|
Seq
|
Element Name
|
Req
|
Type
|
Len
|
Comments
|
|
1
|
Segment ID (IN1)
|
R
|
ID
|
3
|
IN1_1, HL7TEMPLATE Field
|
|
2
|
Insurance Plan ID
|
R
|
AN
|
60
|
|
|
3
|
Insurance Company ID
|
R
|
AN
|
59
|
|
|
4
|
Insurance Company Name
|
O
|
AN
|
130
|
|
|
5
|
Insurance Company Address
|
O
|
AN
|
106
|
Address1^Address2^
City^State^Zip
|
|
6
|
Insurance Co. Contact Person
|
NU
|
AN
|
48
|
Not used
|
|
7
|
Insurance Co. Phone Number
|
O
|
AN
|
40
|
|
|
8
|
Group Number
|
O
|
AN
|
12
|
|
|
9
|
Group Name
|
O
|
AN
|
130
|
|
|
10
|
Insured's Group Emp ID
|
O
|
AN
|
12
|
|
|
11
|
Insured's Group Emp Name
|
O
|
AN
|
130
|
|
|
12
|
Plan Effective Date
|
O
|
AN
|
8
|
YYYYMMDD
|
|
13
|
Plan Expiration Date
|
NU
|
AN
|
8
|
Not used
|
|
14
|
Authorization Information
|
O
|
AN
|
55
|
|
|
15
|
Plan Type
|
O
|
AN
|
3
|
|
|
16
|
Name Of Insured
|
O
|
AN
|
48
|
|
|
17
|
Insured's Relationship To Patient
|
O
|
AN
|
2
|
|
|
18
|
Insured's Date Of Birth
|
O
|
AN
|
8
|
YYYYMMDD
|
|
19
|
Insured's Address
|
O
|
AN
|
106
|
Address1^Address2^
City^State^Zip
|
|
20
|
Assignment Of Benefits
|
NU
|
AN
|
2
|
Not used
|
|
21
|
Coordination Of Benefits
|
NU
|
AN
|
2
|
Not used
|
|
22
|
Coord. Of Ben. Priority
|
NU
|
AN
|
2
|
Not used
|
|
23
|
Notice Of Admission Flag
|
NU
|
AN
|
2
|
Not used
|
|
24
|
Notice Of Admission Date
|
NU
|
AN
|
8
|
Not used
|
|
25
|
Report Of Eligibility Flag
|
NU
|
AN
|
2
|
Not used
|
|
26
|
Report Of Eligibility Date
|
NU
|
AN
|
8
|
Not used
|
|
27
|
Release Information Code
|
NU
|
AN
|
2
|
Not used
|
|
28
|
Pre-Admit Cert (PAC)
|
NU
|
AN
|
15
|
Not used
|
|
29
|
Verification Date/Time
|
NU
|
AN
|
26
|
Not used
|
|
30
|
Verification By
|
NU
|
AN
|
60
|
Not used
|
|
31
|
Type
Of Agreement Code |
NU
|
AN
|
2
|
Not
used |
|
32
|
Billing
Status |
O |
AN |
2 |
|
|
33
|
Lifetime
Reserve Days |
NU |
AN |
4 |
Not
used |
|
34
|
Delay
Before L.R. Day |
NU |
AN |
4 |
Not
used |
|
35
|
Company
Plan Code |
O |
AN |
8 |
|
|
36
|
Policy Number |
O |
AN |
15
|
|
|
37
|
Policy Deductible |
NU |
AN |
12
|
Not used |
|
38
|
Policy Limit - Amount |
NU |
AN |
12
|
Not used |
|
39
|
Policy Limit - Days |
NU |
AN |
4
|
Not used |
|
40
|
Room Rate - Semi-Private |
NU |
AN |
12
|
Not used |
|
41
|
Room Rate - Private |
NU |
AN |
12
|
Not used |
|
42
|
Insured's Employment Status |
O |
AN |
60
|
|
|
43
|
Insured's Sex |
O |
AN |
1
|
F – female, M – male, U – unknown |
|
44
|
Insured's Employer Address |
O |
AN |
106
|
Address1^Address2^ City^State^Zip |
|
45
|
Verification Status |
NU |
AN |
2
|
Not used |
|
46
|
Prior Insurance Plan ID |
NU |
AN |
8
|
Not used |
|
47
|
Coverage Type |
NU |
AN |
3
|
Not used |
|
48
|
Handicap |
NU |
AN |
2
|
Not used |
|
49
|
Insured's
ID Number |
O |
AN |
12
|
|
