Segment
X12 EDI Release 00304
To provide information on health coverage
Elements
Code identifying the specific type of item maintenance.
Codes (41)- 001Change
- 002Delete
- 003Add Full Item Detail
- 004Withdraw Item (Temporary)
- 005Restore Item
- 006Membership Type
- 007Purchase Eligibility
- 008Verified
- 009Not Verified
- 010Periodic Report
- 021Addition
- 022Change in Status
- 023Change in Rate Factors
- 024Cancellation or Termination
- 025Reinstatement
- 026Correction
- 028Policy Adjustment
- 029Inquiry
- 030Audit or Compare
- 032Employee Information Not Applicable
- 050Original
- 051Denial
- 052Initial Payment
- 053Change in Benefit Amount
- 054Change in Benefit Type
- 055Reinstatement of Benefit
- 056Reduced Earnings
- 057Final
- 058
- 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
- ZZZMutually Defined
Code identifying the reason for the maintenance change.
Codes (56)- 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
- 01Divorce
- 02Birth
- 03Death
- 04Retirement
- 05Adoption
- 06Strike
- 07Termination of Benefits
- 08Termination of Employment
- 09Consolidation Omnibus Budget Reconciliation Act (COBRA)
- XBBecame Medical Only
- XIIndemnity
- XLBecame Lost Time
- XMMedical Only
- XNNotification Only
- XTTransfer
- ZZMutually Defined
Code identifying a group of insurance products.
Codes (34)- 403403(B) Tax Sheltered Annuity
- ACBasic Life
- AFSupplemental Life
- APPaid Up Life
- ARDependent Life
- BCDeath and Dismemberment
- BESupplemental Death and Dismemberment
- BHWeekly Indemnity
- BKWeekly Indemnity - New York Employees
- CVEmployee Comprehensive
- LLLifestyle Life (Individualized Basic Life)
- NQNon-Qualified
- ULUniversal Life
- URUtilization Review
- ADDAccidental Death or Dismemberment
- CLFContributory Life
- DENDental
- 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
- 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
