| | | | | | | | | | | |
| | _Ref_ | Id | _________Element Name__________ | Req | Type | Min/Max | | |
| | SBR01 | 1138 | Payer Responsibility Sequence Number Code | M | ID | 1/1 | | |
| | | | Description: Code identifying the insurance carrier's level of responsibility for a payment of a claim |
| | | | | Code | Name_______________________________ |
| | | | | P | Primary |
| | | | | S | Secondary |
| | | | | T | Tertiary |
| | SBR02 | 1069 | Individual Relationship Code | O | ID | 2/2 | | |
| | | | Description: Code indicating the relationship between two individuals or entities |
| | | | | Code | Name_______________________________ |
| | | | | 18 | Self |
| | SBR03 | 127 | Reference Identification | O | AN | 1/30 | | |
| | | | Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier |
| | SBR04 | 93 | Name | O | AN | 1/60 | | |
| | | | Description: Free-form name |
| | SBR05 | 1336 | Insurance Type Code | O | ID | 1/3 | | |
| | | | Description: Code identifying the type of insurance policy within a specific insurance program |
| | | | | Code | Name_______________________________ |
| | | | | 12 | Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan |
| | | | | 13 | Medicare Secondary End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan |
| | | | | 14 | Medicare Secondary, No-fault Insurance including Auto is Primary |
| | | | | 15 | Medicare Secondary Worker's Compensation |
| | | | | 16 | Medicare Secondary Public Health Service (PHS)or Other Federal Agency |
| | | | | 41 | Medicare Secondary Black Lung |
| | | | | 42 | Medicare Secondary Veteran's Administration |
| | | | | 43 | Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) |
| | | | | 47 | Medicare Secondary, Other Liability Insurance is Primary |
| | SBR09 | 1032 | Claim Filing Indicator Code | O | ID | 1/2 | | |
| | | | Description: Code identifying type of claim |
| | | | | Code | Name_______________________________ |
| | | | | 09 | Self-pay |
| | | | | 10 | Central Certification |
| | | | | 11 | Other Non-Federal Programs |
| | | | | 12 | Preferred Provider Organization (PPO) |
| | | | | 13 | Point of Service (POS) |
| | | | | 14 | Exclusive Provider Organization (EPO) |
| | | | | 15 | Indemnity Insurance |
| | | | | 16 | Health Maintenance Organization (HMO) Medicare Risk |
| | | | | AM | Automobile Medical |
| | | | | BL | Blue Cross/Blue Shield |
| | | | | CH | Champus |
| | | | | CI | Commercial Insurance Co. |
| | | | | DS | Disability |
| | | | | HM | Health Maintenance Organization |
| | | | | LI | Liability |
| | | | | LM | Liability Medical |
| | | | | MB | Medicare Part B |
| | | | | MC | Medicaid |
| | | | | OF | Other Federal Program |
| | | | | TV | Title V |
| | | | | VA | Veteran Administration Plan |
| | | | | WC | Workers' Compensation Health Claim |
| | | | | ZZ | Mutually Defined |
