INS Insured Benefit

Opt

AtMax 1

To provide benefit, characteristics, and identification information on insured entities.

Elements

Position	Element	Name		Type	Min/Max	Repeat

1	1073	Yes/No Condition or Response Code	Mandatory	ID	1/1	AtMax 1
2	1069	Individual Relationship Code	Mandatory	ID	2/2	AtMax 1
3	875	Maintenance Type Code	Opt	ID	3/3	AtMax 1
4	1203	Maintenance Reason Code	Opt	ID	2/3	AtMax 1
5	1216	Benefit Status Code	Opt	ID	1/1	AtMax 1
C052Medicare Status CodeOpt AtMax 1
7	1219	Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code	Opt	ID	1/2	AtMax 1
8	584	Employment Status Code	Opt	ID	2/2	AtMax 1
9	1220	Student Status Code	Opt	ID	1/1	AtMax 1
10	1073	Yes/No Condition or Response Code	Opt	ID	1/1	AtMax 1
11	1250	Date Time Period Format Qualifier	Rel	ID	2/3	AtMax 1
12	1251	Date Time Period	Rel	Alphanumeric	1/35	AtMax 1
13	1165	Confidentiality Code	Opt	ID	1/1	AtMax 1
14	19	City Name	Opt	Alphanumeric	2/30	AtMax 1
15	156	State or Province Code	Opt	ID	2/2	AtMax 1
16	26	Country Code	Opt	ID	2/3	AtMax 1
17	1470	Number	Opt	Number	1/9	AtMax 1
18	1792	Changed Identifying Information Code	Opt	ID	1/2	AtMax 20
19	1793	Provider Network Status Information Code	Opt	ID	1/2	AtMax 1

ID1073

NameYes/No Condition or Response Code

LengthMin 1 / Max 1

Position1

RequirementMandatory

Codes