010 |
|
2000 - Member Level Detail |
|
|
010 |
INS |
Member Level Detail |
R |
1 |
|
020 |
REF |
Subscriber Number |
R |
1 |
|
020 |
REF |
Member Policy Number |
S |
1 |
|
020 |
REF |
Member Identification Number |
S |
5 |
|
020 |
REF |
Prior Coverage Months |
S |
1 |
|
025 |
DTP |
Member Level Dates |
S |
20 |
|
030 |
|
2100A - Member Name |
|
|
030 |
NM1 |
Member Name |
R |
1 |
|
040 |
PER |
Member Communications Numbers |
S |
1 |
|
050 |
N3 |
Member Residence Street Address |
S |
1 |
|
060 |
N4 |
Member Residence City, State, Zip Code |
S |
1 |
|
080 |
DMG |
Member Demographics |
S |
1 |
|
110 |
ICM |
Member Income |
S |
1 |
|
120 |
AMT |
Member Policy Amounts |
S |
4 |
|
130 |
HLH |
Member Health Information |
S |
1 |
|
150 |
LUI |
Member Language |
S |
5 |
|
|
030 |
|
2100B - Incorrect Member Name |
|
|
030 |
NM1 |
Incorrect Member Name |
R |
1 |
|
080 |
DMG |
Incorrect Member Demographics |
S |
1 |
|
|
030 |
|
2100C - Member Mailing Address |
|
|
030 |
NM1 |
Member Mailing Address |
R |
1 |
|
050 |
N3 |
Member Mail Street Address |
S |
1 |
|
060 |
N4 |
Member Mail City, State, Zip |
S |
1 |
|
|
030 |
|
2100D - Member Employer |
|
|
030 |
NM1 |
Member Employer |
R |
1 |
|
040 |
PER |
Member Employer Communications Numbers |
S |
1 |
|
050 |
N3 |
Member Employer Street Address |
S |
1 |
|
060 |
N4 |
Member Employer City, State, Zip |
S |
1 |
|
|
030 |
|
2100E - Member School |
|
|
030 |
NM1 |
Member School |
R |
1 |
|
040 |
PER |
Member School Communications Numbers |
S |
1 |
|
050 |
N3 |
Member School Street Address |
S |
1 |
|
060 |
N4 |
Member School City, State, Zip |
S |
1 |
|
|
030 |
|
2100F - Custodial Parent |
|
|
030 |
NM1 |
Custodial Parent |
R |
1 |
|
040 |
PER |
Custodial Parent Communications Numbers |
S |
1 |
|
050 |
N3 |
Custodial Parent Street Address |
S |
1 |
|
060 |
N4 |
Custodial Parent City, State, Zip |
S |
1 |
|
|
030 |
|
2100G - Responsible Person |
|
|
030 |
NM1 |
Responsible Person |
R |
1 |
|
040 |
PER |
Responsible Person Communications Numbers |
S |
1 |
|
050 |
N3 |
Responsible Person Street Address |
S |
1 |
|
060 |
N4 |
Responsible Person City, State, Zip |
S |
1 |
|
|
200 |
|
2200 - Disability Information |
|
|
200 |
DSB |
Disability Information |
R |
1 |
|
210 |
DTP |
Disability Eligibility Dates |
S |
2 |
|
|
260 |
|
2300 - Health Coverage |
|
|
260 |
HD |
Health Coverage |
R |
1 |
|
270 |
DTP |
Health Coverage Dates |
R |
4 |
|
280 |
AMT |
Health Coverage Policy |
S |
4 |
|
290 |
REF |
Health Coverage Policy Number |
S |
2 |
|
300 |
IDC |
Identification Card |
S |
10 |
|
310 |
|
2310 - Provider Information |
|
|
310 |
LX |
Provider Information |
R |
1 |
|
320 |
NM1 |
Provider Name |
R |
1 |
|
360 |
N4 |
Provider City, State, Zip Code |
S |
1 |
|
370 |
PER |
Provider Communications Numbers |
S |
2 |
|
395 |
PLA |
PCP Change Reason |
S |
1 |
|
|
400 |
|
2320 - Coordination of Benefits |
|
|
400 |
COB |
Coordination of Benefits |
R |
1 |
|
405 |
REF |
Additional Coordination of Benefits Identifiers |
S |
5 |
|
410 |
N1 |
Other Insurance Company Name |
S |
1 |
|
450 |
DTP |
Coordination of Benefits Eligibility Dates |
S |
2 |
|
|
|