To supply eligibility or benefit information
Position | Element | Name | Type | Min/Max | Repeat | ||
---|---|---|---|---|---|---|---|
1 | 1390 | Eligibility or Benefit Information Code | Mandatory | ID | 1/2 | 1 | |
2 | 1207 | Coverage Level Code | Opt | ID | 3/3 | 1 | |
3 | 1365 | Service Type Code | Opt | ID | 1/2 | 99 | |
4 | 1336 | Insurance Type Code | Opt | ID | 1/3 | 1 | |
5 | 1204 | Plan Coverage Description | Opt | Alphanumeric | 1/50 | 1 | |
6 | 615 | Time Period Qualifier | Opt | ID | 1/2 | 1 | |
7 | 782 | Monetary Amount | Opt | Decimal | 1/18 | 1 | |
8 | 954 | Percentage as Decimal | Opt | Decimal | 1/10 | 1 | |
9 | 673 | Quantity Qualifier | Rel | ID | 2/2 | 1 | |
10 | 380 | Quantity | Rel | Decimal | 1/15 | 1 | |
11 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | 1 | |
12 | 1073 | Yes/No Condition or Response Code | Opt | ID | 1/1 | 1 | |
1 | |||||||
1 |