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6.4.7 IN2 - insurance additional information segment

The IN2 segment contains additional insurance policy coverage and benefit information necessary for proper billing and reimbursement. Fields used by this segment are defined by HCFA or other regulatory agencies.

Figure 6-7. IN2 attributes

SEQ

LEN

DT

OPT

RP/#

TBL#

ITEM#

ELEMENT NAME

1

59

CX

O

Y


00472

Insured’s Employee ID

2

11

ST

O



00473

Insured’s Social Security Number

3

130

XCN

O

Y


00474

Insured’s Employer Name

4

1

IS

O


0139

00475

Employer Information Data

5

1

IS

O

Y

0137

00476

Mail Claim Party

6

15

ST

O



00477

Medicare Health Ins Card Number

7

48

XPN

O

Y


00478

Medicaid Case Name

8

15

ST

O



00479

Medicaid Case Number

9

48

XPN

O

Y


00480

Champus Sponsor Name

10

20

ST

O



00481

Champus ID Number

11

80

CE

O



00482

Dependent Of Champus Recipient

12

25

ST

O



00483

Champus Organization

13

25

ST

O



00484

Champus Station

14

14

IS

O


0140

00485

Champus Service

15

2

IS

O


0141

00486

Champus Rank/Grade

16

3

IS

O


0142

00487

Champus Status

17

8

DT

O



00488

Champus Retire Date

18

1

ID

O


0136

00489

Champus Non-Avail Cert On File

19

1

ID

O


0136

00490

Baby Coverage

20

1

ID

O


0136

00491

Combine Baby Bill

21

1

ST

O



00492

Blood Deductible

22

48

XPN

O

Y


00493

Special Coverage Approval Name

23

30

ST

O



00494

Special Coverage Approval Title

24

8

IS

O

Y

0143

00495

Non-Covered Insurance Code

25

59

CX

O

Y


00496

Payor ID

26

59

CX

O

Y


00497

Payor Subscriber ID

27

1

IS

O


0144

00498

Eligibility Source

28

25

CM

O

Y

0145/ 0146

00499

Room Coverage Type/Amount

29

25

CM

O

Y

0147/ 0193

00500

Policy Type/Amount

30

25

CM

O



00501

Daily Deductible

31

2

IS

O


0223

00755

Living Dependency

32

2

IS

O


0009

00145

Ambulatory Status

33

4

IS

O


0171

00129

Citizenship

34

60

CE

O


0296

00118

Primary Language

35

2

IS

O


0220

00742

Living Arrangement

36

80

IS

O


0215

00743

Publicity Indicator

37

1

ID

O


0136

00744

Protection Indicator

38

2

IS

O


0231

00745

Student Indicator

39

3

IS

O


0006

00120

Religion

40

48

XPN

O



00746

Mother’s Maiden Name

41

80

CE

O


0212

00739

Nationality

42

3

IS

O


0189

00125

Ethnic Group

43

1

IS

O

Y

0002

00119

Marital Status

44

8

DT

O



00787

Insured’s Employment Start Date

45

8

DT

O



00783

Insured’s Employment Stop Date

46

20

ST

O



00785

Job Title

47

20

JCC

O


0327/
0328

00786

Job Code/Class

48

2

IS

O


0311

00752

Job Status

49

48

XPN

O

Y


00789

Employer Contact Person Name

50

40

XTN

O

Y


00790

Employer Contact Person Phone Number

51

2

IS

O


0222

00791

Employer Contact Reason

52

48

XPN

O

Y


00792

Insured’s Contact Person’s Name

53

40

XTN

O

Y


00793

Insured’s Contact Person Telephone Number

54

2

IS

O

Y

0222

00794

Insured’s Contact Person Reason

55

8

DT

O



00795

Relationship To The Patient Start Date

56

8

DT

O

Y


00796

Relationship To The Patient Stop Date

57

2

IS

O


0232

00797

Insurance Co. Contact Reason

58

40

XTN

O



00798

Insurance Co Contact Phone Number

59

2

IS

O


0312

00799

Policy Scope

60

2

IS

O


0313

00800

Policy Source

61

60

CX

O



00801

Patient Member Number

62

2

IS

O


0063

00802

Guarantor’s Relationship To Insured

63

40

XTN

O

Y


00803

Insured’s Telephone Number - Home

64

40

XTN

O

Y


00804

Insured’s Employer Telephone Number

65

60

CE

O



00805

Military Handicapped Program

66

2

ID

O


0136

00806

Suspend Flag

67

2

ID

O


0136

00807

Copay Limit Flag

68

2

ID

O


0136

00808

Stoploss Limit Flag

69

130

XON

O

Y


00809

Insured Organization Name And ID

70

130

XON

O

Y


00810

Insured Employer Organization Name And ID

71

1

IS

O


0005

00113

Race

72

60

CE

O



00811

HCFA Patient Relationship to Insured

6.4.7.0 IN2 field definitions

6.4.7.1 Insured's employee ID (CX) 00472

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 fields contains the employee ID of the insured.

6.4.7.2 Insured’s social security number (ST) 00473

Definition: This fields contains the social security number of the insured.

6.4.7.3 Insured's employer name (XCN) 00474

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: This field contains the name of insured’s employer or the person who purchased the insurance for the insured. Multiple names for the same employer 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. When the employer is an organization use IN2-70-insured employer organization name and ID. The components for this data type are described in Chapter 2.

6.4.7.4 Employer information data (IS) 00475

Definition: This field contains the required employer information data for UB82 form locator 71. Refer to user-defined table 0139 - Employer information data for suggested values.

6.4.7.5 Mail claim party (IS) 00476

Definition: This field contains the party to which the claim should be mailed. Refer to user-defined table 0137 - Mail claim party for suggested values.

User-defined Table 0137 - Mail claim party

Value

Description

E

G

I

O

P

Employer

Guarantor

Insurance company

Other

Patient

6.4.7.6 Medicare health ins card number (ST) 00477

Definition: This field contains the Medicare Health Insurance Number (HIN), defined by HCFA or other regulatory agencies.

6.4.7.7 Medicaid case name (XPN) 00478

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 Medicaid case name, defined by HCFA or other regulatory agencies. Multiple names for the same 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 for this data type are described in Chapter 2.

6.4.7.8 Medicaid case number (ST) 00479

Definition: This field contains the Medicaid case number, defined by HCFA or other regulatory agencies, which uniquely identifies a patient’s Medicaid policy.

6.4.7.9 Champus sponsor name (XPN) 00480

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 is defined by HCFA or other regulatory agencies. Multiple names for the same 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.

6.4.7.10 Champus ID number (ST) 00481

Definition: This field contains the Champus ID number, defined by HCFA or other regulatory agencies, which uniquely identifies a patient’s Champus policy.

6.4.7.11 Dependent of champus recipient (CE) 00482

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 is defined by HCFA or other regulatory agencies.

6.4.7.12 Champus organization (ST) 00483

Definition: This field is defined by HCFA or other regulatory agencies.

6.4.7.13 Champus station (ST) 00484

Definition: This field is defined by HCFA or other regulatory agencies.

6.4.7.14 Champus service (IS) 00485

Definition: This field is defined by HCFA or other regulatory agencies. Refer to user-defined table 0140 - Champus service for suggested values.

6.4.7.15 Champus rank/grade (IS) 00486

Definition: This user-defined field identifies the Champus military rank/grade of the insured. Refer to user-defined table 0141 - Champus rank/grade for suggested values.

6.4.7.16 Champus status (IS) 00487

Definition: This field is defined by HCFA or other regulatory agencies. Refer to user-defined table 0142 - Champus status for suggested values.

6.4.7.17 Champus retire date (DT) 00488

Definition: This field is defined by HCFA or other regulatory agencies.

6.4.7.18 Champus non-avail cert on file (ID) 00489

Definition: Refer to HL7 table 0136 - Yes/no indicator for valid values.

6.4.7.19 Baby coverage (ID) 00490

Definition: Refer to HL7 table 0136 - Yes/no indicator for valid values.

6.4.7.20 Combine baby bill (ID) 00491

Definition: Refer to HL7 table 0136 - Yes/no indicator for valid values.

6.4.7.21 Blood deductible (ST) 00492

Definition: Use this field instead of UB2-2-blood deductible, as the blood deductible can be associated with the specific insurance plan via this field.

6.4.7.22 Special coverage approval name (XPN) 00493

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 individual who approves any special coverage. Multiple names for the same 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.

6.4.7.23 Special coverage approval title (ST) 00494

Definition: This field contains the title of the person who approves special coverage.

6.4.7.24 Non-covered insurance code (IS) 00495

Definition: This field contains the code that describes why a service is not covered. Refer to user-defined table 0143 - Non-covered insurance code for suggested values.

6.4.7.25 Payor ID (CX) 00496

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 is required for NEIC processing, and it identifies the organization from which reimbursement is expected.

6.4.7.26 Payor subscriber ID (CX) 00497

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 is required for NEIC processing, and it identifies the specific office within the insurance carrier that is designated as responsible for the claim.

6.4.7.27 Eligibility source (IS) 00498

Definition: This field is required for NEIC processing, and it identifies the source of information about the insured’s eligibility for benefits. Refer to user-defined table 0144 - Eligibility source for suggested values.

User-defined Table 0144 - Eligibility source

Value

Description

1

Insurance company

2

Employer

3

Insured presented policy

4

Insured presented card

5

Signed statement on file

6

Verbal information

7

None

6.4.7.28 Room coverage type/amount (CM) 00499

Components: <room type (IS)> ^ <amount type (IS)> ^ <coverage amount(NM)>

Definition: Use this field instead of IN1-40-room rate - semi-private and IN1-41-room rate - private. This field contains room type (e.g., private, semi-private), amount type (e.g., limit, percentage) and amount covered by the insurance. Refer to user-defined tables 0145 - Room type and 0146 - Amount type for suggested values.

User-defined Table 0145 - Room type

Value

Description

PRI

Private room

2PRI

Second private room

SPR

Semi-private room

2SPR

Second semi-private room

ICU

Intensive care unit

2ICU

Second intensive care unit

User-defined Table 0146 - Amount type

Value

Description

DF

Differential

LM

Limit

PC

Percentage

RT

Rate

UL

Unlimited

6.4.7.29 Policy type/amount (CM) 00500

Components: <policy type (IS)> ^ <amount class (IS)> ^ <amount (NM)>

Definition: This field contains the policy type (e.g., ancillary, major medical) and amount (e.g., amount, percentage, limit) covered by the insurance. Use this field instead of IN1-38-policy limit - amount. Refer to user-defined tables 0147 - Policy type and 0193 - Amount class for suggested values.

User-defined Table 0147 - Policy type

Value

Description

ANC

Ancillary

2ANC

Second ancillary

MMD

Major medical

2MMD

Second major medical

3MMD

Third major medical

User-defined Table 0193 - Amount class

Value

Description

AT

Amount

LM

Limit

PC

Percentage

UL

Unlimited

6.4.7.30 Daily deductible (CM) 00501

Components: <delay days (NM)> ^ <amount (NM)> ^ <number of days (NM)>

Definition: This field contains the number of days after which the daily deductible begins, the amount of the deductible, and the number of days to apply the deductible.

6.4.7.31 Living dependency (IS) 00755

Definition: This field identifies the specific living conditions for the insured. Refer to user-defined table 0223- Living dependency for suggested values.

6.4.7.32 Ambulatory status (IS) 00145

Definition: This field identifies the insured’s state of mobility. Refer to user-defined table 0009 - Ambulatory status for suggested values.

6.4.7.33 Citizenship (IS) 00129

Definition: This field contains the code that identifies the insured’s citizenship. HL7 recommends using ISO table 3166 as the suggested vlues in user-defined table 0171 - Citizenship..

6.4.7.34 Primary language (CE) 00118

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 identifies the insured’s primary speaking language. HL7 recommends using ISO table 639 as the suggested values in user-defined table 0296 - Language.

6.4.7.35 Living arrangement (IS) 00742

Definition: This field indicates the situation in which the insured person lives at his primary residence. Refer to user-defined table 0220 - Living arrangement for suggested values.

6.4.7.36 Publicity indicator (IS) 00743

Definition: This field contains a user-defined code indicating what level of publicity is allowed (e.g., No Publicity, Family Only) for the insured. Refer to user-defined table 0215 - Publicity code for suggested values.

6.4.7.37 Protection indicator (ID) 00744

Definition: This field identifies the insured’s protection, which determines whether or not access to information about this enrollee should be restricted from users who do not have adequate authority. Refer to HL7 table 0136 - Yes/no indicator for valid values.

Y restrict access

N do not restrict access

6.4.7.38 Student indicator (IS) 00745

Definition: This field identifies whether the insured is currently a student or not, and whether the patient is a full-time or a part-time student. This field does not indicate the degree level (high school, college) of student, or his/her field of study (accounting, engineering, etc.). Refer to user-defined table 0231 - Student status for suggested values.

6.4.7.39 Religion (IS) 00120

Definition: This field indicates the type of religion practiced by the insured. Refer to user-defined table 0006 - Religion for suggested values.

6.4.7.40 Mother’s maiden name (XPN) 00746

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 indicates the insured’s mother’s maiden name.

6.4.7.41 Nationality (CE) 00739

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 code that identifies the nation or national grouping to which the insured person belongs. This information may be different from a person’s citizenship in countries in which multiple nationalities are recognized (for example, Spain: Basque, Catalan, etc.). HL7 recommends using ISO table 3166 as he suggested values in user-defined table 0212 - Nationality.

6.4.7.42 Ethnic group (IS) 00125

Definition: This field indicates the insured’s ethnic group. ERISA has a published list of ethnic classifications that may be used by local agreement at a site. Refer to user-defined table 0189 - Ethnic group for suggested values.

6.4.7.43 Marital status (IS) 00119

Definition: This field contains the insured’s marital status. Refer to user-defined table 0002 - Marital status for suggested values. Same values as those for PID-16-marital status.

6.4.7.44 Insured’s employment start date (DT) 00787

Definition: This field indicates the date on which the insured’s employment with a particular employer began.

6.4.7.45 Insured’s employment stop date (DT) 00783

Definition: This field indicates the date on which the person’s employment with a particular employer ended.

6.4.7.46 Job title (ST) 00785

Definition: This field contains a descriptive name for the insured’s occupation (for example, Sr. Systems Analyst, Sr. Accountant).

6.4.7.47 Job code/class (JCC) 00786

Components: <job code (IS)> ^ <job class (IS)>

Definition: This field indicates a code that identifies the insured’s job code ( for example, programmer, analyst, doctor, etc.). Refer to user-defined tables 0327 - Job code and 0328 - Job class for suggested values.

6.4.7.48 Job status (IS) 00752

Definition: This field indicates a code that identifies the insured’s current job status (for example, part time/workers comp, full-time/leave of absence, full-time/suspended, etc.). Refer to user-defined table 0311 - Job status for suggested values.

6.4.7.49 Employer contact person name (XPN) 00789

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 contact person that should be contacted at the insured’s place of employment. (Joe Smith is the insured. He works at GTE. Contact Sue Jones at GTE regarding Joe Smith’s policy). Multiple names for the same person may be sent in this sequence. 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 for this data type are described in Chapter 2.

6.4.7.50 Employer contact person telephone number (XTN) 00790

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 telephone number for Sue Jones who is the contact person at GTE (Joe Smith’s place of employment). Joe Smith is the insured. Multiple phone numbers for the same contact person may be sent in this sequence, not multiple contacts. The primary telephone number is assumed to be in the first repetition. When no primary telephone number is sent, a repeat delimiter must be present for the first repetition. The components for this data type are described in Chapter 2.

6.4.7.51 Employer contact reason code (IS) 00791

Definition: This field contains the reason(s) that Sue Jones should be contacted on behalf of Joe Smith, a GTE employer. Refer to user-defined table 0222 - Contact reason for suggested values.

6.4.7.52 Insured’s contact person name (XPN) 00792

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 contact person for the insured. The components for this data type are described in Chapter 2.

6.4.7.53 Insured’s contact person telephone number (XTN) 00793

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 telephone number for the contact person for the insured. Multiple names for the same person may be sent in this contact, not multiple contacts. 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 for this data type are described in Chapter 2.

6.4.7.54 Insured’s contact reason code (IS) 00794

Definition: This field contains the reason(s) the person should be contacted regarding the insured. Refer to user-defined table - 0222 - Contact reason for suggested values.

6.4.7.55 Relationship to the patient start date (DT) 00795

Definition: This field indicates the date on which the insured’s patient relationship (defined in IN1-17-insured’s relationship to patient) became effective (began).

6.4.7.56 Relationship to the patient stop date (DT) 00796

Definition: This field indicates the date after which the relationship (defined in IN1-17-insured’s relationship to patient) is no longer effective.

6.4.7.57 Insurance company contact reason (IS) 00797

Definition: This field contains a user-defined code that specifies how the contact should be used. Refer to user-defined table 0232 - Insurance company contact reason for suggested values.

User-defined Table 0232 - Insurance company contact reason

Value

Description

01

Medicare claim status

02

Medicaid claim status

03

name/address change

6.4.7.58 Insurance company contact phone number (XTN) 00798

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 telephone number of the person who should be contacted at the insurance company for questions regarding an insurance policy/claim, etc. Multiple phone numbers for the insurance company may be sent in this sequence. The primary telephone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition. The components for this data type are described in Chapter 2.

6.4.7.59 Policy scope (IS) 00799

Definition: This field contains a user-defined code designating the extent of the coverage for a participating member (e.g., "single," "family," etc. Refer to user-defined table 0312 - Policy scope for suggested values.

6.4.7.60 Policy source (IS) 00800

Definition: This user-defined field identifies how the policy information got established. Refer to user-defined table 0313 - Policy source for suggested values.

6.4.7.61 Patient member number (CX) 00801

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 an identifying number assigned by the payor for each individual covered by the insurance policy issued to the insured. For example, each individual family member may have a different member number from the insurance policy number issued to the head of household.

6.4.7.62 Guarantor’s relationship to insured (ID) 00802

Definition: This field specifies the relationship of the guarantor to the insurance subscriber. Refer to user-defined table 0063-Relationship for suggested values.

6.4.7.63 Insured’s telephone number - home (XTN) 00803

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: The value of this field represents the insured’s telephone number. Multiple phone numbers may be sent in this sequence. The primary telephone number is assumed to be in the first repetition (PRN - Primary, PH - Telephone). When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition. The components for this data type are described in Chapter 2.

6.4.7.64 Insured’s employer telephone number (XTN) 00804

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: The value of this field represents the insured’s employer’s telephone number. Multiple phone numbers may be sent in this sequence. The primary telephone number is assumed to be in the first repetition. When the primary telephone number is not sent, a repeat delimiter must be sent first for the first repetition. The components for this data type are described in Chapter 2.

6.4.7.65 Military handicapped program code (CE) 00805

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 indicates the Champus program for the handicapped in which the patient is enrolled.

6.4.7.66 Suspend flag (ID) 00806

Definition: This field indicates whether charges should be suspended for a patient. Refer to HL7 table 0136 - Yes/no indicator for valid values.

Y charges should be suspended

N charges should NOT be suspended

6.4.7.67 Co-pay limit flag (ID) 00807

Definition: This field indicates if the patient has reached the co-pay limit so that no more co-pay charges should be calculated for the patient. Refer to HL7 table 0136 - Yes/no indicator for valid values.

Y the patient is at or exceeds the co-pay limit

N the patient is under the co-pay limit

6.4.7.68 Stoploss limit flag (ID) 00808

Definition: This field indicates if the patient has reached the stoploss limit established in the Contract Master. Refer to HL7 table 0136 - Yes/no indicator for valid values.

Y the patient has reached the stoploss limit

N the patient has not reached the stoploss limit

6.4.7.69 Insured organization name and ID (XON) 00809

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 indicates the name of the insured if the insured/subscriber is an organization. Multiple names for the insured may be sent in this sequence, not multiple insured people. 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 for this data type are described in Chapter 2.

6.4.7.70 Insured employer organization name and ID (XON) 00810

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 indicates the name of the insured’s employer, or the organization that purchased the insurance for the insured, if the employer is an organization. Multiple names and identifiers for the same organization may be sent in this field, not multiple organizations. 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 for this data type are described in Chapter 2.

6.4.7.71 Race (IS) 00113

Definition: ERISA has a published list of ethnic classifications that may be used by local agreement at a site. Refer to user-defined table 0005 - Race for suggested values.

6.4.7.72 HCFA Patient relationship to insured (CE) 00811

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 indicates the relationship of the patient to the insured, as defined by HCFA or other regulatory agencies.

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