This functionality is available in a Stedi module. Contact us for details.
INS loop in an 834 Health Care Benefit Enrollment and Maintenance, you can send batches of INS loops to Stedi’s Stage Fragment API, and Stedi will securely store them until you’re ready to send the complete file.
Once you stage all the fragments, you call the Create Outbound Transaction API to combine the fragments together into a single EDI file and deliver it to your trading partner.
Find the Guide JSON Schema
Unless you’re using mappings, you must send fragments in Guide JSON, a JSON format that matches the JSON Schema of the guide associated with the outbound transaction setting. To find the JSON Schema for a fragment:- Navigate to the Trading partners page.
- Select the partnership.
- Click the name of the guide associated with the outbound transaction setting.
- Open the Actions menu and select View schema.
- Find the segment that you selected to split the file. The shape for that segment is the JSON Schema you must use when sending fragments to Stedi.
Loop 2000 (Member Level Detail) in an 834 Healthcare Benefit Enrollment and Maintenance transaction. The start of this loop is the INS segment, which is where Stedi will split the file.
Example JSON Schema for Loop 2000 in an 834
Example JSON Schema for Loop 2000 in an 834
{
"member_level_detail_INS_loop": [
{
"member_level_detail_INS": {
"member_indicator_01": "Y",
"individual_relationship_code_02": "18",
"maintenance_type_code_03": "021",
"maintenance_reason_code_04": "20",
"benefit_status_code_05": "A",
"employment_status_code_08": "FT"
},
"subscriber_identifier_REF": {
"reference_identification_qualifier_01": "0F",
"subscriber_identifier_02": "123456789"
},
"member_policy_number_REF": {
"reference_identification_qualifier_01": "1L",
"member_group_or_policy_number_02": "123456001"
},
"member_level_dates_DTP": [
{
"date_time_qualifier_01": "356",
"date_time_period_format_qualifier_02": "D8",
"status_information_effective_date_03": "19960523"
}
],
"member_name_NM1_loop": {
"member_name_NM1": {
"entity_identifier_code_01": "IL",
"entity_type_qualifier_02": "1",
"member_last_name_03": "DOE",
"member_first_name_04": "JOHN",
"member_middle_name_05": "P",
"identification_code_qualifier_08": "34",
"member_identifier_09": "123456789"
},
"member_communications_numbers_PER": {
"contact_function_code_01": "IP",
"communication_number_qualifier_03": "HP",
"communication_number_04": "7172343334",
"communication_number_qualifier_05": "WP",
"communication_number_06": "7172341240"
},
"member_residence_street_address_N3": {
"member_address_line_01": "100 MARKET ST",
"member_address_line_02": "APT 3G"
},
"member_city_state_zip_code_N4": {
"member_city_name_01": "CAMP HILL",
"member_state_code_02": "PA",
"member_postal_zone_or_zip_code_03": "17011",
"location_qualifier_05": "CY",
"location_identifier_06": "CUMBERLAND"
},
"member_demographics_DMG": {
"date_time_period_format_qualifier_01": "D8",
"member_birth_date_02": "19400816",
"gender_code_03": "M"
}
},
"health_coverage_HD_loop": [
{
"health_coverage_HD": {
"maintenance_type_code_01": "021",
"insurance_line_code_03": "HLT"
},
"health_coverage_dates_DTP": [
{
"date_time_qualifier_01": "348",
"date_time_period_format_qualifier_02": "D8",
"coverage_period_03": "19960601"
}
],
"coordination_of_benefits_COB_loop": [
{
"coordination_of_benefits_COB": {
"payer_responsibility_sequence_number_code_01": "P",
"member_group_or_policy_number_02": "890111",
"coordination_of_benefits_code_03": "5"
}
}
]
},
{
"health_coverage_HD": {
"maintenance_type_code_01": "021",
"insurance_line_code_03": "DEN"
},
"health_coverage_dates_DTP": [
{
"date_time_qualifier_01": "348",
"date_time_period_format_qualifier_02": "D8",
"coverage_period_03": "19960601"
}
]
},
{
"health_coverage_HD": {
"maintenance_type_code_01": "021",
"insurance_line_code_03": "VIS"
},
"health_coverage_dates_DTP": [
{
"date_time_qualifier_01": "348",
"date_time_period_format_qualifier_02": "D8",
"coverage_period_03": "19960601"
}
]
}
]
}
]
}
{
"$schema": "https://json-schema.org/draft/2020-12/schema",
"additionalProperties": false,
"properties": {
"member_level_detail_INS_loop": {
"items": {
"additionalProperties": false,
"properties": {
"member_level_detail_INS": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P1112",
"type": "object",
"dependentRequired": {
"date_time_period_format_qualifier_11": [
"member_individual_death_date_12"
],
"member_individual_death_date_12": [
"date_time_period_format_qualifier_11"
]
}
}
],
"description": "To provide benefit information on insured entities",
"properties": {
"member_indicator_01": {
"description": "Code indicating a Yes or No condition or response\n\n- INS01 indicates status of the insured. A \"Y\" value indicates the insured is a subscriber: an \"N\" value indicates the insured is a dependent.",
"enum": ["N", "Y"],
"title": "Member Indicator",
"type": "string",
"x12-codes": {
"N": {
"description": "No",
"code": "N"
},
"Y": {
"description": "Yes",
"code": "Y"
}
}
},
"individual_relationship_code_02": {
"description": "Code indicating the relationship between two individuals or entities",
"enum": [
"01",
"03",
"04",
"05",
"06",
"07",
"08",
"09",
"10",
"11",
"12",
"13",
"14",
"15",
"16",
"17",
"18",
"19",
"23",
"24",
"25",
"26",
"31",
"38",
"53",
"60",
"D2",
"G8",
"G9"
],
"title": "Individual Relationship Code",
"type": "string",
"x12-codes": {
"10": {
"description": "Foster Child",
"code": "10"
},
"11": {
"description": "Son-in-law or Daughter-in-law",
"code": "11"
},
"12": {
"description": "Brother-in-law or Sister-in-law",
"code": "12"
},
"13": {
"description": "Mother-in-law or Father-in-law",
"code": "13"
},
"14": {
"description": "Brother or Sister",
"code": "14"
},
"15": {
"description": "Ward",
"code": "15"
},
"16": {
"description": "Stepparent",
"code": "16"
},
"17": {
"description": "Stepson or Stepdaughter",
"code": "17"
},
"18": {
"description": "Self",
"code": "18"
},
"19": {
"description": "Child",
"code": "19"
},
"23": {
"description": "Sponsored Dependent",
"code": "23",
"x12-usage-notes": "Dependents between the ages of 19 and 25 not attending school; age qualifications may vary depending on policy."
},
"24": {
"description": "Dependent of a Minor Dependent",
"code": "24"
},
"25": {
"description": "Ex-spouse",
"code": "25"
},
"26": {
"description": "Guardian",
"code": "26"
},
"31": {
"description": "Court Appointed Guardian",
"code": "31"
},
"38": {
"description": "Collateral Dependent",
"code": "38",
"x12-usage-notes": "Relative related by blood or marriage who resides in the home and is dependent on the insured for a major portion of their support."
},
"53": {
"description": "Life Partner",
"code": "53",
"x12-usage-notes": "This is a partner that acts like a spouse without a legal marriage committment."
},
"60": {
"description": "Annuitant",
"code": "60"
},
"01": {
"description": "Spouse",
"code": "01"
},
"03": {
"description": "Father or Mother",
"code": "03"
},
"04": {
"description": "Grandfather or Grandmother",
"code": "04"
},
"05": {
"description": "Grandson or Granddaughter",
"code": "05"
},
"06": {
"description": "Uncle or Aunt",
"code": "06"
},
"07": {
"description": "Nephew or Niece",
"code": "07"
},
"08": {
"description": "Cousin",
"code": "08"
},
"09": {
"description": "Adopted Child",
"code": "09"
},
"D2": {
"description": "Trustee",
"code": "D2"
},
"G8": {
"description": "Other Relationship",
"code": "G8"
},
"G9": {
"description": "Other Relative",
"code": "G9"
}
},
"x12-usage-notes": "- The value 18 must be used for the subscriber.;\n- For dependents, this value identifies their relationship to the subscriber. For example, a daughter would be value 19."
},
"maintenance_type_code_03": {
"description": "Code identifying the specific type of item maintenance",
"enum": ["001", "021", "024", "025", "030"],
"title": "Maintenance Type Code",
"type": "string",
"x12-codes": {
"001": {
"description": "Change",
"code": "001",
"x12-usage-notes": "Use this code to indicate a change to an existing subscriber/dependent record."
},
"021": {
"description": "Addition",
"code": "021",
"x12-usage-notes": "Use this code to add a subscriber or dependent."
},
"024": {
"description": "Cancellation or Termination",
"code": "024",
"x12-usage-notes": "Use this code for cancellation, termination, or deletion of a subscriber or dependent."
},
"025": {
"description": "Reinstatement",
"code": "025",
"x12-usage-notes": "Use this code for reinstatement of a cancelled subscriber/dependent record."
},
"030": {
"description": "Audit or Compare",
"code": "030",
"x12-usage-notes": "Use this code when sending a full file (BGN08 = `4' or `RX') to verify that the sponsor and payer databases are synchronized. See section 1.4.5, Update, Versus Full File Audits, Versus Full File Replacements, for additional information."
}
}
},
"maintenance_reason_code_04": {
"description": "Code identifying the reason for the maintenance change",
"enum": [
"01",
"02",
"03",
"04",
"05",
"06",
"07",
"08",
"09",
"10",
"11",
"14",
"15",
"16",
"17",
"18",
"20",
"21",
"22",
"25",
"26",
"27",
"28",
"29",
"31",
"32",
"33",
"37",
"38",
"39",
"40",
"41",
"43",
"59",
"AA",
"AB",
"AC",
"AD",
"AE",
"AF",
"AG",
"AH",
"AI",
"AJ",
"AL",
"EC",
"XN",
"XT"
],
"title": "Maintenance Reason Code",
"type": "string",
"x12-codes": {
"10": {
"description": "Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid",
"code": "10"
},
"11": {
"description": "Surviving Spouse",
"code": "11"
},
"14": {
"description": "Voluntary Withdrawal",
"code": "14"
},
"15": {
"description": "Primary Care Provider (PCP) Change",
"code": "15"
},
"16": {
"description": "Quit",
"code": "16"
},
"17": {
"description": "Fired",
"code": "17"
},
"18": {
"description": "Suspended",
"code": "18"
},
"20": {
"description": "Active",
"code": "20"
},
"21": {
"description": "Disability",
"code": "21"
},
"22": {
"description": "Plan Change",
"code": "22",
"x12-usage-notes": "Use this code when a member changes from one Plan to a different Plan. This is not intended to identify changes to a Plan."
},
"25": {
"description": "Change in Identifying Data Elements",
"code": "25",
"x12-usage-notes": "Use this code when a change has been made to the primary elements that identify a member. Such primary elements include the following: first name, last name, Social Security Number, date of birth, and employee identification number."
},
"26": {
"description": "Declined Coverage",
"code": "26",
"x12-usage-notes": "Use this code when a member declined a previously active coverage."
},
"27": {
"description": "Pre-Enrollment",
"code": "27",
"x12-usage-notes": "Use this code to enroll newborns prior to receiving the newborn's application."
},
"28": {
"description": "Initial Enrollment",
"code": "28",
"x12-usage-notes": "Use this code the first time the member selected coverage with the Plan Sponsor."
},
"29": {
"description": "Benefit Selection",
"code": "29",
"x12-usage-notes": "Use this code when a member changes benefits within a Plan."
},
"31": {
"description": "Legal Separation",
"code": "31"
},
"32": {
"description": "Marriage",
"code": "32"
},
"33": {
"description": "Personnel Data",
"code": "33",
"x12-usage-notes": "Use this code for any data change that is not included in any of the other allowed codes. An example would be change in Coordination of Benefits information."
},
"37": {
"description": "Leave of Absence with Benefits",
"code": "37"
},
"38": {
"description": "Leave of Absence without Benefits",
"code": "38"
},
"39": {
"description": "Lay Off with Benefits",
"code": "39"
},
"40": {
"description": "Lay Off without Benefits",
"code": "40"
},
"41": {
"description": "Re-enrollment",
"code": "41"
},
"43": {
"description": "Change of Location",
"code": "43",
"x12-usage-notes": "Use this code to indicate a change of address."
},
"59": {
"description": "Non Payment",
"code": "59"
},
"01": {
"description": "Divorce",
"code": "01"
},
"02": {
"description": "Birth",
"code": "02"
},
"03": {
"description": "Death",
"code": "03"
},
"04": {
"description": "Retirement",
"code": "04"
},
"05": {
"description": "Adoption",
"code": "05"
},
"06": {
"description": "Strike",
"code": "06"
},
"07": {
"description": "Termination of Benefits",
"code": "07"
},
"08": {
"description": "Termination of Employment",
"code": "08"
},
"09": {
"description": "Consolidation Omnibus Budget Reconciliation Act (COBRA)",
"code": "09"
},
"AA": {
"description": "Dissatisfaction with Office Staff",
"code": "AA"
},
"AB": {
"description": "Dissatisfaction with Medical Care/Services Rendered",
"code": "AB"
},
"AC": {
"description": "Inconvenient Office Location",
"code": "AC"
},
"AD": {
"description": "Dissatisfaction with Office Hours",
"code": "AD"
},
"AE": {
"description": "Unable to Schedule Appointments in a Timely Manner",
"code": "AE"
},
"AF": {
"description": "Dissatisfaction with Physician's Referral Policy",
"code": "AF"
},
"AG": {
"description": "Less Respect and Attention Time Given than to Other Patients",
"code": "AG"
},
"AH": {
"description": "Patient Moved to a New Location",
"code": "AH"
},
"AI": {
"description": "No Reason Given",
"code": "AI"
},
"AJ": {
"description": "Appointment Times not Met in a Timely Manner",
"code": "AJ"
},
"AL": {
"description": "Algorithm Assigned Benefit Selection",
"code": "AL"
},
"EC": {
"description": "Member Benefit Selection",
"code": "EC",
"x12-usage-notes": "Use this code for initial and subsequent enrollment when an insurance carrier needs to recognize that a member made an explicit plan choice."
},
"XN": {
"description": "Notification Only",
"code": "XN",
"x12-usage-notes": "Use this code in complete enrollment transmissions. This is used when INS03 is equal to 030 (Audit/Compare)."
},
"XT": {
"description": "Transfer",
"code": "XT",
"x12-usage-notes": "Use this code when a member has an organizational change (i.e. a location change within the organization) with no change in benefits or plan."
}
}
},
"benefit_status_code_05": {
"description": "The type of coverage under which benefits are paid",
"enum": ["A", "C", "S", "T"],
"title": "Benefit Status Code",
"type": "string",
"x12-codes": {
"A": {
"description": "Active",
"code": "A"
},
"C": {
"description": "Consolidated Omnibus Budget Reconciliation Act (COBRA)",
"code": "C"
},
"S": {
"description": "Surviving Insured",
"code": "S"
},
"T": {
"description": "Tax Equity and Fiscal Responsibility Act (TEFRA)",
"code": "T"
}
}
},
"medicare_status_code_06": {
"description": "To provide Medicare coverage and associated reason for Medicare eligibility",
"properties": {
"medicare_plan_code_01": {
"description": "Code identifying the Medicare Plan",
"enum": ["A", "B", "C", "D", "E"],
"title": "Medicare Plan Code",
"type": "string",
"x12-codes": {
"A": {
"description": "Medicare Part A",
"code": "A"
},
"B": {
"description": "Medicare Part B",
"code": "B"
},
"C": {
"description": "Medicare Part A and B",
"code": "C"
},
"D": {
"description": "Medicare",
"code": "D"
},
"E": {
"description": "No Medicare",
"code": "E"
}
}
},
"medicare_eligibility_reason_code_02": {
"description": "Code specifying reason for eligibility",
"enum": ["0", "1", "2"],
"title": "Medicare Eligibility Reason Code",
"type": "string",
"x12-codes": {
"0": {
"description": "Age",
"code": "0"
},
"1": {
"description": "Disability",
"code": "1"
},
"2": {
"description": "End Stage Renal Disease (ESRD)",
"code": "2"
}
}
}
},
"required": ["medicare_plan_code_01"],
"title": "Medicare Status Code",
"type": "object",
"x12-usage-notes": "Required if a member is being enrolled or disenrolled in Medicare, is currently in Medicare or has terminated or changed their Medicare enrollment. If not required by this implementation guide, do not send."
},
"consolidated_omnibus_budget_reconciliation_act_cobra_qualifying_event_code_07": {
"description": "A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary",
"enum": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"ZZ"
],
"title": "Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code",
"type": "string",
"x12-codes": {
"1": {
"description": "Termination of Employment",
"code": "1"
},
"2": {
"description": "Reduction of work hours",
"code": "2"
},
"3": {
"description": "Medicare",
"code": "3"
},
"4": {
"description": "Death",
"code": "4"
},
"5": {
"description": "Divorce",
"code": "5"
},
"6": {
"description": "Separation",
"code": "6"
},
"7": {
"description": "Ineligible Child",
"code": "7"
},
"8": {
"description": "Bankruptcy of Retiree's Former Employer (26 U.S.C. 4980B(f)(3)(F))",
"code": "8"
},
"9": {
"description": "Layoff",
"code": "9"
},
"10": {
"description": "Leave of Absence",
"code": "10"
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ"
}
}
},
"employment_status_code_08": {
"description": "Code showing the general employment status of an employee/claimant",
"enum": ["AC", "AO", "AU", "FT", "L1", "PT", "RT", "TE"],
"title": "Employment Status Code",
"type": "string",
"x12-codes": {
"AC": {
"description": "Active",
"code": "AC"
},
"AO": {
"description": "Active Military - Overseas",
"code": "AO"
},
"AU": {
"description": "Active Military - USA",
"code": "AU"
},
"FT": {
"description": "Full-time",
"code": "FT",
"x12-usage-notes": "Full time active employee"
},
"L1": {
"description": "Leave of Absence",
"code": "L1"
},
"PT": {
"description": "Part-time",
"code": "PT",
"x12-usage-notes": "Part time Active Employee"
},
"RT": {
"description": "Retired",
"code": "RT"
},
"TE": {
"description": "Terminated",
"code": "TE"
}
},
"x12-usage-notes": "- If this insurance enrollment is through a non-employment based program such as Medicare or Medicaid then this data element will contain the status of the subscriber in that program, rather than their employment status. Codes for non-employment based programs will be limited to \"AC\", Active and \"TE\", Terminated."
},
"student_status_code_09": {
"description": "Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured",
"enum": ["F", "N", "P"],
"title": "Student Status Code",
"type": "string",
"x12-codes": {
"F": {
"description": "Full-time",
"code": "F"
},
"N": {
"description": "Not a Student",
"code": "N"
},
"P": {
"description": "Part-time",
"code": "P"
}
}
},
"handicap_indicator_10": {
"description": "Code indicating a Yes or No condition or response\n\n- INS10 is the handicapped status indicator. A \"Y\" value indicates an individual is handicapped; an \"N\" value indicates an individual is not handicapped.",
"enum": ["N", "Y"],
"title": "Handicap Indicator",
"type": "string",
"x12-codes": {
"N": {
"description": "No",
"code": "N"
},
"Y": {
"description": "Yes",
"code": "Y"
}
}
},
"date_time_period_format_qualifier_11": {
"description": "Code indicating the date format, time format, or date and time format",
"enum": ["D8"],
"title": "Date Time Period Format Qualifier",
"type": "string",
"x12-codes": {
"D8": {
"description": "Date Expressed in Format CCYYMMDD",
"code": "D8"
}
}
},
"member_individual_death_date_12": {
"description": "Expression of a date, a time, or range of dates, times or dates and times\n\n- INS12 is the date of death.",
"maxLength": 35,
"minLength": 1,
"title": "Member Individual Death Date",
"type": "string"
},
"confidentiality_code_13": {
"description": "Code indicating the access to insured information",
"enum": ["R", "U"],
"title": "Confidentiality Code",
"type": "string",
"x12-codes": {
"R": {
"description": "Restricted Access",
"code": "R"
},
"U": {
"description": "Unrestricted Access",
"code": "U"
}
}
},
"birth_sequence_number_17": {
"description": "A generic number\n\n- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).",
"title": "Birth Sequence Number",
"type": "integer",
"x12-max-length": 9,
"minimum": -999999999,
"maximum": 999999999
}
},
"required": [
"member_indicator_01",
"individual_relationship_code_02",
"maintenance_type_code_03",
"benefit_status_code_05"
],
"title": "Member Level Detail",
"type": "object",
"x12-usage-notes": "- Subscriber information must preceed dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission."
},
"member_policy_number_REF": {
"additionalProperties": false,
"description": "To specify identifying information",
"properties": {
"reference_identification_qualifier_01": {
"description": "Code qualifying the Reference Identification",
"enum": ["1L"],
"title": "Reference Identification Qualifier",
"type": "string",
"x12-codes": {
"1L": {
"description": "Group or Policy Number",
"code": "1L",
"x12-usage-notes": "The submitter sends the payer's pre-assigned Group or Policy Number."
}
}
},
"member_group_or_policy_number_02": {
"description": "Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier",
"maxLength": 50,
"minLength": 1,
"title": "Member Group or Policy Number",
"type": "string"
}
},
"required": [
"reference_identification_qualifier_01",
"member_group_or_policy_number_02"
],
"title": "Member Policy Number",
"type": "object",
"x12-usage-notes": "- The policy number passed in this segment is an attribute of the contract relationship between the plan sponsor (sender) and the payer (receiver) and not an attribute of an individual's participation in any coverage passed in an HD loop.\n- Required when the policy or group number applies to all coverage data (all 2300 loops for this member). If not required by this implementation guide, do not send."
},
"member_supplemental_identifier_REF": {
"items": {
"additionalProperties": false,
"description": "To specify identifying information",
"properties": {
"reference_identification_qualifier_01": {
"description": "Code qualifying the Reference Identification",
"enum": [
"3H",
"4A",
"6O",
"17",
"23",
"ABB",
"D3",
"DX",
"F6",
"P5",
"Q4",
"QQ",
"ZZ"
],
"title": "Reference Identification Qualifier",
"type": "string",
"x12-codes": {
"17": {
"description": "Client Reporting Category",
"code": "17",
"x12-usage-notes": "Used when further identification of a member is required under the insurance contract between the sponsor and the payer and allowed by federal and state regulations."
},
"23": {
"description": "Client Number",
"code": "23",
"x12-usage-notes": "To be used to pass a payer specific identifier for a member. Not to be used after the HIPAA standard National Identifier for Individuals is implemented."
},
"3H": {
"description": "Case Number",
"code": "3H"
},
"4A": {
"description": "Personal Identification Number (PIN)",
"code": "4A",
"x12-usage-notes": "Use this code to transmit a password that is associated with the member's record."
},
"6O": {
"description": "Cross Reference Number",
"code": "6O",
"x12-usage-notes": "Used when further identification of a member is required for reporting, indexing, or other purpose as mutually agreed upon between the sender and receiver of the transaction set."
},
"ABB": {
"description": "Personal ID Number",
"code": "ABB"
},
"D3": {
"description": "National Council for Prescription Drug Programs Pharmacy Number",
"code": "D3"
},
"DX": {
"description": "Department/Agency Number",
"code": "DX",
"x12-usage-notes": "Use when members in a coverage group are set up as different departments or divisions under the terms of the insurance policy."
},
"F6": {
"description": "Health Insurance Claim (HIC) Number",
"code": "F6",
"x12-usage-notes": "Use when reporting Medicare eligibility for a member until the National Identifier is mandated for use."
},
"P5": {
"description": "Position Code",
"code": "P5",
"x12-usage-notes": "Use this code to transmit the title of the member's employment position."
},
"Q4": {
"description": "Prior Identifier Number",
"code": "Q4",
"x12-usage-notes": "Use to pass the Identifier Number under which the member had previous coverage with the payer. This could be the result of a change in employment or coverage that resulted in a new ID number being assigned but left the member covered by the same payer."
},
"QQ": {
"description": "Unit Number",
"code": "QQ",
"x12-usage-notes": "Use when members in a coverage group are set up as different units under the terms of the insurance policy. Units may exist within another grouping such as division or department."
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ"
}
}
},
"member_supplemental_identifier_02": {
"description": "Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier",
"maxLength": 50,
"minLength": 1,
"title": "Member Supplemental Identifier",
"type": "string"
}
},
"required": [
"reference_identification_qualifier_01",
"member_supplemental_identifier_02"
],
"title": "Member Supplemental Identifier",
"type": "object",
"x12-usage-notes": "- Required when sending additional identifying information on the member. If not required by this implementation guide, do not send."
},
"maxItems": 13,
"minItems": 1,
"type": "array"
},
"subscriber_identifier_REF": {
"additionalProperties": false,
"description": "To specify identifying information",
"properties": {
"reference_identification_qualifier_01": {
"description": "Code qualifying the Reference Identification",
"enum": ["0F"],
"title": "Reference Identification Qualifier",
"type": "string",
"x12-codes": {
"0F": {
"description": "Subscriber Number",
"code": "0F",
"x12-usage-notes": "The assignment of the Subscriber Number is designated within the Insurance Contract."
}
}
},
"subscriber_identifier_02": {
"description": "Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier",
"maxLength": 50,
"minLength": 1,
"title": "Subscriber Identifier",
"type": "string"
}
},
"required": [
"reference_identification_qualifier_01",
"subscriber_identifier_02"
],
"title": "Subscriber Identifier",
"type": "object",
"x12-usage-notes": "- This segment must contain a unique SUBSCRIBER identification number (SSN or other). This occurrence is identified by the 0F qualifier (REF01). This identifier is used for linking the subscriber with dependents as required under many policies.\n- The developers recommend using the identifier developed under the HIPAA legislation, when that becomes available."
},
"member_level_dates_DTP": {
"items": {
"additionalProperties": false,
"description": "To specify any or all of a date, a time, or a time period",
"properties": {
"date_time_qualifier_01": {
"description": "Code specifying type of date or time, or both date and time",
"enum": [
"050",
"286",
"296",
"297",
"300",
"301",
"303",
"336",
"337",
"338",
"339",
"340",
"341",
"350",
"351",
"356",
"357",
"383",
"385",
"386",
"393",
"394",
"473",
"474"
],
"title": "Date Time Qualifier",
"type": "string",
"x12-codes": {
"286": {
"description": "Retirement",
"code": "286"
},
"296": {
"description": "Initial Disability Period Return To Work",
"code": "296"
},
"297": {
"description": "Initial Disability Period Last Day Worked",
"code": "297"
},
"300": {
"description": "Enrollment Signature Date",
"code": "300"
},
"301": {
"description": "Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event",
"code": "301"
},
"303": {
"description": "Maintenance Effective",
"code": "303",
"x12-usage-notes": "This code is used to send the effective date of a change to an existing member's information, excluding changes made in Loop 2300."
},
"336": {
"description": "Employment Begin",
"code": "336"
},
"337": {
"description": "Employment End",
"code": "337"
},
"338": {
"description": "Medicare Begin",
"code": "338"
},
"339": {
"description": "Medicare End",
"code": "339"
},
"340": {
"description": "Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin",
"code": "340"
},
"341": {
"description": "Consolidated Omnibus Budget Reconciliation Act (COBRA) End",
"code": "341"
},
"350": {
"description": "Education Begin",
"code": "350",
"x12-usage-notes": "This is the start date for the student at the current educational institution."
},
"351": {
"description": "Education End",
"code": "351",
"x12-usage-notes": "This is the expected graduation date the student at the current educational institution."
},
"356": {
"description": "Eligibility Begin",
"code": "356",
"x12-usage-notes": "The date when a member could elect to enroll or begin benefits in any health care plan through the employer. This is not the actual begin date of coverage, which is conveyed in the DTP segment at position 2700."
},
"357": {
"description": "Eligibility End",
"code": "357",
"x12-usage-notes": "The eligibility end date represents the last date of coverage for which claims will be paid for the individual being terminated. For example, if a date of 02/28/2001 is passed then claims for this individual will be paid through 11:59 p.m. on 02/28/2001."
},
"383": {
"description": "Adjusted Hire",
"code": "383"
},
"385": {
"description": "Credited Service Begin",
"code": "385",
"x12-usage-notes": "The start date from which an employee's length of service, as defined in the plan document, will be calculated."
},
"386": {
"description": "Credited Service End",
"code": "386",
"x12-usage-notes": "The end date to be used in the calculation of an employee's length of service, as defined in the plan document."
},
"393": {
"description": "Plan Participation Suspension",
"code": "393"
},
"394": {
"description": "Rehire",
"code": "394"
},
"473": {
"description": "Medicaid Begin",
"code": "473"
},
"474": {
"description": "Medicaid End",
"code": "474"
},
"050": {
"description": "Received",
"code": "050",
"x12-usage-notes": "Used to identify the date an enrollment application is received."
}
}
},
"date_time_period_format_qualifier_02": {
"description": "Code indicating the date format, time format, or date and time format\n\n- DTP02 is the date or time or period format that will appear in DTP03.",
"enum": ["D8"],
"title": "Date Time Period Format Qualifier",
"type": "string",
"x12-codes": {
"D8": {
"description": "Date Expressed in Format CCYYMMDD",
"code": "D8"
}
}
},
"status_information_effective_date_03": {
"description": "Expression of a date, a time, or range of dates, times or dates and times",
"maxLength": 35,
"minLength": 1,
"title": "Status Information Effective Date",
"type": "string"
}
},
"required": [
"date_time_qualifier_01",
"date_time_period_format_qualifier_02",
"status_information_effective_date_03"
],
"title": "Member Level Dates",
"type": "object",
"x12-usage-notes": "- Required when enrolling a member or when the sponsor is informed of a change to any applicable date listed in DTP01. Only those dates that apply to the particular insurance contract need to be sent. If not required by this implementation guide, do not send.\n- While many of the dates listed for DTP01 are related to termination, the only code that is used to actually terminate a Member is 357 (Eligibility End). Similarly, the Eligibility Begin Date (code 356) is the date the individual is eligible for coverage, not the date coverage is effective."
},
"maxItems": 24,
"minItems": 1,
"type": "array"
},
"member_name_NM1_loop": {
"additionalProperties": false,
"properties": {
"member_name_NM1": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0809",
"type": "object",
"dependentRequired": {
"identification_code_qualifier_08": [
"member_identifier_09"
],
"member_identifier_09": [
"identification_code_qualifier_08"
]
}
}
],
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["74", "IL"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"74": {
"description": "Corrected Insured",
"code": "74",
"x12-usage-notes": "Use this code if this transmission is correcting the identifier information on a member already enrolled. Usage of this code requires the sending of an NM1 with code '70' in loop 2100B."
},
"IL": {
"description": "Insured or Subscriber",
"code": "IL",
"x12-usage-notes": "Use this code for enrolling a new member or updating a member with no change in identifying information. The identifying information for a member is specified under the insurance contract between the sponsor and payer."
}
},
"x12-usage-notes": "- This code identifies if this is a correction to a previous enrollment or if it is a new, or update, enrollment transaction."
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["1"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"1": {
"description": "Person",
"code": "1"
}
}
},
"member_last_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "Member Last Name",
"type": "string"
},
"member_first_name_04": {
"description": "Individual first name",
"maxLength": 35,
"minLength": 1,
"title": "Member First Name",
"type": "string"
},
"member_middle_name_05": {
"description": "Individual middle name or initial",
"maxLength": 25,
"minLength": 1,
"title": "Member Middle Name",
"type": "string"
},
"member_name_prefix_06": {
"description": "Prefix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Member Name Prefix",
"type": "string"
},
"member_name_suffix_07": {
"description": "Suffix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Member Name Suffix",
"type": "string"
},
"identification_code_qualifier_08": {
"description": "Code designating the system/method of code structure used for Identification Code (67)",
"enum": ["34", "ZZ"],
"title": "Identification Code Qualifier",
"type": "string",
"x12-codes": {
"34": {
"description": "Social Security Number",
"code": "34",
"x12-usage-notes": "The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE."
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ",
"x12-usage-notes": "Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used."
}
}
},
"member_identifier_09": {
"description": "Code identifying a party or other code",
"maxLength": 80,
"minLength": 2,
"title": "Member Identifier",
"type": "string"
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02",
"member_last_name_03"
],
"title": "Member Name",
"type": "object",
"x12-usage-notes": ""
},
"member_communications_numbers_PER": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0506",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_05": [
"communication_number_06"
],
"communication_number_06": [
"communication_number_qualifier_05"
]
}
},
{
"x12-condition": "P0708",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_07": [
"communication_number_08"
],
"communication_number_08": [
"communication_number_qualifier_07"
]
}
}
],
"description": "To identify a person or office to whom administrative communications should be directed",
"properties": {
"contact_function_code_01": {
"description": "Code identifying the major duty or responsibility of the person or group named",
"enum": ["IP"],
"title": "Contact Function Code",
"type": "string",
"x12-codes": {
"IP": {
"description": "Insured Party",
"code": "IP"
}
}
},
"communication_number_qualifier_03": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_04": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_05": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_06": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_07": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_08": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
}
},
"required": [
"contact_function_code_01",
"communication_number_qualifier_03",
"communication_number_04"
],
"title": "Member Communications Numbers",
"type": "object",
"x12-usage-notes": "- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).\n- Required when enrolling subscribers, dependents with different contact information, or when changing a member's contact information and the information is provided to the sponsor for the member. If not required by this implementation guide, do not send."
},
"member_residence_street_address_N3": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"member_address_line_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Member Address Line",
"type": "string"
},
"member_address_line_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Member Address Line",
"type": "string"
}
},
"required": ["member_address_line_01"],
"title": "Member Residence Street Address",
"type": "object",
"x12-usage-notes": "- Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send."
},
"member_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": ["member_state_code_02"],
"type": "object",
"properties": {
"member_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": ["member_state_code_02"],
"type": "object",
"properties": {
"member_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0605",
"dependentRequired": {
"location_identifier_06": ["location_qualifier_05"]
}
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": ["country_code_04"]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"member_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Member City Name",
"type": "string"
},
"member_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Member State Code",
"type": "string"
},
"member_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Member Postal Zone or Zip Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"location_qualifier_05": {
"description": "Code identifying type of location",
"enum": ["60", "CY"],
"title": "Location Qualifier",
"type": "string",
"x12-codes": {
"60": {
"description": "Area",
"code": "60"
},
"CY": {
"description": "County/Parish",
"code": "CY"
}
}
},
"location_identifier_06": {
"description": "Code which identifies a specific location",
"maxLength": 30,
"minLength": 1,
"title": "Location Identifier",
"type": "string"
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": ["member_city_name_01"],
"title": "Member City, State, ZIP Code",
"type": "object",
"x12-usage-notes": "- Required when enrolling subscribers, dependents with different address information, or when changing a member's address. If not required by this implementation guide, do not send."
},
"member_demographics_DMG": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P1011",
"type": "object",
"dependentRequired": {
"code_list_qualifier_code_10": [
"race_or_ethnicity_collection_code_11"
],
"race_or_ethnicity_collection_code_11": [
"code_list_qualifier_code_10"
]
}
},
{
"type": "object",
"x12-condition": "C1105",
"dependentRequired": {
"race_or_ethnicity_collection_code_11": [
"composite_race_or_ethnicity_information_05"
]
}
}
],
"description": "To supply demographic information",
"properties": {
"date_time_period_format_qualifier_01": {
"description": "Code indicating the date format, time format, or date and time format",
"enum": ["D8"],
"title": "Date Time Period Format Qualifier",
"type": "string",
"x12-codes": {
"D8": {
"description": "Date Expressed in Format CCYYMMDD",
"code": "D8"
}
}
},
"member_birth_date_02": {
"description": "Expression of a date, a time, or range of dates, times or dates and times\n\n- DMG02 is the date of birth.",
"maxLength": 35,
"minLength": 1,
"title": "Member Birth Date",
"type": "string"
},
"gender_code_03": {
"description": "Code indicating the sex of the individual",
"enum": ["F", "M", "U"],
"title": "Gender Code",
"type": "string",
"x12-codes": {
"F": {
"description": "Female",
"code": "F"
},
"M": {
"description": "Male",
"code": "M"
},
"U": {
"description": "Unknown",
"code": "U",
"x12-usage-notes": "This code is to be used only when the gender is unknown or when it can not be sent due to reporting restrictions."
}
}
},
"marital_status_code_04": {
"description": "Code defining the marital status of a person",
"enum": ["B", "D", "I", "M", "R", "S", "U", "W", "X"],
"title": "Marital Status Code",
"type": "string",
"x12-codes": {
"B": {
"description": "Registered Domestic Partner",
"code": "B"
},
"D": {
"description": "Divorced",
"code": "D"
},
"I": {
"description": "Single",
"code": "I"
},
"M": {
"description": "Married",
"code": "M"
},
"R": {
"description": "Unreported",
"code": "R"
},
"S": {
"description": "Separated",
"code": "S"
},
"U": {
"description": "Unmarried (Single or Divorced or Widowed)",
"code": "U",
"x12-usage-notes": "This code should be used if the previous status is unknown."
},
"W": {
"description": "Widowed",
"code": "W"
},
"X": {
"description": "Legally Separated",
"code": "X"
}
}
},
"composite_race_or_ethnicity_information_05": {
"type": "array",
"items": {
"allOf": [
{
"x12-condition": "P0203",
"type": "object",
"dependentRequired": {
"code_list_qualifier_code_02": [
"race_or_ethnicity_code_03"
],
"race_or_ethnicity_code_03": [
"code_list_qualifier_code_02"
]
}
}
],
"description": "To send general and detailed information on race or ethnicity",
"properties": {
"race_or_ethnicity_code_01": {
"description": "Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes",
"enum": [
"7",
"8",
"A",
"B",
"C",
"D",
"E",
"F",
"G",
"H",
"I",
"J",
"N",
"O",
"P",
"Z"
],
"title": "Race or Ethnicity Code",
"type": "string",
"x12-codes": {
"7": {
"description": "Not Provided",
"code": "7"
},
"8": {
"description": "Not Applicable",
"code": "8"
},
"A": {
"description": "Asian or Pacific Islander",
"code": "A"
},
"B": {
"description": "Black",
"code": "B"
},
"C": {
"description": "Caucasian",
"code": "C"
},
"D": {
"description": "Subcontinent Asian American",
"code": "D"
},
"E": {
"description": "Other Race or Ethnicity",
"code": "E"
},
"F": {
"description": "Asian Pacific American",
"code": "F"
},
"G": {
"description": "Native American",
"code": "G"
},
"H": {
"description": "Hispanic",
"code": "H"
},
"I": {
"description": "American Indian or Alaskan Native",
"code": "I"
},
"J": {
"description": "Native Hawaiian",
"code": "J"
},
"N": {
"description": "Black (Non-Hispanic)",
"code": "N"
},
"O": {
"description": "White (Non-Hispanic)",
"code": "O"
},
"P": {
"description": "Pacific Islander",
"code": "P"
},
"Z": {
"description": "Mutually Defined",
"code": "Z"
}
}
},
"code_list_qualifier_code_02": {
"description": "Code identifying a specific industry code list\n\n- C056-02 and C056-03 are used to specify detailed information about race or ethnicity.",
"enum": ["RET"],
"title": "Code List Qualifier Code",
"type": "string",
"x12-codes": {
"RET": {
"description": "Classification of Race or Ethnicity",
"code": "RET"
}
}
},
"race_or_ethnicity_code_03": {
"description": "Code indicating a code from a specific industry code list",
"maxLength": 30,
"minLength": 1,
"title": "Race or Ethnicity Code",
"type": "string",
"x12-usage-notes": "- CODE SOURCE 859: Classification of Race or Ethnicity"
}
},
"title": "Composite Race or Ethnicity Information",
"type": "object",
"x12-usage-notes": "Required when such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide, do not send."
},
"minItems": 1,
"maxItems": 10
},
"citizenship_status_code_06": {
"description": "Code indicating citizenship status",
"enum": ["1", "2", "3", "4", "5", "6", "7"],
"title": "Citizenship Status Code",
"type": "string",
"x12-codes": {
"1": {
"description": "U.S. Citizen",
"code": "1"
},
"2": {
"description": "Non-Resident Alien",
"code": "2"
},
"3": {
"description": "Resident Alien",
"code": "3"
},
"4": {
"description": "Illegal Alien",
"code": "4"
},
"5": {
"description": "Alien",
"code": "5"
},
"6": {
"description": "U.S. Citizen - Non-Resident",
"code": "6"
},
"7": {
"description": "U.S. Citizen - Resident",
"code": "7"
}
}
},
"code_list_qualifier_code_10": {
"description": "Code identifying a specific industry code list",
"enum": ["REC"],
"title": "Code List Qualifier Code",
"type": "string",
"x12-codes": {
"REC": {
"description": "Race or Ethnicity Collection Code",
"code": "REC"
}
}
},
"race_or_ethnicity_collection_code_11": {
"description": "Code indicating a code from a specific industry code list\n\n- DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.",
"maxLength": 30,
"minLength": 1,
"title": "Race or Ethnicity Collection Code",
"type": "string"
}
},
"required": [
"date_time_period_format_qualifier_01",
"member_birth_date_02",
"gender_code_03"
],
"title": "Member Demographics",
"type": "object",
"x12-usage-notes": "- Required when enrolling a new member, changing a member's demographic information, or terminating a member. If not required by this implementation guide, do not send."
},
"employment_class_EC": {
"items": {
"additionalProperties": false,
"description": "To provide class of employment information",
"properties": {
"employment_class_code_01": {
"description": "Code indicating category of employee",
"enum": [
"01",
"02",
"03",
"04",
"05",
"06",
"07",
"08",
"09",
"10",
"11",
"12",
"17",
"18",
"19",
"20",
"21",
"22",
"23"
],
"title": "Employment Class Code",
"type": "string",
"x12-codes": {
"10": {
"description": "Non-Administrative",
"code": "10"
},
"11": {
"description": "Exempt",
"code": "11"
},
"12": {
"description": "Non-Exempt",
"code": "12"
},
"17": {
"description": "Highly Compensated",
"code": "17"
},
"18": {
"description": "Key-Employee",
"code": "18"
},
"19": {
"description": "Bargaining",
"code": "19"
},
"20": {
"description": "Non-Bargaining",
"code": "20"
},
"21": {
"description": "Owner",
"code": "21"
},
"22": {
"description": "President",
"code": "22"
},
"23": {
"description": "Vice President",
"code": "23"
},
"01": {
"description": "Union",
"code": "01"
},
"02": {
"description": "Non-Union",
"code": "02"
},
"03": {
"description": "Executive",
"code": "03"
},
"04": {
"description": "Non-Executive",
"code": "04"
},
"05": {
"description": "Management",
"code": "05"
},
"06": {
"description": "Non-Management",
"code": "06"
},
"07": {
"description": "Hourly",
"code": "07"
},
"08": {
"description": "Salaried",
"code": "08"
},
"09": {
"description": "Administrative",
"code": "09"
}
}
},
"employment_class_code_02": {
"description": "Code indicating category of employee",
"enum": [
"01",
"02",
"03",
"04",
"05",
"06",
"07",
"08",
"09",
"10",
"11",
"12",
"17",
"18",
"19",
"20",
"21",
"22",
"23"
],
"title": "Employment Class Code",
"type": "string",
"x12-codes": {
"10": {
"description": "Non-Administrative",
"code": "10"
},
"11": {
"description": "Exempt",
"code": "11"
},
"12": {
"description": "Non-Exempt",
"code": "12"
},
"17": {
"description": "Highly Compensated",
"code": "17"
},
"18": {
"description": "Key-Employee",
"code": "18"
},
"19": {
"description": "Bargaining",
"code": "19"
},
"20": {
"description": "Non-Bargaining",
"code": "20"
},
"21": {
"description": "Owner",
"code": "21"
},
"22": {
"description": "President",
"code": "22"
},
"23": {
"description": "Vice President",
"code": "23"
},
"01": {
"description": "Union",
"code": "01"
},
"02": {
"description": "Non-Union",
"code": "02"
},
"03": {
"description": "Executive",
"code": "03"
},
"04": {
"description": "Non-Executive",
"code": "04"
},
"05": {
"description": "Management",
"code": "05"
},
"06": {
"description": "Non-Management",
"code": "06"
},
"07": {
"description": "Hourly",
"code": "07"
},
"08": {
"description": "Salaried",
"code": "08"
},
"09": {
"description": "Administrative",
"code": "09"
}
}
},
"employment_class_code_03": {
"description": "Code indicating category of employee",
"enum": [
"01",
"02",
"03",
"04",
"05",
"06",
"07",
"08",
"09",
"10",
"11",
"12",
"17",
"18",
"19",
"20",
"21",
"22",
"23"
],
"title": "Employment Class Code",
"type": "string",
"x12-codes": {
"10": {
"description": "Non-Administrative",
"code": "10"
},
"11": {
"description": "Exempt",
"code": "11"
},
"12": {
"description": "Non-Exempt",
"code": "12"
},
"17": {
"description": "Highly Compensated",
"code": "17"
},
"18": {
"description": "Key-Employee",
"code": "18"
},
"19": {
"description": "Bargaining",
"code": "19"
},
"20": {
"description": "Non-Bargaining",
"code": "20"
},
"21": {
"description": "Owner",
"code": "21"
},
"22": {
"description": "President",
"code": "22"
},
"23": {
"description": "Vice President",
"code": "23"
},
"01": {
"description": "Union",
"code": "01"
},
"02": {
"description": "Non-Union",
"code": "02"
},
"03": {
"description": "Executive",
"code": "03"
},
"04": {
"description": "Non-Executive",
"code": "04"
},
"05": {
"description": "Management",
"code": "05"
},
"06": {
"description": "Non-Management",
"code": "06"
},
"07": {
"description": "Hourly",
"code": "07"
},
"08": {
"description": "Salaried",
"code": "08"
},
"09": {
"description": "Administrative",
"code": "09"
}
}
}
},
"required": ["employment_class_code_01"],
"title": "Employment Class",
"type": "object",
"x12-usage-notes": "- Required when sending additional employment class information on the member. If not required by this implementation guide, do not send."
},
"minItems": 1,
"type": "array"
},
"member_income_ICM": {
"additionalProperties": false,
"description": "To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions",
"properties": {
"frequency_code_01": {
"description": "Code indicating frequency or type of activities or actions being reported\n\n- ICM01 is the frequency at which an individual's wages are paid.",
"enum": [
"1",
"2",
"3",
"4",
"6",
"7",
"8",
"9",
"B",
"C",
"H",
"Q",
"S",
"U"
],
"title": "Frequency Code",
"type": "string",
"x12-codes": {
"1": {
"description": "Weekly",
"code": "1"
},
"2": {
"description": "Biweekly",
"code": "2"
},
"3": {
"description": "Semimonthly",
"code": "3"
},
"4": {
"description": "Monthly",
"code": "4"
},
"6": {
"description": "Daily",
"code": "6"
},
"7": {
"description": "Annual",
"code": "7"
},
"8": {
"description": "Two Calendar Months",
"code": "8"
},
"9": {
"description": "Lump-Sum Separation Allowance",
"code": "9"
},
"B": {
"description": "Year-to-Date",
"code": "B"
},
"C": {
"description": "Single",
"code": "C"
},
"H": {
"description": "Hourly",
"code": "H"
},
"Q": {
"description": "Quarterly",
"code": "Q"
},
"S": {
"description": "Semiannual",
"code": "S"
},
"U": {
"description": "Unknown",
"code": "U"
}
}
},
"wage_amount_02": {
"description": "Monetary amount\n\n- ICM02 is the yearly wages amount.",
"title": "Wage Amount",
"type": "number",
"x12-max-length": 15
},
"work_hours_count_03": {
"description": "Numeric value of quantity\n\n- ICM03 is the weekly hours.",
"title": "Work Hours Count",
"type": "number",
"x12-max-length": 15
},
"location_identification_code_04": {
"description": "Code which identifies a specific location\n\n- ICM04 is the employer location qualifier such as a department number.",
"maxLength": 30,
"minLength": 1,
"title": "Location Identification Code",
"type": "string"
},
"salary_grade_code_05": {
"description": "The salary grade code assigned by the employer",
"maxLength": 5,
"minLength": 1,
"title": "Salary Grade Code",
"type": "string"
}
},
"required": ["frequency_code_01", "wage_amount_02"],
"title": "Member Income",
"type": "object",
"x12-usage-notes": "- Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send."
},
"member_policy_amounts_AMT": {
"items": {
"additionalProperties": false,
"description": "To indicate the total monetary amount",
"properties": {
"amount_qualifier_code_01": {
"description": "Code to qualify amount",
"enum": ["B9", "C1", "D2", "EBA", "FK", "P3", "R"],
"title": "Amount Qualifier Code",
"type": "string",
"x12-codes": {
"B9": {
"description": "Co-insurance - Actual",
"code": "B9",
"x12-usage-notes": "This will contain any co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract."
},
"C1": {
"description": "Co-Payment Amount",
"code": "C1"
},
"D2": {
"description": "Deductible Amount",
"code": "D2"
},
"EBA": {
"description": "Expected Expenditure Amount",
"code": "EBA"
},
"FK": {
"description": "Other Unlisted Amount",
"code": "FK"
},
"P3": {
"description": "Premium Amount",
"code": "P3"
},
"R": {
"description": "Spend Down",
"code": "R"
}
}
},
"contract_amount_02": {
"description": "Monetary amount",
"title": "Contract Amount",
"type": "number",
"x12-max-length": 15
}
},
"required": [
"amount_qualifier_code_01",
"contract_amount_02"
],
"title": "Member Policy Amounts",
"type": "object",
"x12-usage-notes": "- Required when such transmission is required under the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send."
},
"maxItems": 7,
"minItems": 1,
"type": "array"
},
"member_health_information_HLH": {
"additionalProperties": false,
"description": "To provide health information",
"properties": {
"health_related_code_01": {
"description": "Code indicating a specific health situation",
"enum": ["N", "S", "T", "U", "X"],
"title": "Health Related Code",
"type": "string",
"x12-codes": {
"N": {
"description": "None",
"code": "N"
},
"S": {
"description": "Substance Abuse",
"code": "S"
},
"T": {
"description": "Tobacco Use",
"code": "T"
},
"U": {
"description": "Unknown",
"code": "U"
},
"X": {
"description": "Tobacco Use and Substance Abuse",
"code": "X"
}
}
},
"member_height_02": {
"description": "Vertical dimension of an object measured when the object is in the upright position",
"title": "Member Height",
"type": "number",
"x12-usage-notes": "- The height must be reported in inches.",
"x12-max-length": 8
},
"member_weight_03": {
"description": "Numeric value of weight\n\n- HLH03 is the current weight in pounds.",
"title": "Member Weight",
"type": "number",
"x12-max-length": 10
}
},
"required": ["health_related_code_01"],
"title": "Member Health Information",
"type": "object",
"x12-usage-notes": "- Required on initial enrollment of a member when appropriate medical information about the member is available. If not required by this implementation guide, do not send."
},
"member_language_LUI": {
"items": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0102",
"type": "object",
"dependentRequired": {
"identification_code_qualifier_01": [
"language_code_02"
],
"language_code_02": ["identification_code_qualifier_01"]
}
},
{
"x12-condition": "L040203",
"anyOf": [
{
"dependentRequired": {
"language_use_indicator_04": ["language_code_02"]
},
"type": "object"
},
{
"dependentRequired": {
"language_use_indicator_04": [
"language_description_03"
]
},
"type": "object"
}
]
}
],
"description": "To specify language, type of usage, and proficiency or fluency",
"properties": {
"identification_code_qualifier_01": {
"description": "Code designating the system/method of code structure used for Identification Code (67)",
"enum": ["LD", "LE"],
"title": "Identification Code Qualifier",
"type": "string",
"x12-codes": {
"LD": {
"description": "NISO Z39.53 Language Codes",
"code": "LD"
},
"LE": {
"description": "ISO 639 Language Codes",
"code": "LE"
}
}
},
"language_code_02": {
"description": "Code identifying a party or other code\n\n- LUI02 is the language code.",
"maxLength": 80,
"minLength": 2,
"title": "Language Code",
"type": "string"
},
"language_description_03": {
"description": "A free-form description to clarify the related data elements and their content\n\n- LUI03 is the name of the language.",
"maxLength": 80,
"minLength": 1,
"title": "Language Description",
"type": "string"
},
"language_use_indicator_04": {
"description": "Code indicating the use of a language",
"enum": ["5", "6", "7", "8"],
"title": "Language Use Indicator",
"type": "string",
"x12-codes": {
"5": {
"description": "Language Reading",
"code": "5"
},
"6": {
"description": "Language Writing",
"code": "6"
},
"7": {
"description": "Language Speaking",
"code": "7"
},
"8": {
"description": "Native Language",
"code": "8"
}
}
}
},
"title": "Member Language",
"type": "object",
"x12-usage-notes": "- Required if the sponsor knows that the member's primary language is not English, and such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations. If not required by this implementation guide do not send.\n- Any need to send/collect this information will need to be contained in the trading partner agreement."
},
"minItems": 1,
"type": "array"
}
},
"required": ["member_name_NM1"],
"title": "Member Name Loop",
"type": "object"
},
"incorrect_member_name_NM1_loop": {
"additionalProperties": false,
"properties": {
"incorrect_member_name_NM1": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0809",
"type": "object",
"dependentRequired": {
"identification_code_qualifier_08": [
"prior_incorrect_insured_identifier_09"
],
"prior_incorrect_insured_identifier_09": [
"identification_code_qualifier_08"
]
}
}
],
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["70"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"70": {
"description": "Prior Incorrect Insured",
"code": "70"
}
},
"x12-usage-notes": "- This code identifies that the information that follows is previously reported enrollment information that is being corrected."
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["1"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"1": {
"description": "Person",
"code": "1"
}
}
},
"prior_incorrect_member_last_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "Prior Incorrect Member Last Name",
"type": "string"
},
"prior_incorrect_member_first_name_04": {
"description": "Individual first name",
"maxLength": 35,
"minLength": 1,
"title": "Prior Incorrect Member First Name",
"type": "string"
},
"prior_incorrect_member_middle_name_05": {
"description": "Individual middle name or initial",
"maxLength": 25,
"minLength": 1,
"title": "Prior Incorrect Member Middle Name",
"type": "string"
},
"prior_incorrect_member_name_prefix_06": {
"description": "Prefix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Prior Incorrect Member Name Prefix",
"type": "string"
},
"prior_incorrect_member_name_suffix_07": {
"description": "Suffix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Prior Incorrect Member Name Suffix",
"type": "string"
},
"identification_code_qualifier_08": {
"description": "Code designating the system/method of code structure used for Identification Code (67)",
"enum": ["34", "ZZ"],
"title": "Identification Code Qualifier",
"type": "string",
"x12-codes": {
"34": {
"description": "Social Security Number",
"code": "34",
"x12-usage-notes": "The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE."
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ",
"x12-usage-notes": "Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used."
}
}
},
"prior_incorrect_insured_identifier_09": {
"description": "Code identifying a party or other code",
"maxLength": 80,
"minLength": 2,
"title": "Prior Incorrect Insured Identifier",
"type": "string",
"x12-usage-notes": "- NM109 is the identifier that was previously sent in error. This allows matching with data on receiver's system."
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02",
"prior_incorrect_member_last_name_03"
],
"title": "Incorrect Member Name",
"type": "object",
"x12-usage-notes": "- Required if a corrected name is being sent in loop 2100A or if previously supplied demographics are being changed. If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70. If not required by this implementation guide, do not send.\n- If only the demographics are being changed, the code in NM101 in loop 2100A will be IL, and the code in NM101 in this loop will be 70."
},
"incorrect_member_demographics_DMG": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0102",
"type": "object",
"dependentRequired": {
"date_time_period_format_qualifier_01": [
"prior_incorrect_insured_birth_date_02"
],
"prior_incorrect_insured_birth_date_02": [
"date_time_period_format_qualifier_01"
]
}
},
{
"x12-condition": "P1011",
"type": "object",
"dependentRequired": {
"code_list_qualifier_code_10": [
"race_or_ethnicity_collection_code_11"
],
"race_or_ethnicity_collection_code_11": [
"code_list_qualifier_code_10"
]
}
},
{
"type": "object",
"x12-condition": "C1105",
"dependentRequired": {
"race_or_ethnicity_collection_code_11": [
"composite_race_or_ethnicity_information_05"
]
}
}
],
"description": "To supply demographic information",
"properties": {
"date_time_period_format_qualifier_01": {
"description": "Code indicating the date format, time format, or date and time format",
"enum": ["D8"],
"title": "Date Time Period Format Qualifier",
"type": "string",
"x12-codes": {
"D8": {
"description": "Date Expressed in Format CCYYMMDD",
"code": "D8"
}
}
},
"prior_incorrect_insured_birth_date_02": {
"description": "Expression of a date, a time, or range of dates, times or dates and times\n\n- DMG02 is the date of birth.",
"maxLength": 35,
"minLength": 1,
"title": "Prior Incorrect Insured Birth Date",
"type": "string"
},
"prior_incorrect_insured_gender_code_03": {
"description": "Code indicating the sex of the individual",
"enum": ["F", "M", "U"],
"title": "Prior Incorrect Insured Gender Code",
"type": "string",
"x12-codes": {
"F": {
"description": "Female",
"code": "F"
},
"M": {
"description": "Male",
"code": "M"
},
"U": {
"description": "Unknown",
"code": "U"
}
}
},
"marital_status_code_04": {
"description": "Code defining the marital status of a person",
"enum": ["B", "D", "I", "M", "R", "S", "U", "W", "X"],
"title": "Marital Status Code",
"type": "string",
"x12-codes": {
"B": {
"description": "Registered Domestic Partner",
"code": "B"
},
"D": {
"description": "Divorced",
"code": "D"
},
"I": {
"description": "Single",
"code": "I"
},
"M": {
"description": "Married",
"code": "M"
},
"R": {
"description": "Unreported",
"code": "R"
},
"S": {
"description": "Separated",
"code": "S"
},
"U": {
"description": "Unmarried (Single or Divorced or Widowed)",
"code": "U",
"x12-usage-notes": "This code should be used if the previous status is unknown."
},
"W": {
"description": "Widowed",
"code": "W"
},
"X": {
"description": "Legally Separated",
"code": "X"
}
}
},
"composite_race_or_ethnicity_information_05": {
"type": "array",
"items": {
"allOf": [
{
"x12-condition": "P0203",
"type": "object",
"dependentRequired": {
"code_list_qualifier_code_02": [
"race_or_ethnicity_code_03"
],
"race_or_ethnicity_code_03": [
"code_list_qualifier_code_02"
]
}
}
],
"description": "To send general and detailed information on race or ethnicity",
"properties": {
"race_or_ethnicity_code_01": {
"description": "Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes",
"enum": [
"7",
"8",
"A",
"B",
"C",
"D",
"E",
"F",
"G",
"H",
"I",
"J",
"N",
"O",
"P",
"Z"
],
"title": "Race or Ethnicity Code",
"type": "string",
"x12-codes": {
"7": {
"description": "Not Provided",
"code": "7"
},
"8": {
"description": "Not Applicable",
"code": "8"
},
"A": {
"description": "Asian or Pacific Islander",
"code": "A"
},
"B": {
"description": "Black",
"code": "B"
},
"C": {
"description": "Caucasian",
"code": "C"
},
"D": {
"description": "Subcontinent Asian American",
"code": "D"
},
"E": {
"description": "Other Race or Ethnicity",
"code": "E"
},
"F": {
"description": "Asian Pacific American",
"code": "F"
},
"G": {
"description": "Native American",
"code": "G"
},
"H": {
"description": "Hispanic",
"code": "H"
},
"I": {
"description": "American Indian or Alaskan Native",
"code": "I"
},
"J": {
"description": "Native Hawaiian",
"code": "J"
},
"N": {
"description": "Black (Non-Hispanic)",
"code": "N"
},
"O": {
"description": "White (Non-Hispanic)",
"code": "O"
},
"P": {
"description": "Pacific Islander",
"code": "P"
},
"Z": {
"description": "Mutually Defined",
"code": "Z"
}
}
},
"code_list_qualifier_code_02": {
"description": "Code identifying a specific industry code list\n\n- C056-02 and C056-03 are used to specify detailed information about race or ethnicity.",
"enum": ["RET"],
"title": "Code List Qualifier Code",
"type": "string",
"x12-codes": {
"RET": {
"description": "Classification of Race or Ethnicity",
"code": "RET"
}
}
},
"race_or_ethnicity_code_03": {
"description": "Code indicating a code from a specific industry code list",
"maxLength": 30,
"minLength": 1,
"title": "Race or Ethnicity Code",
"type": "string"
}
},
"title": "Composite Race or Ethnicity Information",
"type": "object",
"x12-usage-notes": "Required when the members Race or Ethnicity is being corrected. If not required this implementation guide, do not send."
},
"minItems": 1,
"maxItems": 10
},
"citizenship_status_code_06": {
"description": "Code indicating citizenship status",
"enum": ["1", "2", "3", "4", "5", "6", "7"],
"title": "Citizenship Status Code",
"type": "string",
"x12-codes": {
"1": {
"description": "U.S. Citizen",
"code": "1"
},
"2": {
"description": "Non-Resident Alien",
"code": "2"
},
"3": {
"description": "Resident Alien",
"code": "3"
},
"4": {
"description": "Illegal Alien",
"code": "4"
},
"5": {
"description": "Alien",
"code": "5"
},
"6": {
"description": "U.S. Citizen - Non-Resident",
"code": "6"
},
"7": {
"description": "U.S. Citizen - Resident",
"code": "7"
}
}
},
"code_list_qualifier_code_10": {
"description": "Code identifying a specific industry code list",
"enum": ["REC"],
"title": "Code List Qualifier Code",
"type": "string",
"x12-codes": {
"REC": {
"description": "Race or Ethnicity Collection Code",
"code": "REC"
}
}
},
"race_or_ethnicity_collection_code_11": {
"description": "Code indicating a code from a specific industry code list\n\n- DMG11 is used to specify how the information in DMG05, including repeats of C056, was collected.",
"maxLength": 30,
"minLength": 1,
"title": "Race or Ethnicity Collection Code",
"type": "string"
}
},
"title": "Incorrect Member Demographics",
"type": "object",
"x12-usage-notes": "- Required when there is a change to the previously supplied demographic information. If not required by this implementation guide, do not send."
}
},
"required": ["incorrect_member_name_NM1"],
"title": "Incorrect Member Name Loop",
"type": "object"
},
"member_mailing_address_NM1_loop": {
"additionalProperties": false,
"properties": {
"member_mailing_address_NM1": {
"additionalProperties": false,
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["31"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"31": {
"description": "Postal Mailing Address",
"code": "31"
}
}
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["1"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"1": {
"description": "Person",
"code": "1"
}
}
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02"
],
"title": "Member Mailing Address",
"type": "object",
"x12-usage-notes": "- Required when the member mailing address is different from the residence address sent in loop 2100A or when the dependent's address is different from the subscriber. If not required by this implementation guide, do not send."
},
"member_mail_street_address_N3": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"member_address_line_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Member Address Line",
"type": "string"
},
"member_address_line_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Member Address Line",
"type": "string"
}
},
"required": ["member_address_line_01"],
"title": "Member Mail Street Address",
"type": "object",
"x12-usage-notes": ""
},
"member_mail_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": ["member_mail_state_code_02"],
"type": "object",
"properties": {
"member_mail_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": ["member_mail_state_code_02"],
"type": "object",
"properties": {
"member_mail_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": ["country_code_04"]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"member_mail_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Member Mail City Name",
"type": "string"
},
"member_mail_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Member Mail State Code",
"type": "string"
},
"member_mail_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Member Mail Postal Zone or ZIP Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": ["member_mail_city_name_01"],
"title": "Member Mail City, State, ZIP Code",
"type": "object",
"x12-usage-notes": ""
}
},
"required": [
"member_mailing_address_NM1",
"member_mail_street_address_N3",
"member_mail_city_state_zip_code_N4"
],
"title": "Member Mailing Address Loop",
"type": "object"
},
"member_employer_NM1_loop": {
"items": {
"additionalProperties": false,
"properties": {
"member_employer_NM1": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0809",
"type": "object",
"dependentRequired": {
"identification_code_qualifier_08": [
"member_employer_identifier_09"
],
"member_employer_identifier_09": [
"identification_code_qualifier_08"
]
}
}
],
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["36"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"36": {
"description": "Employer",
"code": "36"
}
}
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["1", "2"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"1": {
"description": "Person",
"code": "1"
},
"2": {
"description": "Non-Person Entity",
"code": "2"
}
}
},
"member_employer_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "Member Employer Name",
"type": "string"
},
"member_employer_first_name_04": {
"description": "Individual first name",
"maxLength": 35,
"minLength": 1,
"title": "Member Employer First Name",
"type": "string"
},
"member_employer_middle_name_05": {
"description": "Individual middle name or initial",
"maxLength": 25,
"minLength": 1,
"title": "Member Employer Middle Name",
"type": "string"
},
"member_employer_name_prefix_06": {
"description": "Prefix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Member Employer Name Prefix",
"type": "string"
},
"member_employer_name_suffix_07": {
"description": "Suffix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Member Employer Name Suffix",
"type": "string"
},
"identification_code_qualifier_08": {
"description": "Code designating the system/method of code structure used for Identification Code (67)",
"enum": ["24", "34"],
"title": "Identification Code Qualifier",
"type": "string",
"x12-codes": {
"24": {
"description": "Employer's Identification Number",
"code": "24",
"x12-usage-notes": "This is the \"HIPAA Employer Identifier\"."
},
"34": {
"description": "Social Security Number",
"code": "34"
}
}
},
"member_employer_identifier_09": {
"description": "Code identifying a party or other code",
"maxLength": 80,
"minLength": 2,
"title": "Member Employer Identifier",
"type": "string"
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02"
],
"title": "Member Employer",
"type": "object",
"x12-usage-notes": "- Required when the member is employed by someone other than the sponsor and the insurance contract requires the payer to be notified of such employment. If not required by this implementation guide, do not send.\n- This segment is not used to collect Coordination of Benefits (COB) information. COB information must be passed in the 2320 loop."
},
"member_employer_communications_numbers_PER": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0506",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_05": [
"communication_number_06"
],
"communication_number_06": [
"communication_number_qualifier_05"
]
}
},
{
"x12-condition": "P0708",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_07": [
"communication_number_08"
],
"communication_number_08": [
"communication_number_qualifier_07"
]
}
}
],
"description": "To identify a person or office to whom administrative communications should be directed",
"properties": {
"contact_function_code_01": {
"description": "Code identifying the major duty or responsibility of the person or group named",
"enum": ["EP"],
"title": "Contact Function Code",
"type": "string",
"x12-codes": {
"EP": {
"description": "Employer Contact",
"code": "EP"
}
}
},
"member_employer_communications_contact_name_02": {
"description": "Free-form name",
"maxLength": 60,
"minLength": 1,
"title": "Member Employer Communications Contact Name",
"type": "string"
},
"communication_number_qualifier_03": {
"description": "Code identifying the type of communication number",
"enum": ["AP", "BN", "CP", "EM", "EX", "FX", "TE"],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"TE": {
"description": "Telephone",
"code": "TE"
}
}
},
"communication_number_04": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_05": {
"description": "Code identifying the type of communication number",
"enum": ["AP", "BN", "CP", "EM", "EX", "FX", "TE"],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"TE": {
"description": "Telephone",
"code": "TE"
}
}
},
"communication_number_06": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_07": {
"description": "Code identifying the type of communication number",
"enum": ["AP", "BN", "CP", "EM", "EX", "FX", "TE"],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"TE": {
"description": "Telephone",
"code": "TE"
}
}
},
"communication_number_08": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
}
},
"required": [
"contact_function_code_01",
"communication_number_qualifier_03",
"communication_number_04"
],
"title": "Member Employer Communications Numbers",
"type": "object",
"x12-usage-notes": "- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).\n- Required when the Member Employers contact information is provided to the sponsor. If not required by this implementation guide, do not send."
},
"member_employer_street_address_N3": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"member_employer_address_line_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Member Employer Address Line",
"type": "string"
},
"member_employer_address_line_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Member Employer Address Line",
"type": "string"
}
},
"required": ["member_employer_address_line_01"],
"title": "Member Employer Street Address",
"type": "object",
"x12-usage-notes": "- Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send."
},
"member_employer_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": ["member_employer_state_code_02"],
"type": "object",
"properties": {
"member_employer_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": ["member_employer_state_code_02"],
"type": "object",
"properties": {
"member_employer_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": ["country_code_04"]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"member_employer_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Member Employer City Name",
"type": "string"
},
"member_employer_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Member Employer State Code",
"type": "string"
},
"member_employer_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Member Employer Postal Zone or ZIP Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": ["member_employer_city_name_01"],
"title": "Member Employer City, State, ZIP Code",
"type": "object",
"x12-usage-notes": "- Required when the member's employer is not the sponsor and the employer address is provided to the sponsor by the member. If not required by this implementation guide, do not send."
}
},
"required": ["member_employer_NM1"],
"title": "Member Employer Loop",
"type": "object"
},
"maxItems": 3,
"minItems": 1,
"type": "array"
},
"member_school_NM1_loop": {
"items": {
"additionalProperties": false,
"properties": {
"member_school_NM1": {
"additionalProperties": false,
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["M8"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"M8": {
"description": "Educational Institution",
"code": "M8"
}
}
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["2"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"2": {
"description": "Non-Person Entity",
"code": "2"
}
}
},
"school_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "School Name",
"type": "string"
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02",
"school_name_03"
],
"title": "Member School",
"type": "object",
"x12-usage-notes": "- Required when the member is enrolled in school and the payer is required to be notified under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send."
},
"member_school_commmunications_numbers_PER": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0506",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_05": [
"communication_number_06"
],
"communication_number_06": [
"communication_number_qualifier_05"
]
}
},
{
"x12-condition": "P0708",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_07": [
"communication_number_08"
],
"communication_number_08": [
"communication_number_qualifier_07"
]
}
}
],
"description": "To identify a person or office to whom administrative communications should be directed",
"properties": {
"contact_function_code_01": {
"description": "Code identifying the major duty or responsibility of the person or group named",
"enum": ["SK"],
"title": "Contact Function Code",
"type": "string",
"x12-codes": {
"SK": {
"description": "School Clerk",
"code": "SK"
}
}
},
"member_school_communications_contact_name_02": {
"description": "Free-form name",
"maxLength": 60,
"minLength": 1,
"title": "Member School Communications Contact Name",
"type": "string"
},
"communication_number_qualifier_03": {
"description": "Code identifying the type of communication number",
"enum": ["EM", "EX", "FX", "TE"],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"TE": {
"description": "Telephone",
"code": "TE"
}
}
},
"communication_number_04": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_05": {
"description": "Code identifying the type of communication number",
"enum": ["EM", "EX", "FX", "TE"],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"TE": {
"description": "Telephone",
"code": "TE"
}
}
},
"communication_number_06": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_07": {
"description": "Code identifying the type of communication number",
"enum": ["EM", "EX", "FX", "TE"],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"TE": {
"description": "Telephone",
"code": "TE"
}
}
},
"communication_number_08": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
}
},
"required": [
"contact_function_code_01",
"communication_number_qualifier_03",
"communication_number_04"
],
"title": "Member School Commmunications Numbers",
"type": "object",
"x12-usage-notes": "- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).\n- Required when the Member School contact information is provided to the sponsor. If not required by this implementation guide, do not send."
},
"member_school_street_address_N3": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"school_address_line_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "School Address Line",
"type": "string"
},
"school_address_line_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "School Address Line",
"type": "string"
}
},
"required": ["school_address_line_01"],
"title": "Member School Street Address",
"type": "object",
"x12-usage-notes": "- Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send."
},
"member_school_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": ["member_school_state_code_02"],
"type": "object",
"properties": {
"member_school_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": ["member_school_state_code_02"],
"type": "object",
"properties": {
"member_school_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": ["country_code_04"]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"member_school_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Member School City Name",
"type": "string"
},
"member_school_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Member School State Code",
"type": "string"
},
"member_school_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Member School Postal Zone or ZIP Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": ["member_school_city_name_01"],
"title": "Member School City, State, ZIP Code",
"type": "object",
"x12-usage-notes": "- Required when the member is enrolled in school and the school address is provided to the sponsor by the member. If not required by this implementation guide, do not send."
}
},
"required": ["member_school_NM1"],
"title": "Member School Loop",
"type": "object"
},
"maxItems": 3,
"minItems": 1,
"type": "array"
},
"custodial_parent_NM1_loop": {
"additionalProperties": false,
"properties": {
"custodial_parent_NM1": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0809",
"type": "object",
"dependentRequired": {
"identification_code_qualifier_08": [
"custodial_parent_identifier_09"
],
"custodial_parent_identifier_09": [
"identification_code_qualifier_08"
]
}
}
],
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["S3"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"S3": {
"description": "Custodial Parent",
"code": "S3"
}
}
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["1"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"1": {
"description": "Person",
"code": "1"
}
}
},
"custodial_parent_last_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "Custodial Parent Last Name",
"type": "string"
},
"custodial_parent_first_name_04": {
"description": "Individual first name",
"maxLength": 35,
"minLength": 1,
"title": "Custodial Parent First Name",
"type": "string"
},
"custodial_parent_middle_name_05": {
"description": "Individual middle name or initial",
"maxLength": 25,
"minLength": 1,
"title": "Custodial Parent Middle Name",
"type": "string"
},
"custodial_parent_name_prefix_06": {
"description": "Prefix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Custodial Parent Name Prefix",
"type": "string"
},
"custodial_parent_name_suffix_07": {
"description": "Suffix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Custodial Parent Name Suffix",
"type": "string"
},
"identification_code_qualifier_08": {
"description": "Code designating the system/method of code structure used for Identification Code (67)",
"enum": ["34", "ZZ"],
"title": "Identification Code Qualifier",
"type": "string",
"x12-codes": {
"34": {
"description": "Social Security Number",
"code": "34",
"x12-usage-notes": "The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE."
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ",
"x12-usage-notes": "Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used."
}
}
},
"custodial_parent_identifier_09": {
"description": "Code identifying a party or other code",
"maxLength": 80,
"minLength": 2,
"title": "Custodial Parent Identifier",
"type": "string"
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02",
"custodial_parent_last_name_03",
"custodial_parent_first_name_04"
],
"title": "Custodial Parent",
"type": "object",
"x12-usage-notes": "- Required when the custodial parent of a minor dependent is someone other than the subscriber. If not required by this implementation guide, do not send.\n- Any other situation, (examples: Guardianship, Legal Indemnity, Power of Attorney, and/or Separation Agreements) would be handled under the Responsible Party NM1 segment."
},
"custodial_parent_communications_numbers_PER": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0506",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_05": [
"communication_number_06"
],
"communication_number_06": [
"communication_number_qualifier_05"
]
}
},
{
"x12-condition": "P0708",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_07": [
"communication_number_08"
],
"communication_number_08": [
"communication_number_qualifier_07"
]
}
}
],
"description": "To identify a person or office to whom administrative communications should be directed",
"properties": {
"contact_function_code_01": {
"description": "Code identifying the major duty or responsibility of the person or group named",
"enum": ["PQ"],
"title": "Contact Function Code",
"type": "string",
"x12-codes": {
"PQ": {
"description": "Parent or Guardian",
"code": "PQ"
}
}
},
"communication_number_qualifier_03": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_04": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_05": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_06": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_07": {
"description": "Code identifying the type of communication number",
"enum": ["AP", "BN", "CP", "EM", "EX", "HP", "TE", "WP"],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_08": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
}
},
"required": [
"contact_function_code_01",
"communication_number_qualifier_03",
"communication_number_04"
],
"title": "Custodial Parent Communications Numbers",
"type": "object",
"x12-usage-notes": "- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).\n- Required when the Custodial Parent contact information is provided to the sponsor. If not required by this implementation guide, do not send."
},
"custodial_parent_street_address_N3": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"custodial_parent_address_line_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Custodial Parent Address Line",
"type": "string"
},
"custodial_parent_address_line_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Custodial Parent Address Line",
"type": "string"
}
},
"required": ["custodial_parent_address_line_01"],
"title": "Custodial Parent Street Address",
"type": "object",
"x12-usage-notes": "- Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send."
},
"custodial_parent_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": ["custodial_parent_state_code_02"],
"type": "object",
"properties": {
"custodial_parent_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": ["custodial_parent_state_code_02"],
"type": "object",
"properties": {
"custodial_parent_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": ["country_code_04"]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"custodial_parent_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Custodial Parent City Name",
"type": "string"
},
"custodial_parent_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Custodial Parent State Code",
"type": "string"
},
"custodial_parent_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Custodial Parent Postal Zone or ZIP Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": ["custodial_parent_city_name_01"],
"title": "Custodial Parent City, State, ZIP Code",
"type": "object",
"x12-usage-notes": "- Required when the custodial parent of a minor dependent is someone other than the subscriber and the information is provided to the sponsor. If not required by this implementation guide, do not send."
}
},
"required": ["custodial_parent_NM1"],
"title": "Custodial Parent Loop",
"type": "object"
},
"responsible_person_NM1_loop": {
"items": {
"additionalProperties": false,
"properties": {
"responsible_person_NM1": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0809",
"type": "object",
"dependentRequired": {
"identification_code_qualifier_08": [
"responsible_party_identifier_09"
],
"responsible_party_identifier_09": [
"identification_code_qualifier_08"
]
}
}
],
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": [
"6Y",
"9K",
"E1",
"EI",
"EXS",
"GB",
"GD",
"J6",
"LR",
"QD",
"S1",
"TZ",
"X4"
],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"6Y": {
"description": "Case Manager",
"code": "6Y"
},
"9K": {
"description": "Key Person",
"code": "9K"
},
"E1": {
"description": "Person or Other Entity Legally Responsible for a Child",
"code": "E1",
"x12-usage-notes": "Used to identify a legal indemnity situation.\n\r\nThis code is used when a Qualified Medical Child Support Order (QMSCO) is present."
},
"EI": {
"description": "Executor of Estate",
"code": "EI",
"x12-usage-notes": "This is used when the subscriber is deceased and the executor/responsible party is other than a surviving spouse."
},
"EXS": {
"description": "Ex-spouse",
"code": "EXS",
"x12-usage-notes": "This is used to identify a separated spouse under a separation agreement, or that the member is the divorced spouse and self responsible. This is NOT USED to identify the custodial parent for dependent children after a divorce."
},
"GB": {
"description": "Other Insured",
"code": "GB"
},
"GD": {
"description": "Guardian",
"code": "GD"
},
"J6": {
"description": "Power of Attorney",
"code": "J6"
},
"LR": {
"description": "Legal Representative",
"code": "LR"
},
"QD": {
"description": "Responsible Party",
"code": "QD"
},
"S1": {
"description": "Parent",
"code": "S1"
},
"TZ": {
"description": "Significant Other",
"code": "TZ"
},
"X4": {
"description": "Spouse",
"code": "X4"
}
}
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["1"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"1": {
"description": "Person",
"code": "1"
}
}
},
"responsible_party_last_or_organization_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "Responsible Party Last or Organization Name",
"type": "string"
},
"responsible_party_first_name_04": {
"description": "Individual first name",
"maxLength": 35,
"minLength": 1,
"title": "Responsible Party First Name",
"type": "string"
},
"responsible_party_middle_name_05": {
"description": "Individual middle name or initial",
"maxLength": 25,
"minLength": 1,
"title": "Responsible Party Middle Name",
"type": "string"
},
"responsible_party_name_prefix_06": {
"description": "Prefix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Responsible Party Name Prefix",
"type": "string"
},
"responsible_party_suffix_name_07": {
"description": "Suffix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Responsible Party Suffix Name",
"type": "string"
},
"identification_code_qualifier_08": {
"description": "Code designating the system/method of code structure used for Identification Code (67)",
"enum": ["34", "ZZ"],
"title": "Identification Code Qualifier",
"type": "string",
"x12-codes": {
"34": {
"description": "Social Security Number",
"code": "34",
"x12-usage-notes": "The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE."
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ",
"x12-usage-notes": "Value is required if National Individual Identifier is mandated for use. Otherwise, one of the other listed codes may be used."
}
}
},
"responsible_party_identifier_09": {
"description": "Code identifying a party or other code",
"maxLength": 80,
"minLength": 2,
"title": "Responsible Party Identifier",
"type": "string"
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02",
"responsible_party_last_or_organization_name_03"
],
"title": "Responsible Person",
"type": "object",
"x12-usage-notes": "- Required to identify the person(s), other than the subscriber, who are responsible for the member. If not required by this implementation guide, do not send."
},
"responsible_person_communications_numbers_PER": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0506",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_05": [
"communication_number_06"
],
"communication_number_06": [
"communication_number_qualifier_05"
]
}
},
{
"x12-condition": "P0708",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_07": [
"communication_number_08"
],
"communication_number_08": [
"communication_number_qualifier_07"
]
}
}
],
"description": "To identify a person or office to whom administrative communications should be directed",
"properties": {
"contact_function_code_01": {
"description": "Code identifying the major duty or responsibility of the person or group named",
"enum": ["RP"],
"title": "Contact Function Code",
"type": "string",
"x12-codes": {
"RP": {
"description": "Responsible Person",
"code": "RP"
}
}
},
"communication_number_qualifier_03": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_04": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_05": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_06": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_07": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_08": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
}
},
"required": [
"contact_function_code_01",
"communication_number_qualifier_03",
"communication_number_04"
],
"title": "Responsible Person Communications Numbers",
"type": "object",
"x12-usage-notes": "- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).\n- Required when the Responsible Person contact information is provided to the sponsor. If not required by this implementation guide, do not send."
},
"responsible_person_street_address_N3": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"responsible_party_address_line_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Responsible Party Address Line",
"type": "string"
},
"responsible_party_address_line_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Responsible Party Address Line",
"type": "string"
}
},
"required": ["responsible_party_address_line_01"],
"title": "Responsible Person Street Address",
"type": "object",
"x12-usage-notes": "- Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send."
},
"responsible_person_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": ["responsible_person_state_code_02"],
"type": "object",
"properties": {
"responsible_person_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": [
"responsible_person_state_code_02"
],
"type": "object",
"properties": {
"responsible_person_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": ["country_code_04"]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"responsible_person_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Responsible Person City Name",
"type": "string"
},
"responsible_person_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Responsible Person State Code",
"type": "string"
},
"responsible_person_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Responsible Person Postal Zone or ZIP Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": ["responsible_person_city_name_01"],
"title": "Responsible Person City, State, ZIP Code",
"type": "object",
"x12-usage-notes": "- Required when there is a person other than the subscriber who is responsible for the member and the responsible person's address is provided to the sponsor. If not required by this implementation guide, do not send."
}
},
"required": ["responsible_person_NM1"],
"title": "Responsible Person Loop",
"type": "object"
},
"maxItems": 13,
"minItems": 1,
"type": "array"
},
"drop_off_location_NM1_loop": {
"additionalProperties": false,
"properties": {
"drop_off_location_NM1": {
"additionalProperties": false,
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["45"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"45": {
"description": "Drop-off Location",
"code": "45"
}
}
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["1"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"1": {
"description": "Person",
"code": "1"
}
}
},
"name_last_or_organization_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "Name Last or Organization Name",
"type": "string"
},
"name_first_04": {
"description": "Individual first name",
"maxLength": 35,
"minLength": 1,
"title": "Name First",
"type": "string"
},
"name_middle_05": {
"description": "Individual middle name or initial",
"maxLength": 25,
"minLength": 1,
"title": "Name Middle",
"type": "string"
},
"name_prefix_06": {
"description": "Prefix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Name Prefix",
"type": "string"
},
"name_suffix_07": {
"description": "Suffix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Name Suffix",
"type": "string"
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02"
],
"title": "Drop Off Location",
"type": "object",
"x12-usage-notes": "- Required when member has requested shipments to be sent to an address other then their residence or mailing. If not required by this implementation guide, do not send."
},
"drop_off_location_street_address_N3": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"drop_off_location_address_line_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Drop Off Location Address Line",
"type": "string"
},
"drop_off_location_address_line_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Drop Off Location Address Line",
"type": "string"
}
},
"required": ["drop_off_location_address_line_01"],
"title": "Drop Off Location Street Address",
"type": "object",
"x12-usage-notes": "- Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send."
},
"drop_off_location_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": ["drop_off_location_state_code_02"],
"type": "object",
"properties": {
"drop_off_location_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": ["drop_off_location_state_code_02"],
"type": "object",
"properties": {
"drop_off_location_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": ["country_code_04"]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"drop_off_location_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Drop Off Location City Name",
"type": "string"
},
"drop_off_location_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Drop Off Location State Code",
"type": "string"
},
"drop_off_location_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Drop Off Location Postal Zone or ZIP Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": ["drop_off_location_city_name_01"],
"title": "Drop Off Location City, State, ZIP Code",
"type": "object",
"x12-usage-notes": "- Required when member has requested shipments to be sent to an address other than their residence or mailing. If not required by this implementation guide, do not send."
}
},
"required": ["drop_off_location_NM1"],
"title": "Drop Off Location Loop",
"type": "object"
},
"disability_information_DSB_loop": {
"items": {
"additionalProperties": false,
"properties": {
"disability_information_DSB": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0708",
"type": "object",
"dependentRequired": {
"product_or_service_id_qualifier_07": [
"diagnosis_code_08"
],
"diagnosis_code_08": [
"product_or_service_id_qualifier_07"
]
}
}
],
"description": "To supply disability information",
"properties": {
"disability_type_code_01": {
"description": "Code identifying the disability status of the individual",
"enum": ["1", "2", "3", "4"],
"title": "Disability Type Code",
"type": "string",
"x12-codes": {
"1": {
"description": "Short Term Disability",
"code": "1"
},
"2": {
"description": "Long Term Disability",
"code": "2"
},
"3": {
"description": "Permanent or Total Disability",
"code": "3"
},
"4": {
"description": "No Disability",
"code": "4"
}
}
},
"product_or_service_id_qualifier_07": {
"description": "Code identifying the type/source of the descriptive number used in Product/Service ID (234)",
"enum": ["DX", "ZZ"],
"title": "Product or Service ID Qualifier",
"type": "string",
"x12-codes": {
"DX": {
"description": "International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Diagnosis",
"code": "DX"
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ",
"x12-usage-notes": "To be used for the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) - Diagnosis.\n\r\nCODE SOURCE: 897 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)"
}
}
},
"diagnosis_code_08": {
"description": "Code value for describing a medical condition or procedure\n\n- DSB08 is the functional status code for the disability.",
"maxLength": 15,
"minLength": 1,
"title": "Diagnosis Code",
"type": "string"
}
},
"required": ["disability_type_code_01"],
"title": "Disability Information",
"type": "object",
"x12-usage-notes": "- Required when enrolling a disabled member or when disability information about an existing member is added or changed. If not required by this implementation guide, do not send."
},
"disability_eligibility_dates_DTP": {
"items": {
"additionalProperties": false,
"description": "To specify any or all of a date, a time, or a time period",
"properties": {
"date_time_qualifier_01": {
"description": "Code specifying type of date or time, or both date and time",
"enum": ["360", "361"],
"title": "Date Time Qualifier",
"type": "string",
"x12-codes": {
"360": {
"description": "Initial Disability Period Start",
"code": "360"
},
"361": {
"description": "Initial Disability Period End",
"code": "361"
}
}
},
"date_time_period_format_qualifier_02": {
"description": "Code indicating the date format, time format, or date and time format\n\n- DTP02 is the date or time or period format that will appear in DTP03.",
"enum": ["D8"],
"title": "Date Time Period Format Qualifier",
"type": "string",
"x12-codes": {
"D8": {
"description": "Date Expressed in Format CCYYMMDD",
"code": "D8"
}
}
},
"disability_eligibility_date_03": {
"description": "Expression of a date, a time, or range of dates, times or dates and times",
"maxLength": 35,
"minLength": 1,
"title": "Disability Eligibility Date",
"type": "string"
}
},
"required": [
"date_time_qualifier_01",
"date_time_period_format_qualifier_02",
"disability_eligibility_date_03"
],
"title": "Disability Eligibility Dates",
"type": "object",
"x12-usage-notes": "- This segment is used to send the first and last date of disability.\n- Required when enrolling a disabled member or when disability dates change for an existing member, and the disability dates are known by the sponsor. If not required by this implementation guide, do not send."
},
"maxItems": 2,
"minItems": 1,
"type": "array"
}
},
"required": ["disability_information_DSB"],
"title": "Disability Information Loop",
"type": "object"
},
"minItems": 1,
"type": "array"
},
"health_coverage_HD_loop": {
"items": {
"additionalProperties": false,
"properties": {
"health_coverage_HD": {
"additionalProperties": false,
"description": "To provide information on health coverage",
"properties": {
"maintenance_type_code_01": {
"description": "Code identifying the specific type of item maintenance",
"enum": [
"001",
"002",
"021",
"024",
"025",
"026",
"030",
"032"
],
"title": "Maintenance Type Code",
"type": "string",
"x12-codes": {
"001": {
"description": "Change",
"code": "001"
},
"002": {
"description": "Delete",
"code": "002",
"x12-usage-notes": "Use this code for deleting an incorrect coverage record."
},
"021": {
"description": "Addition",
"code": "021"
},
"024": {
"description": "Cancellation or Termination",
"code": "024",
"x12-usage-notes": "Use this code for cancelling/terminating a coverage."
},
"025": {
"description": "Reinstatement",
"code": "025"
},
"026": {
"description": "Correction",
"code": "026",
"x12-usage-notes": "This code is used to correct an incorrect record."
},
"030": {
"description": "Audit or Compare",
"code": "030"
},
"032": {
"description": "Employee Information Not Applicable",
"code": "032",
"x12-usage-notes": "Certain situations, such as military duty and CHAMPUS/TRICARE, classify the subscriber as ineligible for coverage or benefits. However, dependents of the subscribers are still eligible for coverage or benefits under the subscriber. Subscriber identifying elements are needed to accurately identify dependents."
}
},
"x12-usage-notes": "- Required to identify the specific type of item maintenance."
},
"insurance_line_code_03": {
"description": "Code identifying a group of insurance products",
"enum": [
"AG",
"AH",
"AJ",
"AK",
"DCP",
"DEN",
"EPO",
"FAC",
"HE",
"HLT",
"HMO",
"LTC",
"LTD",
"MM",
"MOD",
"PDG",
"POS",
"PPO",
"PRA",
"STD",
"UR",
"VIS"
],
"title": "Insurance Line Code",
"type": "string",
"x12-codes": {
"AG": {
"description": "Preventative Care/Wellness",
"code": "AG"
},
"AH": {
"description": "24 Hour Care",
"code": "AH"
},
"AJ": {
"description": "Medicare Risk",
"code": "AJ"
},
"AK": {
"description": "Mental Health",
"code": "AK"
},
"DCP": {
"description": "Dental Capitation",
"code": "DCP",
"x12-usage-notes": "This identifies a dental managed care organization (DMO)."
},
"DEN": {
"description": "Dental",
"code": "DEN"
},
"EPO": {
"description": "Exclusive Provider Organization",
"code": "EPO"
},
"FAC": {
"description": "Facility",
"code": "FAC"
},
"HE": {
"description": "Hearing",
"code": "HE"
},
"HLT": {
"description": "Health",
"code": "HLT",
"x12-usage-notes": "Includes both hospital and professional coverage."
},
"HMO": {
"description": "Health Maintenance Organization",
"code": "HMO"
},
"LTC": {
"description": "Long-Term Care",
"code": "LTC"
},
"LTD": {
"description": "Long-Term Disability",
"code": "LTD"
},
"MM": {
"description": "Major Medical",
"code": "MM"
},
"MOD": {
"description": "Mail Order Drug",
"code": "MOD"
},
"PDG": {
"description": "Prescription Drug",
"code": "PDG"
},
"POS": {
"description": "Point of Service",
"code": "POS"
},
"PPO": {
"description": "Preferred Provider Organization",
"code": "PPO"
},
"PRA": {
"description": "Practitioners",
"code": "PRA"
},
"STD": {
"description": "Short-Term Disability",
"code": "STD"
},
"UR": {
"description": "Utilization Review",
"code": "UR"
},
"VIS": {
"description": "Vision",
"code": "VIS"
}
}
},
"plan_coverage_description_04": {
"description": "A description or number that identifies the plan or coverage",
"maxLength": 50,
"minLength": 1,
"title": "Plan Coverage Description",
"type": "string"
},
"coverage_level_code_05": {
"description": "Code indicating the level of coverage being provided for this insured",
"enum": [
"CHD",
"DEP",
"E1D",
"E2D",
"E3D",
"E5D",
"E6D",
"E7D",
"E8D",
"E9D",
"ECH",
"EMP",
"ESP",
"FAM",
"IND",
"SPC",
"SPO",
"TWO"
],
"title": "Coverage Level Code",
"type": "string",
"x12-codes": {
"CHD": {
"description": "Children Only",
"code": "CHD"
},
"DEP": {
"description": "Dependents Only",
"code": "DEP"
},
"E1D": {
"description": "Employee and One Dependent",
"code": "E1D",
"x12-usage-notes": "For this code, the dependent is a non-spouse dependent. This code is not used for identification of Employee and Spouse. See code ESP."
},
"E2D": {
"description": "Employee and Two Dependents",
"code": "E2D"
},
"E3D": {
"description": "Employee and Three Dependents",
"code": "E3D"
},
"E5D": {
"description": "Employee and One or More Dependents",
"code": "E5D"
},
"E6D": {
"description": "Employee and Two or More Dependents",
"code": "E6D"
},
"E7D": {
"description": "Employee and Three or More Dependents",
"code": "E7D"
},
"E8D": {
"description": "Employee and Four or More Dependents",
"code": "E8D"
},
"E9D": {
"description": "Employee and Five or More Dependents",
"code": "E9D"
},
"ECH": {
"description": "Employee and Children",
"code": "ECH"
},
"EMP": {
"description": "Employee Only",
"code": "EMP"
},
"ESP": {
"description": "Employee and Spouse",
"code": "ESP"
},
"FAM": {
"description": "Family",
"code": "FAM"
},
"IND": {
"description": "Individual",
"code": "IND"
},
"SPC": {
"description": "Spouse and Children",
"code": "SPC"
},
"SPO": {
"description": "Spouse Only",
"code": "SPO"
},
"TWO": {
"description": "Two Party",
"code": "TWO"
}
},
"x12-usage-notes": "- See section 1.4.6, Coverage Levels and Dependents, for additional information."
},
"late_enrollment_indicator_09": {
"description": "Code indicating a Yes or No condition or response\n\n- HD09 is a late enrollee indicator. A \"Y\" value indicates the insured is a late enrollee, which can result in a reduction of benefits; an \"N\" value indicates the insured is a regular enrollee.",
"enum": ["N", "Y"],
"title": "Late Enrollment Indicator",
"type": "string",
"x12-codes": {
"N": {
"description": "No",
"code": "N"
},
"Y": {
"description": "Yes",
"code": "Y"
}
}
}
},
"required": [
"maintenance_type_code_01",
"insurance_line_code_03"
],
"title": "Health Coverage",
"type": "object",
"x12-usage-notes": "- Required when enrolling a new member or when adding, updating, removing coverage or auditing an existing member. If not required by this implementation guide, do not send.\n- Refer to section 1.4.4 \"Termination\" for additional information relative to removing a member's coverage."
},
"health_coverage_dates_DTP": {
"items": {
"additionalProperties": false,
"description": "To specify any or all of a date, a time, or a time period",
"properties": {
"date_time_qualifier_01": {
"description": "Code specifying type of date or time, or both date and time",
"enum": [
"300",
"303",
"343",
"348",
"349",
"543",
"695"
],
"title": "Date Time Qualifier",
"type": "string",
"x12-codes": {
"300": {
"description": "Enrollment Signature Date",
"code": "300"
},
"303": {
"description": "Maintenance Effective",
"code": "303",
"x12-usage-notes": "This is the effective date of a change where a member's coverage is not being added or removed."
},
"343": {
"description": "Premium Paid to Date End",
"code": "343"
},
"348": {
"description": "Benefit Begin",
"code": "348",
"x12-usage-notes": "This is the effective date of coverage. This code must always be sent when adding or reinstating coverage."
},
"349": {
"description": "Benefit End",
"code": "349",
"x12-usage-notes": "The termination date represents the last date of coverage in which claims will be paid for the individual being terminated. For example, if a date of 02/28/2001 is passed then claims for this individual will be paid through 11:59 p.m. on 2/28/01."
},
"543": {
"description": "Last Premium Paid Date",
"code": "543"
},
"695": {
"description": "Previous Period",
"code": "695",
"x12-usage-notes": "This value is only to be used when reporting Previous Coverage Months."
}
}
},
"date_time_period_format_qualifier_02": {
"description": "Code indicating the date format, time format, or date and time format\n\n- DTP02 is the date or time or period format that will appear in DTP03.",
"enum": ["D8", "RD8"],
"title": "Date Time Period Format Qualifier",
"type": "string",
"x12-codes": {
"D8": {
"description": "Date Expressed in Format CCYYMMDD",
"code": "D8"
},
"RD8": {
"description": "Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD",
"code": "RD8",
"x12-usage-notes": "This value is only to be used when reporting Previous Coverage Months."
}
}
},
"coverage_period_03": {
"description": "Expression of a date, a time, or range of dates, times or dates and times",
"maxLength": 35,
"minLength": 1,
"title": "Coverage Period",
"type": "string"
}
},
"required": [
"date_time_qualifier_01",
"date_time_period_format_qualifier_02",
"coverage_period_03"
],
"title": "Health Coverage Dates",
"type": "object",
"x12-usage-notes": ""
},
"maxItems": 6,
"minItems": 1,
"type": "array"
},
"health_coverage_policy_AMT": {
"items": {
"additionalProperties": false,
"description": "To indicate the total monetary amount",
"properties": {
"amount_qualifier_code_01": {
"description": "Code to qualify amount",
"enum": ["B9", "C1", "D2", "EBA", "FK", "P3", "R"],
"title": "Amount Qualifier Code",
"type": "string",
"x12-codes": {
"B9": {
"description": "Co-insurance - Actual",
"code": "B9",
"x12-usage-notes": "This will contain any co-insurance selection amount. The option of adjusting this amount to produce the actual co-insurance can be defined in the insurance contract."
},
"C1": {
"description": "Co-Payment Amount",
"code": "C1"
},
"D2": {
"description": "Deductible Amount",
"code": "D2"
},
"EBA": {
"description": "Expected Expenditure Amount",
"code": "EBA"
},
"FK": {
"description": "Other Unlisted Amount",
"code": "FK"
},
"P3": {
"description": "Premium Amount",
"code": "P3"
},
"R": {
"description": "Spend Down",
"code": "R"
}
}
},
"contract_amount_02": {
"description": "Monetary amount",
"title": "Contract Amount",
"type": "number",
"x12-max-length": 15
}
},
"required": [
"amount_qualifier_code_01",
"contract_amount_02"
],
"title": "Health Coverage Policy",
"type": "object",
"x12-usage-notes": "- Required when such transmission is required under the insurance contract between the sponsor and the payer. If not required by this implementation guide, do not send."
},
"maxItems": 9,
"minItems": 1,
"type": "array"
},
"health_coverage_policy_number_REF": {
"items": {
"additionalProperties": false,
"description": "To specify identifying information",
"properties": {
"reference_identification_qualifier_01": {
"description": "Code qualifying the Reference Identification",
"enum": [
"1L",
"9V",
"17",
"CE",
"E8",
"M7",
"PID",
"RB",
"X9",
"XM",
"XX1",
"XX2",
"ZX",
"ZZ"
],
"title": "Reference Identification Qualifier",
"type": "string",
"x12-codes": {
"17": {
"description": "Client Reporting Category",
"code": "17"
},
"1L": {
"description": "Group or Policy Number",
"code": "1L",
"x12-usage-notes": "Required when a group number that applies to this individual's participation in the coverage passed in this HD loop is required by the terms of the contract between the sponsor (sender) and payer (receiver); if not required may be sent at the sender's discretion."
},
"9V": {
"description": "Payment Category",
"code": "9V"
},
"CE": {
"description": "Class of Contract Code",
"code": "CE"
},
"E8": {
"description": "Service Contract (Coverage) Number",
"code": "E8"
},
"M7": {
"description": "Medical Assistance Category",
"code": "M7"
},
"PID": {
"description": "Program Identification Number",
"code": "PID"
},
"RB": {
"description": "Rate code number",
"code": "RB"
},
"X9": {
"description": "Internal Control Number",
"code": "X9"
},
"XM": {
"description": "Issuer Number",
"code": "XM"
},
"XX1": {
"description": "Special Program Code",
"code": "XX1"
},
"XX2": {
"description": "Service Area Code",
"code": "XX2"
},
"ZX": {
"description": "County Code",
"code": "ZX"
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ",
"x12-usage-notes": "Use this code for the Payment Plan Type Code (Annual or Quarterly) until a standard code is assigned."
}
}
},
"member_group_or_policy_number_02": {
"description": "Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier",
"maxLength": 50,
"minLength": 1,
"title": "Member Group or Policy Number",
"type": "string"
}
},
"required": [
"reference_identification_qualifier_01",
"member_group_or_policy_number_02"
],
"title": "Health Coverage Policy Number",
"type": "object",
"x12-usage-notes": "- Required when such transmission is required under the Trading Partner Agreement between the sponsor and the payer. If not required by this implementation guide, do not send."
},
"maxItems": 14,
"minItems": 1,
"type": "array"
},
"prior_coverage_months_REF": {
"additionalProperties": false,
"description": "To specify identifying information",
"properties": {
"reference_identification_qualifier_01": {
"description": "Code qualifying the Reference Identification",
"enum": ["QQ"],
"title": "Reference Identification Qualifier",
"type": "string",
"x12-codes": {
"QQ": {
"description": "Unit Number",
"code": "QQ",
"x12-usage-notes": "This code is used in this implementation guide to indicate that the value in REF02 is the response required under the portability provisions of HIPAA."
}
}
},
"prior_coverage_month_count_02": {
"description": "Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier",
"maxLength": 50,
"minLength": 1,
"title": "Prior Coverage Month Count",
"type": "string",
"x12-usage-notes": "- Indicator identifying the number of prior months insurance coverage that may apply under the portability provisions of the Health Insurance Portability and Accountability Act.\n- This field will contain the number of months of prior health insurance coverage that meets the portability requirements of the HIPAA certification requirements. To be sent on new enrollments when available."
}
},
"required": [
"reference_identification_qualifier_01",
"prior_coverage_month_count_02"
],
"title": "Prior Coverage Months",
"type": "object",
"x12-usage-notes": "- Required when the portability provisions of the Health Insurance Portability and Accountability Act require reporting of the number of months of prior health coverage that meet the certification requirements of the Act."
},
"identification_card_IDC": {
"items": {
"additionalProperties": false,
"description": "To provide notification to produce replacement identification card(s)",
"properties": {
"plan_coverage_description_01": {
"description": "A description or number that identifies the plan or coverage",
"maxLength": 50,
"minLength": 1,
"title": "Plan Coverage Description",
"type": "string",
"x12-usage-notes": "- If no additional information is needed, this element will be sent as a single zero."
},
"identification_card_type_code_02": {
"description": "Code identifying the type of identification card",
"enum": ["D", "H", "P"],
"title": "Identification Card Type Code",
"type": "string",
"x12-codes": {
"D": {
"description": "Dental Insurance",
"code": "D"
},
"H": {
"description": "Health Insurance",
"code": "H"
},
"P": {
"description": "Prescription Drug Service Drug Insurance",
"code": "P"
}
},
"x12-usage-notes": "- This code is used to identify that the card issued will be specific to the coverage identified in the related HD segment."
},
"identification_card_count_03": {
"description": "Numeric value of quantity\n\n- IDC03 is the number of cards being requested.",
"title": "Identification Card Count",
"type": "number",
"x12-usage-notes": "- Only non-negative integer values are to be sent.",
"x12-max-length": 15
},
"action_code_04": {
"description": "Code indicating type of action\n\n- IDC04 is the reason for the card being requested, i.e., add or a change.",
"enum": ["1", "2", "RX"],
"title": "Action Code",
"type": "string",
"x12-codes": {
"1": {
"description": "Add",
"code": "1"
},
"2": {
"description": "Change (Update)",
"code": "2"
},
"RX": {
"description": "Replace",
"code": "RX",
"x12-usage-notes": "Use when requesting replacement cards with no change to data."
}
}
}
},
"required": [
"plan_coverage_description_01",
"identification_card_type_code_02"
],
"title": "Identification Card",
"type": "object",
"x12-usage-notes": "- Required when requesting the production of an identification card as the result of an enrollment add, change, or statement. If not required by this implementation guide, do not send.\n- An enrollment statement refers to a situation where no change is being made to the enrollment except to request a replacement ID card."
},
"maxItems": 3,
"minItems": 1,
"type": "array"
},
"provider_information_LX_loop": {
"items": {
"additionalProperties": false,
"properties": {
"provider_information_LX": {
"additionalProperties": false,
"description": "To reference a line number in a transaction set",
"properties": {
"assigned_number_01": {
"description": "Number assigned for differentiation within a transaction set",
"title": "Assigned Number",
"type": "integer",
"x12-usage-notes": "- This is a sequential number representing the number of loops for this insured person. Begin with 1 for each insured person.",
"x12-max-length": 6,
"minimum": -999999,
"maximum": 999999
}
},
"required": ["assigned_number_01"],
"title": "Provider Information",
"type": "object",
"x12-usage-notes": "- Required to provide information about the primary care or capitated physicians and pharmacies chosen by the enrollee in a managed care plan when that selection is made through the sponsor. If not required by this implementation guide, do not send.\n- Use one iteration of the loop to identify each applicable health care service provider.\n- The primary care provider effective date is defaulted to the effective date of the product identified in the DTP segment of the 2300 loop. When an enrollee switches from one primary care provider to another through the sponsor, the new provider must be listed with the effective date of change."
},
"provider_name_NM1": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0809",
"type": "object",
"dependentRequired": {
"identification_code_qualifier_08": [
"provider_identifier_09"
],
"provider_identifier_09": [
"identification_code_qualifier_08"
]
}
}
],
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": [
"1X",
"3D",
"80",
"FA",
"OD",
"P3",
"QA",
"QN",
"Y2"
],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"80": {
"description": "Hospital",
"code": "80"
},
"1X": {
"description": "Laboratory",
"code": "1X"
},
"3D": {
"description": "Obstetrics and Gynecology Facility",
"code": "3D"
},
"FA": {
"description": "Facility",
"code": "FA"
},
"OD": {
"description": "Doctor of Optometry",
"code": "OD"
},
"P3": {
"description": "Primary Care Provider",
"code": "P3"
},
"QA": {
"description": "Pharmacy",
"code": "QA"
},
"QN": {
"description": "Dentist",
"code": "QN"
},
"Y2": {
"description": "Managed Care Organization",
"code": "Y2"
}
}
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["1", "2"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"1": {
"description": "Person",
"code": "1"
},
"2": {
"description": "Non-Person Entity",
"code": "2"
}
}
},
"provider_last_or_organization_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "Provider Last or Organization Name",
"type": "string"
},
"provider_first_name_04": {
"description": "Individual first name",
"maxLength": 35,
"minLength": 1,
"title": "Provider First Name",
"type": "string"
},
"provider_middle_name_05": {
"description": "Individual middle name or initial",
"maxLength": 25,
"minLength": 1,
"title": "Provider Middle Name",
"type": "string"
},
"provider_name_prefix_06": {
"description": "Prefix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Provider Name Prefix",
"type": "string"
},
"provider_name_suffix_07": {
"description": "Suffix to individual name",
"maxLength": 10,
"minLength": 1,
"title": "Provider Name Suffix",
"type": "string"
},
"identification_code_qualifier_08": {
"description": "Code designating the system/method of code structure used for Identification Code (67)",
"enum": ["34", "FI", "SV", "XX"],
"title": "Identification Code Qualifier",
"type": "string",
"x12-codes": {
"34": {
"description": "Social Security Number",
"code": "34",
"x12-usage-notes": "The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE."
},
"FI": {
"description": "Federal Taxpayer's Identification Number",
"code": "FI"
},
"SV": {
"description": "Service Provider Number",
"code": "SV",
"x12-usage-notes": "This is a number assigned by the payer used to identify a provider."
},
"XX": {
"description": "Centers for Medicare and Medicaid Services National Provider Identifier",
"code": "XX"
}
}
},
"provider_identifier_09": {
"description": "Code identifying a party or other code",
"maxLength": 80,
"minLength": 2,
"title": "Provider Identifier",
"type": "string"
},
"entity_relationship_code_10": {
"description": "Code describing entity relationship\n\n- NM110 and NM111 further define the type of entity in NM101.",
"enum": ["25", "26", "72"],
"title": "Entity Relationship Code",
"type": "string",
"x12-codes": {
"25": {
"description": "Established Patient",
"code": "25"
},
"26": {
"description": "Not Established Patient",
"code": "26"
},
"72": {
"description": "Unknown",
"code": "72"
}
},
"x12-usage-notes": "- This element indicates whether or not the member is an existing patient of the provider."
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02",
"entity_relationship_code_10"
],
"title": "Provider Name",
"type": "object",
"x12-usage-notes": "- The National Provider ID must be passed in NM109. Until that ID is available, the Federal Taxpayer's Identification Number or another identification number that is necessary to identify the entity must be sent if available. If the identification number is not available then the Provider's Name must be passed using elements NM103 through NM107 as outlined in segment note 2."
},
"provider_address_N3": {
"items": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"provider_address_line_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Provider Address Line",
"type": "string"
},
"provider_address_line_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Provider Address Line",
"type": "string"
}
},
"required": ["provider_address_line_01"],
"title": "Provider Address",
"type": "object",
"x12-usage-notes": "- Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send."
},
"maxItems": 2,
"minItems": 1,
"type": "array"
},
"provider_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": ["provider_state_code_02"],
"type": "object",
"properties": {
"provider_state_code_02": true
}
},
{
"required": ["country_subdivision_code_07"],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": ["provider_state_code_02"],
"type": "object",
"properties": {
"provider_state_code_02": true
}
},
{
"required": [
"country_subdivision_code_07"
],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": ["country_code_04"]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"provider_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Provider City Name",
"type": "string"
},
"provider_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Provider State Code",
"type": "string"
},
"provider_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Provider Postal Zone or ZIP Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": ["provider_city_name_01"],
"title": "Provider City, State, ZIP Code",
"type": "object",
"x12-usage-notes": "- Required when the location of the named provider needs to be reported. If not required by this implementation guide, do not send."
},
"provider_communications_numbers_PER": {
"items": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0506",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_05": [
"communication_number_06"
],
"communication_number_06": [
"communication_number_qualifier_05"
]
}
},
{
"x12-condition": "P0708",
"type": "object",
"dependentRequired": {
"communication_number_qualifier_07": [
"communication_number_08"
],
"communication_number_08": [
"communication_number_qualifier_07"
]
}
}
],
"description": "To identify a person or office to whom administrative communications should be directed",
"properties": {
"contact_function_code_01": {
"description": "Code identifying the major duty or responsibility of the person or group named",
"enum": ["IC"],
"title": "Contact Function Code",
"type": "string",
"x12-codes": {
"IC": {
"description": "Information Contact",
"code": "IC"
}
}
},
"communication_number_qualifier_03": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_04": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_05": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_06": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
},
"communication_number_qualifier_07": {
"description": "Code identifying the type of communication number",
"enum": [
"AP",
"BN",
"CP",
"EM",
"EX",
"FX",
"HP",
"TE",
"WP"
],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"AP": {
"description": "Alternate Telephone",
"code": "AP"
},
"BN": {
"description": "Beeper Number",
"code": "BN"
},
"CP": {
"description": "Cellular Phone",
"code": "CP"
},
"EM": {
"description": "Electronic Mail",
"code": "EM"
},
"EX": {
"description": "Telephone Extension",
"code": "EX"
},
"FX": {
"description": "Facsimile",
"code": "FX"
},
"HP": {
"description": "Home Phone Number",
"code": "HP"
},
"TE": {
"description": "Telephone",
"code": "TE"
},
"WP": {
"description": "Work Phone Number",
"code": "WP"
}
}
},
"communication_number_08": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
}
},
"required": [
"contact_function_code_01",
"communication_number_qualifier_03",
"communication_number_04"
],
"title": "Provider Communications Numbers",
"type": "object",
"x12-usage-notes": "- When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number always includes the area code and phone number using the format AAABBBCCCC, where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525).\n- Required when the Provider contact information is provided to the sponsor. If not required by this implementation guide, do not send."
},
"maxItems": 2,
"minItems": 1,
"type": "array"
},
"provider_change_reason_PLA": {
"additionalProperties": false,
"description": "To indicate action to be taken for the location specified and to qualify the location specified",
"properties": {
"action_code_01": {
"description": "Code indicating type of action",
"enum": ["2"],
"title": "Action Code",
"type": "string",
"x12-codes": {
"2": {
"description": "Change (Update)",
"code": "2"
}
}
},
"entity_identifier_code_02": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["1P"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"1P": {
"description": "Provider",
"code": "1P"
}
}
},
"provider_effective_date_03": {
"description": "Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year\n\n- PLA03 is the effective date for the action identified in PLA01.",
"format": "date",
"title": "Provider Effective Date",
"type": "string",
"x12-usage-notes": "- This is the effective date of the change of PCP."
},
"maintenance_reason_code_05": {
"description": "Code identifying the reason for the maintenance change",
"enum": [
"14",
"22",
"46",
"AA",
"AB",
"AC",
"AD",
"AE",
"AF",
"AG",
"AH",
"AI",
"AJ"
],
"title": "Maintenance Reason Code",
"type": "string",
"x12-codes": {
"14": {
"description": "Voluntary Withdrawal",
"code": "14"
},
"22": {
"description": "Plan Change",
"code": "22"
},
"46": {
"description": "Current Customer Information File in Error",
"code": "46"
},
"AA": {
"description": "Dissatisfaction with Office Staff",
"code": "AA"
},
"AB": {
"description": "Dissatisfaction with Medical Care/Services Rendered",
"code": "AB"
},
"AC": {
"description": "Inconvenient Office Location",
"code": "AC"
},
"AD": {
"description": "Dissatisfaction with Office Hours",
"code": "AD"
},
"AE": {
"description": "Unable to Schedule Appointments in a Timely Manner",
"code": "AE"
},
"AF": {
"description": "Dissatisfaction with Physician's Referral Policy",
"code": "AF"
},
"AG": {
"description": "Less Respect and Attention Time Given than to Other Patients",
"code": "AG"
},
"AH": {
"description": "Patient Moved to a New Location",
"code": "AH"
},
"AI": {
"description": "No Reason Given",
"code": "AI"
},
"AJ": {
"description": "Appointment Times not Met in a Timely Manner",
"code": "AJ"
}
},
"x12-usage-notes": "- If none of the specific Maintenance Reasons apply, send 'AI', No Reason Given."
}
},
"required": [
"action_code_01",
"entity_identifier_code_02",
"provider_effective_date_03",
"maintenance_reason_code_05"
],
"title": "Provider Change Reason",
"type": "object",
"x12-usage-notes": "- Required to report the reason and the effective date that a member changes providers as described by the NM1 segment in Loop 2310. If not required by this implementation guide, do not send."
}
},
"required": [
"provider_information_LX",
"provider_name_NM1"
],
"title": "Provider Information Loop",
"type": "object"
},
"maxItems": 30,
"minItems": 1,
"type": "array"
},
"coordination_of_benefits_COB_loop": {
"items": {
"additionalProperties": false,
"properties": {
"coordination_of_benefits_COB": {
"additionalProperties": false,
"description": "To supply information on coordination of benefits",
"properties": {
"payer_responsibility_sequence_number_code_01": {
"description": "Code identifying the insurance carrier's level of responsibility for a payment of a claim",
"enum": ["P", "S", "T", "U"],
"title": "Payer Responsibility Sequence Number Code",
"type": "string",
"x12-codes": {
"P": {
"description": "Primary",
"code": "P"
},
"S": {
"description": "Secondary",
"code": "S"
},
"T": {
"description": "Tertiary",
"code": "T"
},
"U": {
"description": "Unknown",
"code": "U"
}
}
},
"member_group_or_policy_number_02": {
"description": "Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier\n\n- COB02 is the policy number.",
"maxLength": 50,
"minLength": 1,
"title": "Member Group or Policy Number",
"type": "string"
},
"coordination_of_benefits_code_03": {
"description": "Code identifying whether there is a coordination of benefits",
"enum": ["1", "5", "6"],
"title": "Coordination of Benefits Code",
"type": "string",
"x12-codes": {
"1": {
"description": "Coordination of Benefits",
"code": "1"
},
"5": {
"description": "Unknown",
"code": "5"
},
"6": {
"description": "No Coordination of Benefits",
"code": "6",
"x12-usage-notes": "This code is sent when it has been determined that there is no COB."
}
}
},
"service_type_code_04": {
"items": {
"description": "Code identifying the classification of service",
"enum": [
"1",
"35",
"48",
"50",
"54",
"89",
"90",
"A4",
"AG",
"AL",
"BB"
],
"title": "Service Type Code",
"type": "string",
"x12-codes": {
"1": {
"description": "Medical Care",
"code": "1"
},
"35": {
"description": "Dental Care",
"code": "35"
},
"48": {
"description": "Hospital - Inpatient",
"code": "48"
},
"50": {
"description": "Hospital - Outpatient",
"code": "50"
},
"54": {
"description": "Long Term Care",
"code": "54"
},
"89": {
"description": "Free Standing Prescription Drug",
"code": "89"
},
"90": {
"description": "Mail Order Prescription Drug",
"code": "90"
},
"A4": {
"description": "Psychiatric",
"code": "A4"
},
"AG": {
"description": "Skilled Nursing Care",
"code": "AG"
},
"AL": {
"description": "Vision (Optometry)",
"code": "AL"
},
"BB": {
"description": "Partial Hospitalization (Psychiatric)",
"code": "BB"
}
}
},
"maxItems": 9,
"minItems": 1,
"type": "array"
}
},
"required": [
"payer_responsibility_sequence_number_code_01",
"coordination_of_benefits_code_03"
],
"title": "Coordination of Benefits",
"type": "object",
"x12-usage-notes": "- Required whenever an individual has another insurance plan with benefits similar to those covered by the insurance product specified in the HD segment for this occurrence of Loop ID-2300. If not required by this implementation guide, do not send."
},
"additional_coordination_of_benefits_identifiers_REF": {
"items": {
"additionalProperties": false,
"description": "To specify identifying information",
"properties": {
"reference_identification_qualifier_01": {
"description": "Code qualifying the Reference Identification",
"enum": ["6P", "60", "SY", "ZZ"],
"title": "Reference Identification Qualifier",
"type": "string",
"x12-codes": {
"60": {
"description": "Account Suffix Code",
"code": "60"
},
"6P": {
"description": "Group Number",
"code": "6P"
},
"SY": {
"description": "Social Security Number",
"code": "SY",
"x12-usage-notes": "The social security number may not be used for any Federally administered programs such as Medicare or CHAMPUS/TRICARE."
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ",
"x12-usage-notes": "Mutually Defined, will be used in this REF01 for National Individual Identifier until a standard code is defined."
}
}
},
"member_group_or_policy_number_02": {
"description": "Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier",
"maxLength": 50,
"minLength": 1,
"title": "Member Group or Policy Number",
"type": "string"
}
},
"required": [
"reference_identification_qualifier_01",
"member_group_or_policy_number_02"
],
"title": "Additional Coordination of Benefits Identifiers",
"type": "object",
"x12-usage-notes": "- Required if additional COB identifiers are supplied by the subscriber. If not required by this implementation guide, do not send.\n- Use the Social Security Number until the National ID Number for individuals is available."
},
"maxItems": 4,
"minItems": 1,
"type": "array"
},
"coordination_of_benefits_eligibility_dates_DTP": {
"items": {
"additionalProperties": false,
"description": "To specify any or all of a date, a time, or a time period",
"properties": {
"date_time_qualifier_01": {
"description": "Code specifying type of date or time, or both date and time",
"enum": ["344", "345"],
"title": "Date Time Qualifier",
"type": "string",
"x12-codes": {
"344": {
"description": "Coordination of Benefits Begin",
"code": "344"
},
"345": {
"description": "Coordination of Benefits End",
"code": "345"
}
}
},
"date_time_period_format_qualifier_02": {
"description": "Code indicating the date format, time format, or date and time format\n\n- DTP02 is the date or time or period format that will appear in DTP03.",
"enum": ["D8"],
"title": "Date Time Period Format Qualifier",
"type": "string",
"x12-codes": {
"D8": {
"description": "Date Expressed in Format CCYYMMDD",
"code": "D8"
}
}
},
"coordination_of_benefits_date_03": {
"description": "Expression of a date, a time, or range of dates, times or dates and times",
"maxLength": 35,
"minLength": 1,
"title": "Coordination of Benefits Date",
"type": "string"
}
},
"required": [
"date_time_qualifier_01",
"date_time_period_format_qualifier_02",
"coordination_of_benefits_date_03"
],
"title": "Coordination of Benefits Eligibility Dates",
"type": "object",
"x12-usage-notes": "- Required when the submitter needs to send effective dates for coordination of benefits. If not required by this implementation guide, do not send."
},
"maxItems": 2,
"minItems": 1,
"type": "array"
},
"coordination_of_benefits_related_entity_NM1_loop": {
"items": {
"additionalProperties": false,
"properties": {
"coordination_of_benefits_related_entity_NM1": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "P0809",
"type": "object",
"dependentRequired": {
"identification_code_qualifier_08": [
"coordination_of_benefits_insurer_identification_code_09"
],
"coordination_of_benefits_insurer_identification_code_09": [
"identification_code_qualifier_08"
]
}
}
],
"description": "To supply the full name of an individual or organizational entity",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["36", "GW", "IN"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"36": {
"description": "Employer",
"code": "36"
},
"GW": {
"description": "Group",
"code": "GW"
},
"IN": {
"description": "Insurer",
"code": "IN"
}
}
},
"entity_type_qualifier_02": {
"description": "Code qualifying the type of entity\n\n- NM102 qualifies NM103.",
"enum": ["2"],
"title": "Entity Type Qualifier",
"type": "string",
"x12-codes": {
"2": {
"description": "Non-Person Entity",
"code": "2"
}
}
},
"coordination_of_benefits_insurer_name_03": {
"description": "Individual last name or organizational name",
"maxLength": 60,
"minLength": 1,
"title": "Coordination of Benefits Insurer Name",
"type": "string"
},
"identification_code_qualifier_08": {
"description": "Code designating the system/method of code structure used for Identification Code (67)",
"enum": ["FI", "NI", "XV"],
"title": "Identification Code Qualifier",
"type": "string",
"x12-codes": {
"FI": {
"description": "Federal Taxpayer's Identification Number",
"code": "FI"
},
"NI": {
"description": "National Association of Insurance Commissioners (NAIC) Identification",
"code": "NI"
},
"XV": {
"description": "Centers for Medicare and Medicaid Services PlanID",
"code": "XV",
"x12-usage-notes": "Use when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID)."
}
}
},
"coordination_of_benefits_insurer_identification_code_09": {
"description": "Code identifying a party or other code",
"maxLength": 80,
"minLength": 2,
"title": "Coordination of Benefits Insurer Identification Code",
"type": "string"
}
},
"required": [
"entity_identifier_code_01",
"entity_type_qualifier_02"
],
"title": "Coordination of Benefits Related Entity",
"type": "object",
"x12-usage-notes": "- Required to send the name of the insurance company when provided to the sponsor. If not required by this implementation guide, do not send."
},
"coordination_of_benefits_related_entity_address_N3": {
"additionalProperties": false,
"description": "To specify the location of the named party",
"properties": {
"address_information_01": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Address Information",
"type": "string"
},
"address_information_02": {
"description": "Address information",
"maxLength": 55,
"minLength": 1,
"title": "Address Information",
"type": "string"
}
},
"required": ["address_information_01"],
"title": "Coordination of Benefits Related Entity Address",
"type": "object",
"x12-usage-notes": "- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send."
},
"coordination_of_benefits_other_insurance_company_city_state_zip_code_N4": {
"additionalProperties": false,
"allOf": [
{
"x12-condition": "E0207",
"oneOf": [
{
"oneOf": [
{
"required": [
"coordination_of_benefits_other_insurance_company_state_code_02"
],
"type": "object",
"properties": {
"coordination_of_benefits_other_insurance_company_state_code_02": true
}
},
{
"required": [
"country_subdivision_code_07"
],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
},
{
"not": {
"anyOf": [
{
"required": [
"coordination_of_benefits_other_insurance_company_state_code_02"
],
"type": "object",
"properties": {
"coordination_of_benefits_other_insurance_company_state_code_02": true
}
},
{
"required": [
"country_subdivision_code_07"
],
"type": "object",
"properties": {
"country_subdivision_code_07": true
}
}
]
}
}
]
},
{
"type": "object",
"x12-condition": "C0704",
"dependentRequired": {
"country_subdivision_code_07": [
"country_code_04"
]
}
}
],
"description": "To specify the geographic place of the named party",
"properties": {
"coordination_of_benefits_other_insurance_company_city_name_01": {
"description": "Free-form text for city name\n\n- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.",
"maxLength": 30,
"minLength": 2,
"title": "Coordination of Benefits Other Insurance Company City Name",
"type": "string"
},
"coordination_of_benefits_other_insurance_company_state_code_02": {
"description": "Code (Standard State/Province) as defined by appropriate government agency\n\n- N402 is required only if city name (N401) is in the U.S. or Canada.",
"maxLength": 2,
"minLength": 2,
"title": "Coordination of Benefits Other Insurance Company State Code",
"type": "string"
},
"coordination_of_benefits_other_insurance_company_postal_zone_or_zip_code_03": {
"description": "Code defining international postal zone code excluding punctuation and blanks (zip code for United States)",
"maxLength": 15,
"minLength": 3,
"title": "Coordination of Benefits Other Insurance Company Postal Zone or ZIP Code",
"type": "string"
},
"country_code_04": {
"description": "Code identifying the country",
"maxLength": 3,
"minLength": 2,
"title": "Country Code",
"type": "string",
"x12-usage-notes": "- Use the alpha-2 country codes from Part 1 of ISO 3166."
},
"country_subdivision_code_07": {
"description": "Code identifying the country subdivision",
"maxLength": 3,
"minLength": 1,
"title": "Country Subdivision Code",
"type": "string",
"x12-usage-notes": "- Use the country subdivision codes from Part 2 of ISO 3166."
}
},
"required": [
"coordination_of_benefits_other_insurance_company_city_name_01"
],
"title": "Coordination of Benefits Other Insurance Company City, State, ZIP Code",
"type": "object",
"x12-usage-notes": "- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send."
},
"administrative_communications_contact_PER": {
"additionalProperties": false,
"description": "To identify a person or office to whom administrative communications should be directed",
"properties": {
"contact_function_code_01": {
"description": "Code identifying the major duty or responsibility of the person or group named",
"enum": ["CN"],
"title": "Contact Function Code",
"type": "string",
"x12-codes": {
"CN": {
"description": "General Contact",
"code": "CN"
}
}
},
"communication_number_qualifier_03": {
"description": "Code identifying the type of communication number",
"enum": ["TE"],
"title": "Communication Number Qualifier",
"type": "string",
"x12-codes": {
"TE": {
"description": "Telephone",
"code": "TE"
}
}
},
"communication_number_04": {
"description": "Complete communications number including country or area code when applicable",
"maxLength": 256,
"minLength": 1,
"title": "Communication Number",
"type": "string"
}
},
"required": [
"contact_function_code_01",
"communication_number_qualifier_03",
"communication_number_04"
],
"title": "Administrative Communications Contact",
"type": "object",
"x12-usage-notes": "- Required when detailed COB coverage information is agreed to be exchanged. If not required by this implementation guide, do not send."
}
},
"required": [
"coordination_of_benefits_related_entity_NM1"
],
"title": "Coordination of Benefits Related Entity Loop",
"type": "object"
},
"maxItems": 3,
"minItems": 1,
"type": "array"
}
},
"required": ["coordination_of_benefits_COB"],
"title": "Coordination of Benefits Loop",
"type": "object"
},
"maxItems": 5,
"minItems": 1,
"type": "array"
}
},
"required": ["health_coverage_HD", "health_coverage_dates_DTP"],
"title": "Health Coverage Loop",
"type": "object"
},
"maxItems": 99,
"minItems": 1,
"type": "array"
},
"member_reporting_categories_LX_loop": {
"items": {
"additionalProperties": false,
"properties": {
"member_reporting_categories_LX": {
"additionalProperties": false,
"description": "To reference a line number in a transaction set",
"properties": {
"assigned_number_01": {
"description": "Number assigned for differentiation within a transaction set",
"title": "Assigned Number",
"type": "integer",
"x12-usage-notes": "- Use this sequential non-negative integer for LX loops for this member's additional reporting categories.",
"x12-max-length": 6,
"minimum": -999999,
"maximum": 999999
}
},
"required": ["assigned_number_01"],
"title": "Member Reporting Categories",
"type": "object",
"x12-usage-notes": "- Required when needed to provide additional reporting categories about the member. If not required by this implementation guide, do not send."
},
"reporting_category_N1_loop": {
"additionalProperties": false,
"properties": {
"reporting_category_N1": {
"additionalProperties": false,
"description": "To identify a party by type of organization, name, and code",
"properties": {
"entity_identifier_code_01": {
"description": "Code identifying an organizational entity, a physical location, property or an individual",
"enum": ["75"],
"title": "Entity Identifier Code",
"type": "string",
"x12-codes": {
"75": {
"description": "Participant",
"code": "75"
}
}
},
"member_reporting_category_name_02": {
"description": "Free-form name",
"maxLength": 60,
"minLength": 1,
"title": "Member Reporting Category Name",
"type": "string"
}
},
"required": [
"entity_identifier_code_01",
"member_reporting_category_name_02"
],
"title": "Reporting Category",
"type": "object",
"x12-usage-notes": "- Required to specify the name of the reporting category of the member's participating entity."
},
"reporting_category_reference_REF": {
"additionalProperties": false,
"description": "To specify identifying information",
"properties": {
"reference_identification_qualifier_01": {
"description": "Code qualifying the Reference Identification",
"enum": [
"00",
"3L",
"6M",
"9V",
"9X",
"17",
"18",
"19",
"26",
"GE",
"LU",
"PID",
"XX1",
"XX2",
"YY",
"ZZ"
],
"title": "Reference Identification Qualifier",
"type": "string",
"x12-codes": {
"17": {
"description": "Client Reporting Category",
"code": "17"
},
"18": {
"description": "Plan Number",
"code": "18"
},
"19": {
"description": "Division Identifier",
"code": "19"
},
"26": {
"description": "Union Number",
"code": "26"
},
"00": {
"description": "Contracting District Number",
"code": "00"
},
"3L": {
"description": "Branch Identifier",
"code": "3L"
},
"6M": {
"description": "Application Number",
"code": "6M"
},
"9V": {
"description": "Payment Category",
"code": "9V"
},
"9X": {
"description": "Account Category",
"code": "9X"
},
"GE": {
"description": "Geographic Number",
"code": "GE"
},
"LU": {
"description": "Location Number",
"code": "LU"
},
"PID": {
"description": "Program Identification Number",
"code": "PID"
},
"XX1": {
"description": "Special Program Code",
"code": "XX1"
},
"XX2": {
"description": "Service Area Code",
"code": "XX2"
},
"YY": {
"description": "Geographic Key",
"code": "YY"
},
"ZZ": {
"description": "Mutually Defined",
"code": "ZZ"
}
}
},
"member_reporting_category_reference_id_02": {
"description": "Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier",
"maxLength": 50,
"minLength": 1,
"title": "Member Reporting Category Reference ID",
"type": "string"
}
},
"required": [
"reference_identification_qualifier_01",
"member_reporting_category_reference_id_02"
],
"title": "Reporting Category Reference",
"type": "object",
"x12-usage-notes": "- Required to specify the reference identifier associated with the reporting category of the member's participating entity."
},
"reporting_category_date_DTP": {
"additionalProperties": false,
"description": "To specify any or all of a date, a time, or a time period",
"properties": {
"date_time_qualifier_01": {
"description": "Code specifying type of date or time, or both date and time",
"enum": ["007"],
"title": "Date Time Qualifier",
"type": "string",
"x12-codes": {
"007": {
"description": "Effective",
"code": "007"
}
}
},
"date_time_period_format_qualifier_02": {
"description": "Code indicating the date format, time format, or date and time format\n\n- DTP02 is the date or time or period format that will appear in DTP03.",
"enum": ["D8", "RD8"],
"title": "Date Time Period Format Qualifier",
"type": "string",
"x12-codes": {
"D8": {
"description": "Date Expressed in Format CCYYMMDD",
"code": "D8"
},
"RD8": {
"description": "Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD",
"code": "RD8",
"x12-usage-notes": "A range of dates expressed in the format CCYYMMDD-CCYYMMDD where CCYY is the numerical expression of the century CC and year YY. MM is the numerical expression of the month within the year, and DD is the numerical expression of the day within the year; the first occurrence of CCYYMMDD is the beginning date and the second occurrence is the ending date."
}
}
},
"member_reporting_category_effective_dates_03": {
"description": "Expression of a date, a time, or range of dates, times or dates and times",
"maxLength": 35,
"minLength": 1,
"title": "Member Reporting Category Effective Date(s)",
"type": "string"
}
},
"required": [
"date_time_qualifier_01",
"date_time_period_format_qualifier_02",
"member_reporting_category_effective_dates_03"
],
"title": "Reporting Category Date",
"type": "object",
"x12-usage-notes": "- Required when called for in the insurance contract between the sponsor and payer. If not required by this implementation guide, do not send.\n- Use this segment to associate a date or date range with a reporting category."
}
},
"required": ["reporting_category_N1"],
"title": "Reporting Category Loop",
"type": "object"
}
},
"required": ["member_reporting_categories_LX"],
"title": "Member Reporting Categories Loop",
"type": "object"
},
"minItems": 1,
"type": "array"
}
},
"required": [
"member_level_detail_INS",
"subscriber_identifier_REF",
"member_name_NM1_loop"
],
"title": "Member Level Detail Loop",
"type": "object"
},
"minItems": 1,
"type": "array"
}
},
"required": ["member_level_detail_INS_loop"],
"type": "object"
}
Find the mapping ID and schema
If you plan to use a mapping to transform fragments into Stedi’s Guide JSON format, you must send fragments to Stedi’s API in the mapping’s source JSON schema. To find the mapping ID and schema:- Go to the Mappings page and copy the ID field for the mapping you want to use.
- Click the mapping’s name to view its details.
- Click Test mapping. The test input JSON shape is the shape you must use when sending fragment data to the Stage Fragment API.
Stage fragments
Call the Stage Fragments API to store a fragment on Stedi until you are ready to generate an outbound EDI file. Stedi stores fragments in groups, specified by thefragmentGroupID included in the path. You can call the API with the same fragmentGroupID as many times as needed until you have staged all of the fragments required for the transaction.
Data format
For each staging call, you can optionally specify a mapping that Stedi will use to transform the fragment from your system’s JSON format into Stedi’s Guide JSON format.- If you don’t use a mapping, the fragment must match the Guide JSON format for the specified guide.
- If you use a mapping, the fragment must match the mapping’s source JSON schema.
Sample request and response
The following example shows a cURL request and response for staging a fragment without a mapping. The fragment contains iterations ofLoop 2000 (Member Level Detail) in an 834 Healthcare Benefit Enrollment.
curl --request POST \
--url https://core.us.stedi.com/2023-08-01/fragments/{fragmentGroupId} \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--data '{
"guideId": "01HQ1XPE9C3SCEB2ND7VC53A8M",
"fragment": {
"member_level_detail_INS_loop": [ ... ]
}
}'
curl --request POST \
--url https://core.us.stedi.com/2023-08-01/fragments/{fragmentGroupId} \
--header 'Authorization: <api-key>' \
--header 'Content-Type: application/json' \
--data '{
"guideId": "01HQ1XPE9C3SCEB2ND7VC53A8M",
"fragment": {
"member_level_detail_INS_loop": [
{
"member_level_detail_INS": {
"member_indicator_01": "Y",
"individual_relationship_code_02": "18",
"maintenance_type_code_03": "001",
"maintenance_reason_code_04": "22",
"benefit_status_code_05": "A",
"employment_status_code_08": "FT"
},
"member_policy_number_REF": {
"reference_identification_qualifier_01": "1L",
"member_group_or_policy_number_02": "123456001"
},
"subscriber_identifier_REF": {
"reference_identification_qualifier_01": "0F",
"subscriber_identifier_02": "202443307"
},
"member_name_NM1_loop": {
"member_name_NM1": {
"entity_identifier_code_01": "IL",
"entity_type_qualifier_02": "1",
"member_last_name_03": "SMITH",
"member_first_name_04": "WILLIAM",
"identification_code_qualifier_08": "ZZ",
"member_identifier_09": "2024433307"
}
},
"health_coverage_HD_loop": [
{
"health_coverage_HD": {
"maintenance_type_code_01": "021",
"insurance_line_code_03": "DEN"
},
"health_coverage_dates_DTP": [
{
"date_time_qualifier_01": "348",
"date_time_period_format_qualifier_02": "D8",
"coverage_period_03": "20020701"
}
]
}
]
}
]
}
}'
{
"fragmentGroupId": "some-transaction-id",
"createdAt": "2024-02-21T00:00:00Z",
"fragmentId": "d3b3e3e3-3e3e-3e3e-3e3e-3e3e3e3e3e3e"
}
Create outbound transaction
Call the Create Outbound Transaction API and Stedi combines all of the fragments matching thefragmentGroupId into a single, compliant EDI file and delivers it to your trading partner.
Once you call the Transaction API with a fragmentGroupId, that ID is locked, meaning that you cannot add new fragments to the group and you cannot call the API again with that ID. This feature prevents you from accidentally sending duplicate data to partners.
Data format
When calling the API with fragments, you provide a fragment wrapper for the transaction. The wrapper contains all of the transaction data except for the contents of the repeated loop segment where Stedi should insert the fragments. Instead, you leave an empty array in place of the loop contents - for example,member_level_detail_INS_loop: [].
Fragment wrapper for an 834 benefit enrollment
Fragment wrapper for an 834 benefit enrollment
"transaction": {
"heading": {
"transaction_set_header_ST": {
"transaction_set_identifier_code_01": "834",
"transaction_set_control_number_02": 12345,
"implementation_convention_reference_03": "005010X220A1"
},
"beginning_segment_BGN": {
"transaction_set_purpose_code_01": "00",
"transaction_set_reference_number_02": "12456",
"transaction_set_creation_date_03": "1998-05-20",
"transaction_set_creation_time_04": "12:00",
"action_code_08": "2"
},
"payer_N1_loop": {
"payer_N1": {
"entity_identifier_code_01": "IN",
"identification_code_qualifier_03": "FI",
"insurer_identification_code_04": "654456654"
}
},
"sponsor_name_N1_loop": {
"sponsor_name_N1": {
"entity_identifier_code_01": "P5",
"identification_code_qualifier_03": "FI",
"sponsor_identifier_04": "999888777"
}
}
},
"detail": {
"member_level_detail_INS_loop": []
}
}
Sample request and response
The following example shows a cURL request and response to generate an 834 Benefit Enrollment and Maintenance. Notice that themember_level_detail_INS_loop is an empty array - this is where Stedi will insert the fragments from the specified fragment group.
curl --location 'https://core.us.stedi.com/2023-08-01/partnerships/<PARTNERSHIP_ID>/transactions/<TRANSACTION_SETTING_ID>' \
--header 'Content-Type: application/json' \
--header 'Accept: application/json' \
--header 'Authorization: Key <YOUR_STEDI_API_KEY_HERE>' \
--data '
{
"fragmentGroupId": "plan_file_2023-12-12",
"transaction": {
"heading": {},
"detail": {}
}
}'
curl --location 'https://core.us.stedi.com/2023-08-01/partnerships/<PARTNERSHIP_ID>/transactions/<TRANSACTION_SETTING_ID>' \
--header 'Content-Type: application/json' \
--header 'Accept: application/json' \
--header 'Authorization: Key <YOUR_STEDI_API_KEY_HERE>' \
--data '
{
"fragmentGroupId": "plan_file_2023-12-12",
"transaction": {
"heading": {
"transaction_set_header_ST": {
"transaction_set_identifier_code_01": "834",
"transaction_set_control_number_02": 12345,
"implementation_convention_reference_03": "005010X220A1"
},
"beginning_segment_BGN": {
"transaction_set_purpose_code_01": "00",
"transaction_set_reference_number_02": "12456",
"transaction_set_creation_date_03": "1998-05-20",
"transaction_set_creation_time_04": "12:00",
"action_code_08": "2"
},
"payer_N1_loop": {
"payer_N1": {
"entity_identifier_code_01": "IN",
"identification_code_qualifier_03": "FI",
"insurer_identification_code_04": "654456654"
}
},
"sponsor_name_N1_loop": {
"sponsor_name_N1": {
"entity_identifier_code_01": "P5",
"identification_code_qualifier_03": "FI",
"sponsor_identifier_04": "999888777"
}
}
},
"detail": {
"member_level_detail_INS_loop": []
}
}
}'
{
"fileExecutionId": "d3b3e3e3-3e3e-3e3e-3e3e-3e3e3e3e3e3e"
}