Segment
X12 EDI Release 00401
To record information specific to the primary insured and the insurance carrier for that insured
Elements
Code indicating the relationship between two individuals or entities
Codes (153)- 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
- 45Widow
- 46Widower
- 47State Fund
- 48Stepfather
- 49Stepmother
- 50Foster Parent
- 51Emergency Contact
- 52Employer
- 53Life Partner
- 55Adopted Daughter
- 56Adopted Son
- 57Adoptive Father
- 58Adoptive Mother
- 59Adoptive Parents
- 60Annuitant
- 61Aunt
- 62Brother
- 63Brother-in-Law
- 64Business
- 65Business Associate
- 66Business Insurance Trust
- 67Business Partner
- 68Charity
- 70Children of Marriage
- 71Company
- 72Corporation
- 73Creditor
- 74Daughter
- 75Daughter-in-Law
- 76Dependent
- 78Estate
- 79Ex-wife
- 80Family Member
- 81Father-in-Law
- 82Fiancé (Male)
- 83Financée (Female)
- 84Fiduciary
- 86Foster Daughter
- 87Foster Father
- 88Foster Mother
- 90Foster Son
- 91God Daughter
- 92God Father
- 93God Parents
- 94God Son
- 95Grandchildren
- 96Granddaughter
- 97Grandfather
- 98Grandmother
- 99Grandparents
- 01Spouse
- 02Son or Daughter
- 03Father or Mother
- 04Grandfather or Grandmother
- 05Grandson or Granddaughter
- 06Uncle or Aunt
- 07Nephew or Niece
- 08Cousin
- 09Adopted Child
- A1Grandson
- A2Great Aunt
- A3Ex-husband
- A4Half Brother
- A5Half Sister
- A6Husband
- A7Institution
- A8Mortgage Holder
- A9Mother-in-Law
- B1Nephew
- B2Niece
- B3Parents-in-Law
- B4Partnership
- B5Partner
- B6Personal Insurance Trust
- B7Sister
- B8Sister-in-Law
- B9Sole Proprietorship
- C1Son
- C2Son-in-Law
- C3Step Brother
- C4Step Children
- C5Step Daughter
- C8Step Sister
- C9Step Son
- D1Trust
- D2Trustee
- D3Uncle
- D4Wife
- D5Teacher
- D6School Counselor
- D7School Principal
- D8Other School Administrator
- D9Coach
- E1Activity Sponsor
- E2Supervisor
- E3Co-worker
- E4Minister or Priest
- E5Ecclesiastical or Religious Leader
- E6God Mother
- E7Probation Officer
- E8Accountant
- E9Advisor
- F1Alma Mater
- F2Applicant
- F3Banker
- F6Clergyman
- F7Client
- F8Club or Organization Officer
- F9Doctor
- G2Educator/Teacher/Instructor
- G3Betrothed
- G4Insured
- G5Lawyer
- G6Medical Care Provider
- G7Neighbor
- G8Other Relationship
- G9Other Relative
- H1Owner
- H4Payor
- N1None
- OTNon-applicable Individual Relationship Category
- ZZMutually Defined
Code identifying the type of insurance policy within a specific insurance program
Codes (45)- 12Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
- 13Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
- 14Medicare Secondary, No-fault Insurance including Auto is Primary
- 15Medicare Secondary Worker's Compensation
- 16Medicare Secondary Public Health Service (PHS)or Other Federal Agency
- 41Medicare Secondary Black Lung
- 42Medicare Secondary Veteran's Administration
- 43Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
- 47Medicare Secondary, Other Liability Insurance is Primary
- DDisability
- APAuto Insurance Policy
- C1Commercial
- COConsolidated Omnibus Budget Reconciliation Act (COBRA)
- CPMedicare Conditionally Primary
- DBDisability Benefits
- EPExclusive Provider Organization
- FFFamily or Friends
- GPGroup Policy
- HMHealth Maintenance Organization (HMO)
- HNHealth Maintenance Organization (HMO) - Medicare Risk
- HSSpecial Low Income Medicare Beneficiary
- INIndemnity
- IPIndividual Policy
- LCLong Term Care
- LDLong Term Policy
- LILife Insurance
- LTLitigation
- MAMedicare Part A
- MBMedicare Part B
- MCMedicaid
- MHMedigap Part A
- MIMedigap Part B
- MPMedicare Primary
- OTOther
- PEProperty Insurance - Personal
- PLPersonal
- PPPersonal Payment (Cash - No Insurance)
- PRPreferred Provider Organization (PPO)
- PSPoint of Service (POS)
- QMQualified Medicare Beneficiary
- RPProperty Insurance - Real
- SPSupplemental Policy
- TFTax Equity Fiscal Responsibility Act (TEFRA)
- WCWorkers Compensation
- WUWrap Up Policy
Code identifying whether there is a coordination of benefits
Codes (9)- 1Coordination of Benefits
- 2Coordination of Benefits applies to Spouse Only
- 3Coordination of Benefits applies to Spouse and Dependents
- 4Coordination of Benefits applies to Dependents Only
- 5Unknown
- 6No Coordination of Benefits
- 7Coordination of Benefits Applies to Subscriber Only
- 8Conflict in Coordination of Benefit
- 9Coordination of Benefits Applies to Whole Family
Code showing the general employment status of an employee/claimant
Codes (69)- AALeave of Absence with Pay
- ABLeave of Absence without Pay
- ACActive
- ADApprenticeship Full-time
- AEActive Reserve
- AFFlexible Work Plan
- AGAlerted
- AHAssigned
- AOActive Military - Overseas
- APApprenticeship Part-time
- AUActive Military - USA
- CANon-applicable Employment Status Category
- COConsolidated Omnibus Budget Reconciliation Act (COBRA)
- CTContinued
- DCDischarged or Terminated for Cause
- DDDishonorably Discharged
- 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
- HDHonorably Discharged
- IAInactive
- IRInactive Reserves
- L1Leave of Absence
- LALeave of Absence:Personal
- LELeave of Absence:Education
- LFLeave of Absence:Family Medical Leave Act (FMLA)
- LMLeave of Absence:Maternity
- LSLeave of Absence:Sickness
- LULeave of Absence:Union
- LWLeave of Absence:Without Permission, Unauthorized
- LXLeave of Absence:Military
- NENot Employed
- OSOn Strike
- OTOther
- PAPromoted
- PEPlan to Enlist
- PTPart-time
- PVPrevious
- PWPiece Worker
- RAResigned:Retired
- RBRelocated
- RCReassigned
- RDResigned:Moved
- RERecommissioned
- RIResigned:Injury
- RMRetired Military - Overseas
- RPResigned:Personal Reasons
- RTRetired
- RURetired Military - USA
- RWDual Retired Status
- SAResigned:Accepted Separation Allowance
- SBSeparated
- SESelf-Employed
- SLSeasonal
- SUSuspended
- TETerminated
- TFTemporary Full-Time
- TMTemporary
- TPTemporary Part-Time
- TRTransferred
- UKUnknown
- VOVolunteer
- ZZMutually Defined
Code identifying type of claim
Codes (45)- 10Central Certification
- 11Other Non-Federal Programs
- 12Preferred Provider Organization (PPO)
- 13Point of Service (POS)
- 14Exclusive Provider Organization (EPO)
- 15Indemnity Insurance
- 16Health Maintenance Organization (HMO) Medicare Risk
- 17Dental Maintenance Organization
- 18Deed-in-Lieu Property Sold
- 19Deed-in-Lieu Property Not Sold
- 20Foreclosure Complete Property Sold
- 21Foreclosure Complete Property Not Sold
- 22Liability Insurance
- 01Property Conveyance
- 02Mortgage Assignment
- 03Automatic Mortgage Assignment
- 04Mortgage Coinsurance
- 05Supplemental Claim
- 06Property Nonconveyance (Claim without Conveyance of Title)
- 07Property Preforeclosure Sale
- 08Initial Claim
- 09Self-pay
- AMAutomobile Medical
- BLBlue Cross/Blue Shield
- CHChampus
- CICommercial Insurance Co.
- CNContractual
- DSDisability
- FIFederal Employees Program
- HMHealth Maintenance Organization
- LILiability
- LMLiability Medical
- MAMedicare Part A
- MBMedicare Part B
- MCMedicaid
- MHManaged Care Non-HMO
- OFOther Federal Program
- SASelf-administered Group
- TVTitle V
- VAVeterans Affairs Plan
- WBWorkers' Compensation First Report of Injury
- WCWorkers' Compensation Health Claim
- WDWorkers' Compensation Subsequent Report of Injury
- WEWorkers' Compensation Combined First and Subsequent Report
- ZZMutually Defined