Segment
X12 EDI Release 00504
To record information specific to the primary insured and the insurance carrier for that insured
Elements
Code identifying the insurance carrier's level of responsibility for a payment of a claim
Codes (14)- APayer Responsibility Four
- BPayer Responsibility Five
- CPayer Responsibility Six
- DPayer Responsibility Seven
- EPayer Responsibility Eight
- FPayer Responsibility Nine
- GPayer Responsibility Ten
- HPayer Responsibility Eleven
- NUnconfirmed
- ONoncapitated Agreement
- PPrimary
- SSecondary
- TTertiary
- UUnknown
Code indicating the relationship between two individuals or entities
Codes (155)- 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
- 16Stepparent
- 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
- DCChild of a Domestic Partner
- 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 (51)- 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
- 17Dental
- 18Vision
- 19Prescription Drugs
- 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
- EMedicare - Point of Service (POS)
- UMultiple Options Health Plan
- 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
- MDMedicare Part D
- 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 (91)- 00Substitute
- AALeave of Absence with Pay
- ABLeave of Absence without Pay
- ACActive
- ADApprenticeship Full-time
- AEActive Reserve
- AFFlexible Work Plan
- AGAlerted
- AHAssigned
- AIAffiliated with Outside Organization
- AJAdjunct
- AOActive Military - Overseas
- APApprenticeship Part-time
- AQApprenticeship
- ASAcademy Student
- ATPresidential Appointee
- AUActive Military - USA
- CANon-applicable Employment Status Category
- CCContractor
- COConsolidated Omnibus Budget Reconciliation Act (COBRA)
- CTContinued
- DCDischarged or Terminated for Cause
- DDDishonorably Discharged
- DIDeceased
- DQDisqualified: Medical or Physical Condition
- DRDisqualified: Other
- DSDisabled
- EOEmployed by Outside Organization
- FAFurloughed: Job Abolished, Force Reduction
- FBFurloughed: Bumped or Displaced
- FCFurloughed: Facility Closed
- FOFurloughed: Other
- FTFull-time
- HDHonorably Discharged
- IAInactive
- IRInactive Reserves
- L1Leave of Absence
- L2Administrative Leave of Absence
- L3Annual Leave of Absence
- L4Leave of Absence due to Bereavement
- L5Jury Duty
- L6Suspension
- L7Sabbatical Leave of Absence
- LALeave of Absence: Personal
- LELeave of Absence: Education
- LFLeave of Absence: Family Medical Leave Act (FMLA)
- LMLeave of Absence: Maternity
- LOLeave of Absence for Non-Military Government Request Other Than Jury Duty
- LSLeave of Absence: Sickness
- LULeave of Absence: Union
- LWLeave of Absence: Without Permission, Unauthorized
- LXLeave of Absence: Military
- NENot Employed
- OSOn Strike
- OTOther
- PAPromoted
- PCPart-time Contractual
- PEPlan to Enlist
- PMPermanent
- PNPart-time Noncontractual
- PRProbationary
- PTPart-time
- PVPrevious
- PWPiece Worker
- RAResigned: Retired
- RBRelocated
- RCReassigned
- RDResigned: Moved
- RERecommissioned
- RIResigned: Injury
- RMRetired Military - Overseas
- RPResigned: Personal Reasons
- RRRetired Without Recall
- RTRetired
- RURetired Military - USA
- RWDual Retired Status
- SAResigned: Accepted Separation Allowance
- SBSeparated
- SESelf-Employed
- SLSeasonal
- SUSuspended
- TETerminated
- TFTemporary Full-Time
- TMTemporary
- TNTenured
- TPTemporary Part-Time
- TRTransferred
- UKUnknown
- VOVolunteer
- XDExtra Duties Not Requiring Certification
- ZZMutually Defined
Code identifying type of claim
Codes (50)- 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
- 31Special Forbearance
- 32Loan Modifications
- 33Partial Claim
- 34Managed Dental
- 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
- MDMedicare Part D
- 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