Segment
X12 EDI Release 00403
To provide information on health coverage
Elements
Code identifying the specific type of item maintenance
Codes (121)- 100Sale of Mortgage Change
- 101Servicer Change
- 102Mortgagor Change
- 104Prepayment Termination
- 105Non-conveyance Termination
- 106Voluntary Action Termination
- 107Loan Refinanced Termination
- 108Transfer Due to Interest and Servicing Sold
- 109Retain Servicing
- 110Transfer Servicing
- 111Assign Servicing
- 112Servicer Loan Number Change
- 113Merger
- 114Acquisition
- 115Receivership
- 116Loan Maturity Maintenance
- 117Binder
- 118New Policy
- 119Renewal Policy
- 123Canceled by Administrator
- 124Canceled by Insured
- 125Re-Write
- 126Non-renewal
- 127Termination of All Endorsements
- 128Termination of Lessor Interest
- 129Termination of Additional Insured Interest
- 130Termination of Lienholder or Loss Payee
- 131Addition of Lessor Endorsement
- 132Addition of Lienholder Endorsement
- 133Addition of Additional Insured Endorsement
- 134Change of Lessor Endorsement
- 135Change of Lienholder Endorsement
- 136Change of Additional Insured Endorsement
- 137Acquired Unallocated
- 138Acquired Payment
- 139Investigation Pending
- 140Concurrent Benefit
- 141Abbreviated First Report on an Acquired Claim
- 142Employer Paid
- 143Employer Reinstatement
- 144Suspension Directed by Agency
- 145Occupational Safety and Health Administration Injury and Illness Log (OSHA-300)
- 146Occupational Injury Survey
- 147Bureau of Labor and Statistics Survey
- 148First Payment on an Acquired Claim
- 149First Report on an Acquired Claim
- 150Impairment Report
- 151Return to Work Report
- 152Office of Workers Compensation Program Injury Claim Report (OWCP CA-1)
- 153Office of Workers Compensation Program Illness Claim Report (OWCP CA-2)
- 154Occupational Safety and Health Administration Injury and Illness Record (OSHA-301)
- 155First Aid Injury Only
- 001Change
- 002Delete
- 003Add Full Item Detail
- 004Withdraw Item (Temporary)
- 005Restore Item
- 006Membership Type
- 007Purchase Eligibility
- 008Verified
- 009Not Verified
- 010Periodic Report
- 011All Items Refresh
- 012Medical Noncompliance
- 013Administrative Noncompliance
- 014Suspended Pending Settlement Approval
- 015Suspended Pending Appeal or Judicial Review
- 016Injury Report Creation
- 017Illness Report Creation
- 018Transfer of Beneficial Rights
- 019Record Security Instrument
- 020Assignment
- 021Addition
- 022Change in Status
- 023Change in Rate Factors
- 024Cancellation or Termination
- 025Reinstatement
- 026Correction
- 028Policy Adjustment
- 029Inquiry
- 030Audit or Compare
- 031Medical Examination Authorization
- 032Employee Information Not Applicable
- 033Release of Interim Funding Interest
- 050Original
- 051Denial
- 052Initial Payment
- 053Change in Benefit Amount
- 054Change in Benefit Type
- 055Reinstatement of Benefit
- 056Reduced Earnings
- 057Final
- 059Suspension Medically Determined or Qualified to Return to Work
- 060Non-compliance of Medical Requirements
- 061Non-compliance of Administrative Requirements
- 062Compensable Death
- 063Incarceration
- 064Claimant's Whereabouts Unknown
- 065Volunteer
- 066Status Request
- 067Benefits Exhausted
- 068Jurisdictional Change
- 069Payment Notification
- 070Status Request Response
- 071Re-issue Identification Card(s)
- 072Suspension Due to Claimant Death
- 073Partial Denial
- 074Partial Suspension, Returned to Work, or Medically Determined or Qualified to Return to Work
- 075Partial Suspension, Medical Non-compliance
- 076Partial Suspension, Administrative Non-compliance
- 077Partial Suspension, Claimant Death
- 078Partial Suspension, Incarceration
- 079Partial Suspension, Claimant's whereabouts Unknown
- 080Partial Suspension, Benefits Exhausted
- 081Partial Suspension, Jurisdiction Change
- 082Partially Suspended, Benefits Pending Settlement Approval
- 083Partially Suspended, Pending Appeal or Judicial Review
- CEPChange Excluding Price
- PRIPrice Change Only
- TBVTo Be Verified
- ZZZMutually Defined
Code identifying the reason for the maintenance change
Codes (111)- 10Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid
- 11Surviving Spouse
- 12Lay Off
- 13Leave of Absence
- 14Voluntary Withdrawal
- 15Primary Care Provider (PCP) Change
- 16Quit
- 17Fired
- 18Suspended
- 19Sabbatical
- 20Active
- 21Disability
- 22Plan Change
- 23Furloughed
- 24Resigned
- 25Change in Identifying Data Elements
- 26Declined Coverage
- 27Pre-Enrollment
- 28Initial Enrollment
- 29Benefit Selection
- 30Discrimination Test
- 31Legal Separation
- 32Marriage
- 33Personnel Data
- 34Investment Elections and Contribution Rates
- 35Loan Repayment
- 36Contribution or Plan Allocation
- 37Leave of Absence with Benefits
- 38Leave of Absence without Benefits
- 39Lay Off with Benefits
- 40Lay Off without Benefits
- 41Re-enrollment
- 42New Entity
- 43Change of Location
- 44Change of Telephone Number
- 45Went Out of Business
- 46Current Customer Information File in Error
- 47Account Balance Reporting
- 48Fees Processing
- 49Interfund Transfer
- 50Loan Request
- 51Enrollment in Subsequent Benefit Plan
- 52Health Care Facility Change
- 53Name Synonym Add
- 54Sub Location Add
- 55Sub Location Change
- 56Sub Location Expire
- 57Buyout
- 58Merger
- 59Non Payment
- 60Coverage Placed Elsewhere
- 61Duplicate Coverage
- 62Change in Ownership
- 63Business Sold
- 64Underwriting Reason
- 65No Employees, Exposure or Operations
- 66Revocation of Voluntary Market Acceptance
- 67Include Primary Business Management
- 68Exclude Primary Business Management
- 69Failure to Pay Deductible
- 70Misrepresented Information
- 71Rewritten
- 72Adding a Jurisdiction
- 73Deleting a Jurisdiction
- 75Occupational Illness
- 76Change Insured Federal Employer Identification Number (FEIN)
- 77Change Employer Federal Employer Identification Number (FEIN)
- 78Change Employer Unemployment Insurance (UI) Code
- 79Change Policy Number
- 80Modification without a Specific Operating Unit Location in Jurisdiction
- 81Change Policy Effective Date
- 82Change Policy Expiration Date
- 83Change Insurer Federal Employer Identification Number (FEIN)
- 84No Eligible Employees
- 85Reinstatement - Canceled in Error
- 86Change in Insured Information
- 87Change in Employer Information
- 88Parent Identification Change
- 89Change to Expiration Date
- 90Phone Verify Only
- 91Name Synonym Delete
- 92Duplicate Entry on Customer Identification File
- 01Divorce
- 02Birth
- 03Death
- 04Retirement
- 05Adoption
- 06Strike
- 07Termination of Benefits
- 08Termination of Employment
- 09Consolidation Omnibus Budget Reconciliation Act (COBRA)
- 4ABusiness Name Change
- 4BBusiness Name Correction
- 4CPhysical or Mailing Address Correction
- AADissatisfaction with Office Staff
- ABDissatisfaction with Medical Care/Services Rendered
- ACInconvenient Office Location
- ADDissatisfaction with Office Hours
- AEUnable to Schedule Appointments in a Timely Manner
- AFDissatisfaction with Physician's Referral Policy
- AGLess Respect and Attention Time Given than to Other Patients
- AHPatient Moved to a New Location
- AINo Reason Given
- AJAppointment Times not Met in a Timely Manner
- XBBecame Medical Only
- XIIndemnity
- XLBecame Lost Time
- XMMedical Only
- XNNotification Only
- XTTransfer
- ZZMutually Defined
Code identifying a group of insurance products
Codes (52)- 403403(B) Tax Sheltered Annuity
- ACBasic Life
- AFSupplemental Life
- AGPreventative Care/Wellness
- AH24 Hour Care
- AIWorkers Compensation
- AJMedicare Risk
- AKMental Health
- APPaid Up Life
- ARDependent Life
- BCDeath and Dismemberment
- BESupplemental Death and Dismemberment
- BHWeekly Indemnity
- BKWeekly Indemnity - New York Employees
- CVEmployee Comprehensive
- HEHearing
- LLLifestyle Life (Individualized Basic Life)
- MMMajor Medical
- NQNon-Qualified
- ULUniversal Life
- URUtilization Review
- AAADurable Medical Equipment
- AABFoot Care
- AACSubstance Abuse
- ADDAccidental Death or Dismemberment
- CHU403(C) Church Exempt Annuity Plans Covered by ERISA
- CLFContributory Life
- DCPDental Capitation
- DENDental
- EMP408(K) Employer Sponsored Qualified Defined Distribution Plans Funded with Individual IRA's
- EPOExclusive Provider Organization
- FACFacility
- FSAFlexible Spending
- GDC457(B) Government Deferred Compensation
- HLTHealth
- HMOHealth Maintenance Organization
- IRAGroup Individual Retirement Account
- IRC408(B) Individual Retirement Account (IRA) Annuity Contract
- LTCLong-Term Care
- LTDLong-Term Disability
- MODMail Order Drug
- NGD457(F) Non-Government Deferred Compensation
- PDGPrescription Drug
- POSPoint of Service
- PPOPreferred Provider Organization
- PRAPractitioners
- PSPProfit-Sharing Plan
- QDA401(K) Qualified Cash or Deferred Arrangement
- QDC401(A) Qualified Defined Contribution
- STDShort-Term Disability
- VISVision
- ZZZMutually Defined
Code indicating the level of coverage being provided for this insured
Codes (18)- CHDChildren Only
- DEPDependents Only
- E1DEmployee and One Dependent
- E2DEmployee and Two Dependents
- E3DEmployee and Three Dependents
- E5DEmployee and One or More Dependents
- E6DEmployee and Two or More Dependents
- E7DEmployee and Three or More Dependents
- E8DEmployee and Four or More Dependents
- E9DEmployee and Five or More Dependents
- ECHEmployee and Children
- EMPEmployee Only
- ESPEmployee and Spouse
- FAMFamily
- INDIndividual
- SPCSpouse and Children
- SPOSpouse Only
- TWOTwo Party
