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6.4.6 IN1 - insurance segment

The IN1 segment contains insurance policy coverage information necessary to produce properly pro-rated and patient and insurance bills.

Figure 6-6. IN1 attributes

SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM#

ELEMENT NAME

1

4

SI

R



00426

Set ID - IN1

2

60

CE

R


0072

00368

Insurance Plan ID

3

59

CX

R

Y


00428

Insurance Company ID

4

130

XON

O

Y


00429

Insurance Company Name

5

106

XAD

O

Y


00430

Insurance Company Address

6

48

XPN

O

Y


00431

Insurance Co. Contact Person

7

40

XTN

O

Y


00432

Insurance Co Phone Number

8

12

ST

O



00433

Group Number

9

130

XON

O

Y


00434

Group Name

10

12

CX

O

Y


00435

Insured’s Group Emp ID

11

130

XON

O

Y


00436

Insured’s Group Emp Name

12

8

DT

O



00437

Plan Effective Date

13

8

DT

O



00438

Plan Expiration Date

14

55

CM

O



00439

Authorization Information

15

3

IS

O


0086

00440

Plan Type

16

48

XPN

O

Y


00441

Name Of Insured

17

2

IS

O


0063

00442

Insured’s Relationship To Patient

18

26

TS

O



00443

Insured’s Date Of Birth

19

106

XAD

O

Y


00444

Insured’s Address

20

2

IS

O


0135

00445

Assignment Of Benefits

21

2

IS

O


0173

00446

Coordination Of Benefits

22

2

ST

O



00447

Coord Of Ben. Priority

23

2

ID

O


0136

00448

Notice Of Admission Flag

24

8

DT

O



00449

Notice Of Admission Date

25

2

ID

O


0136

00450

Report Of Eligibility Flag

26

8

DT

O



00451

Report Of Eligibility Date

27

2

IS

O


0093

00452

Release Information Code

28

15

ST

O



00453

Pre-Admit Cert (PAC)

29

26

TS

O



00454

Verification Date/Time

30

60

XCN

O



00455

Verification By

31

2

IS

O


0098

00456

Type Of Agreement Code

32

2

IS

O


0022

00457

Billing Status

33

4

NM

O



00458

Lifetime Reserve Days

34

4

NM

O



00459

Delay Before L.R. Day

35

8

IS

O


0042

00460

Company Plan Code

36

15

ST

O



00461

Policy Number

37

12

CP

O



00462

Policy Deductible

38

12

CP

B



00463

Policy Limit - Amount

39

4

NM

O



00464

Policy Limit - Days

40

12

CP

B



00465

Room Rate - Semi-Private

41

12

CP

B



00466

Room Rate - Private

42

60

CE

O


0066

00467

Insured’s Employment Status

43

1

IS

O


0001

00468

Insured’s Sex

44

106

XAD

O

Y


00469

Insured’s Employer Address

45

2

ST

O



00470

Verification Status

46

8

IS

O


0072

00471

Prior Insurance Plan ID

47

3

IS

O


0309

01227

Coverage Type

48

2

IS

O


0310

00753

Handicap

49

12

CX

O

Y


01230

Insured’s ID Number

6.4.6.0 IN1 field definitions

6.4.6.1 Set ID - IN1 (SI) 00426

Definition: IN1-1-set ID contains the number that identifies this transaction . For the first occurrence the sequence number shall be 1, for the second occurrence it shall be 2, etc.

6.4.6.2 Insurance plan ID (CE) 00427

Components: <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)>

Definition: This field contains a unique identifier for the insurance plan. Refer to user-defined table 0072 - Insurance plan ID. To eliminate a plan, the plan could be sent with null values in each subsequent element. If the respective systems can support it, a null value can be sent in the plan field.

6.4.6.3 Insurance company ID (CX) 00428

Components: <ID (ST)> ^ <check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <assigning authority (HD)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains a unique identifier the insurance company.

6.4.6.4 Insurance company name (XON) 00429

Components: <organization name (ST)> ^ <organization name type code (ID)> ^ <ID number (ID)> ^ <check digit (NM)> ^ < check digit scheme (ID)> ^ <assigning authority (HD)> ^ <identifier type code (ID)> ^ <assigning facility ID (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains the name of the insurance company. Multiple names for the same insurance company may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this data type are described in Chapter 2.

6.4.6.5 Insurance company address (XAD) 00430

Components: <street address (ST)> ^ <other designation (ST)> ^ <city (ST)> ^ <state or province (ST)> ^ <zip or postal code(ST)> ^ <country (ID)> ^ < address type (ID)> ^ <other geographic designation (ST)>^ <county/parish code (IS)> ^ <census tract (IS)>

Definition: This field contains the address of the insurance company. Multiple addresses for the same insurance company may be sent in this field. The mailing address is assumed to be in the first repetition. When the mailing address is not sent, a repeat delimiter must be sent first for the first repetition.

6.4.6.6 Insurance co contact person (XPN) 00431

Components: <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <name type code (ID) >

Definition: This field contains the name of the person who should be contacted at the insurance company. Multiple names for the same contact person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this data type are described in Chapter 2.

6.4.6.7 Insurance co phone number (XTN) 00432

Components: [NNN] [(999)]999-9999 [X99999] [B99999] [C any text] ^<telecommunication use code (ID)> ^ <telecommunication equipment type (ID)> ^ <email address (ST)> ^ <country code (NM)> ^ <area/city code (NM)> ^ <phone number (NM)> ^ <extension (NM)> ^ <any text (ST)>

Definition: This field contains the phone number of the insurance company. Multiple phone numbers for the same insurance company may be sent in this field. The primary phone number is assumed to be in the first repetition. When the primary phone number is not sent, a repeat delimiter must be sent first for the first repetition. The components of this data type are described in Chapter 2.

6.4.6.8 Group number (ST) 00433

Definition: This field contains the group number of the insured’s insurance.

6.4.6.9 Group name (XON) 00434

Components: <organization name (ST)> ^ <organization name type code (ID)> ^ <ID number (ID)> ^ <check digit (NM)> ^ < check digit scheme (ID)> ^ <assigning authority (HD)> ^ <identifier type code (ID)> ^ <assigning facility ID (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains the group name of the insured’s insurance. The components of this data type are described in Chapter 2.

6.4.6.10 Insured’s group emp. ID (CX) 00435

Components: <ID (ST)> ^ <check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <assigning authority (HD)> ^ <identifier type code (IS)> ^ <assigning facility (HD)

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field holds the group employer ID for the insured’s insurance.

6.4.6.11 Insured's group emp name (XON) 00436

Components: <organization name (ST)> ^ <organization name type code (ID)> ^ <ID number (ID)> ^ <check digit (NM)> ^ < check digit scheme (ID)> ^ <assigning authority (HD)> ^ <identifier type code (ID)> ^ <assigning facility ID (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This field contains the name of the employer that provides the employee’s insurance. Multiple names for the same employer may be sent in this sequence. The legal name must be sent first. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this data type are described in Chapter 2.

6.4.6.12 Plan effective date (DT) 00437

Definition: This field contains the date that the insurance goes into effect.

6.4.6.13 Plan expiration date (DT) 00438

Definition: This field indicates the last date of service that the insurance will cover or be responsible for.

6.4.6.14 Authorization information (CM) 00439

Components: <authorization number (ST)> ^ <date (DT)> ^ <source (ST)>

Definition: Based on the type of insurance, some coverage plans require that an authorization number or code be obtained prior to all non-emergency admissions, and within 48 hours of an emergency admission. Insurance billing would not be permitted without this number. The date and source of authorization are the components of this field.

6.4.6.15 Plan type (IS) 00440

Definition: This field contains the coding structure that identifies the various plan types, for example, Medicare, Medicaid, Blue Cross, HMO, etc. Refer to user-defined table 0086 - Plan ID for suggested values.

6.4.6.16 Name of insured (XPN) 00441

Components: <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)>^ <name type code (ID) >

Definition: This field contains the name of the insured person. The insured is the person who has an agreement with the insurance company to provide healthcare services to persons covered by the insurance policy. Multiple names for the same insured person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this data type are described in Chapter 2.

6.4.6.17 Insured’s relationship to patient (IS) 00442

Definition: This field indicates the insured’s relationship to the patient. Refer to user-defined table 0063 - Relationship for suggested values.

6.4.6.18 Insured's date of birth (TS) 00443

Definition: This field contains the date of birth of the insured.

6.4.6.19 Insured's address (XAD) 00444

Components: <street address (ST)> ^ <other designation (ST)> ^ <city (ST)> ^ <state or province (ST)> ^ <zip or postal code(ST)> ^ <country (ID)> ^ < address type (ID)> ^ <other geographic designation (ST)>^ <county/parish code (IS)> ^ <census tract (IS)>

Definition: This field contains the address of the insured person. The insured is the person who has an agreement with the insurance company to provide healthcare services to persons covered by an insurance policy. Multiple addresses for the same insured person may be in this field. The mailing address must be sent in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition.

6.4.6.20 Assignment of benefits (IS) 00445

Definition: This field indicates whether the insured agreed to assign the insurance benefits to the healthcare provider. If so, the insurance will pay the provider directly. Refer to user-defined table 0135 - Assignment of benefits for suggested values.

User-defined Table 0135 - Assignment of benefits

Value

Description

Y

N

M

Yes

No

Modified assignment

6.4.6.21 Coordination of benefits (IS) 00446

Definition: This field indicates whether this insurance works in conjunction with other insurance plans, or if it provides independent coverage and payment of benefits regardless of other insurance that might be available to the patient. Refer to user-defined table 0173 - Coordination of benefits for suggested values.

User-defined Table 0173 - Coordination of benefits

Value

Description

CO

Coordination

IN

Independent

6.4.6.22 Coord of ben priority (ST) 00447

Definition: If the insurance works in conjunction with other insurance plans, this field contains priority sequence. Values are: 1, 2, 3, etc.

6.4.6.23 Notice of admission flag (ID) 00448

Definition: This field indicates whether the insurance company requires a written notice of admission from the healthcare provider. Refer to HL7 table 0136 - Yes/no indicator for valid values.

6.4.6.24 Notice of admission date (DT) 00449

Definition: If a notice is required, this field indicates the date that it was sent.

6.4.6.25 Report of eligibility flag (ID) 00450

Definition: This field indicates whether this insurance carrier sends a report that indicates that the patient is eligible for benefits and whether it identifies those benefits. Refer to HL7 table 0136 - Yes/no indicator for valid values.

6.4.6.26 Report of eligibility date (DT) 00451

Definition: This field indicates whether a report of eligibility (ROE) was received, and also indicates the date that it was received.

6.4.6.27 Release information code (IS) 00452

Definition: This field indicates whether the healthcare provider can release information about the patient, and what information can be released. Refer to user-defined table 0093 - Release information code for suggested values.

User-defined Table 0093 - Release information

Value

Description

Y

Yes

N

No


or user-defined codes

6.4.6.28 Pre-admit cert. (PAC) (ST) 00453

Definition: This field contains the pre-admission certification code. If the admission must be certified before the admission, this is the code associated with the admission.

6.4.6.29 Verification date/time (TS) 00454

Definition: This field contains the date/time that the healthcare provider verified that the patient has the indicated benefits.

6.4.6.30 Verification by (XCN) 00455

Components: <ID number (ST)> ^ <family name (ST)> ^ <given name (ST)> ^ <middle initial or name (ST)> ^ <suffix (e.g., JR or III) (ST)> ^ <prefix (e.g., DR) (ST)> ^ <degree (e.g., MD) (ST)> ^ <source table (IS)> ^ <assigning authority (HD)> ^ <name type code(ID)> ^ <identifier check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <identifier type code (IS)> ^ <assigning facility (HD)>

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: Refers to the person who verified the benefits. Multiple names for the same insured person may be sent in this field. The legal name is assumed to be in the first repetition. When the legal name is not sent, a repeat delimiter must be sent first for the first repetition. The components of this data type are described in Chapter 2.

6.4.6.31 Type of agreement code (IS) 00456

Definition: This field is used to further identify an insurance plan. Refer to user-defined table 0098 - Type of agreement for suggested values. Refer to user-defined table 0098 - Type of agreement for suggested values.

User-defined Table 0098 - Type of agreement

Value

Description

S

Standard

U

Unified

M

Maternity

6.4.6.32 Billing status (IS) 00457

Definition: This field indicates whether the particular insurance has been billed and, if so, the type of bill. Refer to user-defined table 0022 - Billing status for suggested values.

6.4.6.33 Lifetime reserve days (NM) 00458

Definition: This field contains the number of days left for a certain service to be provided or covered under an insurance policy.

6.4.6.34 Delay before L.R. day (NM) 00459

Definition: This field indicates the delay before lifetime reserve days.

6.4.6.35 Company plan code (IS) 00460

Definition: This field contains optional information to further define the data in IN1-3-insurance company ID. Refer to user-defined table 0042 - Company plan code. This table contains codes used to identify an insurance plan uniquely.

6.4.6.36 Policy number (ST) 00461

Definition: This field contains the individual policy number of the insured to uniquely identify this patient’s plan. For special types of insurance numbers, there are also special fields in the IN2 segment for Medicaid, Medicare, Champus (i.e., IN2-8-Medicaid case number, IN2-6-Medicare health ins card number, IN2-10-Champus ID number). But we recommend that this field (IN1-36-policy number) be filled even when the patient’s insurance number is also passed in one of these other fields.

6.4.6.37 Policy deductible (CP) 00462

Components: <price (MO)> ^ <price type (ID)> ^ <from value (NM)> ^ <to value (NM)> ^ <range units (CE)> ^ <range type (ID)>

Definition: This field contains the amount specified by the insurance plan that is the responsibility of the guarantor.

6.4.6.38 Policy limit - amount (CP) 00463

Components: <price (MO)> ^ <price type (ID)> ^ <from value (NM)> ^ <to value (NM)> ^ <range units (CE)> ^ <range type (ID)>

Definition: This field has been retained for backward compatibility only. Use IN2-policy type/amount instead of this field. This field contains the maximum amount that the insurance policy will pay. In some cases, the limit may be for a single encounter.

6.4.6.39 Policy limit - days (NM) 00464

Definition: This field contains the maximum number of days that the insurance policy will cover.

6.4.6.40 Room rate - semi-private (CP) 00465

Components: <price (MO)> ^ <price type (ID)> ^ <from value (NM)> ^ <to value (NM)> ^ <range units (CE)> ^ <range type (ID)>

Definition: This field has been retained for backward compatibility only. Use IN2-28-room coverage type/amount instead of this field. When used for backward compatibility, IN2-40-room rate--semi-primate contains the average room rate that the policy covers.

6.4.6.41 Room rate - private (CP) 00466

Components: <price (MO)> ^ <price type (ID)> ^ <from value (NM)> ^ <to value (NM)> ^ <range units (CE)> ^ <range type (ID)>

Definition: This field has been retained for backward compatibility only. Use IN2-28-room coverage type/amount instead of this field. When used for backward compatibility IN2-29-room rate--private contains the maximum private room rate that the policy covers.

6.4.6.42 Insured’s employment status (CE) 00467

Components: <identifier (ST)> ^ <text (ST)> ^ <name of coding system (ST)> ^ <alternate identifier (ST)> ^ <alternate text (ST)> ^ <name of alternate coding system (ST)>

Definition: Refer to user-defined table 0066 - Employment status for suggested values.

6.4.6.43 Insured’s sex (IS) 00468

Definition: This field contains the gender of the insured. Refer to user-defined table 0001 - Sex for valid values.

6.4.6.44 Insured's employer’s address (XAD) 00469

Components: <street address (ST)> ^ <other designation (ST)> ^ <city (ST)> ^ <state or province (ST)> ^ <zip or postal code(ST)> ^ <country (ID)> ^ < address type (ID)> ^ <other geographic designation (ST)> ^ <county/parish code (IS)> ^ <census tract (IS)>

Definition: This field contains the address of the insured employee’s employer. Multiple addresses for the same employer may be sent in this field. The mailing address must be sent first. When the mailing address is not sent, a repeat delimiter must be sent first for the first repetition.

6.4.6.45 Verification status (ST) 00470

Definition: This field contains the status of this patient’s relationship with this insurance carrier.

6.4.6.46 Prior insurance plan ID (IS) 00471

Definition: This field uniquely identifies the prior insurance plan when the plan ID changes. Refer to user-defined table 0072 - Insurance plan ID for suggested values.

6.4.6.47 Coverage type (IS) 01227

Definition: This field contains the coding structure that identifies the type of insurance coverage, or what type of services are covered for the purposes of a billing system. For example, a physician billing system will only want to receive insurance information for plans which cover physician/professional charges. Refer to user-defined table 0309 - Coverage type for suggested values.

User-defined Table 0309 - Coverage type

Value

Description

H

Hospital/Institutional

P

Physician/Professional

B

Both Hospital and Physician

6.4.6.48 Handicap code (IS) 00753

Definition: This field contains a code to describe the insured’s disability. Refer to user-defined table 0310 - Handicap for suggested values.

6.4.6.49 Insured’s ID number (CX) 01230

Components: <ID (ST)> ^ <check digit (ST)> ^ <code identifying the check digit scheme employed (ID)> ^ <assigning authority (HD)> ^ <identifier type code (IS)> ^ <assigning facility (HD)

Subcomponents of assigning authority: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Subcomponents of assigning facility: <namespace ID (IS)> & <universal ID (ST)> & <universal ID type (ID)

Definition: This data element contains a healthcare institution’s identifiers for the insured.

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