Xerox EDI Eligibility Gateway 276/277 Guide Version 5010 Technical Support: egateway@xerox.com Updated October 31, 2014
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Table of Content Revisions... 1 AARP 10431... 5 Advantage Health Solutions 10954... 7 Aetna 10004... 9 Aetna Long Term Care 10397... 11 Affinity Health Plan Medicare 10661... 13 AFLAC 10955... 15 AFLAC - Medicare Supplemental 10663... 17 Alabama Medicaid 10007... 19 Allegiance Benefit Plan Management 10654... 20 American Family Insurance Group- Medicare Supplement and PPO Policies 10487... 22 American Network Ins. Medicare 10899... 24 American Postal Workers Union Health (APWU) 00360... 26 American Republic Insurance Company (ARIC) 00224... 28 AMERIGROUP 10019... 30 AmeriHealth 10974... 32 Amerihealth Caritas Pennsylvania 10340... 34 Ameritas Group... 36 Aetna Better Health of NE 10976... 38 Apex Benefits Services 10708... 40 Arbor Health Plan 10641... 42 ARISE Health Plan-Medicare 10868... 44 Arkansas Medicaid 10023... 46 Banner Health Plans 10707... 48 BCBS AR BCARK... 50 BCBS of Colorado (Wellpoint) 10029... 52 BCBS of Connecticut (Wellpoint) 4816... 54 BCBS of Florida AV294... 56 BCBS of Georgia (Wellpoint) 10032... 58 BCBS of Illinois 00000000551... 60 BCBS of Indiana (Wellpoint) 4820... 62 BCBS of Iowa 10396... 63 BCBS of Kansas 4923... 66 BCBS of Kansas City 10473... 68 BCBS of Kentucky (Wellpoint) 4821... 70 Xerox EDI Eligibility Gateway 276/277 5010 Guide All i
BCBS of Maine (Wellpoint) 4818... 72 BCBS of Massachusetts 00139... 74 BCBS of Minnesota 10039... 76 BCBS Mississippi 10040... 78 BCBS of Missouri (Wellpoint) 4921... 79 BCBS of Nebraska 10384... 81 BCBS of Nevada (Wellpoint) 10260... 83 BCBS of New Hampshire (Wellpoint) 4817... 85 BCBS of New Jersey (Horizon) 00087... 87 BCBS of New Mexico 10042... 89 BCBS of New York (Empire) 10043... 91 BCBS of North Carolina 10383... 93 BCBS of Ohio (Wellpoint) 4823... 95 BCBS of Oklahoma 10582... 97 BCBS of South Carolina 10047... 99 BCBS of South Dakota 10395... 100 BCBS of Tennessee 10430... 103 BCBS of Texas 10048... 105 BCBS of Vermont 10624... 107 BCBS of Virginia BCBSV... 108 BCBS of Wisconsin (Wellpoint) BCBSW... 110 Benefit Management Inc. 10665... 112 Better Health Plans (Unison Health Plan) 00199... 113 Blue Cross of California (Wellpoint) BCCAL... 116 Blue Cross Pennsylvania (Capital) 582... 118 Blue Shield of California 10053... 120 Boon Group 10821... 122 Bravo Health 10399... 124 Bridgespan 10827... 125 CarePlus Health Plan 00324... 127 CarePoint Medicare Advantage 10822... 128 Carolina Care Plan, Inc. (CCP) 10762... 130 CDS Group Health 10667... 132 Cenpatico... 134 Centene... 136 Central Reserve Insurance Company 10450... 138 Central Reserve Life Ins Co Medicare Supp 10539... 140 CMFG Life Insurance 10909... 142 Community Care of Oklahoma 10066... 144 Xerox EDI Eligibility Gateway 276/277 5010 Guide All ii
Continental General Insurance Company 10454... 146 Cooperative Benefit Administrators 00223... 148 CoreSource... 150 Coventry Healthcare... 152 Culinary Health Fund 10775... 154 Definity Health 10828... 156 Denver Health Medical Plan 0000001321... 158 Easy Choice 10703... 160 EBMS (Employee Benefit Management Services) 10862... 161 Emblem Health 10616... 163 Everence Financial 10772... 165 Evergreen Health Co-Op 10860... 167 Federated Insurance Company 00262... 169 Fidelis SecureCare of Michigan 10859... 171 Florida Medicaid 77027... 173 Food Employers & Bakery Workers Benefit 10776... 174 Fresenius Medical Care 10602... 176 Generations Healthcare 10603... 177 Georgia Medicaid 10088... 178 Gilsbar 10509... 180 Golden Rule Insurance 10652... 182 Health First Health Plans 10673... 184 Health Partners of Philadelphia 10098... 186 Health Services for Children with Spec. 10584... 187 HealthChoice AZ 00329... 189 Healthfirst NJ 10438... 190 Healthfirst NY 00240... 191 HealthMarkets 00404... 192 HealthPlan Services - Celtic Insurance Company 10856... 194 Horizon New Jersey Health 2840... 196 IBEW Local 508 Health Plan 10855... 198 IBM Insurance Outsourcing Services 10861... 200 Kaiser Foundation Health Plan of Colorado 10110... 202 Kentucky Health Exchange 10857... 204 Kentucky Medicaid 00000000945... 205 Leon Medical Centers Health Plan 10677... 207 Lincoln Financial 10678... 209 Managed Health Network 10863... 211 Maricopa Health Plan Arizona - 10434... 213 Xerox EDI Eligibility Gateway 276/277 5010 Guide All iii
MedBen (Newark OH) 10681... 215 Medical Mutual of Ohio 00211... 217 Med-Pay, Inc. 10682... 219 Meritain Health 10635... 221 Mississippi Medicaid 00000000786... 223 Missouri Care 10702... 224 Molina Healthcare... 225 Mutual Health Services 10686... 227 MVP Health Care (New York) 00432... 229 National Association of Letter Carriers (NALC)-00214... 231 Network Health Plan of WI 10706... 233 Ohio Medicaid 10158... 234 Operating Engineers Local No.428 10777... 236 Orange County Fire Authority 10951... 238 Passport Health Plan 10368... 239 PENN Treaty Network Medicare Supp. 10924... 240 Planned Administrators Inc. 10886... 242 Plumbers and Pipefitters Local Union 525 10778... 244 Physicians Mutual Insurance Company- 00287... 246 Preferred Care Partners 10691... 248 Primary PhysicianCare Inc 10692... 249 Principal Financial Group... 251 Schaller Anderson Aetna Better 10816... 253 Schaller Anderson Aetna Better Health of OH 10887... 255 Schaller Anderson Delaware Phys 10817... 256 Schaller Anderson MajestaCare VA 10818... 258 Schaller Anderson Maryland Physicians Care 10693... 260 Schaller Anderson Mercy Care 10694... 261 Schaller Anderson Missouri Care 10695... 262 Schaller Anderson Parkland Community 10643... 263 Schaller Anderson Texas CHRISTUS 10696... 264 Select Health of SC 10520... 265 Senior Health Services Center-Universal American Family of Companies 10697... 267 Senior Whole Health 10962... 269 Significa Benefit Services- 00191... 271 Simply Healthcare Plans 10826... 273 SPJST Medicare Supplement 10546... 275 TexanPlus North Texas Area 10604... 277 TexanPlus South Texas Area 10605... 278 Xerox EDI Eligibility Gateway 276/277 5010 Guide All iv
The Kempton Company 10698... 279 The ULLICO Family of Companies 10945... 281 Three Rivers Health Plans (Unison Health Plan) 00198... 283 TMG Network Health Insurance 10688... 285 Today s Health 10606... 286 Today s Options 10505... 287 Triad Healthcare, Inc. 10963... 288 Tribute/SelectCare of Oklahoma 10607... 290 Tricare 10189... 291 Trustmark 00233... 292 Ultimate Health Plans 10888... 294 UMR (Wausau) 10501... 295 Unicare UCARE... 297 United Healthcare 00112... 299 United Healthcare Community Plan Kansas 10835... 301 United Healthcare Facets Detroit Community and State 10836... 303 United Healthcare Facets Pittsburgh Community and State 10834... 305 United Healthcare Nevada Market 10837... 307 United Healthcare Plan of River Valley 10192... 308 University Care Advantage Arizona - 10433... 310 University Care Advantage Arizona 10699... 312 University Family Care Arizona- 10194... 314 University Physicians Healthcare Group Arizona - 10439... 316 University of Arizona Health Plan- UHM 10889... 318 USAA Life Insurance Company 10195... 320 VA Fee Basis Program 00231... 321 VA Health Administration CTR 10956... 322 Vermont Medicaid 10197... 324 VIVA Health Inc. 10468... 325 WebTPA 10532... 327 Western Health Advantage 10201... 329 World Corp 10700... 331 World Insurance (ARIC) 10386... 333 Xerox EDI Eligibility Gateway 276/277 5010 Guide All v
Revisions Date Changes 7/3/2012 Created 7/3/2012 Updated to Xerox Added Aetna-AETNA, Aetna LTC- 10397, American Family Insurance Group- 10487, American Republic Insurance- 00224, Ameritas Group- all, BCBS AR- BCARK, BCBS CO- 10029, BCBS CT- 4816, BCBS FL- AV294, BCBS GA- BCBSG, BCBS IN- 4820, BCBS KS- 4923, BCBS KY- 4821, BCBS ME- 4818, BCBS MA- 00139, BCBS NE- 10384, BCBS NV- 10260, BCBS NH- 4817, BCBS NJ- 00087, BCBS NY Empire- 00000002560, BCBS OH- 4823, BCBS SC- BCBSS, BCBS TN- 10430, BCBS VA- BCBSV, BCBS WI- BCBSW, Better Health- 00199, BC CA- BCCAL, BC PA 7/5/2012 Capital- 582, Central Reserve Insurance- 10450, Cooperative Benefits Admin- 00223, Continental General Insurance- 10454, CoreSource- all, Coventry- all, Florida Medicaid- 77027, Gilsbar- 10509, Healthfirst NJ- 10438, Healthfirst NY- 00240, HealthMarkets- all, Kentucky Medicaid- 00000000945, Medical Mutual of Ohio- 00211, Molina- all, National Assoc of Letter Carriers- 00214, Mississippi Medicaid- 00000000786, Physicians Mutual- 00287, Principal Financial- all, MVP Healthcare- 00432, Three Rivers Health Plans- 00198, Trustmark- 00233, Unicare- UCARE, VA Fee Basis- 00231, World Insurance- 10386 7/6/2012 Updated BCBS AR BCARK- removed Federal Tax ID Added payers American Postal Workers Union Health 00360, Federated Insurance Company 7/6/2012 00262, 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 10624 8/27/2012 Added payers Central Reserve Life Ins Co Medicare Supplement 10539, Significa Benefit Services 00191, United Healthcare 00112, USAA Life Insurance Co 10195 9/28/2012 Added payers Maricopa Health Plan (AZ) 10434, University Care Advantage (AZ) 10433, University Family Care (AZ) 10194, University Physicians Healthcare Group (AZ) 10439 11/6/2012 Correction on CoreSource FMH 00204 2/16/2013 Removed Medical Record Number (REF*EA) from payers as it is no longer used in 5010. 1/30/2014 Added payer search option for SPJST Medicare Supplement 10546 1/30/2014 Added new payer Centene-Magnolia Health Plan -10704 1/30/2014 Added new payer Easy Choice - 10703 1/30/2014 Added new payer Missouri Care - 10702 2/28/2014 Added new payer Affinity Health Plan Medicare -10661 2/28/2014 Added new payer AFLAC - Medicare Supplemental 10663 2/28/2014 Added new payer Benefit Management Inc. - 10665 2/28/2014 Added new payer CDS Group Health - 10667 2/28/2014 Added new payer Health First Health Plan - 10673 2/28/2014 Added new payer Leon Medical Centers Health Plan - 10677 2/28/2014 Added new payer Lincoln Financial -10678 2/28/2014 Added new payer MedBen (Newark OH) - 10681 2/28/2014 Added new payer Med-Pay, Inc. -10682 2/28/2014 Added new payer Kaiser Foundation Health Plan of Colorado - 10110 2/28/2014 Added new payer Mutual Health Services - 10686 2/28/2014 Added new payer Schaller Anderson Mercy Care - 10694 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 1
2/28/2014 Added new payer Schaller Anderson Missouri Care - 10695 2/28/2014 Added new payer Schaller Anderson Maryland Physicians Care - 10693 2/28/2014 Added new payer Senior Health Services Center-Universal American Family of Companies -10697 2/28/2014 Added new payer The Kempton Company - 10698 2/28/2014 Added new payer University Care Advantage Arizona - 10699 2/28/2014 Added new payer World Corp - 10700 2/28/2014 Added new payer Apex Benefits Services 10708 2/28/2014 Added new payer Banner Health Plans - 10707 2/28/2014 Added new payer Molina Healthcare of Illinois - 10685 2/28/2014 Added new payer Network Health Plan of WI - 10706 2/28/2014 Added new payer Primary PhysicianCare Inc - 10692 2/28/2014 Added new payer Preferred Care Partners 10691 2/28/2014 Added new payer WebTPA 10532 3/31/2014 Added new payer TMG Network Health Insurance 10688 3/31/2014 Added the following new payer for Cenpatico: Cenpatico Behavioral Health 10766 Cenpatico - Mississippi 10769 Cenpatico Behavioral Health Texas 10767 Cenpatico - Missouri 10768 Cenpatico - Georgia 10569 Cenpatico - New Hampshire 10770 3/31/2014 Added the following new payer for Centene: (13) Centene - Advantage by Peach State 10763 Centene- IlliniCare Health Plan 10757 Centene - Advantage by Sunshine State 10764 Centene-Kentucky Spirit Health Plan 10620 Centene Advantage Plans 10771 Centene-Louisiana Healthcare Connections 10756 Centene-Coordinated Care 10761 Centene-Magnolia Health Plan 10704 Centene-California Health & Wellness 10759 Centene-Peach State Health Plan 10590 Centene - Granite State Health Plan 10765 Centene-Sunflower State Health (Kansas) 10758 Centene-Home State Health Plan 10760 3/31/2014 Added the new payer Carolina Care Plan, Inc. (CCP) 10762 3/31/2014 Added the new payer Everence Financial 10772 3/31/2014 Added the new payer Health Choice Insurance Company 10773 3/31/2014 Added the new payer Windsor Health Plan 10774 3/31/2014 Added the new payer Culinary Health Fund 10775 3/31/2014 Added the new payer Food Employers & Bakery Workers Benefit 10776 3/31/2014 Added the new payer Operating Engineers Local No.428 10777 3/31/2014 Added the new payer Plumbers and Pipefitters Local Union 525-10778 3/31/2014 Added the new payer Centene-Sunshine State Health Plan - 10451 3/31/2014 Deactivated Windsor Health Plan - 10774 3/31/2014 Added the new payer Windsor Medicare Extra - 10576 3/31/2014 Added the new payer AMERIGROUP 10019 4/30/2014 Added the new payer Bridgespan 10827 4/30/2014 Added the new payer Boon Group 10821 4/30/2014 Added the new payer HealthPlan Services - Celtic Insurance Company 10856 4/30/2014 Added the new payer IBEW Local 508 Health Plan 10855 4/30/2014 Added the new payer Simply Healthcare Plans 10826 4/30/2014 Deactivated payer Health Choice Insurance Company 10773 4/30/2014 Added the new payer Fidelis SecureCare of Michigan 10859 5/30/2014 Added the new payer EBMS (Employee Benefit Management Services) 10862 5/30/2014 Added the new payer Evergreen Health Co-Op 10860 5/30/2014 Added the new payer IBM Insurance Outsourcing Services 10861 5/30/2014 Added the new payer Managed Health Network 10863 6/30/2014 Added the new payer Centene - Total Care Carolina 6/30/2014 Added the new payer Definity Health 10828 6/30/2014 Added the new payer United Healthcare Plan of River Valley 10192 6/30/2014 Added the new payer Kentucky Health Exchange 10857 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 2
6/30/2014 Added the new payer Golden Rule Insurance 10652 6/30/2014 Added the new payer Louisiana Health Exchange 10839 6/30/2014 Added the new payer United Healthcare Community Plan Kansas 10835 6/30/2014 Added the new payer United Healthcare Facets Pittsburgh Community and State 10834 6/30/2014 Added the new payer United Healthcare Facets Detroit Community and State 10836 6/30/2014 Added the new payer United Healthcare Nevada Market 10837 6/30/2014 Added the new payer Passport Health Plan 10368 6/30/2014 Added the new payer BCBS Mississippi 10040 6/30/2014 Added the new payer UMR (Wausau) 10501 6/30/2014 Added the new payer Vermont Medicaid 10197 6/30/2014 Added the new payer Health Partners of Philadelphia 10098 6/30/2014 Added the new payer Bravo Health 10399 6/30/2014 Added the new payer Alabama Medicaid 10007 6/30/2014 Added the new payer Blue Shield of California 10053 6/30/2014 Added the new payer Schaller Anderson Aetna Better Health of OH 10887 6/30/2014 Added the new payer Ultimate Health Plans 10888 7/31/2014 Added the new payer Tricare 10189 7/31/2014 Added the new payer AFLAC 10955 7/31/2014 Added the new payer Denver Health Medical Plan 10331 7/31/2014 Added the new payer VIVA Health Inc. 10468 7/31/2014 Added the new payer Meritain Health 10635 7/31/2014 Added the new payer American Network Ins. Medicare 10889 7/31/2014 Added the new payer ARISE Health Plan-Medicare 10868 7/31/2014 Added the new payer CMFG Life Insurance 10909 7/31/2014 Added the new payer PENN Treaty Network Medicare Supp. 10924 7/31/2014 Added the new payer The ULLICO Family of Companies 10945 7/31/2014 Added the new payer Orange County Fire Authority 10951 7/31/2014 Added the new payer CarePlus Health Plan 10056 7/31/2014 Added the new payer CarePoint Medicare Advantage 10822 7/31/2014 Added the new payer Schaller Anderson MajestaCare VA 10818 7/31/2014 Added the new payer Schaller Anderson Delaware Phys 10817 7/31/2014 Added the new payer Schaller Anderson Aetna Better 10816 7/31/2014 Added the new payer Molina Healthcare of SC 10815 7/31/2014 Added the new payer Presbyterian Health Plan 10646 7/31/2014 Added the new payer Arbor Health Plan 10641 7/31/2014 Added the new payer Emblem Health 10616 7/31/2014 Added the new payer Select Health of SC 10520 7/31/2014 Added the new payer Amerihealth Caritas Pennsylvania 10340 7/31/2014 Added the new payer Horizon New Jersey Health 10337 7/31/2014 Added the new payer Advantage Health Solutions 10954 7/31/2014 Added the new payer VA Health Administration CTR 10956 7/31/2014 Added the new payer Senior Whole Health 10962 7/31/2014 Added the new payer Triad Healthcare, Inc. 10963 7/31/2014 Added the new payer Health Services for Children with Spec. 10584 7/31/2014 Added the new payer AARP 10431 7/31/2014 Changed payer ID Denver Health Medical Plan 0000001321 7/31/2014 Changed payer ID American Network Ins. Medicare 10899 7/31/2014 Changed payer ID CarePlus Health Plan 00324 7/31/2014 Changed payer ID Horizon New Jersey Health 2840 8/29/2014 Added the new payer BCBS of North Carolina 10383 8/29/2014 Added the new payer Ohio Medicaid 10158 8/29/2014 Added the new payer Georgia Medicaid 10088 8/29/2014 Added the new payer AmeriHealth 10974 8/29/2014 Added the new payer University of Arizona Health Plan- UHM 10889 8/29/2014 Added the new payer Planned Administrators Inc. 10886 8/29/2014 Added the payer BCBS of Kansas City 10473 9/30/2014 Added the payer BCBS of Texas 10048 9/30/2014 Added the payer BCBS of BCBS of Iowa 10396 9/30/2014 Added the payer BCBS of South Dakota 10395 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 3
9/30/2014 Added the payer Allegiance Benefit Plan Management 10654 9/30/2014 Added the payer Arkansas Medicaid 10023 9/30/2014 Added the payer Community Care of Oklahoma 10066 9/30/2014 Added the payer Western Health Advantage 10201 9/30/2014 Added the payer Aetna Better Health of NE 10976 10/31/2014 Added the payer BCBS of Illinois 00000000551 10/31/2014 Added the payer BCBS of Minnesota 10039 10/31/2014 Added the payer BCBS of New Mexico 10042 10/31/2014 Added the payer BCBS of Oklahoma 10582 10/31/2014 Deactivated the payer Molina Healthcare of Missouri = 10573 10/31/2014 Deactivated the payer Presbyterian Health Plan 10646 10/31/2014 Deactivated the payer Windsor Medicare Extra 10576 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 4
AARP 10431 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 10431 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 5
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 6
Advantage Health Solutions 10954 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 10954 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 7
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 8
Aetna 10004 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 10004 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D1 2 20 AN [NM108=MI] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 9
Claim Submitter Trace Claim Control Number Claim Dependent O 1 25 AN S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 10
Aetna Long Term Care 10397 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 10397 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 11
Claim Disclaimer: None S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 12
Affinity Health Plan Medicare 10661 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 10661 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 S1 1 35 AN First S1 1 25 AN NM104 Identification Code Qualifier/ Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Unique identification for the transaction Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 13
Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S 17 17 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 276/277 5010 Guide - All 14
AFLAC 10955 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 10955 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 15
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 16
AFLAC - Medicare Supplemental 10663 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 10663 AFLAC - Medicare Supplemental Transunion ID Information Receiver R 1 60 AN AFLAC - Medicare Supplemental Information Receiver ID Code Qualifier R 10 10 N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 17
Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 18
Alabama Medicaid 10007 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 10007 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 1 35 AN First S1 1 25 AN NM104 Member ID S1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 19
Allegiance Benefit Plan Management 10654 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 10654 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 20
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 21
American Family Insurance Group- Medicare Supplement and PPO Policies 10487 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 10487 Information Receiver Federal Tax ID S 9 9 N Service Provider Federal Tax ID S 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 22
Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S 17 17 DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R 17 17 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 276/277 5010 Guide - All 23
American Network Ins. Medicare 10899 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 10899 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 24
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 25
American Postal Workers Union Health (APWU) 00360 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 00360 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 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 26
Claim Control Number O 1 25 AN [REF01=1K] Send if known unknown, send 0. Claim S 17 17 DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 27
American Republic Insurance Company (ARIC) 00224 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 00224 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 10 10 AN Service Provider Provider ID S 2 7 N Federal Tax ID S 9 9 N NPI S 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 28
Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 29
AMERIGROUP 10019 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 10019 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 30
Claim Service Date R 17 17 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 276/277 5010 Guide - All 31
AmeriHealth 10974 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 10974 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 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 32
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 33
Amerihealth Caritas Pennsylvania 10340 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 10340 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 34
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 35
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 00425 Reliance Standard Life 00427 First Ameritas of New York 00426 Standard Insurance 00429 First Reliance Standard Life 00428 Standard Insurance of New York 00430 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 276/277 5010 Guide - All 36
Level: 2100D Last S1,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Claim S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Disclaimer: None R 17 17 DT Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 37
Aetna Better Health of NE 10976 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 10976 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 38
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 39
Apex Benefits Services 10708 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 10708 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 40
Claim Service Date R 17 17 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 276/277 5010 Guide - All 41
Arbor Health Plan 10641 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 10641 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 42
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 43
ARISE Health Plan-Medicare 10868 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 10868 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 44
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 45
Arkansas Medicaid 10023 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 10023 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 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 46
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 47
Banner Health Plans 10707 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 10707 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 48
Claim Service Date R 17 17 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 276/277 5010 Guide - All 49
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 50
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 51
BCBS of Colorado (Wellpoint) 10029 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 10029 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 52
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 53
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 54
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 55
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 56
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 57
BCBS of Georgia (Wellpoint) 10032 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,D1 1 35 AN First S1 1 25 AN NM104 Member Id S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200d If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 58
Dependent Birth Date D1 8 8 DT Dependent Level: 2000e Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100e Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 59
BCBS of Illinois 00000000551 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 00000000551 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 60
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R 17 17 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 276/277 5010 Guide - All 61
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 62
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R 17 17 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 10396 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 63
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 10396 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 64
Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R 17 17 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 276/277 5010 Guide - All 65
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 10 10 N Service Provider NPI R 10 10 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, D1 1 35 AN First S1 1 25 AN NM104 Member Id S1, D1 2 20 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 276/277 5010 Guide - All 66
Claim Dependent R 17 17 DT Dependent Level: 2000e Birth Date R 8 8 DT Gender R 1 1 ID F,M DMG03 Dependent Level: 2100e Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Medical Record Number Claim Disclaimer: None O 1 25 AN O 1 30 AN R 17 17 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 276/277 5010 Guide - All 67
BCBS of Kansas City 10473 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 10473 Nm109 Information Receiver NPI R 10 10 N Service Provider NPI R 10 10 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, D1 1 35 AN First S1 1 25 AN NM104 Member Id S1, D1 2 20 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 276/277 5010 Guide - All 68
Claim Dependent R 17 17 DT Dependent Level: 2000e Birth Date R 8 8 DT Gender R 1 1 ID F,M DMG03 Dependent Level: 2100e Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Medical Record Number Claim Disclaimer: None O 1 25 AN O 1 30 AN R 17 17 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 276/277 5010 Guide - All 69
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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 70
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 71
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 72
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R 17 17 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 276/277 5010 Guide - All 73
BCBS of Massachusetts 00139 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 00139 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 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 276/277 5010 Guide - All 74
unknown, send 0. Claim S 17 17 DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Bill Type Identifier Claim Disclaimer: None. O 1 30 AN O 1 30 AN R 17 17 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 276/277 5010 Guide - All 75
BCBS of Minnesota 10039 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 10039 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 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 276/277 5010 Guide - All 76
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Bill Type Identifier Claim Disclaimer: None. O 1 30 AN O 1 30 AN R 17 17 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 276/277 5010 Guide - All 77
BCBS Mississippi 10040 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 10040 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 78
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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D1 2 20 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 276/277 5010 Guide - All 79
Claim R 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D1 1 35 AN Last First S1 1 25 AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 80
BCBS of Nebraska 10384 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 10384 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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 81
Claim Control Number O 1 25 AN Claim Dependent R 17 17 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, D1 1 35 AN Last First S1 1 25 AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 82
BCBS of Nevada (Wellpoint) 10260 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 10260 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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D1 2 20 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 276/277 5010 Guide - All 83
Claim R 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D1 1 35 AN Last First S1 1 25 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 17 17 DT Disclaimer: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 84
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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D Send if known Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 85
unknown, send 0. Claim R 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D1 1 35 AN Last First S1 1 25 AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 86
BCBS of New Jersey (Horizon) 00087 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 00087 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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 87
Claim Control Number O 1 25 AN Claim Dependent R 17 17 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, D1 1 35 AN Last First S1 1 25 AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Level: 2100E Claim Control Number O 1 25 AN Claim R 17 17 DT [REF01=1K] Disclaimer: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 88
BCBS of New Mexico 10042 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 10042 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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member Id S1, D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN Claim R 17 17 DT [REF01=1K] Level: 2200d Send If Known If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 89
Dependent Level: 2000e Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100e Last S1, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 90
BCBS of New York (Empire) 10043 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 10043 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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member Id S1, D1 2 20 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 276/277 5010 Guide - All 91
Claim R 17 17 DT Dependent Level: 2000e Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100e Last S1, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 92
BCBS of North Carolina 10383 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 10383 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known unknown, send 0. Dependent Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 93
Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 94
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known If amount unknown send 0 Dependent Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 95
Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, An=Alphanumeric, Dt=Date Format, Id=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 96
BCBS of Oklahoma 10582 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 10582 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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member Id S1, D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN Claim R 17 17 DT [REF01=1K] Level: 2200d Send If Known If Amount Is Unknown, Send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 97
Dependent Level: 2000e Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100e Last S1, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 98
BCBS of South Carolina 10047 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 10047 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Claim S 17 17 DT Level: 2200D unknown send 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 99
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim R 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. BCBS of South Dakota 10395 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 100
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 10395 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Claim S 17 17 DT Level: 2200D unknown send 0 Dependent Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 101
Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim R 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 102
BCBS of Tennessee 10430 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 10430 Information Receiver NPI R 10 10 N Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D unknown send 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 103
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 25 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 104
BCBS of Texas 10048 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 10048 Information Receiver NPI R 10 10 N Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D unknown send 0 Dependent Dependent Level: 2000E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 105
Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 25 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 106
BCBS of Vermont 10624 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 10624 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 N Service Provider [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Level: 2000D Level: 2100D Last S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R 17 17 DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 107
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=MI] Gender S1 2 2 ID F,M,U DMG03 Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 108
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 109
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 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 276/277 5010 Guide - All 110
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 111
Benefit Management Inc. 10665 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 10665 Benefit Management Inc. Transunion ID Information Receiver R 1 60 AN Benefit Management Inc. Information Receiver ID Code Qualifier R 10 10 N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 112
Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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) 00199 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 113
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 00199 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 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 276/277 5010 Guide - All 114
Claim S 17 17 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 17 17 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 276/277 5010 Guide - All 115
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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 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 276/277 5010 Guide - All 116
Claim S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 117
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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 118
Bill Type Identifier Claim O 1 30 AN S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 119
Blue Shield of California 10053 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 10053 Blue Shield of California Transunion ID Information Receiver R 1 60 AN Health First Health Plans Information Receiver ID Code Qualifier R 10 10 N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S 10 10 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 120
Claim Control Number O 1 25 AN [REF01=1K] Monetary Amount unknown, send 0. Claim Service S 17 17 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 D1 1 35 AN First D1 1 25 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 17 17 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 276/277 5010 Guide - All 121
Boon Group 10821 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 10821 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 122
Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 123
Bravo Health 10399 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 10399 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 1 35 AN First S1 1 25 AN NM104 Member ID S1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 124
Bridgespan 10827 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 10827 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 276/277 5010 Guide - All 125
Claim Control Number S 1 30 AN [REF01=1K] Required if known. unknown, send 0. Claim R 17 17 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 276/277 5010 Guide - All 126
CarePlus Health Plan 00324 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 00324 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Last S1,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 276/277 5010 Guide - All 127
CarePoint Medicare Advantage 10822 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 10822 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 128
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 129
Carolina Care Plan, Inc. (CCP) 10762 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 10762 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 276/277 5010 Guide - All 130
Claim Control Number S 1 30 AN [REF01=1K] Required if known. unknown, send 0. Claim R 17 17 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 276/277 5010 Guide - All 131
CDS Group Health 10667 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 10667 Transunion ID Information Receiver R 1 60 AN CDS Group Health Information Receiver ID Code Qualifier R 10 10 N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 132
Claim Control Number O 1 25 AN [REF01=1K] Monetary Amount unknown, send 0. Claim Service S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 133
Cenpatico Option Element 1 Element 2 Element 3 Element 4 S1 Member ID Last First Date of Birth s ID ID Cenpatico Behavioral Health 10766 Cenpatico - Mississippi 10769 Cenpatico Behavioral Health Texas 10767 Cenpatico - Missouri 10768 Cenpatico - Georgia 10569 Cenpatico - New Hampshire 10770 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 S1 1 35 AN First S1 1 25 AN NM104 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 134
Member ID S1 2 20 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 17 17 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 276/277 5010 Guide - All 135
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 10763 Centene-Kentucky Spirit Health Plan 10620 Centene - Advantage by Sunshine State 10764 Centene-Louisiana Healthcare Connections 10756 Centene Advantage Plans 10771 Centene-Magnolia Health Plan 10704 Centene-Coordinated Care 10761 Centene-Peach State Health Plan 10590 Centene-California Health & Wellness 10759 Centene-Sunflower State Health (Kansas) 10758 Centene - Granite State Health Plan 10765 Centene-Sunshine State Health Plan 10451 Centene-Home State Health Plan 10760 Centene - Total Care Carolina 10866 Centene- IlliniCare Health Plan 10757 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 276/277 5010 Guide - All 136
Level: 2000D Date of Birth S1 8 8 DT CCYYMMDD Level: 2100D Last S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 17 17 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 276/277 5010 Guide - All 137
Central Reserve Insurance Company 10450 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 10450 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 138
Claim S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 139
Central Reserve Life Ins Co Medicare Supp 10539 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 10539 Information Receiver Federal Tax ID S 9 9 N NPI S 10 10 AN Service Provider Federal Tax ID S 9 9 N NPI S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 276/277 5010 Guide - All 140
Claim Disclaimer: None S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 141
CMFG Life Insurance 10909 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 10909 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 142
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 143
Community Care of Oklahoma 10066 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 10066 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Claim S 17 17 DT Level: 2200D unknown send 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 144
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim R 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 145
Continental General Insurance Company 10454 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 10454 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 146
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 147
Cooperative Benefit Administrators 00223 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 00223 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 148
Claim Control Number Claim Dependent O 1 25 AN S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 149
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 00205 CoreSource Ohio 00239 CoreSource- MD/PA/IL/NC/AZ/IN/MN 00236 CoreSource FMH 00204 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,D1 1 35 AN First S1 1 25 AN NM104 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 150
Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 151
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 10307 CHCCares- South Carolina 10420 Altius Health Plans 00364 Coventry Healthcare Carenet 00190 CHC of Delaware 00166 Diamond Plan (Maryland Medicaid) 00177 CHC of Georgia 00154 Group Health Plan (GHP) 00184 CHC of Iowa 00170 HealthAmerica and Health Assurance 00148 CHC of Kansas 10208 Healthcare Inc (Promina) 00193 CHC Carelink Medicaid 00182 Healthcare USa (HCUSA) 00186 CHC of Louisiana 00158 Omnicare (Michigan) 00284 CHC of Nebraska 00176 CHC-PersonalCare/Coventry Health of Illinois 00179 Coventry Advantra Savings 10419 Southern Health Services (SHS) 00156 Coventry Health and Life (OK only) 00441 University of Missouri 10428 Coventry Health Life- TN only 10405 Wellpath Select (Carolinas) 00164 CHC Carelink (Advantra) 00160 Advantra- (Texas, New Mexico, Arizona only) 10447 Coventry Health and Life (Nevada) 10448 Coventry Missouri 10449 CHC- Mail Handler s Benefit Plan 00251 CHC- CoventryOne 10440 Coventry Healthcare National Network 10084 Vista (MCD, FHK, LTC) 10483 Coventry Health Care Federal 10481 Coventry Nebraska Medicaid 10548 CHC- Florida/Vista/Summit 10551 CoventryCares 10614 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 276/277 5010 Guide - All 152
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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN Claim Submitter Trace Claim Control Number Claim Disclaimer: None. S 1 30 AN R 17 17 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 276/277 5010 Guide - All 153
Culinary Health Fund 10775 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 10775 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 154
Dependent Birth Date D1 8 8 DT Dependent Last D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Dependent Level: 2000E Level: 2100E Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 155
Definity Health 10828 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 10828 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 156
Claim S 17 17 DT Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 157
Denver Health Medical Plan 0000001321 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 0000001321 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 158
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 159
Easy Choice 10703 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 10703 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 160
EBMS (Employee Benefit Management Services) 10862 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 10868 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 161
Claim S 17 17 DT Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 162
Emblem Health 10616 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 10616 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 163
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 164
Everence Financial 10772 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 10772 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 165
Dependent Birth Date D1 8 8 DT Dependent Last D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Dependent Level: 2000E Level: 2100E Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 166
Evergreen Health Co-Op 10860 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 10860 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 167
Dependent Birth Date D1 8 8 DT Dependent Last D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Dependent Level: 2000E Level: 2100E Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 168
Federated Insurance Company 00262 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 00262 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 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 276/277 5010 Guide - All 169
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 170
Fidelis SecureCare of Michigan 10859 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 10859 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 276/277 5010 Guide - All 171
Claim Control Number S 1 30 AN [REF01=1K] Required if known. unknown, send 0. Claim R 17 17 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 276/277 5010 Guide - All 172
Florida Medicaid 77027 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 77027 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 173
Food Employers & Bakery Workers Benefit 10776 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 10776 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 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 276/277 5010 Guide - All 174
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 175
Fresenius Medical Care 10602 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 10602 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 176
Generations Healthcare 10603 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 10603 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim R 17 17 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 276/277 5010 Guide - All 177
Georgia Medicaid 10088 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 10088 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 178
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 179
Gilsbar 10509 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 10509 Information Receiver Federal Tax ID S 10 10 N Service Provider Federal Tax ID S 10 10 N Member ID S1,D1,D2 2 20 AN Claim Submitter Trace Claim Dependent S 17 17 DT Birth Date D1 8 8 DT Dependent First D2 1 25 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 276/277 5010 Guide - All 180
Claim R 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 181
Golden Rule Insurance 10652 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 10652 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 182
Claim S 17 17 DT Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 183
Health First Health Plans 10673 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 10673 Health First Health Plans Transunion ID Information Receiver R 1 60 AN Health First Health Plans Information Receiver ID Code Qualifier R 10 10 N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 184
Claim Control Number O 1 25 AN [REF01=1K] Monetary Amount unknown, send 0. Claim Service S 17 17 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 D1 1 35 AN First D1 1 25 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 17 17 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 276/277 5010 Guide - All 185
Health Partners of Philadelphia 10098 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 10098 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 186
Health Services for Children with Spec. 10584 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 10584 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 187
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 188
HealthChoice AZ 00329 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 00329 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 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 189
Healthfirst NJ 10438 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 10438 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 190
Healthfirst NY 00240 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 00240 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 191
HealthMarkets 00404 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 00207 00206 00208 00248 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,D1 1 35 AN First S1 1 25 AN NM104 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 192
Member ID S1,D1 9 9 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 30 AN S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 DT [REF01=1K] Level: 2200E Send if requesting claim detail. Total number of REF If amount segments is cannot unknown, exceed enter 3. 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 193
HealthPlan Services - Celtic Insurance Company 10856 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 10856 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 194
Claim S 17 17 DT Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 195
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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 196
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 197
IBEW Local 508 Health Plan 10855 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 10855 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 198
Claim S 17 17 DT Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 199
IBM Insurance Outsourcing Services 10861 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 10861 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 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 276/277 5010 Guide - All 200
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 201
Kaiser Foundation Health Plan of Colorado 10110 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 10110 Information Receiver Federal Tax ID S 9 9 N NPI S 10 10 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 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 276/277 5010 Guide - All 202
unknown, send 0. Claim S 17 17 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 276/277 5010 Guide - All 203
Kentucky Health Exchange 10857 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 10857 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 1 35 AN First S1 1 25 AN NM104 Member ID S1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 204
Kentucky Medicaid 00000000945 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 00000000945 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim Control Number O 1 30 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 205
Bill Type Identifier Medical Record Number Claim O 1 30 AN O 1 30 An S 17 17 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 276/277 5010 Guide - All 206
Leon Medical Centers Health Plan 10677 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 10677 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 S1 1 35 AN First S1 1 25 AN NM104 Identification Code Qualifier/ Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Trace Number S 1 30 AN Level: 2200D Unique identification for the transaction Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 207
Claim Control Number O 1 25 AN [REF01=1K] S 1 10 R unknown, send 0. Claim S 17 17 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 276/277 5010 Guide - All 208
Lincoln Financial 10678 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 10678 Transunion ID Information Receiver R 1 60 AN Lincoln Financial Information Receiver ID Code Qualifier R 10 10 N [NM108=46] NPI is required Service Provider Service Provider Level: 2100C S 1 60 AN Identification Code S 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 209
Claim Control Number O 1 25 AN [REF01=1K] Monetary Amount unknown, send 0. Claim Service S 17 17 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 D1 1 35 AN First D1 1 25 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 17 17 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 276/277 5010 Guide - All 210
Managed Health Network 10863 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 10863 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 211
Dependent Birth Date D1 8 8 DT Dependent Last D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Dependent Level: 2000E Level: 2100E Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 212
Maricopa Health Plan Arizona - 10434 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 10434 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 N [NM108=46] Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Last S1,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Claim Service Date R 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 213
Claim Service Date R 17 17 DT [DTP01=472] DISCLAIMER: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 214
MedBen (Newark OH) 10681 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 10681 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 N [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Last S1,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date Dependent S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Level: 2000E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 215
Dependent Claim Submitter Trace Claim Service Date R 17 17 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 276/277 5010 Guide - All 216
Medical Mutual of Ohio 00211 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 00211 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim Disclaimer: None. O 1 30 AN R 17 17 DT [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 217
Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 218
Med-Pay, Inc. 10682 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 10682 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 219
Claim Service Date R 17 17 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 276/277 5010 Guide - All 220
Meritain Health 10635 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 10635 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 221
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 222
Mississippi Medicaid 00000000786 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 00000000786 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim R 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 223
Missouri Care 10702 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 10702 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 224
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 00222 Molina Healthcare of Ohio 00445 Molina Healthcare of Florida 10445 Molina Healthcare of SC 10815 Molina Healthcare of Illinois 10685 Molina Healthcare of Texas 10391 Molina Healthcare of Michigan 00226 Molina Healthcare of Utah 00227 Molina Healthcare of New Mexico 10146 Molina Healthcare of Washington 00228 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 276/277 5010 Guide - All 225
Level: 2100D Last S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 25 AN S 17 17 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 276/277 5010 Guide - All 226
Mutual Health Services 10686 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 10686 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 227
Claim Service Date R 17 17 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 276/277 5010 Guide - All 228
MVP Health Care (New York) 00432 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 00432 Information Receiver Electronic Transmitter ID Number (ETIN) R 2 80 AN [NM108=46] Federal Tax ID R 9 9 N Service Provider NPI R 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 276/277 5010 Guide - All locator 229 4
Claim R 17 17 DT CCYYMMDD- CCYYMMDD Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 230
National Association of Letter Carriers (NALC)-00214 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 00214 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 231
Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 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 D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 232
Network Health Plan of WI 10706 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 10706 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 233
Ohio Medicaid 10158 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 10158 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 234
Claim Service Date R 17 17 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 276/277 5010 Guide - All 235
Operating Engineers Local No.428 10777 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 10777 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=mi] Claim Submitter Trace Claim Control Number Claim O 1 25 AN S 17 17 DT [REF01=1K] Level: 2200D Send if known unknown, enter 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 236
Dependent Birth Date D1 8 8 DT Dependent Last D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Dependent Level: 2000E Level: 2100E Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 237
Orange County Fire Authority 10951 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 10951 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 N Transunion ID [NM108=46] Service Provider Level: 2100C Date of Birth S1 8 8 DT CCYYMMDD Last S1,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 276/277 5010 Guide - All 238
Passport Health Plan 10368 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 10368 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 239
PENN Treaty Network Medicare Supp. 10924 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 10924 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 240
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 241
Planned Administrators Inc. 10886 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 10886 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number Claim O 1 25 AN R 17 17 DT [REF01=1K] Level: 2200D If known unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 242
Dependent Birth Date D1 8 8 DT Dependent Last D1 1 35 AN First D1 1 25 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 17 17 DT unknown, enter 0. Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 243
Plumbers and Pipefitters Local Union 525 10778 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 10778 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 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 276/277 5010 Guide - All 244
Claim Dependent S 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 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 276/277 5010 Guide - All 245
Physicians Mutual Insurance Company- 00287 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 00287 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D If known Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 246
unknown, send 0. Claim R 17 17 DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 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 17 17 DT unknown, enter 0. Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 247
Preferred Care Partners 10691 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 10691 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 248
Primary PhysicianCare Inc 10692 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 10692 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 249
Claim Service Date R 17 17 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 276/277 5010 Guide - All 250
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 00144 Principal Life Insurance Company 00143 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 9 9 N [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 251
Claim Control Number O 1 25 AN [REF01=1K] unknown, send 0. Claim S 17 17 DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Control Number Claim Disclaimer: None O 1 30 AN R 17 17 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 276/277 5010 Guide - All 252
Schaller Anderson Aetna Better 10816 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 10816 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 253
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 254
Schaller Anderson Aetna Better Health of OH 10887 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 10887 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Level: 2000D Level: 2100D Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 255
Schaller Anderson Delaware Phys 10817 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 10817 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 256
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 257
Schaller Anderson MajestaCare VA 10818 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 10818 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number O 1 25 AN [REF01=1K] Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 258
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 259
Schaller Anderson Maryland Physicians Care 10693 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 10693 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 260
Schaller Anderson Mercy Care 10694 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 10694 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 261
Schaller Anderson Missouri Care 10695 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 10695 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 262
Schaller Anderson Parkland Community 10643 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 10643 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 263
Schaller Anderson Texas CHRISTUS 10696 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 10696 [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 S1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 264
Select Health of SC 10520 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 10520 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 265
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 266
Senior Health Services Center-Universal American Family of Companies 10697 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 10697 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN Level: 2000E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 267
First D1 1 25 AN Dependent Claim Submitter Trace Claim Service Date R 17 17 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 276/277 5010 Guide - All 268
Senior Whole Health 10962 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 10962 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 269
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 270
Significa Benefit Services- 00191 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 00287 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim R 17 17 DT Level: 2200D unknown, send 0. Dependent Birth Date D1 8 8 DT Dependent Dependent Level: 2000E Level: 2100E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 271
Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Claim Disclaimer: None R 17 17 DT Level: 2200E unknown, enter 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 272
Simply Healthcare Plans 10826 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 10826 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 276/277 5010 Guide - All 273
Claim Control Number S 1 30 AN [REF01=1K] Required if known. unknown, send 0. Claim R 17 17 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 276/277 5010 Guide - All 274
SPJST Medicare Supplement 10546 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 10546 Information Receiver Federal Tax ID S 9 9 N NPI S 10 10 AN Service Provider Federal Tax ID S 9 9 N NPI S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 276/277 5010 Guide - All 275
Claim Disclaimer: None S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 276
TexanPlus North Texas Area 10604 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 10604 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R 17 17 DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 277
TexanPlus South Texas Area 10605 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 10605 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R 17 17 DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 278
The Kempton Company 10698 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 10698 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 279
Claim Service Date R 17 17 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 276/277 5010 Guide - All 280
The ULLICO Family of Companies 10945 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 10945 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 281
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 282
Three Rivers Health Plans (Unison Health Plan) 00198 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 00198 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 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 17 17 DT [REF01=1K] [REF01=BLT] [REF01=EA] Level: 2200D unknown, send 0. Level: 2210D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 283
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 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 284
TMG Network Health Insurance 10688 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 10688 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R 17 17 DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 285
Today s Health 10606 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 10606 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None. R 17 17 DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 286
Today s Options 10505 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 10505 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None. R 17 17 DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 287
Triad Healthcare, Inc. 10963 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 10963 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 288
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 289
Tribute/SelectCare of Oklahoma 10607 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 10607 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Disclaimer: None R 17 17 DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 290
Tricare 10189 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 10189 Information Receiver Electronic Transmitter Identification Number (ETIN) S 10 10 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Claim R 17 17 DT Level: 2200D unknown, send 0. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 291
Trustmark 00233 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 00233 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=mi] Claim Submitter Trace Level: 2200D Claim S 17 17 DT Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 292
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Claim R 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 293
Ultimate Health Plans 10888 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 10888 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 1 35 AN First S1 1 25 AN NM104 Member ID S1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 294
UMR (Wausau) 10501 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 10501 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, D1 1 35 AN First S1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Member ID S1, D1 2 20 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 276/277 5010 Guide - All 295
Claim R 17 17 DT Dependent Level: 2000E Birth Date D1 8 8 DT Gender D1 1 1 ID F, M, U DMG03 Dependent Level: 2100E Last S1, D1 1 35 AN Last First S1 1 25 AN NM104 First Middle Initial O 1 1 AN NM105 Dependent Claim Control Number O 1 25 AN Claim Disclaimer: None. R 17 17 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 276/277 5010 Guide - All 296
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,D1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 297
unknown, send 0. Claim S 17 17 DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 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 17 17 DT unknown, enter 0. Disclaimer: None Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 298
United Healthcare 00112 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 00112 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,D1 1 35 AN First S1 1 25 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 276/277 5010 Guide - All 299
unknown, send 0. Claim S 17 17 DT Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 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 17 17 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 276/277 5010 Guide - All 300
United Healthcare Community Plan Kansas 10835 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 10835 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 301
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 302
United Healthcare Facets Detroit Community and State 10836 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 10836 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 303
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 304
United Healthcare Facets Pittsburgh Community and State 10834 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 10834 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 305
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 306
United Healthcare Nevada Market 10837 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 10837 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 307
United Healthcare Plan of River Valley 10192 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 10192 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Bill Type Identifier O 1 30 AN [REF01=BLT] Level: 2200D unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 308
Claim S 17 17 DT Dependent Level: 2000E Date of Birth S1 8 8 DT CCYYMMDD Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Dependent Claim Submitter Trace Level: 2200E Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 309
University Care Advantage Arizona - 10433 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 10433 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 N [NM108=46] Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Last S1,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Claim Service Date R 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 310
Claim Service Date R 17 17 DT [DTP01=472] DISCLAIMER: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 311
University Care Advantage Arizona 10699 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 10699 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 312
Claim Service Date R 17 17 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 276/277 5010 Guide - All 313
University Family Care Arizona- 10194 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 10194 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 N [NM108=46] Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Last S1,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Claim Service Date R 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 314
Claim Service Date R 17 17 DT [DTP01=472] DISCLAIMER: None. Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 315
University Physicians Healthcare Group Arizona - 10439 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 10439 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 N [NM108=46] Date of Birth S1 8 8 DT CCYYMMDD Service Provider Level: 2100C Level: 2000D Last S1,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Claim Service Date R 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 316
Claim Service Date R 17 17 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 276/277 5010 Guide - All 317
University of Arizona Health Plan- UHM 10889 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 10889 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 318
Claim Disclaimer: None S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 319
USAA Life Insurance Company 10195 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 10195 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim R 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 320
VA Fee Basis Program 00231 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 00231 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 2 20 AN [NM108=MI] Claim Submitter Trace Level: 2200D Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 321
VA Health Administration CTR 10956 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 10956 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,D1 1 35 AN First S1,D1 1 25 AN NM104 Member ID S1,D1 2 20 AN [NM108=MI] Claim Submitter Trace Claim Control Number O 1 25 AN [REF01=1K] Level: 2200D unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 322
Claim S 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 323
Vermont Medicaid 10197 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 10197 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 S1 1 35 AN First S1 1 25 AN NM104 Member ID S1 1 24 AN [NM108=mi] Claim Submitter Trace Level: 2200D Bill Type Identifier Claim O 1 30 AN S 17 17 DT [REF01=BLT] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 324
VIVA Health Inc. 10468 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 10468 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 325
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 326
WebTPA 10532 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 10532 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 327
Claim Service Date R 17 17 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 276/277 5010 Guide - All 328
Western Health Advantage 10201 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 10201 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 1 24 AN [NM108=mi] Claim Submitter Trace Claim S 17 17 DT Level: 2200D unknown send 0 Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 329
Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim R 17 17 DT Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 330
World Corp 10700 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 10700 Information Receiver Electronic Transmitter ID Number R 2 20 AN Service Provider NPI R 10 10 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 2 20 AN Claim Submitter Trace Trace Number O 1 30 AN Claim Service Date S 17 17 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 D1 1 35 AN First D1 1 25 AN Dependent Claim Submitter Trace NM104 Level: 2000E Level: 2200E Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 331
Claim Service Date R 17 17 DT [DTP01=472] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, send 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 332
World Insurance (ARIC) 10386 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 10386 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,D1 1 35 AN First S1 1 25 AN NM104 Member ID S1,D1 9 9 AN [NM108=MI] Claim Submitter Trace Level: 2200D Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 333
Claim Control Number Claim O 1 25 AN S 17 17 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 3. 0. Dependent Birth Date D1 8 8 DT Dependent Level: 2000E Gender D1 1 1 ID F,M,U DMG03 Dependent Level: 2100E Last D1 1 35 AN First D1 1 25 AN NM104 Middle Initial O 1 1 AN NM105 Dependent Claim Submitter Trace Level: 2200E Claim Control Number Claim O 1 30 AN R 17 17 DT [REF01=1K] Data Type: N=Numeric, AN=Alphanumeric, DT=Date Format, ID=Identification Code, R=Decimal unknown, enter 0. Xerox EDI Eligibility Gateway 276/277 5010 Guide - All 334