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_Ref_ |
Id |
_________Element Name__________ |
Req |
Type |
Min/Max |
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SBR01 |
1138 |
Payer Responsibility Sequence Number Code |
M |
ID |
1/1 |
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Description: Code identifying the insurance carrier's level of responsibility for a payment of a claim |
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Code |
Name_______________________________ |
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P |
Primary |
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S |
Secondary |
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T |
Tertiary |
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SBR02 |
1069 |
Individual Relationship Code |
O |
ID |
2/2 |
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Description: Code indicating the relationship between two individuals or entities |
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Code |
Name_______________________________ |
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18 |
Self |
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SBR03 |
127 |
Reference Identification |
O |
AN |
1/30 |
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Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier |
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SBR04 |
93 |
Name |
O |
AN |
1/60 |
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Description: Free-form name |
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SBR06 |
1143 |
Coordination of Benefits Code |
O |
ID |
1/1 |
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Description: Code identifying whether there is a coordination of benefits |
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Code |
Name_______________________________ |
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1 |
Coordination of Benefits |
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Description: A method of integrating benefits payable under more than one group health insurance plan so that the insured's benefits from all sources do not exceed 100 percent of the allowable medical expenses |
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6 |
No Coordination of Benefits |
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SBR09 |
1032 |
Claim Filing Indicator Code |
O |
ID |
1/2 |
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Description: Code identifying type of claim |
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Code |
Name_______________________________ |
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09 |
Self-pay |
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11 |
Other Non-Federal Programs |
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12 |
Preferred Provider Organization (PPO) |
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13 |
Point of Service (POS) |
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14 |
Exclusive Provider Organization (EPO) |
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15 |
Indemnity Insurance |
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16 |
Health Maintenance Organization (HMO) Medicare Risk |
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17 |
Dental Maintenance Organization |
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BL |
Blue Cross/Blue Shield |
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CH |
Champus |
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CI |
Commercial Insurance Co. |
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DS |
Disability |
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FI |
Federal Employees Program |
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HM |
Health Maintenance Organization |
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LM |
Liability Medical |
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MB |
Medicare Part B |
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MC |
Medicaid |
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MH |
Managed Care Non-HMO |
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OF |
Other Federal Program |
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SA |
Self-administered Group |
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VA |
Veteran Administration Plan |
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WC |
Workers' Compensation Health Claim |
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ZZ |
Mutually Defined |
