ISA15 M Usage Indicator “P” Production 1/1 “T” Test ISA16 M Component element separator “: “ 1/1 GS – Functional Group Header Usage : Mandatory Segment Max Use Within : 1 Repeat : NONE Loop ID : NONE Example: GS*BE*xxxxx4321*xxxxx0123*20120101*1452*000000001*X*005010X220~ Min/Max Segment Usage Name Values Description Length GS01 M Functional Identifier Code “BE” Benefit Enrollment and Maintenance 2/2. GS02 M Application Senders Code Senders ID 2/15 GS03 M Application Receiver’s Code See Duns in Supplement 2/15 GS04 M Date CCYYMMDD 8/8 GS05 M Time HHMM 4/4 GS06 M Group Control Number Must match the control number of the 1/9 GE02 element GS07 M Responsibility Agency Code “X” Accredited Standards Committee X12 1/2 GS08 M Version/Release/Industry Identifier “005010X220” 1/12 Code ST – Transaction Set Header Usage : Mandatory Segment Max Use Within : 1 Repeat : NONE Loop ID : NONE Example: ST*834*0001~ Min/Max Segment Usage Name Values Description Length ST01 M Transaction Set Identifier Code “834” Eligibility coverage or benefit inquiry 3/3 ST02 M Transaction Set Control Number Identifying control number that must be 4/9 unique within the transaction set functional group assigned by the originator for a transaction set. COMMENT: The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with the number, for example “0001”,
and increment from there. This number must be unique within the specific group and interchanges, but can repeat in other groups and interchanges. ST03 M Implementation Convention “005010X220” 1/35 Reference BGN – Beginning Segment Usage : Mandatory Segment Max Use Within : 1 Repeat : NONE Loop ID : NONE Example: BGN*00*54321*20120101*1200****RX~ Min/Max Segment Usage Name Values Description Length BGN01 M Purpose Code “00” Original Transmission 2/2 BGN02 M Reference Number 1/50 BGN03 M Date CCYYMMDD 8/8
Example: INS*Y*18*021**A~ INS*N*19*001*AI*A****F~ INS*N*19*001*AI*A*****Y~ Min/Max Segment Usage Name Values Description Length INS01 M Yes/No Condition “Y” Subscriber 1/1 “N” Dependent INS02 M Individual Relationship Code “01” Spouse 2/2 “09” Adopted Child “18” Self “19” Child “25” Ex-Spouse “53” Life Partner INS03 M Maintenance Type Code “001” Change 3/3 “021” Addition “024” Termination “030” Audit/No Change INS04 O Maintenance Reason Code “03” Death 2/2 “04” Retirement “11” Surviving Spouse “AI” No Reason Given INS05 M Benefit Status Code “A” Active 1/1 “C” COBRA “S” Surviving Spouse INS06 O Medicare Plan Code “A” Medicare Part A 1/1 “B” Medicare Part B “C” Medicare Part A and B “D” Medicare “E” No Medicare INS07 NOT USED INS08 O Employment Status Code “RT” Retired 2/2 INS09 O Student Status Code “F” Full-time 1/1 “N” Not a Student “P” Part-time INS10 O Handicap Status Indicator “Y” Yes, handicapped 1/1 “N” No, not handicapped INS11 NOT USED INS12 NOT USED INS13 NOT USED INS14 NOT USED INS15 NOT USED INS16 NOT USED INS17 NOT USED
Segment Max Use Within : 1 Repeat : 1 Loop ID : 2000 Example: REF*DX*DDP~ Min/Max Segment Usage Name Values Description Length REF01 M Reference ID Qualifier “DX” Department/Agency Number 2/2 REF02 M Reference Identification See Carrier ID in Supplement 4/6 REF03 NOT USED REF04 NOT USED DTP – Member Level Dates (Eligibility End) Usage : Conditional (see comment) Segment Max Use Within : 1 Repeat : 1 Loop ID : 2000 Example: DTP*357*D8*20120101~ Min/Max Segment Usage Name Values Description Length DTP01 M Date/Time Qualifier “357” Eligibility End 3/3 DTP02 M Date Time Period Format Qualifier “D8” Date Format CCYYMMDD 2/2 DTP03 M Date Eligibility End Date 8/8 COMMENT: If a termination is being sent and a 2300 loop is not provided with a benefit end date, this segment date is required. If a benefit end date is provided in the 2300 loop, the term date in the 2000 will be ignored. If a coverage is not specified in a 2300 loop, the termination date in the 2000 loop will be for all coverages. DTP – Member Level Dates (Employment Date/Hire Date) Usage : Conditional (see comment) Segment Max Use Within : 1 Repeat : 1 Loop ID : 2000 Example: DTP*336*D8*19980301~ Min/Max Segment Usage Name Values Description Length DTP01 M Date/Time Qualifier “336” Employment Begin 3/3