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| | _Ref_ | Id | _________Element Name__________ | Req | Type | Min/Max | | |
| | INS01 | 1073 | Yes/No Condition or Response Code | M | ID | 1/1 | | |
| | | | Description: Code indicating a Yes or No condition or response |
| | | | | Code | Name_______________________________ |
| | | | | N | No |
| | | | | Y | Yes |
| | INS02 | 1069 | Individual Relationship Code | M | ID | 2/2 | | |
| | | | Description: Code indicating the relationship between two individuals or entities |
| | | | | Code | Name_______________________________ |
| | | | | 01 | Spouse |
| | | | | 03 | Father or Mother |
| | | | | 04 | Grandfather or Grandmother |
| | | | | 05 | Grandson or Granddaughter |
| | | | | 06 | Uncle or Aunt |
| | | | | 07 | Nephew or Niece |
| | | | | 08 | Cousin |
| | | | | 09 | Adopted Child |
| | | | | 10 | Foster Child |
| | | | | 11 | Son-in-law or Daughter-in-law |
| | | | | 12 | Brother-in-law or Sister-in-law |
| | | | | 13 | Mother-in-law or Father-in-law |
| | | | | 14 | Brother or Sister |
| | | | | 15 | Ward |
| | | | | 17 | Stepson or Stepdaughter |
| | | | | 18 | Self |
| | | | | 19 | Child |
| | | | | | Description: Dependent between the ages of 0 and 19; age qualifications may vary depending on policy |
| | | | | 23 | Sponsored Dependent |
| | | | | | Description: Dependents between the ages of 19 and 25 not attending school; age qualifications may vary depending on policy |
| | | | | 24 | Dependent of a Minor Dependent |
| | | | | | Description: A child not legally of age who has been granted adult status |
| | | | | 25 | Ex-spouse |
| | | | | 26 | Guardian |
| | | | | | Description: An adult who is given legal responsibility for a child by the court |
| | | | | 31 | Court Appointed Guardian |
| | | | | 32 | Mother |
| | | | | 33 | Father |
| | | | | 38 | Collateral Dependent |
| | | | | | Description: Relative related by blood or marriage who resides in the home and is dependent on the insured for a major portion of their support |
| | | | | 48 | Stepfather |
| | | | | 49 | Stepmother |
| | | | | 53 | Life Partner |
| | INS03 | 875 | Maintenance Type Code | O | ID | 3/3 | | |
| | | | Description: Code identifying the specific type of item maintenance |
| | | | | Code | Name_______________________________ |
| | | | | 001 | Change |
| | | | | 021 | Addition |
| | | | | 024 | Cancellation or Termination |
| | | | | 025 | Reinstatement |
| | | | | | Description: To place in force again, without the usual probationary or service period, a group contract or an individual's group insurance that for some reason has terminated |
| | | | | 030 | Audit or Compare |
| | INS04 | 1203 | Maintenance Reason Code | O | ID | 2/3 | | |
| | | | Description: Code identifying the reason for the maintenance change |
| | | | | Code | Name_______________________________ |
| | | | | 01 | Divorce |
| | | | | 02 | Birth |
| | | | | 03 | Death |
| | | | | 04 | Retirement |
| | | | | 05 | Adoption |
| | | | | 06 | Strike |
| | | | | 07 | Termination of Benefits |
| | | | | 08 | Termination of Employment |
| | | | | 09 | Consolidation Omnibus Budget Reconciliation Act (COBRA) |
| | | | | | Description: A federal act that enables an insured, spouse, or dependent to continue benefits after a qualifying event which would otherwise cause them to lose their benefits |
| | | | | 10 | Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid |
| | | | | 11 | Surviving Spouse |
| | | | | 14 | Voluntary Withdrawal |
| | | | | 15 | Primary Care Provider (PCP) Change |
| | | | | 16 | Quit |
| | | | | 17 | Fired |
| | | | | 18 | Suspended |
| | | | | 20 | Active |
| | | | | 21 | Disability |
| | | | | | Description: A physical or mental condition that makes an insured incapable of performing one or more duties of his or her own occupation |
| | | | | 22 | Plan Change |
| | | | | 25 | Change in Identifying Data Elements |
| | | | | | Description: A change has been made to the primary elements that identify a specific employee. Such elements are first name, last name, social security number, date of birth, and employee identification number |
| | | | | 26 | Declined Coverage |
| | | | | 27 | Pre-Enrollment |
| | | | | 28 | Initial Enrollment |
| | | | | 29 | Benefit Selection |
| | | | | 31 | Legal Separation |
| | | | | 32 | Marriage |
| | | | | 33 | Personnel Data |
| | | | | | Description: General information about the participant |
| | | | | 37 | Leave of Absence with Benefits |
| | | | | 38 | Leave of Absence without Benefits |
| | | | | 39 | Lay Off with Benefits |
| | | | | 40 | Lay Off without Benefits |
| | | | | 41 | Re-enrollment |
| | | | | 43 | Change of Location |
| | | | | AI | No Reason Given |
| | | | | XN | Notification Only |
| | | | | XT | Transfer |
| | INS05 | 1216 | Benefit Status Code | O | ID | 1/1 | | |
| | | | Description: The type of coverage under which benefits are paid |
| | | | | Code | Name_______________________________ |
| | | | | A | Active |
| | | | | C | Consolidated Omnibus Budget Reconciliation Act (COBRA) |
| | | | | | Description: A federal act that enables an insured, spouse, or dependent to continue benefits after a qualifying event which would otherwise cause them to lose their benefits |
| | | | | S | Surviving Insured |
| | | | | T | Tax Equity and Fiscal Responsibility Act (TEFRA) |
| | INS06 | 1218 | Medicare Plan Code | O | ID | 1/1 | | |
| | | | Description: Code identifying the Medicare Plan |
| | | | | Code | Name_______________________________ |
| | | | | A | Medicare Part A |
| | | | | | Description: Portion of Medicare bill involving patient's hospital stay; hospital insurance |
| | | | | B | Medicare Part B |
| | | | | | Description: Portion of Medicare bill involving charges by doctor, or other non hospital related services |
| | | | | C | Medicare Part A and B |
| | | | | D | Medicare |
| | | | | | Description: Federal program to pay the medical expenses of those people who are 65 years or older, are disabled to the extent that they receive other Social Security benefits, dependents of deceased Social Security recipients under the age of 21, and chronic renal disease patients |
| | | | | E | No Medicare |
| | INS07 | 1219 | Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code | O | ID | 1/2 | | |
| | | | Description: A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary |
| | | | | Code | Name_______________________________ |
| | | | | 1 | Termination of Employment |
| | | | | | Description: The termination or reduction in hours of the employee's employment, excluding termination due to gross misconduct. Maximum coverage period is 18 months |
| | | | | 2 | Reduction of work hours |
| | | | | | Description: The termination or reduction in hours of the employee's employment, excluding termination due to gross misconduct. Maximum coverage period is 18 months |
| | | | | 3 | Medicare |
| | | | | | Description: The employee's entitlement to Medicare benefits. Dependents only qualify for continuation of coverage. Maximum coverage period is 36 months |
| | | | | 4 | Death |
| | | | | | Description: Death of the employee. Maximum coverage period is 36 months |
| | | | | 5 | Divorce |
| | | | | | Description: Divorce or legal separation of the employee from his or her spouse. Maximum coverage period is 36 months |
| | | | | 6 | Separation |
| | | | | | Description: Divorce or legal separation of the employee from his or her spouse. Maximum coverage period is 36 months |
| | | | | 7 | Ineligible Child |
| | | | | | Description: A dependent child ceases to qualify as a dependent child under the plan's dependent definition. Maximum coverage period is 36 months |
| | | | | 8 | Bankruptcy of a Retired Employee |
| | INS08 | 584 | Employment Status Code | O | ID | 2/2 | | |
| | | | Description: Code showing the general employment status of an employee/claimant |
| | | | | Code | Name_______________________________ |
| | | | | AO | Active Military - Overseas |
| | | | | AU | Active Military - USA |
| | | | | FT | Full-time |
| | | | | L1 | Leave of Absence |
| | | | | PT | Part-time |
| | | | | RT | Retired |
| | | | | TE | Terminated |
| | INS09 | 1220 | Student Status Code | O | ID | 1/1 | | |
| | | | Description: Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured |
| | | | | Code | Name_______________________________ |
| | | | | F | Full-time |
| | | | | N | Not a Student |
| | | | | P | Part-time |
| | INS10 | 1073 | Yes/No Condition or Response Code | O | ID | 1/1 | | |
| | | | Description: Code indicating a Yes or No condition or response |
| | | | | Code | Name_______________________________ |
| | | | | N | No |
| | | | | Y | Yes |
| | INS11 | 1250 | Date Time Period Format Qualifier | C | ID | 2/3 | | |
| | | | Description: Code indicating the date format, time format, or date and time format |
| | | | | Code | Name_______________________________ |
| | | | | D8 | Date Expressed in Format CCYYMMDD |
| | INS12 | 1251 | Date Time Period | C | AN | 1/35 | | |
| | | | Description: Expression of a date, a time, or range of dates, times or dates and times |
| | INS17 | 1470 | Number | O | N0 | 1/9 | | |
| | | | Description: A generic number |
