Table 2: Required Fields for 
Field  Description  Field  Description 
Electronic Correspondence  Source Codes on CWF Assistance 
Referral System for the Web  AUXILIARY RECORD  Record number of MSP  EMPLOYER NAME  Name of the  Requests 
#  auxiliary occurrence at  beneficiarys employer 
(ECRS Web) Quick Reference 
CWF  Value  Required Fields 
ADDRESS  Employers address  
Card 
Note: Part D contractors 
must enter 001 when  CITY  Employers city   CHEK  FIRST NAME 
Rev. 2023/24 April  the Auxiliary record  LAST NAME 
STATE  Employers state  
number is unknown.  ADDRESS 
ZIP  Employers zip code 
CWF Assistance Request Codes  ORIGINATING  Contract number of  CITY 
Enter CWF assistance requests for existing  CONTRACTOR  contractors that created  CHECK NUMBER  Check number  STATE 
MSP records  original MSP occurrence 
CHECK DATE  Date on the check  ZIP 
at CWF 
RELATIONSHIP 
CHECK AMOUNT  Amount of the check 
Table 1: Required Fields on CWF  EFFECTIVE DATE  Effective date of MSP 
CHECK NUMBER 
Assistance Request Detail Pages  coverage  PRE-PAID HEALTH  Pre-paid Health Plan 
CHECK DATE 
PLAN DATE  date 
TERMINATION DATE  Date MSP coverage 
Field  Description  CHECK AMOUNT 
ended  SOCIAL SECURITY  Beneficiarys social 
NUMBER  security number  LTTR  FIRST NAME 
DCN  Document Control  FIRST NAME  Informants first name  
Number  DIAGNOSIS CODES  Diagnosis codes  LAST NAME 
LAST NAME  Informants last name  
ADDRESS 
MEDICARE ID  Beneficiarys Health  Required when 
Insurance Claim  ADDRESS  Informants address   ACTION is DX.  CITY 
Number (HICN) or  STATE 
CITY  Informants city  ICD Indicator  Type of diagnosis code. 
Medicare Beneficiary 
Select ICD-9 or ICD- ZIP 
Identifier (MBI)  STATE  Informants state 
10.  Required if  RELATIONSHIP 
ACTIVITY CODE  Activity code  ZIP  Informants zip code  corresponding Diagnosis 
PHON  FIRST NAME 
Code is submitted. 
ACTION(S)  Action codes  RELATIONSHIP  Informants relationship  LAST NAME 
to the beneficiary  REMARKS  Remarks 
SOURCE  Source of request  ADDRESS 
information  INSURANCE  Insurance company  CITY 
COMPANY NAME  name 
IMPORT HIMR MSP  Select to import HIMR  STATE 
DATA  data for the existing  INSURANCE TYPE  Type of insurance  ZIP 
MSP record  coverage 
RELATIONSHIP 
MSP TYPE  Type of MSP coverage  POLICY NUMBER  Insurance policy number     
(not required if group 
PATIENT  Patient relationship 
number is entered) 
RELATIONSHIP 
GROUP NUMBER  Insurance policy group 
number (not required if 
policy number is 
entered) 
1  Table 3: Related Action Codes on 
Value  Description  Value  Required Fields  Description  Value  Required Fields  Description 
CWF Assistance Requests 
LR  Create duplicate liability record  AP  POLICY NUMBER  Insurer  II  INSURANCE  Insurance 
Value  Description 
and/or GROUP  information for  COMPANY NAME  Company 
MT  Change MSP type 
NUMBER  drug records  If you leave the  Name 
AI  Change attorney information 
MX  SSN/Medicare ID mismatch  INSURANCE TYPE  Insurance Type  following fields blank, 
AP  Add policy and/or group number  NR  Create duplicate no-fault record  Note: available for  the system overwrites 
EGHP MSP types  the previous value on 
AR  Add CWF remark codes 
OH  Change effective date of other drug  only  the MSP auxiliary 
CD  Change date of injury/date of loss   coverage  record at CWF: 
AR  REMARK Code (at  Remarks  STREET, CITY, ST, 
CP  Incorrect ESRD Coordination Period  PC  Update prescription person code  least one)  ZIP, GROUP NO, 
CT  Change termination date  PH  Add PHP date  CD  GROUP NUMBER  DOI/DOL  POLICY NO, 
SUBSCRIBER 
CX  Change Prescription Values (BIN,  PN  Develop for/add PCN  Note: ** available for  changes  NAME 
Group, PCN)  contractor 79001, 
PR  Change patient relationship  Type data in all fields 
NON EGHP MSP 
DA  Develop for attorney information  types D, E, L, and W  to update insurer info 
TD  Add termination date  at CWF. Leave all 
only *** 
DD  Develop for the diagnosis code  fields blank to delete 
VP  Update a record for a vow of poverty 
CP  Note: ** available for  Verification of  insurer info at CWF. 
DE  Develop for employer information 
WN  Notify BCRC of updates to WCMSA  ESRD MSP type B  coordination 
IT  INSURANCE TYPE  Insurance type 
DI  Develop for insurer information  cases  only ***  period 
NEW INSURANCE  New Insurance 
DO  Mark occurrence for deletion  CT  TERMINATION  Termination  TYPE  Type 
Table 4: Required Fields for  DATE  Date 
DR  Investigate closed or deleted record  Action Codes on CWF Assistance  INSURANCE TYPE  Insurance Type  MT  MSP TYPE   MSP Type 
DT  Develop for termination date  Requests  NEW MSP TYPE  New MSP Type  
DX  DIAGNOSIS CODES  Diagnosis 
DX  Change diagnosis codes  (at least one)  codes  MX  SOCIAL SECURITY  SSN/Medicare 
Value  Required Fields  Description 
NUMBER  ID mismatch 
EA  Change employer address  EA  EMPLOYER NAME  Employer 
AI  INFORMANT FIRST  Attorney  information  PH  PRE-PAID HEALTH  Pre-paid Health 
ED  Change effective date 
NAME,  information   PLAN DATE  Plan date 
INFORMANT LAST  ED  EFF DATE   Effective Date 
EF  Develop for the effective date 
PR  PAT REL  Patient 
NAME,  NEW EFF DATE  New Effective 
EI  Change employer information  INFORMANT CITY,  Date   NEW PAT REL  Relationship 
INFORMANT  INSURANCE TYPE  New Patient 
ES  Employer size below minimum  STATE,  EI  EMPLOYER NAME,  Employer  Relationship 
(20 for working aged; 100 for  INFORMANT ZIP,  EMPLOYER  information  Insurance Type 
disability) 
INFORMANT  ADDRESS, 
ID  Investigate possible duplicate for  RELATIONSHIP  EMPLOYER CITY,  TD  TERMINATION  Termination 
deletion  (must be A),  EMPLOYER STATE,  DATE  date 
INSURANCE TYPE  EMPLOYER ZIP  INSURANCE TYPE  Insurance Type 
II  Change insurer information 
Type data in all fields 
WN  Note: ** available for  WCMSA 
IT  Change insurer type  to update employer 
Contractor 79001 only  Notification 
info at CWF. 
*** 
2  Prescription Drug Assistance 
Value  Description  Value  Required  Description  Value  Required  Description 
Request Codes 
Fields  Fields 
BN  Develop for prescription BIN 
Table 5: Required Fields for  -  COVERAGE  Coverage Type  ED  NEW EFF  New Effective Date  
CT  Change termination date 
Source Codes on Prescription  TYPE  (when Policy  DATE  Person Code (when 
Drug Assistance Requests  CX  Change prescription values (BIN,  Number, BIN, PCN,  PERSON  Record Type is 
Group, PCN)  ID, Supplemental  CODE  SUP) 
Value  Required Fields  Type, or Person 
DO  Mark occurrence for deletion 
Code are entered)  EI  PERSON  Person Code (when 
CHEK  INFORMANT FIRST NAME,  EA  Change employer address  CODE  Record Type is 
-  POLICY  Policy Number OR 
INFORMANT LAST NAME,  EMPLR  SUP) 
ED  Change effective date  NUMBER  Group Number 
INFORMANT ADDRESS,  NAME,   
required when 
INFORMANT CITY,  EI  Change employer information  Source Code is  ADDRESS,  Employer 
INFORMANT STATE,  GR  Develop for group number  NOT D, E, L, or W  CITY, ST, ZIP  information 
INFORMANT ZIP, 
INFORMANT  II  Change insurer information  -  GROUP  Group Number  GR  PERSON  Person Code (when 
RELATIONSHIP, CHECK  NUMBER  required when  CODE  Record Type is 
NUMBER, CHECK DATE,  IT  Change insurer type  Coverage Type=U  SUP) 
CHECK AMT  MT  Change MSP type  BN  PERSON  Person Code (when  IT  PERSON  Person Code (when 
LTTR  INFORMANT FIRST NAME,  OH  Change effective date of other  CODE  Record Type is  CODE,  Record Type is 
INFORMANT LAST NAME,  drug coverage  SUP)  INS TYPE  SUP) 
INFORMANT ADDRESS,  PC  Update prescription person code  CT  TERM DATE  Termination Date  NEW INS  Insurance type 
INFORMANT CITY, 
TYPE  New Insurance 
INFORMANT STATE,  PN  Develop for/add PCN  PERSON  Person Code (when  Type 
INFORMANT ZIP,  CODE  Record Type is 
INFORMANT  PR  Change patient relationship  SUP)  MT  MSP TYPE,  MSP Type 
RELATIONSHIP  TD  Add termination date  CX  PERSON  Person Code (when  NEW MSP  New MSP Type 
PHON  INFORMANT FIRST NAME,  CODE  Record Type is  TYPE,  Record Type (must 
INFORMANT LAST NAME,  Table 7: Required Fields for  BIN, PCN,  SUP)  RECORD  be PRI) 
INFORMANT ADDRESS,  GROUP  BIN, PCN, OR  TYPE 
Action Codes on Prescription 
INFORMANT CITY,  Group Number is 
Drug Assistance Requests  PC  PERSON  Person Code  
INFORMANT STATE,  required 
CODE 
INFORMANT ZIP, 
Value  Required  Description  DO  PERSON  Person Code (when 
INFORMANT  PN  PERSON  Person Code (when 
RELATIONSHIP  Fields  CODE  Record Type is  CODE  Record Type is 
SUP) 
SUP) 
AP  PERSON  Person Code (when 
EA  PERSON  Person Code (when 
Table 6: Action Codes on  CODE  Record Type is  PR  PERSON  Person Code (when 
CODE  Record Type is 
Prescription Drug Assistance  SUP)  CODE,   Record Type is 
Requests  EMPLOYER  SUP)  NEW PAT  SUP) 
-  INFMT  Informant  NAME  Employer Name 
REL  New Patient 
NAME,  information (when 
Value  Description  Relationship 
ADDRESS,  Source Type is 
CITY, ST, ZIP  Letter, Check, or 
AP  Add policy and/or group number 
Phone) 
3  Value  Required  Description  Field  Description  Field  Description  Field  Description 
Fields 
LAST NAME   Informants last name  ADDRESS  Employers address  GROUP  Group number 
TD  PERSON  Person Code (when  Note: required when MSP  Note: required when 
ADDRESS   Informants address 
CODE,  Record Type is  Type is F and Send to  Coverage Type is U. 
TERM DT  SUP)  CITY   Informants city  CWF is Yes. 
ID  ID number 
Termination Date 
STATE   Informants state  CITY  Employers city 
Note: required when 
ZIP  Informants zip code  Note: required when MSP  Coverage Type is U. 
MSP Inquiry Codes  Type is F and Send to 
Note: Action codes are not required for  RELATIONSHIP  Informants relationship  CWF is Yes.  SUPPLEMENTAL  Type of supplemental 
MSP inquiries.  to the beneficiary  TYPE  insurance 
STATE  Employers state  Note: must be L when 
INSURANCE  Name of beneficiarys 
Note: required when MSP  Record Type is 
Table 8: Required Fields on MSP  COMPANY NAME  insurer 
Type is F and Send to  Supplemental. 
Inquiry Detail Pages 
ADDRESS LINE 1  First line of insurers  CWF is Yes. 
PERSON CODE  Person code 
address 
Field  Description  ZIP  Employers zip code  Note: required when 
Note: required when 
Note: required when MSP  Record Type is 
Insurance Company 
DCN  Document Control  Type is F and Send to  Supplemental and 
Name is entered. 
Number  CWF is Yes.  Supplemental type is L. 
CITY  Insurers city 
MEDICARE ID  Beneficiarys Health  CHECK NUMBER  Check number 
Insurance Claim Number  Note: required when 
(HICN) or Medicare  Insurance Company  CHECK AMOUNT  Amount on the check 
Beneficiary Identifier  Name is entered. 
CHECK DATE  Date on the check 
(MBI)  
STATE  Insurers state 
DIAGNOSIS  Diagnosis codes 
ACTIVITY CODE  Activity code  Note: required when  CODES  Note: If the MSP Type is 
Insurance Company 
SOURCE  Source of request  A, B, or G, the system 
Name is entered. 
information  will prevent the entry of 
ZIP  Insurers zip code  diagnosis codes. 
PATIENT  Patients relationship  
RELATIONSHIP  Note: required when  Note: required when  ICD Indicator  Type of diagnosis code. 
action code is blank and  Insurance Company  Select ICD-9 or ICD-
MSP type is F.  Name is entered.  10.  Required if 
corresponding Diagnosis 
INSURANCE TYPE  Type of insurance 
EFFECTIVE DATE  Effective date of MSP  Code is submitted 
coverage  EMPLOYER NAME  Name of beneficiarys 
BIN  BIN 
employer 
TERMINATION  Date MSP coverage 
Note: required when 
DATE  ended  Note: required when MSP 
Coverage Type is U. 
Type is F and Send to 
CMS GROUPING  CMS grouping code 
CWF is Yes.  PCN  PCN 
CODE 
Note: required when 
FIRST NAME  Informants first name   Coverage Type is U. 
4  Table 9: Related Action Codes on 
Value  Required Fields  Value  Required Fields  Field  Description 
MSP Inquiries 
CL  MSP TYPE (must be D, E, or L)  PHON  MSP TYPE  SEND TO MBD  Select Yes to send 
Value  Description 
PATIENT RELATIONSHIP (must be  FIRST NAME  inquiry to MBD 
CA  Class action suit  D, E, or L)  LAST NAME  SUBMTTER TYPE  Submitter type 
EFFECTIVE DATE (must be D, E, or 
ADDRESS 
CL  Closed or settled case  CHECK NUMBER  Check number 
L) 
CITY 
TERMINATION DATE (must be D,  CHECK DATE  Date on the check 
STATE 
Table 10: Required Fields for  E, or L) 
ZIP  CHECK AMOUNT  Amount on the check 
Action Codes on MSP Inquiries  DIAGNOSIS CODES 
RELATIONSHIP  INFORMANT FIRST  Informants first name  
Informant Name, Address, City, State 
Value  Required Fields  NAME 
and Zip are required unless Insurance 
Company Address, City, State and Zip  Prescription Drug Inquiry Codes 
CA  MSP TYPE   INFORMANT LAST   Informants last name 
have been entered. 
NAME 
PATIENT RELATIONSHIP (when 
Note: Must enter A as relationship  Table 12: Required Fields on 
MSP Type is L)  INFORMANT   Informants address 
if Informant information is entered.  Prescription Drug Inquiry Detail 
EFFECTIVE DATE (when MSP  ADDRESS 
Pages 
Type is L) 
Table 11: Required Fields for  INFORMANT CITY   Informants city 
CMS GROUPING CODE (when 
Field  Description 
MSP Type is L)  Source Codes on MSP Inquiries  INFORMANT STATE   Informants state 
INSURANCE COMPANY NAME,  Value  Required Fields  DCN  Document Control  INFORMANT ZIP  Informants zip code 
INSURANCE TYPE  Number 
INFORMANT  Informants 
DIAGNOSIS CODES  CHEK  FIRST NAME 
MEDICARE ID  Beneficiarys Health  RELATIONSHIP  relationship to the 
Informant Name, Address, City, State  LAST NAME  Insurance Claim  beneficiary 
and Zip are required unless Insurance  ADDRESS  Number (HICN) or 
Company Address, City, State and Zip  Medicare Beneficiary  INSURANCE  Name of the insurance 
have been entered.  CITY  Identifier (MBI)  COMPANY NAME  carrier for drug 
STATE  coverage.   
Note: Must enter A as relationship 
ACTIVITY CODE  Activity code 
if Informant information is entered.  ZIP  EFFECTIVE DATE  Effective date of 
RELATIONSHIP  SOURCE  Source of request  prescription coverage 
information 
CHECK NUMBER 
TERMINATION  Date prescription 
CHECK AMOUNT  MSP TYPE  MSP type  DATE  coverage ends 
CHECK DATE  Note: Leave MSP  Note: automatically 
Type blank when  populated when 
LTTR  FIRST NAME 
Record Type is  Coverage Type is U. 
LAST NAME  Supplemental 
BIN  BIN 
ADDRESS 
PATIENT  Patients relationship  
Note: required when 
CITY 
RELATIONSHIP  Note: required when  Coverage Type is U. 
STATE 
action code is blank 
ZIP  and MSP type is F. 
RELATIONSHIP 
5  Table 15: Coverage Type Codes  Table 18: General - MSP Type 
Field  Description  Value  Required Fields 
on Prescription Drug Inquiries  Codes (EGHP) 
PCN  PCN  LTTR  INFORMANT FIRST NAME 
Value  Description  Value  Description 
Note: required when  INFORMANT ADDRESS 
Coverage Type is U.  INFORMANT CITY  U  Drug Network  A  Working Aged 
GROUP  Group number  INFORMANT STATE 
V  Drug Non-network  B  End-Stage Renal Disease (ESRD) 
Note: required when  INFORMANT ZIP 
Z  Health Reimbursement account  C  Conditional Payment 
Coverage Type is U.  INFORMANT RELATIONSHIP 
F  Federal (Public) 
ID  ID number  PHON  INFORMANT FIRST NAME 
General Codes 
Note: required when  INFORMANT ADDRESS  The following codes apply to CWF  G  Disabled 
Coverage Type is U. 
INFORMANT CITY  assistance requests, MSP inquiries, and  H  Black Lung 
PERSON CODE  Person code  INFORMANT STATE  workers compensation set-aside trust  I  Veterans 
Note: required when  INFORMANT ZIP  cases. 
Record Type is 
INFORMANT RELATIONSHIP  Table 19: General - Source Codes 
Supplemental, or when 
Table 16: General - Activity Codes 
Record Type is blank 
Value  Description 
Table 14: Prescription Drug 
and Supplemental type 
Value  Description 
is L.  Supplemental Type Codes on 
CHEK  Unsolicited check 
Prescription Drug Inquiries  C  Claims (Pre-Payment) (22001) 
LTTR  Letter 
Table 13: Required Fields for 
D  Debt Collection (42021) 
Value  Description 
Source Codes on Prescription  PHON  Phone call 
G  Group Health Plan (42003)  
Drug Inquiries  L  Supplemental  SCLM  Medicare Secondary Claim payment  
I  General Inquiry (42004) 
Value  Required Fields  M  Medigap  SRVY  Survey (Part D only) 
N  Liability, No-Fault, Workers 
N  Non-qualified SPAP 
Compensation, and Federal Tort Claim 
CHEK  CHECK NUMBER 
Table 20: General - Status Codes 
O  Other  Act (FTCA) (42002) 
CHECK DATE 
CHECK AMOUNT  P  PAP  Value  Description 
Table 17: General - MSP Type 
INFORMANT FIRST NAME  Q  Qualified SPAP  Codes (Non-EGHP)  CM  Completed 
INFORMANT ADDRESS 
R  Charity  DE  Delete (do not process) ECRS request 
INFORMANT CITY  Value  Description 
S  ADAP  HD  Hold, individual not yet a Medicare 
INFORMANT STATE 
D  Automobile Insurance, No Fault  beneficiary (WC) (RAC) 
INFORMANT ZIP  T  Federal Government Programs 
E  Workers Compensation  IP  In process, being edited by COB 
INFORMANT RELATIONSHIP  1  Medicaid 
L  Liability  NW  New, not yet read by COB 
2  Tricare 
W  Workers Compensation Set-Aside 
3  Major Medical 
6  Table 21: General - Reason Codes 
Value  Description  Value  Description  Value  Description 
Value  Description 
33  WCSA record  can only be updated  62  Development letter sent, closed, no  84  Missing information, unable to update 
by RO, record closed by CWF  response to development  CWF 
01  Not yet read by BCRC, used with NW 
Analyst 
status  63  Development complete, no MSP  85  Venue changed 
34  Record is N validity  we do not 
02  Being processed by BCRC, used with  64  Development letter sent  86  Unable to verify address, used with 
develop for N records 
IP status  CM status (for CWF assistant requests 
65  Deceased, used with CM status 
36  Policy Holder Retired (G record)  only) 
03  Under development by BCRC, used 
66  ESRD/DIB conflict 
with IP status  37  Beneficiary verified existing record,  87  MSP record exists, used with CM 
no update needed  67  No response from CWF  status (for MSP inquiries only) 
04  Update sent to CWF, used with IP 
status  38  Outreach development already in  68  Closed for Self-Report  88  No update, not lead contractor 
process 
05  Error received from CWF, being  69  Developed to GHP, no response  91  Duplicate in process 
resolved by BCRC, used with IP status  45  Insufficient information to process, 
70  Developed to non-EGHP, no response  92  Change of Venue not allowed after 90 
used with HD status (RAC only) 
06  Sent to EDB for beneficiary info, used  days 
71  Developed to beneficiary; closed, no 
with IP status  46  RAC did not update hold records, 
response received  93  No Part D Enrollment found 
used with DE status (RAC only) 
07  Auditor follow-up development in 
72  Developed to informant, no response  94  Closed, no response/no update 
progress, used with IP status  50  Requested action(s) accepted - Posted 
to CWF  73  Medicare beneficiary retired  96  Per hierarchy guidelines, request 
10  Not processing 
cannot be honored. 
51  No changes (additions, modifications,  74  Spouse retired 
11  Not yet eligible for Medicare, used 
or deletions) made to CWF, used with  97  Existing record is invalid and has 
with HD status  75  GHP lifetime of yearly benefits past 
CM status  been deleted. New record created to 
maximum amount 
12  Needs diagnosis, used with HD status  include changes requested. 
52  Returnedrejected by CWF; 
(for WC set-aside trust cases only)  76  No coverage with insurance company 
conflicting information, used with CM 
13  Future-dated workers compensation  status  77  Medicare Supplemental Plan  Table 22: General - Patient 
case, used with HD status (for WC 
set-aside trust cases only)  53  Returnedduplicate ECRS request,  78  Employer has less than 20 employees  Relationship Codes 
used with CM status  (No MSP) 
Value  Description 
14  Duplicate request, development 
already in process, used with HD  54  100 or more thresholds met, Disability  79  Per employer, Medicare beneficiary is 
status  55  20 or more thresholds met, Working  not covered under spouses GHP  01  Patient is policy holder 
15  Requested Prescription Drug action(s)  Aged  80  Employer has less than 100  02  Spouse 
accepted - Posted to MBD  56  OBRA does not apply, no update  employees (No MSP)  03  Natural child, insured has financial 
30  No action taken per SEE approval -  57  Record already updated  81  Medicare is primary due to ESRD  responsibility 
Medicare primary  coordination period being met  04  Natural child, insured has no financial 
58  Non-compliant GHP 
31  Action code and comments conflict  82  Per insurance, seasonal employee and  responsibility 
59  Employer verified existing record, no  not eligible for the month 
05  Stepchild 
32  Record terminated/deleted due to  update 
OBRA 93  83  Incoming request conflicts with  06  Foster child 
60  Invalid Medicare ID  information on file 
07  Ward of the Court 
61  No Part A entitlement 
7  Value  Description  Value  Description  Value  Description 
08  Employee  R  Beneficiary representative (other  E  Third Party Administrator 
than attorney)  arrangement with stop loss insurance 
09  Unknown 
issued from any entity (STOP LOSS 
S  Spouse 
10  Handicapped dependent  TPA) 
U  Unknown 
11  Organ donor  F  Self-Insured/Self-Administered 
W  Pharmacy  (SELF-INSURED) 
12  Cadaver donor 
G  Collectively-Bargained Health and 
13  Grandchild 
Table 24: General - Relationship  Welfare Fund (HEALTH/WELFAR) 
14  Niece/nephew  to Insured Codes 
H  Multiple Employer Health Plan with 
15  Injured plaintiff  at least one employer who has more 
Value  Description 
than 100 full- and/or part-time 
16  Sponsored dependent 
employees (EMPLOYER+100) 
B  Beneficiary 
17  Minor dependent of a minor dependent 
I  Multiple Employer Health Plan with 
C  Child 
18  Parent  at least one employer who has more 
E  Employer  than 20 full- and/or part-time 
19  Grandparent dependent  employees (EMPLOYER+20) 
F  Father 
20  Domestic partner  J  Hospitalization Only Plan covering 
M  Mother 
inpatient hospital services 
(HOSPITAL ONLY) 
Table 23: General - Informant  N  Non-relative 
Relationship Codes  K  Medical Services Only Plan covering 
O  Other relative 
only non-inpatient medical services 
Value  Description  S  Spouse  (MEDICAL ONLY) 
U  Unknown  M  Medicare Supplemental Plan, 
A  Attorney representing beneficiary 
Medigap, Medicare Wraparound Plan, 
B  Beneficiary  or Medicare Carve Out Plan 
Table 25: General - Insurance 
(SUPPLEMENTAL) 
C  Child  Type Codes 
R  GHP Health Reimbursement 
D  Defendants attorney 
Value  Description  Arrangement 
E  Employer 
S  GHP Health Savings Account 
A  Insurance or Indemnity (OTHER 
F  Father 
TYPES)  Blank  Unknown (UNKNOWN) 
I  Insurer 
B  Group Health Organization (GHO)   
M  Mother 
C  Preferred Provider Organization 
N  Non-relative  (PPO) 
O  Other relative  D  Third Party Administrator 
arrangement under an Administrative 
P  Provider 
Service Only (ASO) contract without 
stop loss from any entity (TPA/ASO) 
8