 9 S 2100C
Page 6 of 32
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271 4010A1 271 5010

15, 42, 43, 45, 47,

48, 49, 51, 52, 56, 15, 35, 42, 43, 45,
57, 58, 60, 61, 62, 47, 48, 49, 51, 52,
63, 64, 65, 66, 67, 56, 57, 58, 60, 61,
68, 71, 72, 73, 74, 62, 63, 71, 72, 73,
AAA03 Reject Reason Code ID 2-2 R 75, 76, 77, 78 AAA03 Reject Reason Code ID 2-2 R 74, 75, 76, 77, 78 Code Deleted
PRV PROVIDER INFORMATION 1 S 2100C New Element

AD, AT, BI, CO,
CV, H, HH, LA,
OT, P1, P2, PC,
PRV01 Provider Code ID 1-3 R PE, R, RF, SK, SU
PROVIDER SPECIALITY
DMG INFORMATION 1 S 2100C DMG INFORMATION 1 S 2100C
DMG03 Gender Code ID 1-1 S F, M, U DMG03 Gender Code ID 1-1 S F, M, U
DMG04 Marital Status Code ID 1-1 N/U DMG04 Marital Status
COMPOSITE CodeOR
RACE ID 1-1 N/U
DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05 ETHNICITY INFORMATION ID 1-1 N/U
DMG10 Code List Qalifier Code ID 1-3 N/U New Element
INS REALTIONSHIP 1 S 2100C INS RELATIONSHIP 1 S 2100C
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271 4010A1 271 5010

INS01 Response Code ID 1-1 R Y INS01 Response Code ID 1-1 R Y
INS02 Individual Relationship Code ID 2-2 R 18 INS02 Individual Relationship Code ID 2-2 R 18
INS03 Maintenance Type Code ID 3-3 S 001 INS03 Maintenance Type Code ID 3-3 S 001
INS04 Maintenance Reason Code ID 2-3 S 25 INS04 Maintenance Reason Code ID 2-3 S 25
INS06 Medicare Plan Code ID 1-1 N/U INS06 MEDICARE STATUS CODE ID 1-1 N/U
INS09 Student Status Code ID 1-1 S F, N, P INS09 Student Status Code ID 1-1 S F, N, P
INS10 Response Code ID 1-1 S N, Y INS10 Response Code ID 1-1 S N, Y
SUBSCRIBER HEALTH
HI CARE DIAGNOSIS CODE 1 S 2100C New Element
HEALTH CARE CODE
HI01 INFORMATION R
Yes/No Condition or
HEALTH CARE CODE
HI02 INFORMATION S
Page 8 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

Yes/No Condition or
HEALTH CARE CODE
HI03 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI04 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI05 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI06 INFORMATION S
Page 9 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

Yes/No Condition or
HEALTH CARE CODE
HI07 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI08 INFORMATION S

Yes/No Condition or
HEALTH CARE CODE
HI09 INFORMATION
HEALTH CARE CODE
HI10 INFORMATION
HEALTH CARE CODE
HI11 INFORMATION
HEALTH CARE CODE
HI12 INFORMATION
Page 10 of 32
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271 4010A1 271 5010
DTP SUBSCRIBER DATE 9 S 2100C DTP SUBSCRIBER DATE 9 S 2100C

096, 102, 152,
102, 152, 291, 291, 307, 318,
307, 318, 340, 340, 341, 342,
341, 342, 343, 343, 346, 347,
346, 347, 356, 356, 357, 382,
357, 382, 435, 435, 442, 458,
442, 458, 472, 472, 539, 540,
DTP01 Date/Time Qualifier ID 3-3 R 539, 540, 636, 771 DTP01 Date Time Qualifier ID 3-3 R 636, 771 Code Added
CCYYMMDD,
CCYYMMDD- CCYYMMDD-
DTP03 Date Time Period AN 1-35 R CCYYMMDD DTP03 Date Time Period AN 1-35 R CCYYMMDD Code Added
SUBSCRIBER MILITARY
PERSONNEL
MPI INFORMATION 1 S 2100C New Element
MPI01 Information Status Code ID 1-1 R A, C, L, O, P, S, T
AE, AO, AS, AT,
AU, CC, DD, HD,
IR, LX, PE, RE,
MPI02 Employment Status Code ID 2-2 R RM, RR, RU
A, B, C, D, E, F,
G, H, I, J, K, L, M,
Government Service Affiliation N, O, Q, R, S, U,
MPI03 Code ID 1-1 R W
MPI04 Description AN 1-80 S
A1, A2, A3, B1,

B2, C1, C2, C3,
C4, C5, C6, C7,
C8, C9, E1, F1,
F2, F3, F4, G1,
G4, L1, L2, L3, L4,
L5, L6, M1, M2,
M3, M4, M5, M6,
P1, P2, P3, P4,
P5, R1, S1, S2,
S3, S4, S5, S6,
S7, S8, S9, SA,
SB, SC, T1, V1,
MPI05 Military Service Rank Code ID 2-2 S W1
MPI06 Qualifier ID 2-3 S D8, RD8
MPI07 Date Time Period AN 1-35 S
Page 11 of 32
ELIGIBILITY STATUS
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271 4010A1 271 5010

SUBSCRIBER ELIGIBILITY/ SUBSCRIBER ELIGIBILITY/
EB BENEFIT INFORMATION 1 S 2110C >1 EB BENEFIT INFORMATION 1 S 2110C >1
1, 2, 3, 4, 5, 6, 7, 1, 2, 3, 4, 5, 6, 7,
8, 9, A, B, C, CB, 8, A, B, C, CB, D,
D, E, F, G, H, I, J, E, F, G, H, I, J, K,
K, L, M, MC, N, O, L, M, MC, N, O, P,
Eligibility or Benefit P, Q, R, S, T, U, Eligibility or Benefit Q, R, S, T, U, V,
EB01 Information ID 1-2 R V, W, X, Y EB01 Information ID 1-2 R W, X, Y
CHD, DEP, ECH, CHD, DEP, ECH,
EMP, ESP, FAM, EMP, ESP, FAM,
EB02 Coverage Level Code ID 3-3 S IND, SPC, SPO EB02 Coverage Level Code ID 3-3 S IND, SPC, SPO
1, 2, 3, 4, 5, 6, 7,
8, 9, 10, 11, 12,
13, 14, 15, 16, 17,
18, 19, 20, 21, 22,
23, 24, 25, 26, 27,
28, 30, 32, 33, 34,
35, 36, 37, 38, 39,
40, 41, 42, 43, 44,
1, 2, 3, 4, 5, 6, 7, 45, 46, 47, 48, 49,
8, 9, 10, 11, 12, 50, 51, 52, 53, 54,
13, 14, 15, 16, 17, 44, 56, 57, 58, 59,
18, 19, 20, 21, 22, 60, 61, 62, 63, 64,
23, 24, 25, 26, 27, 65, 66, 67, 68, 69,
28, 30, 32, 33, 34, 70, 71, 72, 73, 74,
35, 36, 37, 38, 39, 75, 76, 77, 78, 79,
40, 41, 42, 43, 44, 80, 81, 82, 83, 84,
45, 46, 47, 48, 49, 85, 86, 87, 99, 89,
50, 51, 52, 53, 54, 90, 91, 92, 93, 94,
44, 56, 57, 58, 59, 95, 96, 97, 98, 99,
60, 61, 62, 63, 64, A0, A1, A2, A3,
65, 66, 67, 68, 69, A4, A5, A6, A7,
70, 71, 72, 73, 74, A8, A9, AA, AB,
75, 76, 77, 78, 79, AC, AD, AE, AF,
80, 81, 82, 83, 84, AG, AH, AI, AJ,
85, 86, 87, 99, 89, AK, AL, AM, AN,
90, 91, 92, 93, 94, AO, AQ, AR, B1,
95, 96, 97, 98, 99, B2, B3, BA, BB,
A0, A1, A2, A3, BC, BD, BE, BF,
A4, A5, A6, A7, BG, BH, BI, BJ,
A8, A9, AA, AB, BK, BL BM, BN,
AC, AD, AE, AF, BP, BQ, BR, BS,
AG, AH, AI, AJ, BT, BU, BV, BW,
AK, AL, AM, AN, BX, BY, BZ, C1,
AO, AQ, AR, BA, CA, CB, CC, CD,
BB, BC, BD, BE, CE, CF, CG, CH,
BF, BG, BH, BI, CI, CJ, CK, CL,
BJ, BK, BL BM, CM, CN, CO, CP,
BN, BP, BQ, BR, CQ, DG, DM, DS,
EB03 Service Type Code ID 1-2 S BS EB03 Service Type Code ID 1-2 S GF, GY, IC, MH, Code Added
Page 12 of 32
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271 4010A1 271 5010
12, 13, 14, 15, 16, 12, 13, 14, 15, 16,
41, 42, 43, 47, AP, 41, 42, 43, 47, AP,
C1, CO, CP, D, C1, CO, CP, D,
DB, EP, FF, GP, DB, EP, FF, GP,
HM, HN, HS, IN, HM, HN, HS, IN,
LC, LD, LI, LT, IP, LC, LD, LI, LT,
MA, MB, MC, MH, MA, MB, MC, MH,
MI, MP, OT, PE, MI, MP, OT, PE,
PL, PP, PR, PS, PL, PP, PR, PS,
QM, RP, SP, TF, QM, RP, SP, TF,
EB04 Insurance Type Code ID 1-3 S WC, WU EB04 Insurance Type Code ID 1-3 S WC, WU
EB05 Plan Coverage Description AN 1-50 S EB05 Plan Coverage Description AN 1-50 S
6, 7, 13, 21, 22, 6, 7, 13, 21, 22,

23, 24, 25, 26, 27, 23, 24, 25, 26, 27,
28, 29, 30, 31, 32, 28, 29, 30, 31, 32,
EB06 Time Period Qualifier ID 1-2 S 33, 34, 35, 36 EB06 Time Period Qualifier ID 1-2 S 33, 34, 35, 36
EB07 Monetary Amount R 1-18 S EB07 Monetary Amount R 1-18 S
EB08 Percent R 1-10 S EB08 Percentage as Decimal R 1-10 S

8H, 99, CA, CE,
99, CA, CE, DB, DB, DY, HS, LA,
DY, HS, LA, LE, LE, M2, MN, P6,
MN, P6, QA, S7, QA, S7, S8, VS,
EB09 Quantity Qualifier ID 2-2 S S8, VS, YY EB09 Quantity Qualifier ID 2-2 S YY Code Added
EB10 Quantity R 1-15 S EB10 Quantity R 1-15 S

EB11 Response Code ID 1-1 S N,U,Y EB11 Response Code ID 1-1 S N,U,Y
EB12 ResponseMEDICAL
COMPOSITE Code ID 1-1 S N,U,Y EB12 ResponseMEDICAL
COMPOSITE Code ID 1-1 S N,U,W,Y Code Added
EB13 PROCEDURE IDENTIFIER S EB13 PROCEDURE IDENTIFIER S
EB13 - 1 Product/Service ID Qualifier ID 2-2 R IV, N4, ZZ EB13 - 1 Product/Service ID Qualifier ID 2-2 R IV, N4, ZZ
EB13 - 2 Product/Service ID AN 1-48 R EB13 - 2 Product/Service ID AN 1-48 R
EB13 - 3 Procedure Modifier AN 2-2 S EB13 - 3 Procedure Modifier AN 2-2 S
EB13 - 7 Description AN 1-80 N/U EB13 - 7 Description AN 1-80 N/U
EB13 - 8 Product/Service ID AN 1-48 S New Element
COMPOSITE DIAGNOSIS
EB14 CODE POINTER S New Element
EB14 - 1 Diagnosis Code Pointer N0 1-2 R New Element
EB14 - 2 Diagnosis Code Pointer N0 1-2 S New Element
Page 13 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

HEALTH CARE SERVICES HEALTH CARE SERVICES

HSD DELIVERY 9 S 2110C HSD DELIVERY 9 S 2110C
DY, FL, HS, MN, DY, FL, HS, MN,
HSD01 Quantity Qualifier ID 2-2 S VS HSD01 Quantity Qualifier ID 2-2 S VS
HSD02 Quantity R 1-15 S HSD02 Quantity R 1-15 S
Unit or Basis for DA, MO, VS, WK, Unit or Basis for DA, MO, VS, WK,
HSD03 Measurement Code ID 2-2 S YR HSD03 Measurement Code ID 2-2 S YR
HSD04 Sample Selection Modulus R 1-6 S HSD04 Sample Selection Modulus R 1-6 S
6, 7, 21, 22, 23, 6, 7, 21, 22, 23,
24, 25, 26, 27, 28, 24, 25, 26, 27, 28,
29, 30, 31, 32, 33, 29, 30, 31, 32, 33,
HSD05 Time Period Qualifier ID 1-2 S 34, 35 HSD05 Time Period Qualifier ID 1-2 S 34, 35
HSD06 Number of Periods N0 1-3 S HSD06 Number of Periods N0 1-3 S
1, 2, 3, 4, 5, 6, 7, 1, 2, 3, 4, 5, 6, 7,
8, 9, A, B, C, D, E, 8, 9, A, B, C, D, E,
F, G, ,H, J, K, L ,M F, G, ,H, J, K, L ,M
N, O, P, Q, R, S, N, O, P, Q, R, S,
SG, SL, SP, SX, SG, SL, SP, SX,
Ship/Delivery or Calendar SY, SZ, T, U, V, Ship/Delivery or Calendar SY, SZ, T, U, V,
HSD07 Pattern Code ID 1-2 S W, X, Y HSD07 Pattern Code ID 1-2 S W, X, Y
Ship/Delivery Pattern Time A, B, C, D, E, F, Ship/Delivery Pattern Time A, B, C, D, E, F,
HSD08 Code ID 1-1 S G, Y HSD08 Code ID 1-1 S G, Y

18, 1L, 1W, 49,
18, 1L, 1W, 49, 6P, 9F, ALS, CLI,
Reference Identification 6P, 9F, A6, F6, Reference Identification F6, FO, G1, IG,
REF01 Qualifier ID 2-3 R G1, IG, N6, NQ REF01 Qualifier ID 2-3 R M7, N6, NQ Code Change

SUBSCRIBER SUBSCRIBER ELIGIBILITY/

DTP ELIGIBILITY/BENEFIT DATE 20 S 2110C DTP BENEFIT DATE 20 S 2110C
Page 14 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

096, 193, 194,
198, 290, 291,
193, 194, 198, 292, 295, 304,
290, 292, 295, 307, 318, 346,
304, 307, 318, 348, 349, 356,
348, 349, 356, 357, 435, 472,
DTP01 Date/Time Qualifier ID 3-3 R 357, 435, 472, 636 DTP01 Date Time Qualifier ID 3-3 R 636, 771 Code Added
DTP02 Qualifier ID 2-3 R D8, RD8 DTP02 Qualifier ID 2-3 R R8, RD8
CCYYMMDD,
CCYYMMDD- CCYYMMDD-
DTP03 Date Time Period AN 1-35 R CCYYMMDD DTP03 Date Time Period AN 1-35 R CCYYMMDD Code Added
SUBSCRIBER REQUEST SUBSCRIBER REQUEST

AAA VALIDATION 9 S 2110C AAA VALIDATION 9 S 2110C
15, 33, 52, 53, 54,

55, 56, 57, 60, 61,
15, 52, 53, 55, 56, 62, 63, 69, 70, 98,
57, 60, 61, 62, 63, AA, AE, AF, AG,
AAA03 Reject Reason Code ID 2-2 R 69, 70 AAA03 Reject Reason Code ID 2-2 R AO, CI, E8, IA, MA Code Added
AAA04 Follow-up Action code ID 1-1 R C, N, R, W, X, Y AAA04 Follow-up Action code ID 1-1 R C, N, R, W, X, Y
MSG MESSAGE TEXT 10 S 2110C MSG MESSAGE TEXT 10 S 2110C

MSG01 Free-Form Message Text AN 1-264 R MSG01 Free-Form Message Text AN 1-264 R
MSG02 Printer Carriage Control Code ID 2-2 N/U MSG02 Printer Carriage Control Code ID 2-2 N/U
MSG03 Number N0 1-9 N/U MSG03 Number N0 1-9 N/U
SUBSCRIBER
SUBSCRIBER ELIGIBILITY/ ELIGIBILITY/BENEFIT
BENEFIT ADDITIONAL ADDITIONAL
III INFORMATION 1 S 2115C 10 III INFORMATION 1 S 2115C 10
Code Change
Usage change to
III01 Code List Quantifier Code ID 1-3 R BF, BK, ZZ III01 Code List Quantifier Code ID 1-3 S GR, NI, ZZ Situational
Page 15 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010
If III01=ZZ: 01, 03,

04, 05, 06, 07, 08,
If III01=ZZ: 11, 12, 11, 12, 13, 14, 15,
21, 22, 23, 24, 25, 20, 21, 22, 23, 24,
26, 31, 32, 33, 34, 25, 26, 31, 32, 33,
41, 42, 50, 51, 52, 34, 41, 42, 49, 50,
53, 54, 55, 56, 60, 51, 52, 53, 54, 55, Code Added
61, 62, 65, 71, 72, 56, 57, 60, 61, 62, Usage change to
III02 Industry Code AN 1-30 R 81, 99 III02 Industry Code AN 1-30 S 65, 71, 72, 81, 99 Situational
Code Added
Usage change to
III03 Code Category ID 2-2 N/U III03 Code Category ID 2-2 S 44 Situational
Usage change to
III04 Free-Form Message Text AN 1-264 N/U III04 Free-Form Message Text AN 1-264 S Situational
LS LOOP HEADER 1 S 2110C LS LOOP HEADER 1 S 2110C

LS01 Loop Identifier Code AN 1-6 R 2120 LS01 Loop Identifier Code AN 1-4 R 2120 Decrease from 6 - 4
SUBSCRIBER BENEFIT SUBSCRIBER BENEFIT

NM1 RELATED ENTITY NAME 1 S 2120C 1 NM1 RELATED ENTITY NAME 1 S 2120C 23
13, 1I, 1P, 2B, 36,
13, 1P, 2B, 36, 73, 73, FA, GP, GW,
FA, GP, IL, LR, I3, IL, LR, OC, P3,
P3, P4, P5, PR, P4, P5, PR, PRP,
PRP, SEP, TTP, SEP, TTP, VN,
NM101 Entity Identifier Code ID 2-3 R VN, X3 NM101 Entity Identifier Code ID 2-3 R VY, X3 Code Added
24, 34, 46, FA, FI, 24, 34, 46, FA, FI,
MI, NI, PI, PP, SV, II, MI, NI, PI, PP,
NM108 Identification Code Qualifier ID 1-2 S XV, XX, ZZ NM108 Identification Code Qualifier ID 1-2 S SV, XV, XX Code Change
Page 16 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

Usage change to
01, 02, 27, 41, 48, Situational
NM110 Entity Relationship Code ID 2-2 N/U NM110 Entity Relationship Code ID 2-2 S 65, 72 Code Added
SUBSCRIBER BENEFIT
SUBSCRIBER RELATED RELATED ENTITY
N3 ENTITY ADDRESS 1 S 2120C N3 ADDRESS 1 S 2120C

RELATED CITY/STATE/ZIP RELATED ENTITY
N4 CODE 1 S 2110C N4 CITY/STATE/ZIP CODE 1 S 2120C
N405 Location Qualifier ID 1-2 S RJ N405 Location Qualifier ID 1-2 S RJ
N406 Location Qualifier AN 1-30 S N406 Location Qualifier AN 1-30 S
N407 Country Subdivision Code ID 1-3 S Code Added

RELATED ENTITY RELATED ENTITY
PER CONTACT INFORMATION 3 S 2120C PER CONTACT INFORMATION 3 S 2120C
Communication Number ED, EM, FX, TE, Communication Number ED, EM, FX, TE,
PER03 Qualifier ID 2-2 S WP PER03 Qualifier ID 2-2 S UR, WP Code Added
PER09 Contact Inquiry Reference AN 1-20 N/U PER09 Contact Inquiry Reference AN 1-20 N/U

RELATED PROVIDER RELATED PROVIDER
PRV INFORMATION 1 S 2120C PRV INFORMATION 1 S 2120C
Page 17 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

OT, P1, P2, PC, OT, P1, P2, PC,
Code Change
Reference Identification 9K, D3, EI, HPI, Reference Identification Usage change to
PRV02 Qualifier ID 2-3 R SY, TJ, ZZ PRV02 Qualifier ID 2-3 S PXC Situational
Usage change to
LE LOOP TRAILER 1 S 2110C LE LOOP TRAILER 1 S 2120C

LE01 Loop Identifier Code AN 1-6 R 2120 LE01 Loop Identifier Code AN 1-4 R Decrease from 6 - 4
HL DEPENDENT LEVEL 1 S 2000D >1 HL DEPENDENT LEVEL 1 S 2000D >1

DEPENDENT TRACE DEPENDENT TRACE

TRN NUMBER 3 S 2000D TRN NUMBER 3 S 2000D
TRN01 Trace Type Code ID 1-2 R 1, 2 TRN01 Trace Type Code ID 1-2 R 1, 2
TRN02 Reference Identification AN 1-30 R TRN02 Reference Identification AN 1-50 R Increase from 30 - 50
NM1 DEPENDENT NAME 1 R 2100D 1 NM1 DEPENDENT NAME 1 R 2100D 1

NM101 Entity Identifier Code ID 2-3 R 03 NM101 Entity Identifier Code ID 2-3 R 03
Page 18 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

Code Deleted
NM108 Identification Code Qualifier ID 1-2 S MI, ZZ NM108 Identification Code Qualifier ID 1-2 N/U Usage change to Not Used
NM109 Identification Code AN 2-80 S NM109 Identification Code AN 2-80 N/U Usage change to Not Used

18, 1L, 49, 6P, CT,
18, 1L, 1W, 49, EA, EJ, F6, GH,
6P, A6, CT, EA, HJ, IF, IG, MRC,
Reference Identification EJ, F6, CJ, HC, Reference Identification N6, NQ, Q4, SY,
REF01 Qualifier ID 2-3 R ID, IV, N4, ZZ REF01 Qualifier ID 2-3 R Y4 Code Change
N3 DEPENDENT ADDRESS 1 S 2100D N3 DEPENDENT ADDRESS 1 S 2100D

DEPENDENT DEPENDENT
N407 Country Subdivision Code ID 1-3 New Element
DEPENDENT CONTACT
PER INFORMATION 3 S 2100D Segment Deleted
Page 19 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

DEPENDENT REQUEST DEPENDENT REQUEST

AAA VALIDATION 9 S 2100D AAA VALIDATION 9 S 2100D
15, 42, 43, 45, 47, 15, 35, 42, 43, 45,
48, 49, 51, 52, 56, 47, 48, 49, 51, 52,
57, 58, 60, 61, 62, 56, 57, 58, 60, 61,
63, 64, 65, 66, 67, 62, 63, 64, 65, 66,
AAA03 Reject Reason Code ID 2-2 R 68, 71 AAA03 Reject Reason Code ID 2-2 R 67, 68, 71, 77 Code Added
PRV PROVIDER INFORMATION 1 S 2100D New Segment

AD, AT, BI, CO,
CV, H, HH, LA,
OT, P1, P2, PC,
PRV01 Provider Code ID 1-3 R PE, R, SK, SU
PROVIDER SPECIALTY
DEPENDENT DEPENDENT
DMG INFORMATION 1 S 2100D DMG INFORMATION 1 S 2100D
DMG03 Gender Code ID 1-1 S F, M, U DMG03 Gender Code ID 1-1 S F, M, U
COMPOSITE RACE OR
DMG05 Race or Ethnicity Code ID 1-1 N/U DMG05 ETHNICITY INFORMATION N/U Name Change
Page 20 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

DMG10 Code List Qalifier Code ID 1-3 N/U New Element
DEPENDENT DEPENDENT
INS RELATIONSHIP 1 S 2100D INS RELATIONSHIP 1 S 2100D
INS01 Response Code ID 1-1 R N INS01 Response Code ID 1-1 R N
01, 19, 20, 21, 39,
INS02 Individual Relationship Code ID 2-2 R 01, 19, 21, 34 INS02 Individual Relationship Code ID 2-2 R 40, 53, G8 Code Change
INS03 Maintenance Type Code ID 3-3 S 001 INS03 Maintenance Type Code ID 3-3 S 001
INS04 Maintenance Reason Code ID 2-3 S 25 INS04 Maintenance Reason Code ID 2-3 S 25
INS06 Medicare Plan Code ID 1-1 N/U INS06 MEDICARE STATUS CODE N/U
Usage change to Not Used

INS09 Student Status Code ID 1-1 S F, N, P INS09 Student Status Code ID 1-1 N/U Code Deleted
Yes/No Condition or Yes/No Condition or Usage change to Not Used

INS10 Response Code ID 1-1 S N, Y INS10 Response Code ID 1-1 N/U Code Deleted
DEPENDENT HEALTH
HI CARE DIAGNOSIS CODE 1 S 2100D New Segment
HEALTH CARE CODE
HI01 INFORMATION R
Yes/No Condition or
Page 21 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

HEALTH CARE CODE
HI02 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI03 INFORMATION S
Yes/No Condition or
HEALTH CARE CODE
HI04 INFORMATION S

Yes/No Condition or
HEALTH CARE CODE
HI05 INFORMATION S
Page 22 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

Yes/No Condition or
HEALTH CARE CODE
HI06 INFORMATION S

Yes/No Condition or
HEALTH CARE CODE
HI07 INFORMATION S
HI07 - 2 Industry
Date Time Code
Period Format AN 1-30 R

Yes/No Condition or
HEALTH CARE CODE
HI08 INFORMATION S

Page 23 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

Yes/No Condition or
HEALTH CARE CODE
HEALTH CARE CODE
HEALTH CARE CODE
HI11 INFORMATION
HEALTH CARE CODE N/U
DTP DEPENDENT DATE 9 S 2100D DTP DEPENDENT DATE 9 S 2100D
096, 102, 152,

102, 152, 291, 291, 307, 318,
307, 318, 340, 340, 341, 342,
341, 342, 343, 343, 346, 347, 356
346, 347, 382, 357, 382, 435,
435, 442, 458, 442, 458, 472,
DTP01 Date/Time Qualifier ID 3-3 R 472, 539, 540, 636 DTP01 Date Time Qualifier ID 3-3 R 539, 540, 636, 771 Code Added

CCYYMMDD,
CCYYMMDD-
DTP03 Date Time Period AN 1-35 R DTP03 Date Time Period AN 1-35 R CCYYMMDD Code Deleted
DEPENDENT MILITARY
PERSONNEL
MPI INFORMATION 1 S 2100D New Segment
MPI01 Information Status Code ID 1-1 R A, C, L, O, P, S, T
AE, AO, AS, AT,
AU, CC, DD, HD,
IR, LX, PE, RE,
MPI02 Employment Status Code ID 2-2 R RM, RR, RU
A, B, C, D, E, F,
G, H, I, J, K, L, M,
Government Service Affiliation N, O, Q, R, S, U,
MPI03 Code ID 1-1 R W
Page 24 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

MPI04 Description AN 1-80 S A1, A2, A3, B1,
MPI05 Military Service Rank Code ID 2-2 S B2, C1, C2, C3,

MPI06 Qualifier ID 2-3 S D8, RD8
MPI07 Date Time Period AN 1-35 S
DEPENDENT DEPENDENT
EB INFORMATION 1 S 2110D >1 EB INFORMATION 1 2110D >1
1, 2, 3, 4, 5, 6, 7, 1, 2, 3, 4, 5, 6, 7,
8, A, B, C, CB, D, 8, A, B, C, CB, D,
E, F, G, H, I, J, K, E, F, G, H, I, J, K,
L, M, MC, N, O, P, L, M, MC, N, O, P,
Q, R, S,T, U, V, Eligibility or Benefit Q, R, S, T, U, V,
EB01 Eligibility/ Benefit Information ID 1-2 R W, X, Y EB01 Information Code ID 1-2 R W, X, Y
CHD, DEP, ECH, CHD, DEP, ECH,
ESP, FAM, IND, EMP, ESP, FAM,
EB02 Coverage Level Code ID 3-3 S SPC, SPO EB02 Coverage Level Code ID 3-3 S IND, SPC, SPO Code Added
Page 25 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

1, 2, 3, 4, 5, 6, 7,
8, 9, 10, 11, 12,
13, 14, 15, 16, 17,
18, 19, 20, 21, 22,
23, 24, 25, 26, 27,
28, 30, 32, 33, 34,
35, 36, 37, 38, 39,
40, 41, 42, 43, 44,
1, 2, 3, 4, 5, 6, 7, 45, 46, 47, 48, 49,
8, 9, 10, 11, 12, 50, 51, 52, 53, 54,
13, 14, 15, 16, 17, 44, 56, 57, 58, 59,
18, 19, 20, 21, 22, 60, 61, 62, 63, 64,
23, 24, 25, 26, 27, 65, 66, 67, 68, 69,
28, 29, 30, 32, 33, 70, 71, 72, 73, 74,
34, 35, 36, 37, 38, 75, 76, 77, 78, 79,
39, 40, 41, 42, 43, 80, 81, 82, 83, 84,
44, 45, 46, 47, 48, 85, 86, 87, 99, 89,
49, 50, 51, 52, 53, 90, 91, 92, 93, 94,
54, 55, 56, 57, 58, 95, 96, 97, 98, 99,
59, 60, 61, 62, 63, A0, A1, A2, A3,
64, 65, 66, 67, 68, A4, A5, A6, A7,
69, 70, 71, 72, 73, A8, A9, AA, AB,
74, 75, 76, 77, 78, AC, AD, AE, AF,
79, 80, 81, 82, 83, AG, AH, AI, AJ,
84, 85, 86, 87, 88, AK, AL, AM, AN,
89, 90, 91, 92, 93, AO, AQ, AR, B1,
94, 95, 96, 97, 98, B2, B3, BA, BB,
99, A0, A1, A2, BC, BD, BE, BF,
A3, A4, A5, A6, BG, BH, BI, BJ,
A7, A8, A9, AA, BK, BL BM, BN,
AB, AC, AD, AE, BP, BQ, BR, BS,
AF, AG, AH, AI, BT, BU, BV, BW,
AJ, AK, AL, AM, BX, BY, BZ, C1,
AN, AO, AQ, AR, CA, CB, CC, CD,
BA, BB, BC, BD, CE, CF, CG, CH,
BE, BF, BG, BH, CI, CJ, CK, CL,
BI, BJ, BK, BL, CM, CN, CO, CP,
BM, BN, BP, BQ, CQ, DG, DM, DS,
EB03 Service Type Code ID 1-2 S BR, BS EB03 Service Type Code ID 1-2 S GF, GY, IC, MH,
12, 13, 14, 15, 16, 12, 13, 14, 15, 16,
41, 42, 43, 47, AP, 41, 42, 43, 47, AP,
C1, CO, CP, D, C1, CO, CP, D,
DB, EP, FF, GP, DB, EP, FF, GP,
HM, HN, HS, IN, HM, HN, HS, IN,
IP, LC, LD, LI, LT, IP, LC, LD, LI, LT,
MA, MB, MC, MH, MA, MB, MC, MH,
MI, MP, OT, PE, MI, MP, OT, PE,
PL, PP, PR, PS, PL, PP, PR, PS,
QM, RP, SP, TF, QM, RP, SP, TF,
EB04 Insurance Type Code ID 1-3 S WC, WU EB04 Insuarance Type Code ID 1-3 S WC, WU
EB05 Plan Coverage Description AN 1-50 S EB05 Plan Coverage Description AN 1-50 S
Page 26 of 32
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271 4010A1 271 5010
6, 7, 13, 21, 22, 6, 7, 13, 21, 22,

23, 24, 25, 26, 27, 23, 24, 25, 26, 27,
28, 29, 30, 31, 32, 28, 29, 30, 31, 32,
EB06 Time Period Qualifier ID 2-2 S 33, 34, 35, 36 EB06 Time Period Qualifier ID 1-2 S 33, 34, 35, 36
EB07 Monetary Amount R 1-18 S EB07 Monetary Amount R 1-18 S
EB08 Percent R 1-10 S EB08 Percentage as Decimal R 1-10 S
8H, 99, CA, CE,

99, CA, CE, DB, D3, DB, DY, HS,
DY, HS, LA, LE, LA, LE, M2, MN,
MN, P6, S7, S8, P6, QA, S7, S8,
EB09 Quantity Qualifier ID 2-2 S VS, YY EB09 Quantity Qualifier ID 2-2 S VS, YY Code Added
EB10 Quantity R 1-15 S EB10 Quantity R 1-15 S
EB11 Response Code ID 1-1 S N, U, Y EB11 Response Code ID 1-1 S N,U,Y
EB12 Response Code ID 1-1 S N, U, Y EB12 Response Code ID 1-1 S N,U,W,Y Code Added
EB13 PROCEDURE IDENTIFIER S EB13 PROCEDURE IDENTIFIER S
EB13 - 1 Product/Service ID Qualifier ID 2-2 R ND, ZZ EB13 - 1 Product/Service ID Qualifier ID 2-2 R IV, N4, ZZ Code Change
EB13 - 2 Product/Service ID AN 1-48 R EB13 - 2 Product/Service ID AN 1-48 R
EB13 - 7 Description AN 1-80 N/U EB13 - 7 Description AN 1-80 N/U
EB13 - 8 Product/Service ID AN 1-48 S New Element
COMPOSITE DIAGNOSIS
EB14 CODE POINTER S New Element
EB14 - 1 Diagnosis Code Pointer N0 1-2 R New Element
HEALTH CARE SERVICES HEALTH CARE SERVICES

HSD DELIVERY 9 S 2110D HSD DELIVERY 9 2110C
DY, FL, HS, MN, DY, FL, HS, MN,
HSD01 Quantity Qualifier ID 2-2 S VS HSD01 Quantity Qualifier ID 2-2 S VS
HSD02 Quantity R 1-15 S HSD02 Quantity R 1-15 S
Unit or Basis for DA, MO, VS, WK, Unit or Basis for DA, MO, VS, WK,
HSD03 Measurement Code ID 2-2 S YR HSD03 Measurement Code ID 2-2 S YR
HSD04 Sample Selection Modulus R 1-6 S HSD04 Sample Selection Modulus R 1-6 S
6, 7, 21, 22, 23, 6, 7, 21, 22, 23,
24, 25, 26, 27, 28, 24, 25, 26, 27, 28,
29, 30, 31, 32, 33, 29, 30, 31, 32, 33,
HSD05 Time Period Qualifier ID 1-2 S 34, 35 HSD05 Time Period Qualifier ID 1-2 S 34, 35
Page 27 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

HSD06 Number of Periods N0 1-3 S HSD06 Number of Periods N0 1-3 S
1, 2, 3, 4, 5, 6, 7, 1, 2, 3, 4, 5, 6, 7,
8, 9, A, B, C, D, E, 8, 9, A, B, C, D, E,
F, G, H, I, J, K, L, F, G, H, I, J, K, L,
M, N, O, P, Q, R, M, N, O, P, Q, R,
S, SG, SL, SP, S, SG, SL, SP,
Ship/Delivery or Calendar SX, SY, SZ, T, U, Ship/Delivery or Calendar SX, SY, SZ, T, U,
HSD07 Pattern Code ID 1-2 S V, W, X, Y HSD07 Pattern Code ID 1-2 S V, W, X, Y
Ship/Delivery Pattern Time A, B, C, D, E, F, Ship/Delivery Pattern Time A, B, C, D, E, F,
HSD08 Code ID 1-1 S G, Y HSD08 Code ID 1-1 S G, Y

18, 1L, 1W, 49,
18, 1L, 1W, 49, 6P, 9F, ALS, CLI,
Reference Identification 6P, 9F, A6, F6, Reference Identification F6, FO, G1, IG,
REF01 Qualifier ID 2-3 R G1, IG, N6, NQ REF01 Qualifier ID 2-3 R N6, NQ Code Change
DEPENDENT DEPENDENT
DTP ELIGIBILITY/BENEFIT DATE 20 S 2110D DTP ELIGIBILITY/BENEFIT DATE 20 S 2110D
096, 193, 194,
193, 194, 198, 198, 290, 291,
290, 292, 295, 292, 295, 304,
304, 307, 318, 307, 318, 346,
348, 349, 356, 348, 349, 356,
357, 435, 472, 357, 435, 472,
DTP01 Date/Time Qualifier ID 3-3 R 636, 771 DTP01 Date Time Qualifier ID 3-3 R 636, 771 Code Added
CCYYMMDD,
CCYYMMDD-
DTP03 Date Time Period AN 1-35 R DTP03 Date Time Period AN 1-35 R CCYYMMDD Code Added
DEPENDENT REQUEST DEPENDENT REQUEST

AAA VALIDATION 9 S 2110D AAA VALIDATION 9 S 2110D
15, 33, 52, 53, 54,

55, 56, 57, 60, 61,
15, 52, 53, 54, 55, 62, 63, 69, 70, 98,
56, 57, 60, 61, 62, AA, AE, AF, AG,
AAA03 Reject Reason Code ID 2-2 R 63, 69, 70 AAA03 Reject Reason Code ID 2-2 R AO, CI, E8, IA, MA Code Added
Page 28 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

AAA04 Follow-up Action Code ID 1-1 R C, N, R, W, X, Y AAA04 Follow-up Action Code ID 1-1 R C, N, R, W, X, Y
MSG MESSAGE TEXT 10 S 2110D MSG MESSAGE TEXT 10 S 2110D

MSG01 Free-Form Message Text AN 1-264 R MSG01 Free-Form Message Text AN 1-264 R
MSG02 Printer Carriage Control Code ID 2-2 N/U MSG02 Printer Carriage Control Code ID 2-2 N/U
MSG03 Number N0 1-9 N/U MSG03 Number N0 1-9 N/U
DEPENDENT DEPENDENT
III INFORMATION 1 S 2115D 10 III INFORMATION 1 S 2115D 10
Code Change
Usage change to
III01 Code List Qualifier Code ID 1-3 R BF, BK, ZZ III01 Code List Qualifier Code ID 1-3 S GR, NI, ZZ Situational
If III01=ZZ: 01, 03,

04, 05, 06, 07, 08,
If III01=ZZ: 11, 12, 11, 12, 13, 14, 15,
21, 22, 23, 24, 25, 20, 21, 22, 23, 24,
26, 31, 32, 33, 34, 25, 26, 31, 32, 33,
41, 42, 50, 51, 52, 34, 41, 42, 49, 50,
53, 54, 55, 56, 60, 51, 52, 53, 54, 55, Code Change
61, 62, 65, 71, 72, 56, 57, 60, 61, 62, Usage change to
III02 Industry Code AN 1-30 R 81, 99 III02 Industry Code AN 1-30 S 65, 71, 72, 81, 99 Situational
Code Added
Usage change to
III03 Code Category ID 2-2 N/U III03 Code Category ID 2-2 S 44 Situational
DEPENDENT ELIGIBILITY/
LS BENEFIT INFORMATION 1 S 2110D LS LOOP HEADER 1 S 2115D
LS01 Loop Identifier Code AN 1-6 R 2120 LS01 Loop Identifier Code AN 1-4 R 2120 Decrease from 6 - 4
DEPENDENT BENEFIT DEPENDENT BENEFIT

NM1 RELATED ENTITY NAME 1 S 2120D 1 NM1 RELATED ENTITY NAME 1 S 2120D 23
Page 29 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010 13, 1I, 1P, 2B, 36,

13, 1P, 2B, 36, 73, 73, FA, GP, GW,
FA, GP, IL, LR, I3, IL, LR, OC, P3,
P3, P4, P5, PR, P4, PR, PRP,
PRP, SEP, TTP, SEP, TTP, VN,
NM101 Entity Identifier Code ID 2-3 R VN, X3 NM101 Entity Identifier Code ID 2-3 R VY, X3 Code Change
24, 34, 46, FA, FI, 24, 34, 46, FA, FI,
MI, NI, PI, PP, SV, II, MI, NI, PI, PP,
NM108 Identification Code Qualifier ID 1-2 S XV, XX, ZZ NM108 Identification Code Qualifier ID 1-2 S SV, XV, XX Code Change
Usage change to
01, 02, 27, 41, 48, Situational
NM110 Entity Relationship Code ID 2-2 N/U NM110 Entity Relationship Code ID 2-2 S 65, 72 Code Added

N3 ADDRESS 1 S 2120D N3 ADDRESS 1 S 2120D

N405 Location Qualifier ID 1-2 S RJ N405 Location Qualifier ID 1-2 S RJ
N406 Location Qualifier AN 1-30 S N406 Location Qualifier AN 1-30 S

PER CONTACT INFORMATION 3 S 2120D PER CONTACT INFORMATION 3 S 2120D
Page 30 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

Communication Number ED, EM, EX, FX, Communication Number ED, EM, EX, FX,
PER05 Qualifier ID 2-2 S TE, WP PER05 Qualifier ID 2-2 S TE, UR, WP Code Added
Communication Number ED, EM, EX, FX, Communication Number ED, EM, EX, FX,
PER07 Qualifier ID 2-2 S TE, WP PER07 Qualifier ID 2-2 S TE, UR, WP Code Added
PER09 Contact Inquiry AN 1-20 N/U PER09 Contact Inquiry Reference AN 1-20 N/U

RELATED PROVIDER RELATED PROVIDER
PRV INFORMATION 1 S 2120D PRV INFORMATION 1 S 2120D
OT, P1, P2, PC, OT, P1, P2, PC,
Code Change
Reference Identification 9K, D3, EI, HPI, Reference Identification Usage change to
PRV02 Qualifier ID 2-3 R SY, TJ, ZZ PRV02 Qualifier ID 2-3 S PXC Situational
Usage change to
LE LOOP TRAILER 1 S 2110D LE LOOP TRAILER 1 S

LE01 Lopp Identifier Code AN 1-6 R 2120 LE01 Lopp Identifier Code AN 1-4 R 2120 Decrease from 6 - 4

SE TRAILER 1 R SE TRAILER 1 R
SE01 Segments N0 1-10 R SE01 Segments N0 1-10 R
SE02 Number AN 4-9 R SE02 Number AN 4-9 R

GE TRAILER GE TRAILER 1 R
Number of Transaction Sets Number of Transaction Sets
GE01 Included N0 1-6 R GE01 Included N0 1-6 R
GE02 Group Control Number N0 1-9 R Must=GS06 GE02 Group Control Number N0 1-9 R Code Deleted
Page 31 of 32
ELIGIBILITY STATUS
4010A1 5010
271 4010A1 271 5010

IEA TRAILER IEA TRAILER 1 R
IEA01 Functional Groups N0 1-5 R IEA01 Functional Groups N0 1-5 R
IEA02 Interchange Control Number N0 9-9 R IEA02 Interchange Control Number N0 9-9 R
Page 32 of 32

Eligibility A 1 To 5010

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Eligibility A 1 To 5010

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ELIGIBILITY STATUS

270 4010A1 270 5010

ISA14 Acknowledgement Requested ID 1-1 R 0, 1 ISA14 Acknowledgement Requested ID 1-1 R 0, 1

ISA15 Usage Indicator ID 1-1 R P, T ISA15 Interchange Usage Indicator ID 1-1 R P, T

FUNCTIONAL GROUP FUNCTIONAL GROUP

270 4010A1 270 5010

INFORMATION SOURCE INFORMATION SOURCE

INFORMATION SOURCE INFORMATION SOURCE

Name Last or Organization Name Last or Organization Increase from 35 - 60

270 4010A1 270 5010

INFORMATION RECEIVER INFORMATION RECEIVER

Name Last or Organization Name Last or Organization Increase from 35 - 60

INFORMATION RECEIVER INFORMATION RECEIVER

INFORMATION RECEIVER INFORMATION RECEIVER

INFORMATION RECEIVER INFORMATION RECEIVER

270 4010A1 270 5010

INFORMATION RECEIVER INFORMATION RECEIVER

HL SUBSCRIBER LEVEL 1 R 2000C >1 HL SUBSCRIBER LEVEL 1 R 2000C >1

270 4010A1 270 5010

NM1 SUBSCRIBER NAME 1 R 2100C 1 NM1 SUBSCRIBER NAME 1 R 2100C 1

SUBSCRIBER ADDITIONAL SUBSCRIBER ADDITIONAL

N3 SUBSCRIBER ADDRESS 1 S 2100C N3 SUBSCRIBER ADDRESS 1 S 2100C

SUBSCRIBER CITY/ STATE/ SUBSCRIBER

270 4010A1 270 5010

SUBSCRIBER MULTIPLE BIRTH

270 4010A1 270 5010

270 4010A1 270 5010

270 4010A1 270 5010

DTP SUBSCRIBER DATE 2 S 2100C DTP SUBSCRIBER DATE 2 S 2100C

270 4010A1 270 5010

270 4010A1 270 5010

SUBSCRIBER SPEND SUBSCRIBER SPEND

270 4010A1 270 5010

SUBSRIBER ADDITIONAL SUBSCRIBER ADDITIONAL

HL DEPENDENT LEVEL 1 S 2000D >1 HL DEPENDENT LEVEL 1 S 2000D >1

DEPENDENT TRACE DEPENDENT TRACE

NM1 DEPENDENT NAME 1 R 2100D 1 NM1 DEPENDENT NAME 1 R 2100D 1

270 4010A1 270 5010

DEPENDENT ADDITIONAL DEPENDENT ADDITIONAL

N3 DEPENDENT ADDRESS 1 S 2100D N3 DEPENDENT ADDRESS 1 S 2100D

PRV PROVIDER INFORMATION 1 S 2100D PRV PROVIDER INFORMATION 1 S 2100D

270 4010A1 270 5010

270 4010A1 270 5010

270 4010A1 270 5010

270 4010A1 270 5010

DTP DEPENDENT DATE 2 S 2100D DTP DEPENDENT DATE 2 S 2100D

DEPENDENT ELIGIBILITY/ DEPENDENT

270 4010A1 270 5010

270 4010A1 270 5010

DEPENDENT ELIGIBILITY/ DEPENDENT

DEPENDENT ADDITIONAL DEPENDENT ADDITIONAL

DEPENDENT ELIGIBILITY/ DEPENDENT ELIGIBILITY/

270 4010A1 270 5010

TRANSACTION SET TRANSACTION SET

FUNCTIONAL GROUP FUNCTIONAL GROUP

INTERCHANGE CONTROL INTERCHANGE CONTROL

271 4010A1 271 5010

ISA14 Acknowledgement Requested ID 1/1 R 0, 1 ISA14 Acknowledgement Requested ID 1-1 R 0, 1

FUNCTIONAL GROUP FUNCTIONAL GROUP

271 4010A1 271 5010

INFORMATION SOURCE INFORMATION SOURCE

AAA REQUEST VALIDATION 9 S 2000A AAA REQUEST VALIDATION 9 S 2000A