Xerox EDI Eligibility Gateway 276/277 Payer Guide

Transcription

1 Xerox EDI Eligibility Gateway 276/277 Guide Version 5010 Technical Support: Updated October 31, 2014

2 2014 Xerox Corporation. All rights reserved. XEROX and XEROX and Design are trademarks of the Xerox Corporation in the United States and/or other countries. Other company trademarks are also acknowledged. Document Version: October 2014

3 Table of Content Revisions... 1 AARP Advantage Health Solutions Aetna Aetna Long Term Care Affinity Health Plan Medicare AFLAC AFLAC - Medicare Supplemental Alabama Medicaid Allegiance Benefit Plan Management American Family Insurance Group- Medicare Supplement and PPO Policies American Network Ins. Medicare American Postal Workers Union Health (APWU) American Republic Insurance Company (ARIC) AMERIGROUP AmeriHealth Amerihealth Caritas Pennsylvania Ameritas Group Aetna Better Health of NE Apex Benefits Services Arbor Health Plan ARISE Health Plan-Medicare Arkansas Medicaid Banner Health Plans BCBS AR BCARK BCBS of Colorado (Wellpoint) BCBS of Connecticut (Wellpoint) BCBS of Florida AV BCBS of Georgia (Wellpoint) BCBS of Illinois BCBS of Indiana (Wellpoint) BCBS of Iowa BCBS of Kansas BCBS of Kansas City BCBS of Kentucky (Wellpoint) Xerox EDI Eligibility Gateway 276/ Guide All i

4 BCBS of Maine (Wellpoint) BCBS of Massachusetts BCBS of Minnesota BCBS Mississippi BCBS of Missouri (Wellpoint) BCBS of Nebraska BCBS of Nevada (Wellpoint) BCBS of New Hampshire (Wellpoint) BCBS of New Jersey (Horizon) BCBS of New Mexico BCBS of New York (Empire) BCBS of North Carolina BCBS of Ohio (Wellpoint) BCBS of Oklahoma BCBS of South Carolina BCBS of South Dakota BCBS of Tennessee BCBS of Texas BCBS of Vermont BCBS of Virginia BCBSV BCBS of Wisconsin (Wellpoint) BCBSW Benefit Management Inc Better Health Plans (Unison Health Plan) Blue Cross of California (Wellpoint) BCCAL Blue Cross Pennsylvania (Capital) Blue Shield of California Boon Group Bravo Health Bridgespan CarePlus Health Plan CarePoint Medicare Advantage Carolina Care Plan, Inc. (CCP) CDS Group Health Cenpatico Centene Central Reserve Insurance Company Central Reserve Life Ins Co Medicare Supp CMFG Life Insurance Community Care of Oklahoma Xerox EDI Eligibility Gateway 276/ Guide All ii

5 Continental General Insurance Company Cooperative Benefit Administrators CoreSource Coventry Healthcare Culinary Health Fund Definity Health Denver Health Medical Plan Easy Choice EBMS (Employee Benefit Management Services) Emblem Health Everence Financial Evergreen Health Co-Op Federated Insurance Company Fidelis SecureCare of Michigan Florida Medicaid Food Employers & Bakery Workers Benefit Fresenius Medical Care Generations Healthcare Georgia Medicaid Gilsbar Golden Rule Insurance Health First Health Plans Health Partners of Philadelphia Health Services for Children with Spec HealthChoice AZ Healthfirst NJ Healthfirst NY HealthMarkets HealthPlan Services - Celtic Insurance Company Horizon New Jersey Health IBEW Local 508 Health Plan IBM Insurance Outsourcing Services Kaiser Foundation Health Plan of Colorado Kentucky Health Exchange Kentucky Medicaid Leon Medical Centers Health Plan Lincoln Financial Managed Health Network Maricopa Health Plan Arizona Xerox EDI Eligibility Gateway 276/ Guide All iii

6 MedBen (Newark OH) Medical Mutual of Ohio Med-Pay, Inc Meritain Health Mississippi Medicaid Missouri Care Molina Healthcare Mutual Health Services MVP Health Care (New York) National Association of Letter Carriers (NALC) Network Health Plan of WI Ohio Medicaid Operating Engineers Local No Orange County Fire Authority Passport Health Plan PENN Treaty Network Medicare Supp Planned Administrators Inc Plumbers and Pipefitters Local Union Physicians Mutual Insurance Company Preferred Care Partners Primary PhysicianCare Inc Principal Financial Group Schaller Anderson Aetna Better Schaller Anderson Aetna Better Health of OH Schaller Anderson Delaware Phys Schaller Anderson MajestaCare VA Schaller Anderson Maryland Physicians Care Schaller Anderson Mercy Care Schaller Anderson Missouri Care Schaller Anderson Parkland Community Schaller Anderson Texas CHRISTUS Select Health of SC Senior Health Services Center-Universal American Family of Companies Senior Whole Health Significa Benefit Services Simply Healthcare Plans SPJST Medicare Supplement TexanPlus North Texas Area TexanPlus South Texas Area Xerox EDI Eligibility Gateway 276/ Guide All iv

7 The Kempton Company The ULLICO Family of Companies Three Rivers Health Plans (Unison Health Plan) TMG Network Health Insurance Today s Health Today s Options Triad Healthcare, Inc Tribute/SelectCare of Oklahoma Tricare Trustmark Ultimate Health Plans UMR (Wausau) Unicare UCARE United Healthcare United Healthcare Community Plan Kansas United Healthcare Facets Detroit Community and State United Healthcare Facets Pittsburgh Community and State United Healthcare Nevada Market United Healthcare Plan of River Valley University Care Advantage Arizona University Care Advantage Arizona University Family Care Arizona University Physicians Healthcare Group Arizona University of Arizona Health Plan- UHM USAA Life Insurance Company VA Fee Basis Program VA Health Administration CTR Vermont Medicaid VIVA Health Inc WebTPA Western Health Advantage World Corp World Insurance (ARIC) Xerox EDI Eligibility Gateway 276/ Guide All v

8 Revisions Date Changes 7/3/2012 Created 7/3/2012 Updated to Xerox Added Aetna-AETNA, Aetna LTC , American Family Insurance Group , American Republic Insurance , Ameritas Group- all, BCBS AR- BCARK, BCBS CO , BCBS CT- 4816, BCBS FL- AV294, BCBS GA- BCBSG, BCBS IN- 4820, BCBS KS- 4923, BCBS KY- 4821, BCBS ME- 4818, BCBS MA , BCBS NE , BCBS NV , BCBS NH- 4817, BCBS NJ , BCBS NY Empire , BCBS OH- 4823, BCBS SC- BCBSS, BCBS TN , BCBS VA- BCBSV, BCBS WI- BCBSW, Better Health , BC CA- BCCAL, BC PA 7/5/2012 Capital- 582, Central Reserve Insurance , Cooperative Benefits Admin , Continental General Insurance , CoreSource- all, Coventry- all, Florida Medicaid , Gilsbar , Healthfirst NJ , Healthfirst NY , HealthMarkets- all, Kentucky Medicaid , Medical Mutual of Ohio , Molina- all, National Assoc of Letter Carriers , Mississippi Medicaid , Physicians Mutual , Principal Financial- all, MVP Healthcare , Three Rivers Health Plans , Trustmark , Unicare- UCARE, VA Fee Basis , World Insurance /6/2012 Updated BCBS AR BCARK- removed Federal Tax ID Added payers American Postal Workers Union Health 00360, Federated Insurance Company 7/6/ , Fresenius Medical Care 10602, Generations Healthcare 10603, HealthChoice AZ 00329, TexanPlus North Texas Area 10604, TexanPlus Southeast Texas Area 10605, Today s Health 10606, Today s Option 10505, Tribute/Selectcare Oklahoma 10607, BCBS VT /27/2012 Added payers Central Reserve Life Ins Co Medicare Supplement 10539, Significa Benefit Services 00191, United Healthcare 00112, USAA Life Insurance Co /28/2012 Added payers Maricopa Health Plan (AZ) 10434, University Care Advantage (AZ) 10433, University Family Care (AZ) 10194, University Physicians Healthcare Group (AZ) /6/2012 Correction on CoreSource FMH /16/2013 Removed Medical Record Number (REF*EA) from payers as it is no longer used in /30/2014 Added payer search option for SPJST Medicare Supplement /30/2014 Added new payer Centene-Magnolia Health Plan /30/2014 Added new payer Easy Choice /30/2014 Added new payer Missouri Care /28/2014 Added new payer Affinity Health Plan Medicare /28/2014 Added new payer AFLAC - Medicare Supplemental /28/2014 Added new payer Benefit Management Inc /28/2014 Added new payer CDS Group Health /28/2014 Added new payer Health First Health Plan /28/2014 Added new payer Leon Medical Centers Health Plan /28/2014 Added new payer Lincoln Financial /28/2014 Added new payer MedBen (Newark OH) /28/2014 Added new payer Med-Pay, Inc /28/2014 Added new payer Kaiser Foundation Health Plan of Colorado /28/2014 Added new payer Mutual Health Services /28/2014 Added new payer Schaller Anderson Mercy Care Xerox EDI Eligibility Gateway 276/ Guide - All 1

9 2/28/2014 Added new payer Schaller Anderson Missouri Care /28/2014 Added new payer Schaller Anderson Maryland Physicians Care /28/2014 Added new payer Senior Health Services Center-Universal American Family of Companies /28/2014 Added new payer The Kempton Company /28/2014 Added new payer University Care Advantage Arizona /28/2014 Added new payer World Corp /28/2014 Added new payer Apex Benefits Services /28/2014 Added new payer Banner Health Plans /28/2014 Added new payer Molina Healthcare of Illinois /28/2014 Added new payer Network Health Plan of WI /28/2014 Added new payer Primary PhysicianCare Inc /28/2014 Added new payer Preferred Care Partners /28/2014 Added new payer WebTPA /31/2014 Added new payer TMG Network Health Insurance /31/2014 Added the following new payer for Cenpatico: Cenpatico Behavioral Health Cenpatico - Mississippi Cenpatico Behavioral Health Texas Cenpatico - Missouri Cenpatico - Georgia Cenpatico - New Hampshire /31/2014 Added the following new payer for Centene: (13) Centene - Advantage by Peach State Centene- IlliniCare Health Plan Centene - Advantage by Sunshine State Centene-Kentucky Spirit Health Plan Centene Advantage Plans Centene-Louisiana Healthcare Connections Centene-Coordinated Care Centene-Magnolia Health Plan Centene-California Health & Wellness Centene-Peach State Health Plan Centene - Granite State Health Plan Centene-Sunflower State Health (Kansas) Centene-Home State Health Plan /31/2014 Added the new payer Carolina Care Plan, Inc. (CCP) /31/2014 Added the new payer Everence Financial /31/2014 Added the new payer Health Choice Insurance Company /31/2014 Added the new payer Windsor Health Plan /31/2014 Added the new payer Culinary Health Fund /31/2014 Added the new payer Food Employers & Bakery Workers Benefit /31/2014 Added the new payer Operating Engineers Local No /31/2014 Added the new payer Plumbers and Pipefitters Local Union /31/2014 Added the new payer Centene-Sunshine State Health Plan /31/2014 Deactivated Windsor Health Plan /31/2014 Added the new payer Windsor Medicare Extra /31/2014 Added the new payer AMERIGROUP /30/2014 Added the new payer Bridgespan /30/2014 Added the new payer Boon Group /30/2014 Added the new payer HealthPlan Services - Celtic Insurance Company /30/2014 Added the new payer IBEW Local 508 Health Plan /30/2014 Added the new payer Simply Healthcare Plans /30/2014 Deactivated payer Health Choice Insurance Company /30/2014 Added the new payer Fidelis SecureCare of Michigan /30/2014 Added the new payer EBMS (Employee Benefit Management Services) /30/2014 Added the new payer Evergreen Health Co-Op /30/2014 Added the new payer IBM Insurance Outsourcing Services /30/2014 Added the new payer Managed Health Network /30/2014 Added the new payer Centene - Total Care Carolina 6/30/2014 Added the new payer Definity Health /30/2014 Added the new payer United Healthcare Plan of River Valley /30/2014 Added the new payer Kentucky Health Exchange Xerox EDI Eligibility Gateway 276/ Guide - All 2

10 6/30/2014 Added the new payer Golden Rule Insurance /30/2014 Added the new payer Louisiana Health Exchange /30/2014 Added the new payer United Healthcare Community Plan Kansas /30/2014 Added the new payer United Healthcare Facets Pittsburgh Community and State /30/2014 Added the new payer United Healthcare Facets Detroit Community and State /30/2014 Added the new payer United Healthcare Nevada Market /30/2014 Added the new payer Passport Health Plan /30/2014 Added the new payer BCBS Mississippi /30/2014 Added the new payer UMR (Wausau) /30/2014 Added the new payer Vermont Medicaid /30/2014 Added the new payer Health Partners of Philadelphia /30/2014 Added the new payer Bravo Health /30/2014 Added the new payer Alabama Medicaid /30/2014 Added the new payer Blue Shield of California /30/2014 Added the new payer Schaller Anderson Aetna Better Health of OH /30/2014 Added the new payer Ultimate Health Plans /31/2014 Added the new payer Tricare /31/2014 Added the new payer AFLAC /31/2014 Added the new payer Denver Health Medical Plan /31/2014 Added the new payer VIVA Health Inc /31/2014 Added the new payer Meritain Health /31/2014 Added the new payer American Network Ins. Medicare /31/2014 Added the new payer ARISE Health Plan-Medicare /31/2014 Added the new payer CMFG Life Insurance /31/2014 Added the new payer PENN Treaty Network Medicare Supp /31/2014 Added the new payer The ULLICO Family of Companies /31/2014 Added the new payer Orange County Fire Authority /31/2014 Added the new payer CarePlus Health Plan /31/2014 Added the new payer CarePoint Medicare Advantage /31/2014 Added the new payer Schaller Anderson MajestaCare VA /31/2014 Added the new payer Schaller Anderson Delaware Phys /31/2014 Added the new payer Schaller Anderson Aetna Better /31/2014 Added the new payer Molina Healthcare of SC /31/2014 Added the new payer Presbyterian Health Plan /31/2014 Added the new payer Arbor Health Plan /31/2014 Added the new payer Emblem Health /31/2014 Added the new payer Select Health of SC /31/2014 Added the new payer Amerihealth Caritas Pennsylvania /31/2014 Added the new payer Horizon New Jersey Health /31/2014 Added the new payer Advantage Health Solutions /31/2014 Added the new payer VA Health Administration CTR /31/2014 Added the new payer Senior Whole Health /31/2014 Added the new payer Triad Healthcare, Inc /31/2014 Added the new payer Health Services for Children with Spec /31/2014 Added the new payer AARP /31/2014 Changed payer ID Denver Health Medical Plan /31/2014 Changed payer ID American Network Ins. Medicare /31/2014 Changed payer ID CarePlus Health Plan /31/2014 Changed payer ID Horizon New Jersey Health /29/2014 Added the new payer BCBS of North Carolina /29/2014 Added the new payer Ohio Medicaid /29/2014 Added the new payer Georgia Medicaid /29/2014 Added the new payer AmeriHealth /29/2014 Added the new payer University of Arizona Health Plan- UHM /29/2014 Added the new payer Planned Administrators Inc /29/2014 Added the payer BCBS of Kansas City /30/2014 Added the payer BCBS of Texas /30/2014 Added the payer BCBS of BCBS of Iowa /30/2014 Added the payer BCBS of South Dakota Xerox EDI Eligibility Gateway 276/ Guide - All 3

11 9/30/2014 Added the payer Allegiance Benefit Plan Management /30/2014 Added the payer Arkansas Medicaid /30/2014 Added the payer Community Care of Oklahoma /30/2014 Added the payer Western Health Advantage /30/2014 Added the payer Aetna Better Health of NE /31/2014 Added the payer BCBS of Illinois /31/2014 Added the payer BCBS of Minnesota /31/2014 Added the payer BCBS of New Mexico /31/2014 Added the payer BCBS of Oklahoma /31/2014 Deactivated the payer Molina Healthcare of Missouri = /31/2014 Deactivated the payer Presbyterian Health Plan /31/2014 Deactivated the payer Windsor Medicare Extra Xerox EDI Eligibility Gateway 276/ Guide - All 4

12 AARP Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN AARP ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 5

13 Claim S DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 6

14 Advantage Health Solutions Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Advantage Health Solutions [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 7

16 Aetna Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Sub: First Dep: Last Dep: First Option(Cont.) Element 6 Element 7 Dependent D1 Dep: Date of Birth Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN AETNA US HEALTH CARE Aetna Non-HMO or Aetna HMO Provider ID. Either provider ID, tax ID, or NPI is required. Information Receiver Federal Tax ID S 9 9 N Service Provider [NM108=FI] Service Provider Level: 2100C Provider ID S 2 7 N Federal Tax ID S 9 9 N [NM108=SV] [NM108=FI] Aetna Non-HMO or Aetna HMO Provider ID. Either provider ID, tax ID, or NPI is required. Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D AN [NM108=MI] Xerox EDI Eligibility Gateway 276/ Guide - All 9

17 Claim Submitter Trace Claim Control Number Claim Dependent O 1 25 AN S DT Birth Date D1 8 8 DT [REF01=1K] Level: 2200D unknown, send 0. Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 10

18 Aetna Long Term Care Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Provider ID S 2 7 N Federal Tax ID S 9 9 N AETNA LONG TERM CARE [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=SV] [NM108=FI] Aetna Non-HMO or Aetna HMO Provider ID. Either provider ID, tax ID, or NPI is required. Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 11

19 Claim Disclaimer: None S DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 12

20 Affinity Health Plan Medicare Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Affinity Health Plan Medicare Information Receiver Last or Electronic Transmitter ID Number R 1 60 S 2 10 AN [NM108=46] Service Provider Last or s 60 Service Provider Level: 2100C NPI or Federal Tax ID S 2 7 N [NM108=SV] Either provider ID, tax ID, or NPI is required. Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Identification Code Qualifier/ Member ID S AN [NM108=MI] Claim Submitter Trace Level: 2200D Unique identification for the transaction Xerox EDI Eligibility Gateway 276/ Guide - All 13

21 Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S DT CCYYMMDD [DTP01= 472] [DTP02=RD8 or D8] Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 14

22 AFLAC Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN AFLAC ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 15

23 Claim Service Date R DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 16

24 AFLAC - Medicare Supplemental Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Sub: First Dep: Last Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN AFLAC - Medicare Supplemental Transunion ID Information Receiver R 1 60 AN AFLAC - Medicare Supplemental Information Receiver ID Code Qualifier R N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S N [NM108=FI] Tax ID is required Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 17

25 Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S DT [DTP01=472] RD8 = date range D8 = fixed date Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number Claim O 1 30 AN R DT [REF01=1K] [DTP01=472] Level: 2200E unknown, enter 0. Disclaimer: The Provider understands that receipt or use of this information does not guarantee payment of any health care claim by Aetna, and such information is subject to change, even retroactively, at any time. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 18

26 Alabama Medicaid Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Alabama Medicaid ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 19

27 Allegiance Benefit Plan Management Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Allegiance Benefit Plan Management [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/ Guide - All 20

28 Claim S DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 21

29 American Family Insurance Group- Medicare Supplement and PPO Policies Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S N AMERICAN FAMILY INSURANCE GROUP [NM108=FI] Service Provider Level: 2100C [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 22

30 Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R DT [REF01=1K] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 23

31 American Network Ins. Medicare Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes American Network Ins. R 1 35 AN Medicare ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 24

33 American Postal Workers Union Health (APWU) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N AMERICAN POSTAL WORKERS UNION HEALTH [NM108=FI] Electronic Transmitter ID Number S 9 9 AN [NM108=46] Service Provider Federal Tax ID S 9 9 N NPI S AN Service Provider Level: 2100C [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 26

34 Claim Control Number O 1 25 AN [REF01=1K] Send if known unknown, send 0. Claim S DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E Send if known unknown, enter 0. Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 27

35 American Republic Insurance Company (ARIC) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN AMERICAN REPUBLIC INSURANCE COMPANY Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Electronic Transmitter ID Number S 9 9 AN [NM108=46] NPI S AN Service Provider Provider ID S 2 7 N Federal Tax ID S 9 9 N NPI S AN Service Provider Level: 2100C [NM108=SV] [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Xerox EDI Eligibility Gateway 276/ Guide - All 28

36 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E Send if known unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 29

37 AMERIGROUP Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN AMERIGROUP ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 30

38 Claim Service Date R DT [DTP01=472] DISCLAIMER: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 31

39 AmeriHealth Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN AmeriHealth ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 32

41 Amerihealth Caritas Pennsylvania Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Amerihealth Caritas Pennsylvania [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 34

43 Ameritas Group Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender s ID ID Ameritas Life Reliance Standard Life First Ameritas of New York Standard Insurance First Reliance Standard Life Standard Insurance of New York Element Use Min Max Type Codes and Values Element Notes R 1 35 AN See Plans Table Above ID R 5 5 AN See Plans Table Above Information Receiver Electronic Transmitter ID Number S 9 9 AN Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N [NM108=46] [NM108=FI] Service Provider Level: 2100C [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Xerox EDI Eligibility Gateway 276/ Guide - All 36

44 Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Claim S DT [NM108=MI] Member s SSN Level: 2200D unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Disclaimer: None R DT Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 37

45 Aetna Better Health of NE Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Aetna Better Health of NE [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 38

47 Apex Benefits Services Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Apex Benefits Services ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 40

49 Arbor Health Plan Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Arbor Health Plan ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 42

51 ARISE Health Plan-Medicare Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes ARISE Health Plan- R 1 35 AN Medicare ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 44

53 Arkansas Medicaid Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Arkansas Medicaid ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 46

55 Banner Health Plans Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Banner Health Plans ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 48

57 BCBS AR BCARK Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS AR ID R 5 5 AN BCARK Information Receiver Submitter ID Code R 5 5 N [NM108=46] Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 50

58 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 51

59 BCBS of Colorado (Wellpoint) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF COLORADO ID R 5 5 AN Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 52

60 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E Send if known unknown, enter 0. Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 53

61 BCBS of Connecticut (Wellpoint) 4816 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN 4816 Information Receiver Service Provider BCBS OF CONNECTICUT Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 54

62 Claim Dependent S DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 55

63 BCBS of Florida AV294 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF FLORIDA ID R 5 5 AN AV294 Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 56

65 BCBS of Georgia (Wellpoint) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes And Values Element Notes Information Source Level: 2100a R 1 35 AN BCBS OF GEORGIA Id R 5 5 AN BCBSG Information Receiver Service Provider Information Receiver Level: 2100b Service Provider Level: 2100c Date Of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000d Level: 2100d Last S1,D AN First S AN NM104 Member Id S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200d If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 58

66 Dependent Birth Date D1 8 8 DT Dependent Level: 2000e Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100e Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200e If Amount Is Unknown, Enter 0. Data Type: N=Numeric, An=Alphanumeric, Dt=Date Format, Id=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 59

67 BCBS of Illinois Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF Illinois ID R 5 5 AN Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 60

68 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R DT [REF01=1K] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 61

69 BCBS of Indiana (Wellpoint) 4820 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF INDIANA ID R 5 5 AN 4820 Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 62

70 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R DT [REF01=1K] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal BCBS of Iowa Xerox EDI Eligibility Gateway 276/ Guide - All 63

71 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option(Cont.) Element 6 Dependent D1 Dep: Gender Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF Iowa ID R 5 5 AN Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/ Guide - All 64

72 Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R DT [REF01=1K] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 65

73 BCBS of Kansas 4923 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes And Values Element Notes Information Source Level: 2100a R 1 35 AN BCBS OF KANSAS Id R 5 5 AN 4923 Nm109 Information Receiver NPI R N Service Provider NPI R N Information Receiver Level: 2100b Service Provider Level: 2100c Date Of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M DMG03 Level: 2000d Level: 2100d Last S1, D AN First S AN NM104 Member Id S1, D AN [NM108=MI] Gender S1 2 2 ID F, M DMG03 Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] [AMY01=T3] Level: 2200d Send If Known. If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 66

74 Claim Dependent R DT Dependent Level: 2000e Birth Date R 8 8 DT Gender R 1 1 ID F,M DMG03 Dependent Level: 2100e Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Medical Record Number Claim Disclaimer: None O 1 25 AN O 1 30 AN R DT [REF01=1K] [REF01=EA] Level: 2200e Send If Known. If Amount Is Unknown, Send 0. Data Type: N=Numeric, An=Alphanumeric, Dt=Date Format, Id=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 67

75 BCBS of Kansas City Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes And Values Element Notes Information Source Level: 2100a R 1 35 AN BCBS of Kansas City Id R 5 5 AN Nm109 Information Receiver NPI R N Service Provider NPI R N Information Receiver Level: 2100b Service Provider Level: 2100c Date Of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M DMG03 Level: 2000d Level: 2100d Last S1, D AN First S AN NM104 Member Id S1, D AN [NM108=MI] Gender S1 2 2 ID F, M DMG03 Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] [AMY01=T3] Level: 2200d Send If Known. If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 68

76 Claim Dependent R DT Dependent Level: 2000e Birth Date R 8 8 DT Gender R 1 1 ID F,M DMG03 Dependent Level: 2100e Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Medical Record Number Claim Disclaimer: None O 1 25 AN O 1 30 AN R DT [REF01=1K] [REF01=EA] Level: 2200e Send If Known. If Amount Is Unknown, Send 0. Data Type: N=Numeric, An=Alphanumeric, Dt=Date Format, Id=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 69

77 BCBS of Kentucky (Wellpoint) 4821 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Sub: First Dep: Last Dep: First Option(Cont.) Element 6 Element 7 Dependent D1 Dep: Date of Birth Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF KENTUCKY ID R 5 5 AN 4821 Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 70

79 BCBS of Maine (Wellpoint) 4818 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF MAINE ID R 5 5 AN 4818 Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 72

80 Claim Dependent S DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R DT [REF01=1K] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 73

81 BCBS of Massachusetts Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Service Provider Provider ID S 2 7 N BLUE CROSS BLUE SHIELD OF MA Service Provider Level: 2100C [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number Bill Type Identifier O 1 25 AN O 1 30 AN [REF01=1K] [REF01=BLT] Xerox EDI Eligibility Gateway 276/ Guide - All 74

82 unknown, send 0. Claim S DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Bill Type Identifier Claim Disclaimer: None. O 1 30 AN O 1 30 AN R DT [REF01=1K] [REF01=BLT] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 75

83 BCBS of Minnesota Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Service Provider Provider ID S 2 7 N BLUE CROSS BLUE SHIELD OF Minnesota Service Provider Level: 2100C [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Bill Type Identifier O 1 25 AN O 1 30 AN [REF01=1K] [REF01=BLT] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 76

84 Claim Dependent S DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Bill Type Identifier Claim Disclaimer: None. O 1 30 AN O 1 30 AN R DT [REF01=1K] [REF01=BLT] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 77

85 BCBS Mississippi Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS Mississippi ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Provider ID S 2 20 AN Service Provider Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) S 2 7 AN [NM108=SV] Service Provider Level: 2100C [NM108=FI] [NM108=46] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 78

86 BCBS of Missouri (Wellpoint) 4921 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Date of Dep: Last Dep: First Birth Option (cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF MISSOURI ID R 5 5 AN 4921 Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 79

87 Claim R DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D AN Last First S AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R DT [REF01=1K] Level: 2100E Send if known unknown send 0 Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 80

88 BCBS of Nebraska Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Date of Dep: Last Dep: First Birth Option (cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF NEBRASKA ID R 5 5 AN Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 81

89 Claim Control Number O 1 25 AN Claim Dependent R DT Birth Date D1 8 8 DT [REF01=1K] Send if known unknown, send 0. Level: 2000E Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D AN Last First S AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R DT [REF01=1K] Level: 2100E Send if known unknown send 0 Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 82

90 BCBS of Nevada (Wellpoint) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Date of Dep: Last Dep: First Birth Option (cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF NEVADA ID R 5 5 AN Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 83

91 Claim R DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D AN Last First S AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN [REF01=1K] Level: 2100E Send if known unknown send 0 Claim R DT Disclaimer: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 84

92 BCBS of New Hampshire (Wellpoint) 4817 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Date of Dep: Last Dep: First Birth Option (cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN 4817 Information Receiver Service Provider BCBS OF NEW HAMPSHIRE Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known Xerox EDI Eligibility Gateway 276/ Guide - All 85

93 unknown, send 0. Claim R DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D AN Last First S AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R DT [REF01=1K] Level: 2100E Send if known unknown send 0 Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 86

94 BCBS of New Jersey (Horizon) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Date of Dep: Last Dep: First Birth Option (cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS NJ HORIZON ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N [NM108=FI] Service Provider Level: 2100C [NM108=Fi] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 87

95 Claim Control Number O 1 25 AN Claim Dependent R DT Birth Date D1 8 8 DT [REF01=1K] unknown, send 0. Level: 2000E Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D AN Last First S AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Level: 2100E Claim Control Number O 1 25 AN Claim R DT [REF01=1K] Disclaimer: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 88

96 BCBS of New Mexico Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option (cont.) Element 6 Dependent D1 Dep: Gender Dep: Date of Birth Element Use Min Max Type Codes And Values Element Notes Information Source Level: 2100a R 1 35 AN BCBS OF Mexico Id R 5 5 AN Information Receiver Service Provider Date Of Birth S1 8 8 DT CCYYMMDD Information Receiver Level: 2100b Service Provider Level: 2100c Level: 2000d Level: 2100d Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member Id S1, D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN Claim R DT [REF01=1K] Level: 2200d Send If Known If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 89

97 Dependent Level: 2000e Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100e Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R DT [REF01=1K] Level: 2100e Send If Known If Amount Unknown Send 0 Data Type: N=Numeric, An=Alphanumeric, Dt=Date Format, Id=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 90

98 BCBS of New York (Empire) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Date of Dep: Last Dep: First Birth Option (cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes And Values Element Notes R 1 35 AN Id R 5 5 AN Information Receiver Service Provider BCBS OF NEW YORK EMPIRE Information Source Level: 2100a Information Receiver Level: 2100b Service Provider Level: 2100c Date Of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000d Level: 2100d Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member Id S1, D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200d Send If Known If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 91

99 Claim R DT Dependent Level: 2000e Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100e Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R DT [REF01=1K] Level: 2100e Send If Known If Amount Unknown Send 0 Data Type: N=Numeric, An=Alphanumeric, Dt=Date Format, Id=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 92

100 BCBS of North Carolina Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Sub: First Dep: Last Dep: First Option(Cont.) Element 6 Dependent D1 Dep: Date of Birth Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS of North Carolina ID R 5 5 AN Information Receiver Service Provider Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, send 0. Dependent Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/ Guide - All 93

101 Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E Send if known unknown, enter 0. Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 94

102 BCBS of Ohio (Wellpoint) 4823 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF OHIO ID R 5 5 AN 4823 Information Receiver Service Provider Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known If amount unknown send 0 Dependent Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/ Guide - All 95

103 Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, An=Alphanumeric, Dt=Date Format, Id=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 96

104 BCBS of Oklahoma Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option (cont.) Element 6 Dependent D1 Dep: Gender Dep: Date of Birth Element Use Min Max Type Codes And Values Element Notes Information Source Level: 2100a R 1 35 AN BCBS of Oklahoma Id R 5 5 AN Information Receiver Service Provider Date Of Birth S1 8 8 DT CCYYMMDD Information Receiver Level: 2100b Service Provider Level: 2100c Level: 2000d Level: 2100d Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member Id S1, D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN Claim R DT [REF01=1K] Level: 2200d Send If Known If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 97

105 Dependent Level: 2000e Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100e Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R DT [REF01=1K] Level: 2100e Send If Known If Amount Unknown Send 0 Data Type: N=Numeric, An=Alphanumeric, Dt=Date Format, Id=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 98

106 BCBS of South Carolina Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS SC ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim S DT Level: 2200D unknown send 0 Xerox EDI Eligibility Gateway 276/ Guide - All 99

107 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim R DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. BCBS of South Dakota Xerox EDI Eligibility Gateway 276/ Guide - All 100

108 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option(Cont.) Element 6 Dependent D1 Dep: Gender Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS of South Dakota ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim S DT Level: 2200D unknown send 0 Dependent Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/ Guide - All 101

109 Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim R DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 102

110 BCBS of Tennessee Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS Tennessee ID R 5 5 AN Information Receiver NPI R N Service Provider NPI R N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D unknown send 0 Xerox EDI Eligibility Gateway 276/ Guide - All 103

111 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 25 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 104

112 BCBS of Texas Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option(Cont.) Element 6 Dependent D1 Dep: Gender Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS Texas ID R 5 5 AN Information Receiver NPI R N Service Provider NPI R N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D unknown send 0 Dependent Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/ Guide - All 105

113 Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 25 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 106

114 BCBS of Vermont Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF VERMONT ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N Service Provider [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 107

115 BCBS of Virginia BCBSV Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF VIRGINIA ID R 5 5 AN BCBSV Information Receiver Service Provider Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Gender S1 2 2 ID F,M,U DMG03 Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known Xerox EDI Eligibility Gateway 276/ Guide - All 108

116 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Send if known unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 109

117 BCBS of Wisconsin (Wellpoint) BCBSW Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN BCBS OF WISCONSIN ID R 5 5 AN BCBSW Information Receiver Service Provider Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Gender S1 2 2 ID F, M, U DMG03 Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 110

118 Claim Dependent S DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Send if known unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 111

119 Benefit Management Inc Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Benefit Management Inc. Transunion ID Information Receiver R 1 60 AN Benefit Management Inc. Information Receiver ID Code Qualifier R N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S N Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI or XX] Gender S1 2 2 ID F, M, U DMG03 Either the Tax ID or NPI is required Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 112

120 Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S DT [DTP01=472] RD8 = date range D8 = fixed date Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Better Health Plans (Unison Health Plan) Xerox EDI Eligibility Gateway 276/ Guide - All 113

121 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N BETTER HEALTH PLANS [NM108=FI] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Bill Type Identifier Medical Record Number O 1 25 AN O 1 30 AN O 1 30 AN [REF01=1K] [REF01=BLT] [REF01=EA] Level: 2200D Send if known unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 114

122 Claim S DT Claim Submitter Trace Required for Institutional claims For Professional Claims, either Claims Service Date (2200D DTP) or Line Service Date (2210D DTP) required. Level: 2200D Product or Service ID Qualifier R 2 2 ID SVC01-1 Service Identifier Code R 1 48 AN SVC01-2 Modifier 1 S 2 2 AN SVC01-3 Modifier 2 S 2 2 AN SVC01-4 Modifier 3 S 2 2 AN SVC01-5 Modifier 4 S 2 2 AN SVC01-6 Line Item Original Units of Service Line item Control Number Service Line Date SVC02 S 1 15 N SVC07 R 1 30 AN R DT [REF01=FJ] [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Required if submitted on the original claim service Required line. if submitted on the original claim service Required line. if submitted on the original claim service Required line. if submitted on the original claim service line. Required when the submitted units are greater than 1. Xerox EDI Eligibility Gateway 276/ Guide - All 115

123 Blue Cross of California (Wellpoint) BCCAL Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN BCCAL Information Receiver BLUE CROSS OF CALIFORNIA Service Provider Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Gender S1 2 2 ID F, M, U DMG03 Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known Xerox EDI Eligibility Gateway 276/ Guide - All 116

124 Claim S DT unknown, enter 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Send if known unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 117

125 Blue Cross Pennsylvania (Capital) 582 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option (cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN CAPITAL BLUECROSS ID R 5 5 AN 582 Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 118

126 Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] unknown, enter 0. Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 119

127 Blue Shield of California Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Sub: First Dep: Last Dep: First Option(Cont.) Element 6 Element 7 Dependent D1 Dep: Date of Birth Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Blue Shield of California Transunion ID Information Receiver R 1 60 AN Health First Health Plans Information Receiver ID Code Qualifier R N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S N [NM108=FI or XX] Either the Tax ID or NPI is required Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S1,D AN First S1,D AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 120

128 Claim Control Number O 1 25 AN [REF01=1K] Monetary Amount unknown, send 0. Claim Service S DT [DTP01=472] RD8 = date range D8 = fixed date Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number Claim S 1 30 AN O 1 10 R S DT [REF01=1K] [DTP01=472] Level: 2200E unknown, enter 0. Disclaimer: The Provider understands that receipt or use of this information does not guarantee payment of any health care claim by Aetna, and such information is subject to change, even retroactively, at any time. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 121

129 Boon Group Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Date of Birth Last First Member ID Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Boon Group ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 122

130 Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 123

131 Bravo Health Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Bravo Health ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 124

132 Bridgespan Option Element 1 Element 2 Element 3 Element 4 S1 Date of Birth Last First Member ID Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Bridgespan ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N Provider ID S 2 7 N [NM108=FI] [NM108=FI] [NM108=SV] Service Provider Level: 2100C Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Member ID S AN Claim Submitter Trace [NM108=MI] Member ID Commercial Plans: 11 digits Medicaid Plans: 10 digits OR Medicaid Recipient ID 8-12 digits Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 125

133 Claim Control Number S 1 30 AN [REF01=1K] Required if known. unknown, send 0. Claim R DT The earliest service date in the claim must be used but cannot be more than 18 months in the past. Disclaimer: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 126

134 CarePlus Health Plan Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes Orange County Fire R 1 35 AN Authority ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Level: 2100D Level: 2200D unknown, send 0 Xerox EDI Eligibility Gateway 276/ Guide - All 127

135 CarePoint Medicare Advantage Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN CarePoint Medicare Advantage [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 128

137 Carolina Care Plan, Inc. (CCP) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Date of Birth Member ID Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N Provider ID S 2 7 N Carolina Care Plan, Inc. (CCP) [NM108=FI] [NM108=FI] [NM108=SV] Service Provider Level: 2100C Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Member ID S AN Claim Submitter Trace [NM108=MI] Member ID Commercial Plans: 11 digits Medicaid Plans: 10 digits OR Medicaid Recipient ID 8-12 digits Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 130

139 CDS Group Health Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN CDS Group Health ID R 5 5 AN Transunion ID Information Receiver R 1 60 AN CDS Group Health Information Receiver ID Code Qualifier R N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S N Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI or XX] Gender S1 2 2 ID F, M, U DMG03 Either the Tax ID or NPI is required Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 132

140 Claim Control Number O 1 25 AN [REF01=1K] Monetary Amount unknown, send 0. Claim Service S DT [DTP01=472] RD8 = date range D8 = fixed date Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number Claim O 1 30 AN R DT [REF01=1K] [DTP01=472] Level: 2200E unknown, enter 0. Disclaimer: The Provider understands that receipt or use of this information does not guarantee payment of any health care claim by Aetna, and such information is subject to change, even retroactively, at any time. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 133

141 Cenpatico Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth s ID ID Cenpatico Behavioral Health Cenpatico - Mississippi Cenpatico Behavioral Health Texas Cenpatico - Missouri Cenpatico - Georgia Cenpatico - New Hampshire Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N Provider ID S 2 7 N See Plans table above. See Plans table above. [NM108=FI] [NM108=FI] [NM108=SV] Service Provider Level: 2100C Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Xerox EDI Eligibility Gateway 276/ Guide - All 134

142 Member ID S AN [NM108=MI] Member ID Commercial Plans: 11 digits Medicaid Plans: 10 digits OR Medicaid Recipient ID 8-12 digits Claim Submitter Trace Claim Control Number S 1 30 AN [REF01=1K] Level: 2200D Required if known. unknown, send 0. Claim R DT The earliest service date in the claim must be used but cannot be more than 18 months in the past. Disclaimer: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 135

143 Centene Option Element 1 Element 2 Element 3 Element 4 S1 Last First Date of Birth Member ID s ID ID Centene - Advantage by Peach State Centene-Kentucky Spirit Health Plan Centene - Advantage by Sunshine State Centene-Louisiana Healthcare Connections Centene Advantage Plans Centene-Magnolia Health Plan Centene-Coordinated Care Centene-Peach State Health Plan Centene-California Health & Wellness Centene-Sunflower State Health (Kansas) Centene - Granite State Health Plan Centene-Sunshine State Health Plan Centene-Home State Health Plan Centene - Total Care Carolina Centene- IlliniCare Health Plan Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N Provider ID S 2 7 N See Plans table above. See Plans table above. [NM108=FI] [NM108=FI] [NM108=SV] Service Provider Level: 2100C Xerox EDI Eligibility Gateway 276/ Guide - All 136

144 Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Member ID Commercial Plans: 11 digits Medicaid Plans: 10 digits OR Medicaid Recipient ID 8-12 digits Claim Submitter Trace Claim Control Number S 1 30 AN [REF01=1K] Level: 2200D Required if known. unknown, send 0. Claim R DT The earliest service date in the claim must be used but cannot be more than 18 months in the past. Disclaimer: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 137

145 Central Reserve Insurance Company Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN CENTRAL RESERVE ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Service Provider Federal Tax ID S 9 9 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=FI] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/ Guide - All 138

146 Claim S DT unknown, enter 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 139

147 Central Reserve Life Ins Co Medicare Supp Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N NPI S AN Service Provider Federal Tax ID S 9 9 N NPI S AN Central Reserve Medicare Supp [NM108=FI] Service Provider Level: 2100C [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 140

149 CMFG Life Insurance Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN CMFG Life Insurance ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 142

151 Community Care of Oklahoma Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option(Cont.) Element 6 Dependent D1 Dep: Gender Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Community Care of Oklahoma [NM108=FI] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim S DT Level: 2200D unknown send 0 Xerox EDI Eligibility Gateway 276/ Guide - All 144

152 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim R DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 145

153 Continental General Insurance Company Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N CONTINENTAL GENERAL [NM108=FI] Service Provider Federal Tax ID S 9 9 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=FI] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/ Guide - All 146

154 Claim Dependent S DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 147

155 Cooperative Benefit Administrators Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N COOPERATIVE BENEFIT ADMINISTRATOR [NM108=FI] Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 148

156 Claim Control Number Claim Dependent O 1 25 AN S DT Birth Date D1 8 8 DT [REF01=1K] Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 149

157 CoreSource Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender s CoreSource Little Rock CoreSource Ohio CoreSource- MD/PA/IL/NC/AZ/IN/MN CoreSource FMH Element Use Min Max Type Codes and Values Element Notes R 1 35 AN See Plans table above. ID R 5 5 AN See Plans table above. Information Receiver Federal Tax ID S 9 9 N Service Provider Provider ID S 2 7 N Federal Tax ID S 9 9 N [NM108=FI] Service Provider Level: 2100C [NM108=SV] [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Xerox EDI Eligibility Gateway 276/ Guide - All 150

158 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known. unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Level: 2200E Send if known. unknown, enter 0. Disclaimer: The Provider understands that receipt or use of this information does not guarantee payment of any health care claim by Aetna, and such information is subject to change, even retroactively, at any time. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 151

159 Coventry Healthcare Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender s ID ID Advantra Freedom CHCCares- South Carolina Altius Health Plans Coventry Healthcare Carenet CHC of Delaware Diamond Plan (Maryland Medicaid) CHC of Georgia Group Health Plan (GHP) CHC of Iowa HealthAmerica and Health Assurance CHC of Kansas Healthcare Inc (Promina) CHC Carelink Medicaid Healthcare USa (HCUSA) CHC of Louisiana Omnicare (Michigan) CHC of Nebraska CHC-PersonalCare/Coventry Health of Illinois Coventry Advantra Savings Southern Health Services (SHS) Coventry Health and Life (OK only) University of Missouri Coventry Health Life- TN only Wellpath Select (Carolinas) CHC Carelink (Advantra) Advantra- (Texas, New Mexico, Arizona only) Coventry Health and Life (Nevada) Coventry Missouri CHC- Mail Handler s Benefit Plan CHC- CoventryOne Coventry Healthcare National Network Vista (MCD, FHK, LTC) Coventry Health Care Federal Coventry Nebraska Medicaid CHC- Florida/Vista/Summit CoventryCares The following are Medicaid plans: CHC CareLink Medicaid, Coventry Health Care CareNet, CHCcares- South Carolina, Diamond Plan, HealthCare USA. Coventry Advantra Savings is a Medicare MSA plan. Element Use Min Max Type Codes and Values Element Notes R 1 35 AN See Plans table above. ID R 5 5 AN See Plans table above. Information Receiver Federal Tax ID S 9 9 N Service Provider [NM108=FI] Service Provider Level: 2100C Xerox EDI Eligibility Gateway 276/ Guide - All 152

160 Federal Tax ID S 9 9 N Provider ID S 2 7 N [NM108=FI] [NM108=SV] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN Claim Submitter Trace Claim Control Number Claim Disclaimer: None. S 1 30 AN R DT [NM108=MI] [REF01=1K] Member ID Commercial Plans: 11 digits Medicaid Plans: 10 digits OR Medicaid Recipient ID 8-12 digits Level: 2200D Required if known. unknown, send 0. The earliest service date in the claim must be used but cannot be more than 18 months in the past. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 153

161 Culinary Health Fund Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Culinary Health Fund ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 154

162 Dependent Birth Date D1 8 8 DT Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Dependent Level: 2000E Level: 2100E Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Send if known unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 155

163 Definity Health Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Definity Health ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 156

164 Claim S DT Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 157

165 Denver Health Medical Plan Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes Denver Health Medical R 1 35 AN Plan ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 158

167 Easy Choice Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Date of Birth Member ID Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Member ID Search options: S1 1 AN [NM108= MI] Level: 2100C Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 160

168 EBMS (Employee Benefit Management Services) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Date of Birth Last First Member ID Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver EBMS (Employee Benefit Management Services) Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 161

170 Emblem Health Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Emblem Health ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 163

172 Everence Financial Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Everence Financial ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 165

174 Evergreen Health Co-Op Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Evergreen Health Co- Op Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 167

176 Federated Insurance Company Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver FEDERATED INSURANCE CO Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 169

177 Claim Dependent S DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Send if known unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 170

178 Fidelis SecureCare of Michigan Option Element 1 Element 2 Element 3 Element 4 S1 Date of Birth Last First Member ID Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N Provider ID S 2 7 N Fidelis SecureCare of Michigan [NM108=FI] [NM108=FI] [NM108=SV] Service Provider Level: 2100C Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Member ID S AN Claim Submitter Trace [NM108=MI] Member ID Commercial Plans: 11 digits Medicaid Plans: 10 digits OR Medicaid Recipient ID 8-12 digits Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 171

180 Florida Medicaid Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN FLORIDA MEDICAID ID R 5 5 AN Information Receiver Service Provider Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None. R DT Level: 2200D unknown, send 0. -Up to one year prior to the current date. -No future dates. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 173

181 Food Employers & Bakery Workers Benefit Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Food Employers & Bakery Workers Benefit Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 174

182 Claim Dependent S DT Dependent Level: 2000E Birth Date D1 8 8 DT Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Send if known unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 175

183 Fresenius Medical Care Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Fresenius Medical Care ID R 5 5 AN Information Receiver Electronic Transmitter ID Service Provider S 9 9 N [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None. R DT Level: 2200D unknown, send 0. -Up to one year prior to the current date. -No future dates. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 176

184 Generations Healthcare Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Fresenius Medical Care ID R 5 5 AN Information Receiver Electronic Transmitter ID Service Provider S 9 9 N [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim R DT Level: 2200D unknown, send 0. -Up to one year prior to the current date. -No future dates. Disclaimer: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 177

185 Georgia Medicaid Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Georgia Medicaid ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 178

187 Gilsbar Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Dependent D1 Sub: Member ID Dep: Date of Birth Dependent D2 Sub: Member ID Dep: First Element Use Min Max Type Codes and Values Element Notes R 1 35 AN GILSBAR ID R 5 5 AN Information Receiver Federal Tax ID S N Service Provider Federal Tax ID S N Member ID S1,D1,D AN Claim Submitter Trace Claim Dependent S DT Birth Date D1 8 8 DT Dependent First D AN Dependent Claim Submitter Trace [NM108=FI] Service Provider Level: 2100C [NM108=FI] [NM108=mi] NM104 Level: 2000D Level: 2200D Dependent Level: 2000E Level: 2100E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 180

188 Claim R DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 181

189 Golden Rule Insurance Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Golden Rule Insurance ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 182

191 Health First Health Plans Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Health First Health Plans Transunion ID Information Receiver R 1 60 AN Health First Health Plans Information Receiver ID Code Qualifier R N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S N Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI or XX] Gender S1 2 2 ID F, M, U DMG03 Either the Tax ID or NPI is required Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 184

193 Health Partners of Philadelphia Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Health Partners of Philadelphia Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 186

194 Health Services for Children with Spec Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Health Services for Children with Spec. [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/ Guide - All 187

196 HealthChoice AZ Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN HealthChoice AZ ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Service Provider Federal Tax ID S 9 9 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=FI] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim S DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 189

197 Healthfirst NJ Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN HEALTHFIRST OF NJ ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) S 2 20 AN Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD [NM108=46] Service Provider Level: 2100C [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim S DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 190

198 Healthfirst NY Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN HEALTHFIRST OF NY ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) S 2 20 AN Service Provider Provider ID S 2 7 N [NM108=46] Service Provider Level: 2100C [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim S DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 191

199 HealthMarkets Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender s HealtMarkets Chesapeake National Life HealtMarkets Mid-West National Life HealtMarkets TransAmerica Life HealtMarkets Mega Life and Health Insurance Element Use Min Max Type Codes and Values Element Notes R 1 35 AN See above table ID R 5 5 AN See table above Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Service Provider Federal Tax ID S 9 9 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=FI] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Xerox EDI Eligibility Gateway 276/ Guide - All 192

200 Member ID S1,D1 9 9 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 30 AN S DT [REF01=1K] Level: 2200D Send if requesting claim detail. Total number of REF segments cannot If amount exceed is 3. unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E Send if requesting claim detail. Total number of REF If amount segments is cannot unknown, exceed enter Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 193

201 HealthPlan Services - Celtic Insurance Company Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Date of Birth Last First Member ID Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver HealthPlan Services - Celtic Insurance Company Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 194

203 Horizon New Jersey Health 2840 Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN 2840 Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Horizon New Jersey Health [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 196

205 IBEW Local 508 Health Plan Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Date of Birth Last First Member ID Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN IBEW Local 508 Health Plan ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 198

207 IBM Insurance Outsourcing Services Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N IBM Insurance Outsourcing Services Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 200

209 Kaiser Foundation Health Plan of Colorado Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N NPI S AN Service Provider Federal Tax ID S 9 9 N Kaiser Foundation Health Plan of CO Transunion ID [NM108=FI] Service Provider Level: 2100C [NM108=FI] NPI S AN Federal Tax ID if NM108=FI NPI if NM108 = XX Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Unique identification for the transaction Send if known Xerox EDI Eligibility Gateway 276/ Guide - All 202

210 unknown, send 0. Claim S DT RD8 = date range D8 = fixed date Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 203

211 Kentucky Health Exchange Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Kentucky Health Exchange ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 204

212 Kentucky Medicaid Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN KENTUCKY MEDICAID ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) S 2 20 AN Service Provider [NM108=46] The 8 digit Medicaid provider number should have 2 trailing zeroes Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] The 8 digit Medicaid provider number should have 2 trailing zeroes Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim Control Number O 1 30 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/ Guide - All 205

213 Bill Type Identifier Medical Record Number Claim O 1 30 AN O 1 30 An S DT REF01=BLT] REF01=EA] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 206

214 Leon Medical Centers Health Plan Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Leon Medical Centers Health Plan Transunion ID Information Receiver Last or Electronic Transmitter ID Number R 1 60 S 2 10 AN [NM108=46] Service Provider Last or s 60 Service Provider Level: 2100C NPI or Federal Tax ID S 2 7 N [NM108=SV] Either provider ID, tax ID, or NPI is required. Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Identification Code Qualifier/ Member ID S AN [NM108=MI] Claim Submitter Trace Trace Number S 1 30 AN Level: 2200D Unique identification for the transaction Xerox EDI Eligibility Gateway 276/ Guide - All 207

215 Claim Control Number O 1 25 AN [REF01=1K] S 1 10 R unknown, send 0. Claim S DT CCYYMMDD [DTP01= 472] [DTP02=RD8 or D8] Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 208

216 Lincoln Financial Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Lincoln Financial ID R 5 5 AN Transunion ID Information Receiver R 1 60 AN Lincoln Financial Information Receiver ID Code Qualifier R N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S N Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI or XX] Gender S1 2 2 ID F, M, U DMG03 Either the Tax ID or NPI is required Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 209

218 Managed Health Network Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Managed Health Network Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 211

220 Maricopa Health Plan Arizona Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes Maricopa Health Plan R 1 35 AN AZ ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N [NM108=46] Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Claim Service Date R DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0. Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 213

221 Claim Service Date R DT [DTP01=472] DISCLAIMER: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 214

222 MedBen (Newark OH) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Note: is also known by the following names: Medical Benefits Administrators/MedBen, Medical Benefits Administrators Inc. (Newark OH), Medical Benefits Companies (Newark OH), Medical Benefits Mutual (Newark OH), Medical Benefits Mutual/MedBen, Medical Benefits Mutual Life Insurance Co. Element Use Min Max Type Codes and Values Element Notes R 1 35 AN MedBen (Newark OH) ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date Dependent S DT [NM108=MI] [DTP01=472] Date of Birth D1 8 8 DT CCYYMMDD [ Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Level: 2100D Level: 2200D unknown, send 0 unknown, send 0 Dependent Level: 2000E Dependent Last D AN First D AN NM104 Level: 2000E Xerox EDI Eligibility Gateway 276/ Guide - All 215

223 Dependent Claim Submitter Trace Claim Service Date R DT [DTP01=472] DISCLAIMER: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 216

224 Medical Mutual of Ohio Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID R 9 9 N Service Provider Federal Tax ID R 9 9 N MEDICAL MUTUAL OF OHIO [NM108=FI] Service Provider Level: 2100C [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 217

225 Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 218

226 Med-Pay, Inc Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Med-Pay, Inc. ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 219

228 Meritain Health Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Meritain Health ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 221

230 Mississippi Medicaid Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN MISSISSIPPI MEDICAID ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N [NM108=46] Service Provider Service Provider Level: 2100C [NM108=SV] Provider ID S 2 7 N Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim R DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 223

231 Missouri Care Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Date of Birth Member ID Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN Missouri Care NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Member ID Search options: S1 1 AN [NM108= MI] Level: 2100C Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 224

232 Molina Healthcare Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender s Molina Healthcare of California Molina Healthcare of Ohio Molina Healthcare of Florida Molina Healthcare of SC Molina Healthcare of Illinois Molina Healthcare of Texas Molina Healthcare of Michigan Molina Healthcare of Utah Molina Healthcare of New Mexico Molina Healthcare of Washington Element Use Min Max Type Codes and Values Element Notes R 1 35 AN See Plans table above. ID R 5 5 AN See Plans table above. Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) S 2 20 AN Service Provider Federal Tax ID S 9 9 N Provider ID S 2 20 N [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Xerox EDI Eligibility Gateway 276/ Guide - All 225

233 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 226

234 Mutual Health Services Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Med-Pay, Inc. ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 227

236 MVP Health Care (New York) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Notes: MVP Preferred Care is not included and any member ID s not beginning with 8 is not going to be matched or returned. Element Use Min Max Type Codes and Values Element Notes R 1 35 AN MVP ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 2 80 AN [NM108=46] Federal Tax ID R 9 9 N Service Provider NPI R N [NM108=FI] Service Provider Level: 2100C Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number Bill Type Identifier R 1 30 AN O 1 30 AN [REF01=1K] [REF01=BLT] Required for institutional claims inquiries. Found on UB92 record 40 4 Found on 837I in CLM-05 Found on UB92 paper form Xerox EDI Eligibility Gateway 276/ Guide - All locator 229 4

237 Claim R DT CCYYMMDD- CCYYMMDD Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 230

238 National Association of Letter Carriers (NALC) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN NALC ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Electronic Transmitter ID Number (ETIN) S 2 20 AN [NM108=46] Service Provider Federal Tax ID S 9 9 N Provider ID S 2 20 AN Service Provider Level: 2100C [NM108=FI] [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Xerox EDI Eligibility Gateway 276/ Guide - All 231

239 Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D If known unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E If known and individual claim is sought. unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 232

240 Network Health Plan of WI Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN Network Health Plan of WI NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Search options: Level: 2100C Member ID S1 1 AN [NM108= MI] Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 233

241 Ohio Medicaid Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Ohio Medicaid ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 234

243 Operating Engineers Local No Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Operating Engineers Local No.428 Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 236

245 Orange County Fire Authority Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes Orange County Fire R 1 35 AN Authority ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Level: 2100D Level: 2200D unknown, send 0 Xerox EDI Eligibility Gateway 276/ Guide - All 238

246 Passport Health Plan Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Passport Health Plan ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Provider ID S 2 20 AN Service Provider Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) S 2 7 AN [NM108=SV] Service Provider Level: 2100C [NM108=FI] [NM108=46] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 239

247 PENN Treaty Network Medicare Supp Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes PENN Treaty Network R 1 35 AN Medicare Supp ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 240

249 Planned Administrators Inc Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N ETIN S 2 80 AN Service Provider Federal Tax ID S 9 9 N Provider ID S 2 80 AN Planned Administrators Inc. Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN R DT [REF01=1K] Level: 2200D If known unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 242

250 Dependent Birth Date D1 8 8 DT Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Dependent Level: 2000E Level: 2100E Level: 2200E Claim Control Number O 1 30 AN [REF01=1K] If known and individual claim is sought. Claim R DT unknown, enter 0. Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 243

251 Plumbers and Pipefitters Local Union Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) Service Provider S 2 20 AN Federal Tax ID S 9 9 N Provider ID S 2 7 N Plumbers and Pipefitters Local Union 525 Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/ Guide - All 244

253 Physicians Mutual Insurance Company Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN PHYSICIANS MUTUAL ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N ETIN S 2 80 AN Service Provider Federal Tax ID S 9 9 N Provider ID S 2 80 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=FI] [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D If known Xerox EDI Eligibility Gateway 276/ Guide - All 246

254 unknown, send 0. Claim R DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number O 1 30 AN [REF01=1K] If known and individual claim is sought. Claim R DT unknown, enter 0. Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 247

255 Preferred Care Partners Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN Preferred Care Partners NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Search options: Level: 2100C Member ID S1 1 AN [NM108= MI] Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 248

256 Primary PhysicianCare Inc Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option (cont.) Element 6 Dependent D1 Dep: Gender Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes Primary PhysicianCare R 1 35 AN Inc ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Gender D1 1 1 ID F,M,U DMG03 Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 249

258 Principal Financial Group Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Element 7 Dependent D1 Dep: Gender s Nippon Life Insurance Co of America Principal Life Insurance Company Element Use Min Max Type Codes and Values Element Notes R 1 35 AN See Plans table above. ID R 5 5 AN See Plans table above. Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N [NM108=FI] Service Provider Level: 2100C [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D1 9 9 N [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 251

259 Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R DT [REF01=1K] Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 252

260 Schaller Anderson Aetna Better Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Schaller Anderson Aetna Better [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 253

262 Schaller Anderson Aetna Better Health of OH Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Schaller Anderson Aetna Better Health of OH Information Receiver Electronic Transmitter ID Number (ETIN) Service Provider R 9 9 N Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD [NM108=46] Service Provider Level: 2100C [NM108=SV] Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Level: 2000D Level: 2100D Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 255

263 Schaller Anderson Delaware Phys Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Schaller Anderson Delaware Phys [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/ Guide - All 256

265 Schaller Anderson MajestaCare VA Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Schaller Anderson MajestaCare VA [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/ Guide - All 258

267 Schaller Anderson Maryland Physicians Care Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN Schaller Anderson Maryland Physicians Care NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Search options: Level: 2100C Member ID S1 1 AN [NM108= MI] Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 260

268 Schaller Anderson Mercy Care Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN Schaller Anderson Mercy Care NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Search options: Level: 2100C Member ID S1 1 AN [NM108= MI] Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 261

269 Schaller Anderson Missouri Care Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN Schaller Anderson Missouri Care NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Search options: Level: 2100C Member ID S1 1 AN [NM108= MI] Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 262

270 Schaller Anderson Parkland Community Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN Schaller Anderson Parkland Community NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Search options: Level: 2100C Member ID S1 1 AN [NM108= MI] Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 263

271 Schaller Anderson Texas CHRISTUS Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Date of Birth Member ID Element Use Min Max Type Codes and Values Element Notes ID R 5 5 ID [NM108= PI] Transunion ID Provider Last or R 60 AN Schaller Anderson Texas CHRISTUS NPI R 2 2 ID [NM108= XX] National Provider ID if NM108 = XX Search options: Level: 2100C Member ID S1 1 AN [NM108= MI] Last S AN First S AN NM104 Date of Birth S1 8 8 DT CCYYMMDD Usage: Data Type: R=Required, O=Optional, S=Situational N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code Xerox EDI Eligibility Gateway 276/ Guide - All 264

272 Select Health of SC Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Select Health of SC ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 265

274 Senior Health Services Center-Universal American Family of Companies Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dep: Last Dep: First Dep: Date of Dependent D1 Sub: Member ID Sub: Last Birth Element Use Min Max Type Codes and Values Element Notes Senior Health Services Center-Universal R 1 35 AN American Family of Companies ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN Level: 2000E Xerox EDI Eligibility Gateway 276/ Guide - All 267

275 First D AN Dependent Claim Submitter Trace Claim Service Date R DT NM104 [DTP01=472] DISCLAIMER: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 268

276 Senior Whole Health Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Senior Whole Health ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 269

278 Significa Benefit Services Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dep: Last Dep: First Dep: Date of Dependent D1 Sub: Member ID Sub: Last Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN PHYSICIANS MUTUAL ID R 5 5 AN Information Receiver ETIN S 2 80 AN Service Provider Provider ID S 2 80 AN Date of Birth S1 8 8 DT CCYYMMDD [NM108=46] Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim R DT Level: 2200D unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Dependent Level: 2000E Level: 2100E Xerox EDI Eligibility Gateway 276/ Guide - All 271

279 Last D AN First D AN NM104 Dependent Claim Submitter Trace Claim Disclaimer: None R DT Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 272

280 Simply Healthcare Plans Option Element 1 Element 2 Element 3 Element 4 S1 Date of Birth Last First Member ID Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Simply Healthcare Plans ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N Provider ID S 2 7 N [NM108=FI] [NM108=FI] [NM108=SV] Service Provider Level: 2100C Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Member ID S AN Claim Submitter Trace [NM108=MI] Member ID Commercial Plans: 11 digits Medicaid Plans: 10 digits OR Medicaid Recipient ID 8-12 digits Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 273

282 SPJST Medicare Supplement Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N NPI S AN Service Provider Federal Tax ID S 9 9 N NPI S AN SPJST MEDICARE SUPP [NM108=FI] Service Provider Level: 2100C [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 275

284 TexanPlus North Texas Area Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N Service Provider Provider ID S 2 7 N TexanPlus North Texas Area [NM108=46] Service Provider Level: 2100C [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 277

285 TexanPlus South Texas Area Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N Service Provider Provider ID S 2 7 N TexanPlus South Texas Area [NM108=46] Service Provider Level: 2100C [NM108=SV] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 278

286 The Kempton Company Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes The Kempton R 1 35 AN Company ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 279

288 The ULLICO Family of Companies Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes The ULLICO Family of R 1 35 AN Companies ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 281

290 Three Rivers Health Plans (Unison Health Plan) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Provider ID S 2 7 N THREE RIVER HEALTH PLANS [NM108=FI] Service Provider Level: 2100C [NM108=SV] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Control Number Bill Type Identifier Medical Record Number Claim Service Line Information O 1 30 AN O 1 30 AN O 1 30 AN R DT [REF01=1K] [REF01=BLT] [REF01=EA] Level: 2200D unknown, send 0. Level: 2210D Xerox EDI Eligibility Gateway 276/ Guide - All 283

291 Product or Service ID Qualifier R 2 2 ID SVC01-1 Service Identifier Code S 1 48 AN SVC01-2 Modifier 1 S 2 2 AN SVC01-3 Modifier 2 S 2 2 AN SVC01-4 Modifier 3 S 2 2 AN SVC01-5 Modifier 4 S 2 2 AN SVC01-6 Line Item Original Units of Service Line item Control Number SVC02 S 1 15 N SVC07 R 1 30 AN [REF01=FJ] Required if submitted on the original claim service Required line. if submitted on the original claim service Required line. if submitted on the original claim service Required line. if submitted on the original claim service line. Required when the submitted units are greater than 1. Service Line Date R DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 284

292 TMG Network Health Insurance Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N Service Provider Provider ID S 2 7 N TMG Network Health Insurance [NM108=46] Service Provider Level: 2100C [NM108=SV] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 285

293 Today s Health Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Today s Health ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N Service Provider Provider ID S 2 7 N [NM108=46] Service Provider Level: 2100C [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None. R DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 286

294 Today s Options Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Today s Options ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N Service Provider Provider ID S 2 7 N [NM108=46] Service Provider Level: 2100C [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None. R DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 287

295 Triad Healthcare, Inc Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Triad Healthcare, Inc. ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 288

297 Tribute/SelectCare of Oklahoma Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N Service Provider Provider ID S 2 7 N Tribute/SelectCare of Oklahoma [NM108=46] Service Provider Level: 2100C [NM108=SV] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 290

298 Tricare Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Tricare ID R 5 5 AN Information Receiver Electronic Transmitter Identification Number (ETIN) S N Service Provider Provider ID S 2 7 N [NM108=46] Service Provider Level: 2100C [NM108=SV] Date of Birth S1 8 8 DT CCYYMMDD Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Claim R DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 291

299 Trustmark Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN TRUSTMARK ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim S DT Xerox EDI Eligibility Gateway 276/ Guide - All 292

300 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim R DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 293

301 Ultimate Health Plans Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Ultimate Health Plans ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 294

302 UMR (Wausau) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Date of Dep: Last Dep: First Birth Option (cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN UMR (Wausau) ID R 5 5 AN Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1, D AN First S AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 295

303 Claim R DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D AN Last First S AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R DT [REF01=1K] Level: 2100E Send if known unknown send 0 Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 296

304 Unicare UCARE Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN UNICARE ID R 5 5 AN UCARE Information Receiver Service Provider Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D1 9 9 AN [NM108=MI] Gender S1 2 2 ID F, M, U DMG03 Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Send if known Medical Record Number O 1 30 AN [REF01=EA] Xerox EDI Eligibility Gateway 276/ Guide - All 297

305 unknown, send 0. Claim S DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number O 1 30 AN [REF01=1K] Level: 2200E Send if known Medical Record Number O 1 30 AN [REF01=EA] Claim R DT unknown, enter 0. Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 298

306 United Healthcare Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Service Provider UNITED HEALTH CARE Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D1 9 9 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if requesting claim detail. The total number of REF segments in the 2200D loop cannot exceed 3. Xerox EDI Eligibility Gateway 276/ Guide - All 299

307 unknown, send 0. Claim S DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number O 1 30 AN [REF01=1K] Level: 2200E unknown, enter 0. Claim R DT Disclaimer: The Provider understands that receipt or use of this information does not guarantee payment of any health care claim by Aetna, and such information is subject to change, even retroactively, at any time. *Note: the Location Number for a dependent transaction is to be sent in the 2200E loop although this is not supported in the implementation guide. UHC needs this information to return a unique match. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/ Guide - All 300

308 United Healthcare Community Plan Kansas Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver United Healthcare Community Plan Kansas Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 301

310 United Healthcare Facets Detroit Community and State Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver United Healthcare Facets Detroit Community and State Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 303

312 United Healthcare Facets Pittsburgh Community and State Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver United Healthcare Facets Pittsburgh Community and State Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 305

314 United Healthcare Nevada Market Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN United Healthcare Nevada Market ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 307

315 United Healthcare Plan of River Valley Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Dep: Last Dep: First Dependent D1 Sub: Member ID Sub: Last Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN United Healthcare Plan of River Valley ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) R 9 9 N [NM108=46] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 308

317 University Care Advantage Arizona Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes University Care R 1 35 AN Advantage Arizona ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N [NM108=46] Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Claim Service Date R DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0. Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 310

319 University Care Advantage Arizona Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes University Care R 1 35 AN Advantage Arizona ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 312

321 University Family Care Arizona Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes University Family Care R 1 35 AN Arizona ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N [NM108=46] Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Claim Service Date R DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0. Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 314

323 University Physicians Healthcare Group Arizona Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes University Physicians R 1 35 AN Healthcare Group Arizona ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N [NM108=46] Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Claim Service Date R DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0. Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 316

325 University of Arizona Health Plan- UHM Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN Provider ID S 2 7 N Federal Tax ID S 9 9 N University of Arizona Health Plan- UHM Date of Birth S1 8 8 DT CCYYMMDD [NM108=FI] [NM108=46] Service Provider Level: 2100C [NM108=SV] [NM108=FI] Aetna Non-HMO or Aetna HMO Provider ID. Either provider ID, tax ID, or NPI is required. Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 318

327 USAA Life Insurance Company Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN USAA ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 9 9 N [NM108=FI] Service Provider Level: 2100C [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim R DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 320

328 VA Fee Basis Program Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Provider ID S 2 20 AN Service Provider Federal Tax ID S 9 9 N Electronic Transmitter ID Number (ETIN) S 2 7 AN VA FEE BASIS PROGRAM [NM108=FI] [NM108=SV] Service Provider Level: 2100C [NM108=FI] [NM108=46] Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 321

329 VA Health Administration CTR Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Electronic Transmitter ID Number Service Provider S 2 10 AN VA Health Administration CTR [NM108=FI] [NM108=46] Service Provider Level: 2100C Provider ID S 2 7 N [NM108=SV] ID, tax ID, or NPI is required. Federal Tax ID S 9 9 N [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S1,D AN NM104 Member ID S1,D AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 322

331 Vermont Medicaid Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Last First Member ID Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN Vermont Medicaid ID R 5 5 AN Information Receiver Electronic Transmitter ID Number (ETIN) Service Provider R 9 9 N Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD [NM108=46] Service Provider Level: 2100C [NM108=SV] Level: 2000D Level: 2100D Last S AN First S AN NM104 Member ID S AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 324

332 VIVA Health Inc Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN VIVA Health Inc. ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 325

334 WebTPA Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option Element 6 Dependent D1 Dep:Gender Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN WebTPA ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Gender D1 1 1 ID F,M,U DMG03 Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 327

336 Western Health Advantage Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Option(Cont.) Element 6 Dependent D1 Dep: Gender Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N Western Health Advantage [NM108=FI] Service Provider Provider ID S 2 7 N Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C [NM108=SV] Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D AN [NM108=mi] Claim Submitter Trace Claim S DT Level: 2200D unknown send 0 Xerox EDI Eligibility Gateway 276/ Guide - All 329

337 Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim R DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 330

338 World Corp Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Element Use Min Max Type Codes and Values Element Notes R 1 35 AN World Corp ID R 5 5 AN Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Federal Tax ID if NM108=FI NPI if NM108 = XX Level: 2000D Last S1,D AN First S AN NM104 Member ID S1,D AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S DT [NM108=MI] [DTP01=472] Level: 2100D Level: 2200D unknown, send 0 Dependent Dependent Level: 2000E Date of Birth D1 8 8 DT CCYYMMDD [ Dependent Last D AN First D AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/ Guide - All 331

339 Claim Service Date R DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/ Guide - All 332

340 World Insurance (ARIC) Option Element 1 Element 2 Element 3 Element 4 Element 5 S1 Member ID Last First Date of Birth Gender Dependent D1 Sub: Member ID Sub: Last Dep: Last Dep: First Dep: Date of Birth Option(Cont.) Element 6 Dependent D1 Dep: Gender Element Use Min Max Type Codes and Values Element Notes R 1 35 AN WORLD INSURANCE ID R 5 5 AN Information Receiver Federal Tax ID S 9 9 N [NM108=FI] Electronic Transmitter ID Number (ETIN) S 2 20 N [NM108=46] Service Provider Provider ID S 2 7 N Federal Tax ID S 9 9 N Service Provider Level: 2100C [NM108=SV] [NM108=FI] Date of Birth S1 8 8 DT CCYYMMDD Gender S1 2 2 ID F, M, U DMG03 Level: 2000D Level: 2100D Last S1,D AN First S AN NM104 Member ID S1,D1 9 9 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/ Guide - All 333

341 Claim Control Number Claim O 1 25 AN S DT [REF01=1K] Send if requesting claim detail. The total number of REF segments in the 2200D If amount loop is cannot unknown, exceed send Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D AN First D AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/ Guide - All 334