| | | | | | | | | | | |
| | _Ref_ | Id | _________Element Name__________ | Req | Type | Min/Max | | |
| | EQ01 | 1365 | Service Type Code | C | ID | 1/2 | | |
| | | | Description: Code identifying the classification of service |
| | | | | Code | Name_______________________________ |
| | | | | 1 | Medical Care |
| | | | | 2 | Surgical |
| | | | | 3 | Consultation |
| | | | | 4 | Diagnostic X-Ray |
| | | | | 5 | Diagnostic Lab |
| | | | | 6 | Radiation Therapy |
| | | | | 7 | Anesthesia |
| | | | | 8 | Surgical Assistance |
| | | | | 9 | Other Medical |
| | | | | 10 | Blood Charges |
| | | | | 11 | Used Durable Medical Equipment |
| | | | | 12 | Durable Medical Equipment Purchase |
| | | | | 13 | Ambulatory Service Center Facility |
| | | | | 14 | Renal Supplies in the Home |
| | | | | 15 | Alternate Method Dialysis |
| | | | | 16 | Chronic Renal Disease (CRD) Equipment |
| | | | | 17 | Pre-Admission Testing |
| | | | | 18 | Durable Medical Equipment Rental |
| | | | | 19 | Pneumonia Vaccine |
| | | | | 20 | Second Surgical Opinion |
| | | | | 21 | Third Surgical Opinion |
| | | | | 22 | Social Work |
| | | | | 23 | Diagnostic Dental |
| | | | | 24 | Periodontics |
| | | | | 25 | Restorative |
| | | | | 26 | Endodontics |
| | | | | 27 | Maxillofacial Prosthetics |
| | | | | 28 | Adjunctive Dental Services |
| | | | | 30 | Health Benefit Plan Coverage |
| | | | | 32 | Plan Waiting Period |
| | | | | 33 | Chiropractic |
| | | | | 34 | Chiropractic Office Visits |
| | | | | 35 | Dental Care |
| | | | | 36 | Dental Crowns |
| | | | | 37 | Dental Accident |
| | | | | 38 | Orthodontics |
| | | | | 39 | Prosthodontics |
| | | | | 40 | Oral Surgery |
| | | | | 41 | Routine (Preventive) Dental |
| | | | | 42 | Home Health Care |
| | | | | 43 | Home Health Prescriptions |
| | | | | 44 | Home Health Visits |
| | | | | 45 | Hospice |
| | | | | 46 | Respite Care |
| | | | | 47 | Hospital |
| | | | | 48 | Hospital - Inpatient |
| | | | | 49 | Hospital - Room and Board |
| | | | | 50 | Hospital - Outpatient |
| | | | | 51 | Hospital - Emergency Accident |
| | | | | 52 | Hospital - Emergency Medical |
| | | | | 53 | Hospital - Ambulatory Surgical |
| | | | | 54 | Long Term Care |
| | | | | 55 | Major Medical |
| | | | | 56 | Medically Related Transportation |
| | | | | 57 | Air Transportation |
| | | | | 58 | Cabulance |
| | | | | 59 | Licensed Ambulance |
| | | | | 60 | General Benefits |
| | | | | 61 | In-vitro Fertilization |
| | | | | 62 | MRI/CAT Scan |
| | | | | 63 | Donor Procedures |
| | | | | 64 | Acupuncture |
| | | | | 65 | Newborn Care |
| | | | | 66 | Pathology |
| | | | | 67 | Smoking Cessation |
| | | | | 68 | Well Baby Care |
| | | | | 69 | Maternity |
| | | | | 70 | Transplants |
| | | | | 71 | Audiology Exam |
| | | | | 72 | Inhalation Therapy |
| | | | | 73 | Diagnostic Medical |
| | | | | 74 | Private Duty Nursing |
| | | | | 75 | Prosthetic Device |
| | | | | 76 | Dialysis |
| | | | | 77 | Otological Exam |
| | | | | 78 | Chemotherapy |
| | | | | 79 | Allergy Testing |
| | | | | 80 | Immunizations |
| | | | | 81 | Routine Physical |
| | | | | 82 | Family Planning |
| | | | | 83 | Infertility |
| | | | | 84 | Abortion |
| | | | | 85 | AIDS |
| | | | | 86 | Emergency Services |
| | | | | 87 | Cancer |
| | | | | 88 | Pharmacy |
| | | | | 89 | Free Standing Prescription Drug |
| | | | | 90 | Mail Order Prescription Drug |
| | | | | 91 | Brand Name Prescription Drug |
| | | | | 92 | Generic Prescription Drug |
| | | | | 93 | Podiatry |
| | | | | 94 | Podiatry - Office Visits |
| | | | | 95 | Podiatry - Nursing Home Visits |
| | | | | 96 | Professional (Physician) |
| | | | | 97 | Anesthesiologist |
| | | | | 98 | Professional (Physician) Visit - Office |
| | | | | 99 | Professional (Physician) Visit - Inpatient |
| | | | | A0 | Professional (Physician) Visit - Outpatient |
| | | | | A1 | Professional (Physician) Visit - Nursing Home |
| | | | | A2 | Professional (Physician) Visit - Skilled Nursing Facility |
| | | | | A3 | Professional (Physician) Visit - Home |
| | | | | A4 | Psychiatric |
| | | | | A5 | Psychiatric - Room and Board |
| | | | | A6 | Psychotherapy |
| | | | | A7 | Psychiatric - Inpatient |
| | | | | A8 | Psychiatric - Outpatient |
| | | | | A9 | Rehabilitation |
| | | | | AA | Rehabilitation - Room and Board |
| | | | | AB | Rehabilitation - Inpatient |
| | | | | AC | Rehabilitation - Outpatient |
| | | | | AD | Occupational Therapy |
| | | | | AE | Physical Medicine |
| | | | | AF | Speech Therapy |
| | | | | AG | Skilled Nursing Care |
| | | | | AH | Skilled Nursing Care - Room and Board |
| | | | | AI | Substance Abuse |
| | | | | AJ | Alcoholism |
| | | | | AK | Drug Addiction |
| | | | | AL | Vision (Optometry) |
| | | | | AM | Frames |
| | | | | AN | Routine Exam |
| | | | | AO | Lenses |
| | | | | AQ | Nonmedically Necessary Physical |
| | | | | | Description: These physicals are required by other entities e.g., insurance application, pilot license, employment or school |
| | | | | AR | Experimental Drug Therapy |
| | | | | BA | Independent Medical Evaluation |
| | | | | BB | Partial Hospitalization (Psychiatric) |
| | | | | BC | Day Care (Psychiatric) |
| | | | | BD | Cognitive Therapy |
| | | | | BE | Massage Therapy |
| | | | | BF | Pulmonary Rehabilitation |
| | | | | BG | Cardiac Rehabilitation |
| | | | | BH | Pediatric |
| | | | | BI | Nursery |
| | | | | BJ | Skin |
| | | | | BK | Orthopedic |
| | | | | BL | Cardiac |
| | | | | BM | Lymphatic |
| | | | | BN | Gastrointestinal |
| | | | | BP | Endocrine |
| | | | | BQ | Neurology |
| | | | | BR | Eye |
| | | | | BS | Invasive Procedures |
| | EQ02 | C003 | Composite Medical Procedure Identifier | C | Comp | | | |
| | | | Description: To identify a medical procedure by its standardized codes and applicable modifiers |
| | | 235 | Product/Service ID Qualifier | M | ID | 2/2 | | |
| | | | Description: Code identifying the type/source of the descriptive number used in Product/Service ID (234) |
| | | | | Code | Name_______________________________ |
| | | | | AD | American Dental Association Codes |
| | | | | | Description: This association's membership consists of U.S. dentists. It sets standards for the dental profession |
| | | | | CJ | Current Procedural Terminology (CPT) Codes |
| | | | | | Description: Published by the AMA. It is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians; the uniform language accurately designates medical, surgical, and diagnostic services, and thereby provides reliable communications among physicians, patients, and payers |
| | | | | HC | Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes |
| | | | | | Description: HCFA coding scheme to group procedure(s) performed on an outpatient basis for payment to hospital under Medicare; primarily used for ambulatory surgical and other diagnostic departments |
| | | | | ID | International Classification of Diseases Clinical Modification (ICD-9-CM) - Procedure |
| | | | | | Description: The International Classification of Diseases, Clinical Modification, is designated for the classification of morbidity and mortality information for statistical purposes and for the indexing of hospital records by disease and operations, for data storage and retrieval; this is a procedure code |
| | | | | IV | Home Infusion EDI Coalition (HIEC) Product/Service Code |
| | | | | ND | National Drug Code (NDC) |
| | | | | ZZ | Mutually Defined |
| | | 234 | Product/Service ID | M | AN | 1/48 | | |
| | | | Description: Identifying number for a product or service |
| | | 1339 | Procedure Modifier | O | AN | 2/2 | | |
| | | | Description: This identifies special circumstances related to the performance of the service, as defined by trading partners |
| | | 1339 | Procedure Modifier | O | AN | 2/2 | | |
| | | | Description: This identifies special circumstances related to the performance of the service, as defined by trading partners |
| | | 1339 | Procedure Modifier | O | AN | 2/2 | | |
| | | | Description: This identifies special circumstances related to the performance of the service, as defined by trading partners |
| | | 1339 | Procedure Modifier | O | AN | 2/2 | | |
| | | | Description: This identifies special circumstances related to the performance of the service, as defined by trading partners |
| | EQ03 | 1207 | Coverage Level Code | O | ID | 3/3 | | |
| | | | Description: Code indicating the level of coverage being provided for this insured |
| | | | | Code | Name_______________________________ |
| | | | | CHD | Children Only |
| | | | | DEP | Dependents Only |
| | | | | ECH | Employee and Children |
| | | | | EMP | Employee Only |
| | | | | ESP | Employee and Spouse |
| | | | | FAM | Family |
| | | | | IND | Individual |
| | | | | SPC | Spouse and Children |
| | | | | SPO | Spouse Only |
| | EQ04 | 1336 | Insurance Type Code | O | ID | 1/3 | | |
| | | | Description: Code identifying the type of insurance policy within a specific insurance program |
| | | | | Code | Name_______________________________ |
| | | | | AP | Auto Insurance Policy |
| | | | | C1 | Commercial |
| | | | | CO | Consolidated Omnibus Budget Reconciliation Act (COBRA) |
| | | | | GP | Group Policy |
| | | | | | Description: Two or more people who are part of complete unit who enter into an insurance contract with an insurance company |
| | | | | HM | Health Maintenance Organization (HMO) |
| | | | | IP | Individual Policy |
| | | | | OT | Other |
| | | | | PR | Preferred Provider Organization (PPO) |
| | | | | PS | Point of Service (POS) |
| | | | | SP | Supplemental Policy |
| | | | | | Description: An insurance policy intended to cover non-covered charges of another insurance policy |
| | | | | WC | Workers Compensation |
| | | | | | Description: Coverage provides medical treatment, rehabilitation, lost wages and related expenses arising from a job related injury or disease |
