Segment
X12 EDI Release 00303
To record claim information specific to the primary insured and the insurance carrier for that insured
Elements
Code indicating the relationship between two individuals or entities.
Codes (41)- 10Foster Child
- 11Son-in-law or Daughter-in-law
- 12Brother-in-law or Sister-in-law
- 13Mother-in-law or Father-in-law
- 14Brother or Sister
- 15Ward
- 17Stepson or Stepdaughter
- 18Self
- 19Child
- 20Employee
- 21Unknown
- 22Handicapped Dependent
- 23Sponsored Dependent
- 24Dependent of a Minor Dependent
- 25Ex-spouse
- 26Guardian
- 27Student
- 28Friend
- 29Significant Other
- 30Both Parents
- 31Court Appointed Guardian
- 32Mother
- 33Father
- 34Other Adult
- 36Emancipated Minor
- 37Agency Representative
- 38Collateral Dependent
- 39Organ Donor
- 40Cadaver Donor
- 41Injured Plaintiff
- 43Child Where Insured Has No Financial Responsibility
- 01Spouse
- 02Son or Daughter
- 03Father or Mother
- 04Grandfather or Grandmother
- 05Grandson or Granddaughter
- 06Uncle or Aunt
- 07Nephew or Niece
- 08Cousin
- 09Adopted Child
- ZZMutually Defined
Code identifying the type of insurance policy within a specific insurance program
Codes (20)- 12Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14Medicare Secondary, No-fault Insurance including Auto is Primary
- 15Medicare Secondary Worker's Compensation
- 16Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41Medicare Secondary Black Lung
- 42Medicare Secondary Veteran's Administration
- 43Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- APAuto Insurance Policy
- CPMedicare Conditionally Primary
- GPGroup Policy
- IPIndividual Policy
- LDLong Term Policy
- LTLitigation
- MCMedicaid
- MG
- MPMedicare Primary
- OTOther
- PPPersonal Payment (Cash - No Insurance)
- SPSupplemental Policy
Code identifying whether there is a coordination of benefits
Codes (7)- 1Coordination of Benefits
- 2Coordination of Benefits applies to Spouse Only
- 3Coordination of Benefits applies to Spouse and Dependents
- 4Coordination of Benefits applies to Dependents Only
- 5Unknown
- 6No Coordination of Benefits
- 7Coordination of Benefits Applies to Subscriber Only
Code showing the general employment status of an employee/claimant.
Codes (41)- AALeave of Absence with Pay
- ABLeave of Absence without Pay
- ACActive
- AFFlexible Work Plan
- AOActive Military - Overseas
- AUActive Military - USA
- COConsolidated Omnibus Budget Reconciliation Act (COBRA)
- CTContinued
- DCDischarged or Terminated for Cause
- DIDeceased
- DQDisqualified: Medical or Physical Condition
- DRDisqualified: Other
- DSDisabled
- FAFurloughed: Job Abolished, Force Reduction
- FBFurloughed: Bumped or Displaced
- FCFurloughed: Facility Closed
- FOFurloughed: Other
- FTFull-time
- IAInactive
- L1Leave of Absence
- LALeave of Absence: Personal
- LELeave of Absence: Education
- LMLeave of Absence: Maternity
- LSLeave of Absence: Sickness
- LULeave of Absence: Union
- LWLeave of Absence: Without Permission, Unauthorized
- NENot Employed
- PTPart-time
- RAResigned: Retired
- RIResigned: Injury
- RMRetired Military - Overseas
- RPResigned: Personal Reasons
- RTRetired
- RURetired Military - USA
- RWDual Retired Status
- SAResigned: Accepted Separation Allowance
- SESelf-Employed
- SUSuspended
- TETerminated
- UKUnknown
- ZZMutually Defined
Code identifying the type of health insurance or program.
Codes (15)- BLBlue Cross/Blue Shield
- CHChampus
- CICommercial Insurance Co.
- FIFederal Employees Program
- HMHealth Maintenance Organization
- MAMedicare Part A
- MBMedicare Part B
- MCMedicaid
- MHManaged Care Non-HMO
- OFOther Federal Program
- SASelf-administered Group
- TVTitle V
- VAVeterans Affairs Plan
- WCWorkers' Compensation Health Claim
- ZZMutually Defined
