Segment
X12 EDI Release 00303
To provide benefit information on insured entities
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 specific type of item maintenance.
Codes (16)- 001Change
- 002Delete
- 003Add Full Item Detail
- 004Withdraw Item (Temporary)
- 005Restore Item
- 021Addition
- 022Change in Status
- 023Change in Rate Factors
- 024Cancellation or Termination
- 025Reinstatement
- 026Correction
- 028Policy Adjustment
- 029Inquiry
- 030Audit or Compare
- 032Employee Information Not Applicable
- ZZZMutually Defined
Code identifying the reason for the maintenance change.
Codes (42)- 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
- 01Divorce
- 02Birth
- 03Death
- 04Retirement
- 05Adoption
- 06Strike
- 07Termination of Benefits
- 08Termination of Employment
- 09Consolidation Omnibus Budget Reconciliation Act (COBRA)
- ZZMutually Defined
- INS071219Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event CodeIDO可选(Optional)
A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary.
Codes (9)- 1Termination of Employment
- 2Reduction of work hours
- 3Medicare
- 4Death
- 5Divorce
- 6Separation
- 7Ineligible Child
- 8Bankruptcy of Retiree's Former Employer (26 U.S.C. 4980B(f)(3)(F))
- ZZMutually Defined
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 indicating the date format, time format, or date and time format.
Codes (22)- CCFirst Two Digits of Year Expressed in Format CCYY
- CMDate in Format CCYYMM
- CYYear Expressed in Format CCYY
- D6Date Expressed in Format YYMMDD
- D8Date Expression in Format CCYYMMDD
- DDDay of Month in Numeric Format
- DTDate and Time Expressed in Format CCYYMMDDHHMM
- MDMonth of Year and Day of Month Expressed in Format MMDD
- ME
- MMMonth of Year in Numeric Format
- TMTime Expressed in Format HHMM
- TSTime Expressed in Format HHMMSS
- YMYear and Month Expressed in Format YYMM
- YYLast Two Digits of Year Expressed in Format CCYY
- RD2Range of Years Expressed in Format YY-YY
- RD4Range of Years Expressed in Format CCYY-CCYY
- RD6Range of Dates Expressed in Format YYMMDD-YYMMDD
- RD8Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
- RDMRange of Dates Expressed in Format YYMMDD-MMDD
- RDTRange of Date and Time, Expressed in Format CCYYMMDDHHMM-CCYYMMDDHHMM
- RMDRange of Months and Days Expressed in Format MMDD-MMDD
- RTMRange of Time Expressed in Format HHMM-HHMM