Healthcare Leader X12 834 Benefit Enrollment and Maintenance

Healthcare Leader

3 schema elements found

This Draft Standard schema for Trial Use contains the format and data contents of the schema for use within the context of an Electronic Data Interchange (EDI) environment.

ISA

Interchange Control Header

MMax: 1

To start and identify an interchange of zero or more functional groups and interchange-related control segments

ISA01

Authorization Information Qualifier

MIDMIN 2 MAX 2ID: I01

Code identifying the type of information in the Authorization Information

ISA02

Authorization Information

MANMIN 10 MAX 10ID: I02

Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)

ISA03

Security Information Qualifier

MIDMIN 2 MAX 2ID: I03

Code identifying the type of information in the Security Information

ISA04

Security Information

MANMIN 10 MAX 10ID: I04

This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)

ISA05

Interchange ID Qualifier

MIDMIN 2 MAX 2ID: I05

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

ISA06

Interchange Sender ID

MANMIN 15 MAX 15ID: I06

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

ISA07

Interchange ID Qualifier

MIDMIN 2 MAX 2ID: I05

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

ISA08

Interchange Receiver ID

MANMIN 15 MAX 15ID: I07

Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

ISA09

Interchange Date

MDTMIN 6 MAX 6ID: I08

Date of the interchange

ISA10

Interchange Time

MTMMIN 4 MAX 4ID: I09

Time of the interchange

ISA11

Repetition Separator

MMIN 1 MAX 1ID: I65

Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator

ISA12

Interchange Control Version Number

MIDMIN 5 MAX 5ID: I11

Code specifying the version number of the interchange control segments

ISA13

Interchange Control Number

MN0MIN 9 MAX 9ID: I12

A control number assigned by the interchange sender

ISA14

Acknowledgment Requested

MIDMIN 1 MAX 1ID: I13

Code indicating sender's request for an interchange acknowledgment

ISA15

Interchange Usage Indicator

MIDMIN 1 MAX 1ID: I14

Code indicating whether data enclosed by this interchange envelope is test, production or information

ISA16

Component Element Separator

MMIN 1 MAX 1ID: I15

Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

GS

Functional Group Header

MMax: 1

To indicate the beginning of a functional group and to provide control information

GS01

Functional Identifier Code

MIDMIN 2 MAX 2ID: 479

Code identifying a group of application related transaction sets

GS02

Application Sender's Code

MANMIN 2 MAX 15ID: 142

Code identifying party sending transmission; codes agreed to by trading partners

GS03

Application Receiver's Code

MANMIN 2 MAX 15ID: 124

Code identifying party receiving transmission; codes agreed to by trading partners

GS04

Date

MDTMIN 8 MAX 8ID: 373

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

GS05

Time

MTMMIN 4 MAX 8ID: 337

Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

GS06

Group Control Number

MN0MIN 1 MAX 9ID: 28

Assigned number originated and maintained by the sender

GS07

Responsible Agency Code

MIDMIN 1 MAX 2ID: 455

Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480

GS08

Version / Release / Industry Identifier Code

MANMIN 1 MAX 12ID: 480

Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed

transactionSets

Loop: transactionSets

Transaction Set Header

MMax: 1Area: 1Seq: 0100

To indicate the start of a transaction set and to assign a control number

ST01

Transaction Set Identifier Code

MIDMIN 3 MAX 3ID: 143

Code uniquely identifying a Transaction Set

ST02

Transaction Set Control Number

MANMIN 4 MAX 9ID: 329

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

BGN

Beginning Segment

MMax: 1Area: 1Seq: 0200

To indicate the beginning of a transaction set

BGN01

Transaction Set Purpose Code

MIDMIN 2 MAX 2ID: 353

Code identifying purpose of transaction set

00Original

01Cancellation

02Add

03Delete

04Change

05Replace

08Status

BGN02

Reference Identification

MANMIN 1 MAX 50ID: 127

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

BGN03

Date

MDTMIN 8 MAX 8ID: 373

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

BGN04

Time

CTMMIN 4 MAX 8ID: 337

BGN05

Time Code

OIDMIN 2 MAX 2ID: 623

Code identifying the time. In accordance with International Standards Organization standard 8601, time can be specified by a + or - and an indication in hours in relation to Universal Time Coordinate (UTC) time; since + is a restricted character, + and - are substituted by P and M in the codes that follow

ATAlaska Time

CTCentral Time

ETEastern Time

LTLocal Time

MTMountain Time

NTNewfoundland Time

PTPacific Time

TTAtlantic Time

UTUniversal Time Coordinate

BGN06

Reference Identification

OANMIN 1 MAX 50ID: 127

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

BGN07

Transaction Type Code

OIDMIN 2 MAX 2ID: 640

Code specifying the type of transaction

BGN08

Action Code

OIDMIN 1 MAX 2ID: 306

Code indicating type of action

4Verify

3Delete

1Add

2Change (Update)

0Authorize

FFinal

RXReplace

AEActivate

BGN09

Security Level Code

OIDMIN 2 MAX 2ID: 786

Code indicating the level of confidentiality assigned by the sender to the information following

00Company Non-Classified

01Company Internal Use Only

02Company Confidential

03Company Confidential, Restricted (Need to Know)

04Company Registered (Signature Required)

05Personal

06Supplier Proprietary

09Company Defined (Trading Partner Level)

11Competition Sensitive

20Court Restricted

21Juvenile Record Restricted

90Government Non-Classified

92Government Confidential

93Government Secret

94Government Top Secret

99Government Defined (Trading Partner Level)

ZZMutually Defined

REF

Reference Information

OMax: >1Area: 1Seq: 0300

To specify identifying information

REF01

Reference Identification Qualifier

MIDMIN 2 MAX 3ID: 128

Code qualifying the Reference Identification

38Master Policy Number

66Previous Policy Number

69Dental Insurance Policy Number

A4Disability Insurance Policy Number

0KPolicy Form Identifying Number

1LGroup or Policy Number

24Short-term Disability Policy Number

2CLong-term Disability Policy Number

A8Flexible Spending Account (FSA) Insurance Policy Number

AZHealth Insurance Policy Number

B7Life Insurance Policy Number

BARetirement Plan Policy Number

IGInsurance Policy Number

NWAssociated Policy Number

TYPolicy Type

AAHOption Policy Number

ABCPolicy Link Number

ALJTitle Policy Number

ABDSecondary Policy Number

POLPolicy Number

G3Predetermination of Benefits Identification Number

REF02

Reference Identification

CANMIN 1 MAX 50ID: 127

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF03

Description

CANMIN 1 MAX 80ID: 352

A free-form description to clarify the related data elements and their content

DTP

Date or Time or Period

OMax: >1Area: 1Seq: 0400

To specify any or all of a date, a time, or a time period

DTP01

Date/Time Qualifier

MIDMIN 3 MAX 3ID: 374

Code specifying type of date or time, or both date and time

007Effective

DTP02

Date Time Period Format Qualifier

MIDMIN 2 MAX 3ID: 1250

Code indicating the date format, time format, or date and time format

D8Date Expressed in Format CCYYMMDD

DTP03

Date Time Period

MANMIN 1 MAX 35ID: 1251

Expression of a date, a time, or range of dates, times or dates and times

Loop: N1_loop

Repeat: >1

Party Identification

MMax: 1Area: 1Seq: 0700

To identify a party by type of organization, name, and code

N101

Entity Identifier Code

MIDMIN 2 MAX 3ID: 98

Code identifying an organizational entity, a physical location, property or an individual

00Alternate Insurer

70Prior Incorrect Insured

74Corrected Insured

D2Commercial Insurer

G0Dependent Insured

GBOther Insured

GKPrevious Insured

GMSpouse Insured

GQProposed Insured

GRReinsurer

IGInsolvent Insurer

ILInsured or Subscriber

INInsurer

IRSelf Insured

NINon-insured

P2Primary Insured or Subscriber

ACIInsured Location

BEBeneficiary

GOPrimary Beneficiary

ENREnroller

P5Plan Sponsor

TVThird Party Administrator (TPA)

N102

Name

CANMIN 1 MAX 60ID: 93

Free-form name

N103

Identification Code Qualifier

CIDMIN 1 MAX 2ID: 66

Code designating the system/method of code structure used for Identification Code (67)

FIFederal Taxpayer's Identification Number

34Social Security Number

43Alternate Social Security Number

21Health Industry Number (HIN)

C2Health Maintenance Organization (HMO) Provider Number

CICHAMPUS (Civilian Health and Medical Program of the Uniformed Services) Identification Number

HNHealth Insurance Claim (HIC) Number

IIStandard Unique Health Identifier for each Individual in the United States

N104

Identification Code

CANMIN 2 MAX 80ID: 67

Code identifying a party or other code

Party Location

OMax: 2Area: 1Seq: 0900

To specify the location of the named party

N301

Address Information

MANMIN 1 MAX 55ID: 166

Address information

N302

Address Information

OANMIN 1 MAX 55ID: 166

Address information

Geographic Location

OMax: 1Area: 1Seq: 1000

To specify the geographic place of the named party

N401

City Name

OANMIN 2 MAX 30ID: 19

Free-form text for city name

N402

State or Province Code

CIDMIN 2 MAX 2ID: 156

Code (Standard State/Province) as defined by appropriate government agency

N403

Postal Code

OIDMIN 3 MAX 15ID: 116

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N404

Country Code

CIDMIN 2 MAX 3ID: 26

Code identifying the country

Loop: INS_loop

Repeat: >1

INS

Insured Benefit

OMax: 1Area: 2Seq: 0100

To provide benefit information on insured entities

INS01

Yes/No Condition or Response Code

MIDMIN 1 MAX 1ID: 1073

Code indicating a Yes or No condition or response

NNo

UUnknown

WNot Applicable

YYes

INS02

Individual Relationship Code

MIDMIN 2 MAX 2ID: 1069

Code indicating the relationship between two individuals or entities

01Spouse

02Son or Daughter

03Father or Mother

04Grandfather or Grandmother

05Grandson or Granddaughter

06Uncle or Aunt

07Nephew or Niece

08Cousin

09Adopted Child

10Foster Child

14Brother or Sister

18Self

19Child

20Employee

21Unknown

22Handicapped Dependent

23Sponsored Dependent

24Dependent of a Minor Dependent

26Guardian

32Mother

33Father

34Other Adult

62Brother

74Daughter

B5Partner

C1Son

B7Sister

D2Trustee

G4Insured

G9Other Relative

ZZMutually Defined

INS03

Maintenance Type Code

OIDMIN 3 MAX 3ID: 875

Code identifying the specific type of item maintenance

001Change

002Delete

003Add Full Item Detail

004Withdraw Item (Temporary)

005Restore Item

006Membership Type

007Purchase Eligibility

008Verified

009Not Verified

010Periodic Report

011All Items Refresh

012Medical Noncompliance

013Administrative Noncompliance

014Suspended Pending Settlement Approval

015Suspended Pending Appeal or Judicial Review

016Injury Report Creation

017Illness Report Creation

018Transfer of Beneficial Rights

019Record Security Instrument

020Assignment

021Addition

022Change in Status

023Change in Rate Factors

024Cancellation or Termination

025Reinstatement

026Correction

028Policy Adjustment

029Inquiry

030Audit or Compare

031Medical Examination Authorization

032Employee Information Not Applicable

033Release of Interim Funding Interest

050Original

051Denial

052Initial Payment

053Change in Benefit Amount

054Change in Benefit Type

055Reinstatement of Benefit

056Reduced Earnings

057Final

059Suspension Medically Determined or Qualified to Return to Work

060Non-compliance of Medical Requirements

061Non-compliance of Administrative Requirements

062Compensable Death

063Incarceration

064Claimant's Whereabouts Unknown

065Volunteer

066Status Request

067Benefits Exhausted

068Jurisdictional Change

069Payment Notification

070Status Request Response

071Re-issue Identification Card(s)

072Suspension Due to Claimant Death

073Partial Denial

074Partial Suspension, Returned to Work, or Medically Determined or Qualified to Return to Work

075Partial Suspension, Medical Non-compliance

076Partial Suspension, Administrative Non-compliance

077Partial Suspension, Claimant Death

078Partial Suspension, Incarceration

079Partial Suspension, Claimant's whereabouts Unknown

080Partial Suspension, Benefits Exhausted

081Partial Suspension, Jurisdiction Change

082Partially Suspended, Benefits Pending Settlement Approval

083Partially Suspended, Pending Appeal or Judicial Review

084Lump Sum Benefit Payment

085Suspension Denial

100Sale of Mortgage Change

101Servicer Change

102Mortgagor Change

104Prepayment Termination

105Non-conveyance Termination

106Voluntary Action Termination

107Loan Refinanced Termination

108Transfer Due to Interest and Servicing Sold

109Retain Servicing

110Transfer Servicing

111Assign Servicing

112Servicer Loan Number Change

113Merger

114Acquisition

115Receivership

116Loan Maturity Maintenance

117Binder

118New Policy

119Renewal Policy

123Canceled by Administrator

124Canceled by Insured

125Re-Write

126Non-renewal

127Termination of All Endorsements

128Termination of Lessor Interest

129Termination of Additional Insured Interest

130Termination of Lienholder or Loss Payee

131Addition of Lessor Endorsement

132Addition of Lienholder Endorsement

133Addition of Additional Insured Endorsement

134Change of Lessor Endorsement

135Change of Lienholder Endorsement

136Change of Additional Insured Endorsement

137Acquired Unallocated

138Acquired Payment

139Investigation Pending

140Concurrent Benefit

141Abbreviated First Report on an Acquired Claim

142Employer Paid

143Employer Reinstatement

144Suspension Directed by Agency

145Occupational Safety and Health Administration Injury and Illness Log (OSHA-300)

146Occupational Injury Survey

147Bureau of Labor and Statistics Survey

148First Payment on an Acquired Claim

149First Report on an Acquired Claim

150Impairment Report

151Return to Work Report

152Office of Workers Compensation Program Injury Claim Report (OWCP CA-1)

153Office of Workers Compensation Program Illness Claim Report (OWCP CA-2)

154Occupational Safety and Health Administration Injury and Illness Record (OSHA-301)

155First Aid Injury Only

CEPChange Excluding Price

PRIPrice Change Only

TBVTo Be Verified

ZZZMutually Defined

INS04

Maintenance Reason Code

OIDMIN 2 MAX 3ID: 1203

Code identifying the reason for the maintenance change

01Divorce

02Birth

03Death

04Retirement

05Adoption

06Strike

07Termination of Benefits

08Termination of Employment

09Consolidation Omnibus Budget Reconciliation Act (COBRA)

10Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid

11Surviving Spouse

12Lay Off

13Leave of Absence

14Voluntary Withdrawal

15Primary Care Provider (PCP) Change

16Quit

17Fired

18Suspended

19Sabbatical

20Active

21Disability

22Plan Change

23Furloughed

24Resigned

25Change in Identifying Data Elements

26Declined Coverage

27Pre-Enrollment

28Initial Enrollment

29Benefit Selection

30Discrimination Test

31Legal Separation

32Marriage

33Personnel Data

34Investment Elections and Contribution Rates

35Loan Repayment

36Contribution or Plan Allocation

37Leave of Absence with Benefits

38Leave of Absence without Benefits

39Lay Off with Benefits

40Lay Off without Benefits

41Re-enrollment

42New Entity

43Change of Location

44Change of Telephone Number

45Went Out of Business

46Current Customer Information File in Error

47Account Balance Reporting

48Fees Processing

49Interfund Transfer

4ABusiness Name Change

4BBusiness Name Correction

4CPhysical or Mailing Address Correction

50Loan Request

51Enrollment in Subsequent Benefit Plan

52Health Care Facility Change

53Name Synonym Add

54Sub Location Add

55Sub Location Change

56Sub Location Expire

57Buyout

58Merger

59Non Payment

60Coverage Placed Elsewhere

61Duplicate Coverage

62Change in Ownership

63Business Sold

64Underwriting Reason

65No Employees, Exposure or Operations

66Revocation of Voluntary Market Acceptance

67Include Primary Business Management

68Exclude Primary Business Management

69Failure to Pay Deductible

70Misrepresented Information

71Rewritten

72Adding a Jurisdiction

73Deleting a Jurisdiction

75Occupational Illness

76Change Insured Federal Employer Identification Number (FEIN)

77Change Employer Federal Employer Identification Number (FEIN)

78Change Employer Unemployment Insurance (UI) Code

79Change Policy Number

80Modification without a Specific Operating Unit Location in Jurisdiction

81Change Policy Effective Date

82Change Policy Expiration Date

83Change Insurer Federal Employer Identification Number (FEIN)

84No Eligible Employees

85Reinstatement - Canceled in Error

86Change in Insured Information

87Change in Employer Information

88Parent Identification Change

89Change to Expiration Date

90Phone Verify Only

91Name Synonym Delete

92Duplicate Entry on Customer Identification File

93Removal of the Customer Identification File Merge ID

94Removal of the Customer Identification File Buyout ID

95Removal of the Customer Identification File in Error ID

96Re-activation of an Out-of-Business Customer

97Sub-location Reinstatement

AADissatisfaction with Office Staff

ABDissatisfaction with Medical Care/Services Rendered

ACInconvenient Office Location

ADDissatisfaction with Office Hours

AEUnable to Schedule Appointments in a Timely Manner

AFDissatisfaction with Physician's Referral Policy

AGLess Respect and Attention Time Given than to Other Patients

AHPatient Moved to a New Location

AINo Reason Given

AJAppointment Times not Met in a Timely Manner

ALAlgorithm Assigned Benefit Selection

ECMember Benefit Selection

XBBecame Medical Only

XIIndemnity

XLBecame Lost Time

XMMedical Only

XNNotification Only

XTTransfer

ZZMutually Defined

INS05

Benefit Status Code

OIDMIN 1 MAX 1ID: 1216

The type of coverage under which benefits are paid

AActive

CConsolidated Omnibus Budget Reconciliation Act (COBRA)

IInvoluntary

SSurviving Insured

TTax Equity and Fiscal Responsibility Act (TEFRA)

VVoluntary

INS07

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code

OIDMIN 1 MAX 2ID: 1219

A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary

1Termination of Employment

2Reduction of work hours

3Medicare

4Death

5Divorce

6Separation

7Ineligible Child

8Bankruptcy of Retiree's Former Employer (26 U.S.C. 4980B(f)(3)(F))

9Layoff

10Leave of Absence

ZZMutually Defined

INS08

Employment Status Code

OIDMIN 2 MAX 2ID: 584

Code showing the general employment status of an employee/claimant

00Substitute

AALeave of Absence with Pay

ABLeave of Absence without Pay

ACActive

ADApprenticeship Full-time

AEActive Reserve

AFFlexible Work Plan

AGAlerted

AHAssigned

AIAffiliated with Outside Organization

AJAdjunct

AOActive Military - Overseas

APApprenticeship Part-time

AQApprenticeship

ASAcademy Student

ATPresidential Appointee

AUActive Military - USA

CANon-applicable Employment Status Category

CCContractor

COConsolidated Omnibus Budget Reconciliation Act (COBRA)

CTContinued

DCDischarged or Terminated for Cause

DDDishonorably Discharged

DIDeceased

DQDisqualified: Medical or Physical Condition

DRDisqualified: Other

DSDisabled

EOEmployed by Outside Organization

FAFurloughed: Job Abolished, Force Reduction

FBFurloughed: Bumped or Displaced

FCFurloughed: Facility Closed

FOFurloughed: Other

FTFull-time

HDHonorably Discharged

IAInactive

IRInactive Reserves

L1Leave of Absence

L2Administrative Leave of Absence

L3Annual Leave of Absence

L4Leave of Absence due to Bereavement

L5Jury Duty

L6Suspension

L7Sabbatical Leave of Absence

LALeave of Absence: Personal

LELeave of Absence: Education

LFLeave of Absence: Family Medical Leave Act (FMLA)

LMLeave of Absence: Maternity

LOLeave of Absence for Non-Military Government Request Other Than Jury Duty

LSLeave of Absence: Sickness

LULeave of Absence: Union

LWLeave of Absence: Without Permission, Unauthorized

LXLeave of Absence: Military

NENot Employed

OSOn Strike

OTOther

PAPromoted

PCPart-time Contractual

PEPlan to Enlist

PMPermanent

PNPart-time Noncontractual

PRProbationary

PTPart-time

PVPrevious

PWPiece Worker

RAResigned: Retired

RBRelocated

RCReassigned

RDResigned: Moved

RERecommissioned

RIResigned: Injury

RMRetired Military - Overseas

RPResigned: Personal Reasons

RRRetired Without Recall

RTRetired

RURetired Military - USA

RWDual Retired Status

SAResigned: Accepted Separation Allowance

SBSeparated

SESelf-Employed

SLSeasonal

SUSuspended

TETerminated

TFTemporary Full-Time

TMTemporary

TNTenured

TPTemporary Part-Time

TRTransferred

UKUnknown

VOVolunteer

XDExtra Duties Not Requiring Certification

ZZMutually Defined

INS09

Student Status Code

OIDMIN 1 MAX 1ID: 1220

Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured

FFull-time

NNot a Student

PPart-time

INS10

Yes/No Condition or Response Code

OIDMIN 1 MAX 1ID: 1073

Code indicating a Yes or No condition or response

NNo

UUnknown

WNot Applicable

YYes

INS11

Date Time Period Format Qualifier

CIDMIN 2 MAX 3ID: 1250

Code indicating the date format, time format, or date and time format

D8Date Expressed in Format CCYYMMDD

INS12

Date Time Period

CANMIN 1 MAX 35ID: 1251

Expression of a date, a time, or range of dates, times or dates and times

INS13

Confidentiality Code

OIDMIN 1 MAX 1ID: 1165

Code indicating the access to insured information

INS14

City Name

OANMIN 2 MAX 30ID: 19

Free-form text for city name

INS15

State or Province Code

OIDMIN 2 MAX 2ID: 156

Code (Standard State/Province) as defined by appropriate government agency

INS16

Country Code

OIDMIN 2 MAX 3ID: 26

Code identifying the country

INS17

Number

ON0MIN 1 MAX 9ID: 1470

A generic number

INS0601

Medicare Plan CodeCOMPOSITE

MIDMIN 1 MAX 1ID: 1218

Code identifying the Medicare Plan

Medicare Status Code

To provide Medicare coverage and associated reason for Medicare eligibility

AMedicare Part A

BMedicare Part B

CMedicare Part A and B

DMedicare

ENo Medicare

INS0602

Eligibility Reason CodeCOMPOSITE

OIDMIN 1 MAX 1ID: 1701

Code specifying reason for eligibility

Medicare Status Code

To provide Medicare coverage and associated reason for Medicare eligibility

0Age

1Disability

2End Stage Renal Disease (ESRD)

INS0603

Eligibility Reason CodeCOMPOSITE

OIDMIN 1 MAX 1ID: 1701

Code specifying reason for eligibility

Medicare Status Code

To provide Medicare coverage and associated reason for Medicare eligibility

0Age

1Disability

2End Stage Renal Disease (ESRD)

INS0604

Eligibility Reason CodeCOMPOSITE

OIDMIN 1 MAX 1ID: 1701

Code specifying reason for eligibility

Medicare Status Code

To provide Medicare coverage and associated reason for Medicare eligibility

0Age

1Disability

2End Stage Renal Disease (ESRD)

REF

Reference Information

MMax: >1Area: 2Seq: 0200

To specify identifying information

REF01

Reference Identification Qualifier

MIDMIN 2 MAX 3ID: 128

Code qualifying the Reference Identification

0FSubscriber Number

1LGroup or Policy Number

24Short-term Disability Policy Number

2CLong-term Disability Policy Number

38Master Policy Number

66Previous Policy Number

69Dental Insurance Policy Number

A4Disability Insurance Policy Number

A8Flexible Spending Account (FSA) Insurance Policy Number

AZHealth Insurance Policy Number

B7Life Insurance Policy Number

BARetirement Plan Policy Number

IGInsurance Policy Number

NWAssociated Policy Number

AAHOption Policy Number

ABCPolicy Link Number

ABDSecondary Policy Number

ALJTitle Policy Number

POLPolicy Number

23Client Number

4APersonal Identification Number (PIN)

6OCross Reference Number

ABBPersonal ID Number

D3National Council for Prescription Drug Programs Pharmacy Number

DXDepartment/Agency Number

F6Health Insurance Claim (HIC) Number

P5Position Code

Q4Prior Identifier Number

ZZMutually Defined

REF02

Reference Identification

CANMIN 1 MAX 50ID: 127

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF03

Description

CANMIN 1 MAX 80ID: 352

A free-form description to clarify the related data elements and their content

DTP

Date or Time or Period

OMax: >1Area: 2Seq: 0250

To specify any or all of a date, a time, or a time period

DTP01

Date/Time Qualifier

MIDMIN 3 MAX 3ID: 374

Code specifying type of date or time, or both date and time

286Retirement

437Spouse Retirement

348Benefit Begin

292Benefit

349Benefit End

290Coordination of Benefits

344Coordination of Benefits Begin

345Coordination of Benefits End

551Benefit Application Date

772Benefit Adjustment Start

775Benefit Adjustment End

777Benefit Adjustment Period

787Benefit Credit Period

788Benefit Transfer Period

846Benefits Paid

960Adjusted Death Benefit

984Benefit Period

ACFBenefit Type Gross Weekly Amount Effective

ACGBenefit Type Net Weekly Amount Effective

ACHBenefit Type Period Start

ACIBenefit Type Period End

ACJBenefit Debit Start

ACLBenefit Debit End

ACMBenefit Credit Start

ACOBenefit Transfer Start

ACNBenefit Credit End

ACPBenefit Transfer End

382Enrollment

300Enrollment Signature Date

366Plan Period Election

336Employment Begin

337Employment End

338Medicare Begin

339Medicare End

346Plan Begin

350Education Begin

354Illness Begin

356Eligibility Begin

358Cycle Begin

364Plan Period Election Begin

473Medicaid Begin

482Pregnancy Begin

485Injury Begin

091Report End

197End

353Primary Care Provider End

351Education End

347Plan End

357Eligibility End

355Illness End

359Cycle End

474Medicaid End

483Pregnancy End

486Injury End

979Policy Surrender

AEBMedicare Part A Eligibility End Date

AEFMedicare Part B Eligibility End Date

AEMEmployees Temporarily Laid Off End Period

340Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin

341Consolidated Omnibus Budget Reconciliation Act (COBRA) End

301Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event

383Adjusted Hire

DTP02

Date Time Period Format Qualifier

MIDMIN 2 MAX 3ID: 1250

Code indicating the date format, time format, or date and time format

D8Date Expressed in Format CCYYMMDD

DTP03

Date Time Period

MANMIN 1 MAX 35ID: 1251

Expression of a date, a time, or range of dates, times or dates and times

Loop: NM1_loop

Repeat: >1

NM1

Individual or Organizational Name

OMax: 1Area: 2Seq: 0300

To supply the full name of an individual or organizational entity

NM101

Entity Identifier Code

MIDMIN 2 MAX 3ID: 98

Code identifying an organizational entity, a physical location, property or an individual

00Alternate Insurer

74Corrected Insured

GBOther Insured

GMSpouse Insured

GKPrevious Insured

INInsurer

ILInsured or Subscriber

IRSelf Insured

NINon-insured

MRMedical Insurance Carrier

NM102

Entity Type Qualifier

MIDMIN 1 MAX 1ID: 1065

Code qualifying the type of entity

1Person

3Unknown

6Organization

NM103

Name Last or Organization Name

CANMIN 1 MAX 60ID: 1035

Individual last name or organizational name

NM104

Name First

OANMIN 1 MAX 35ID: 1036

Individual first name

NM105

Name Middle

OANMIN 1 MAX 25ID: 1037

Individual middle name or initial

NM106

Name Prefix

OANMIN 1 MAX 10ID: 1038

Prefix to individual name

NM107

Name Suffix

OANMIN 1 MAX 10ID: 1039

Suffix to individual name

NM108

Identification Code Qualifier

CIDMIN 1 MAX 2ID: 66

Code designating the system/method of code structure used for Identification Code (67)

34Social Security Number

FIFederal Taxpayer's Identification Number

TATaxpayer ID Number

47Tax Authority Identification

CInsured's Changed Unique Identification Number

NInsured's Unique Identification Number

C1Insured or Subscriber

HNHealth Insurance Claim (HIC) Number

NINational Association of Insurance Commissioners (NAIC) Identification

SBSocial Insurance Number

NM109

Identification Code

CANMIN 2 MAX 80ID: 67

Code identifying a party or other code

NM110

Entity Relationship Code

CIDMIN 2 MAX 2ID: 706

Code describing entity relationship

01Parent

02Child

12Member

22Sibling

41Spouse

67Self

NM111

Entity Identifier Code

OIDMIN 2 MAX 3ID: 98

Code identifying an organizational entity, a physical location, property or an individual

PER

Administrative Communications Contact

OMax: 1Area: 2Seq: 0400

To identify a person or office to whom administrative communications should be directed

PER01

Contact Function Code

MIDMIN 2 MAX 2ID: 366

Code identifying the major duty or responsibility of the person or group named

IPInsured Party

AIAdditional Insurance Information Contact

1BPreferred Provider Organization (PPO) Contact

1CHealth Maintenance Organization (HMO) Contact

SEService Organization

1GService Team

A1Claim Approver

PER02

Name

OANMIN 1 MAX 60ID: 93

Free-form name

PER03

Communication Number Qualifier

CIDMIN 2 MAX 2ID: 365

Code identifying the type of communication number

EMElectronic Mail

FXFacsimile

TETelephone

PER04

Communication Number

CANMIN 1 MAX 256ID: 364

Complete communications number including country or area code when applicable

PER05

Communication Number Qualifier

CIDMIN 2 MAX 2ID: 365

Code identifying the type of communication number

EMElectronic Mail

EXTelephone Extension

FXFacsimile

TETelephone

PER06

Communication Number

CANMIN 1 MAX 256ID: 364

Complete communications number including country or area code when applicable

PER07

Communication Number Qualifier

CIDMIN 2 MAX 2ID: 365

Code identifying the type of communication number

EMElectronic Mail

EXTelephone Extension

FXFacsimile

TETelephone

PER08

Communication Number

CANMIN 1 MAX 256ID: 364

Complete communications number including country or area code when applicable

Party Location

OMax: 1Area: 2Seq: 0500

To specify the location of the named party

N301

Address Information

MANMIN 1 MAX 55ID: 166

Address information

N302

Address Information

OANMIN 1 MAX 55ID: 166

Address information

Geographic Location

OMax: 1Area: 2Seq: 0600

To specify the geographic place of the named party

N401

City Name

OANMIN 2 MAX 30ID: 19

Free-form text for city name

N402

State or Province Code

CIDMIN 2 MAX 2ID: 156

Code (Standard State/Province) as defined by appropriate government agency

N403

Postal Code

OIDMIN 3 MAX 15ID: 116

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N404

Country Code

CIDMIN 2 MAX 3ID: 26

Code identifying the country

DMG

Demographic Information

OMax: 1Area: 2Seq: 0800

To supply demographic information

DMG01

Date Time Period Format Qualifier

CIDMIN 2 MAX 3ID: 1250

Code indicating the date format, time format, or date and time format

DMG02

Date Time Period

CANMIN 1 MAX 35ID: 1251

Expression of a date, a time, or range of dates, times or dates and times

DMG03

Gender Code

OIDMIN 1 MAX 1ID: 1068

Code indicating the sex of the individual

ANot Provided

BNot Applicable

FFemale

MMale

NNon-sexed

UUnknown

XUnsexable

DMG04

Marital Status Code

OIDMIN 1 MAX 1ID: 1067

Code defining the marital status of a person

ACommon Law

BRegistered Domestic Partner

CNot Applicable

DDivorced

ISingle

KUnknown

MMarried

RUnreported

SSeparated

UUnmarried (Single or Divorced or Widowed)

WWidowed

XLegally Separated

DMG06

Citizenship Status Code

OIDMIN 1 MAX 2ID: 1066

Code indicating citizenship status

1U.S. Citizen

2Non-Resident Alien

3Resident Alien

4Illegal Alien

5Alien

6U.S. Citizen - Non-Resident

7U.S. Citizen - Resident

8Citizen

9Non-citizen with Student Authorization

ANon-permanent Resident Alien

BPermanent Visa

CTemporary Visa

DWork Permit

ENordic Citizen

FNon-Nordic Citizen

GNaturalized Citizen

HEligible Non-citizen

IIneligible Non-citizen

DMG0501

Race or Ethnicity CodeCOMPOSITE

OIDMIN 1 MAX 1ID: 1109

Code indicating the racial or ethnic background of a person; it is normally self-reported; Under certain circumstances this information is collected for United States Government statistical purposes

Composite Race or Ethnicity Information

To send general and detailed information on race or ethnicity

7Not Provided

8Not Applicable

AAsian or Pacific Islander

BBlack

CCaucasian

DSubcontinent Asian American

EOther Race or Ethnicity

FAsian Pacific American

GNative American

HHispanic

IAmerican Indian or Alaskan Native

JNative Hawaiian

NBlack (Non-Hispanic)

OWhite (Non-Hispanic)

PPacific Islander

QBlack or African American (Office of Management and Budget 1997)

RHispanic or Latino (Office of Management and Budget 1997)

SWhite (Office of Management and Budget 1997)

TAmerican Indian or Alaska Native (Office of Management and Budget 1997)

UAsian (Office of Management and Budget 1997)

VNative Hawaiian or Other Pacific Islander (Office of Management and Budget 1997)

WNot Hispanic or Latino (Office of Management and Budget 1997)

ZMutually Defined

ICM

Individual Income

OMax: 1Area: 2Seq: 1100

To supply information to determine benefit eligibility, deductibles, and retirement and investment contributions

ICM01

Frequency Code

MIDMIN 1 MAX 1ID: 594

Code indicating frequency or type of activities or actions being reported

0Annualized; 12-month equivalent

1Weekly

2Biweekly

3Semimonthly

4Monthly

5Other

6Daily

7Annual

8Two Calendar Months

9Lump-Sum Separation Allowance

AQuarter-to-Date

BYear-to-Date

CSingle

DPolicy Period

EClaim Period

FUnit Report Identifier

GMonth-to-Date

HHourly

JCurrent Period

QQuarterly

SSemiannual

UUnknown

ZMutually Defined

ICM02

Monetary Amount

MRMIN 1 MAX 18ID: 782

Monetary amount

ICM03

Quantity

ORMIN 1 MAX 15ID: 380

Numeric value of quantity

ICM04

Location Identifier

OANMIN 1 MAX 30ID: 310

Code which identifies a specific location

ICM05

Salary Grade

OANMIN 1 MAX 5ID: 1214

The salary grade code assigned by the employer

ICM06

Currency Code

OIDMIN 3 MAX 3ID: 100

Code (Standard ISO) for country in whose currency the charges are specified

AMT

Monetary Amount Information

OMax: 10Area: 2Seq: 1200

To indicate the total monetary amount

AMT01

Amount Qualifier Code

MIDMIN 1 MAX 3ID: 522

Code to qualify amount

1Line Item Total

2Batch Total

3Deposit Total

4Lock Box Total

5Total Invoice Amount

6Amount Subject to Total Monetary Discount

7Discount Amount Due

8Total Monetary Discount Amount

9Total Operational Statement Amount

AAdjusted Chargeback Claim Amount

BEstimated

CCity

DPayor Amount Paid

EEstimated Credit

FAnnual Limit

GCollateral

HBid Amount

IInterest

JTrustee Fees

KAttorney and Trustee Fees

LLocal

MAmount Due from Buyer at Appraisal Notice Date

NNet

OCourt Cost

PPenalty

QAmount Owed to Buyer at Appraisal Notice Date

RSpend Down

SSubmitted Chargeback Claim Amount

TTax

UUnderpayment

VCost of Deficiency

WDeficiency Judgment Fees

XDeficiency Judgment Expenses and Fees

YCurrent List Price

ZList Price When Sold

00Downpayment on the Repayment Plan Amount

01Fixed Installment Control Accounting Error

02Graduated Payment Mortgage Adjustment

03Growing Equity Mortgage Adjustment

04Adjustable Rate Mortgage Change

05Fixed Installment Control Substitution Adjustment

06Interest Adjustment

07Deferred Graduated Payment Mortgage Interest Paid

08Interest Accounting Error

09Principal Accounting Error

0AInterest Substitution Adjustment

0BPrincipal Substitution Adjustment

0CPrepaid Interest

0DPrepaid Principal

0EDelinquent Interest

0FDelinquent Principal

0GCurtailment Adjustment

0HSerial Note Principal Available for Distribution

0IServicing Fee

0JGuarantee Fee Adjustment

0KAmount Under-collateralized

0LAmount Over-collateralized

0MTrial Balance Adjustment

0NCustodial Bank Account Adjustment

0PItem

0QSchedule

0RRegular Plan

0SPreviously Billed

0TCurrently Due

0UCoverage Premium

10Shipment Value in U.S. Dollars

11Liabilities at Bankruptcy

12Account Average Balance Account

13Outstanding Balance at Foreclosure

14Legal Obligation Debt Amount

15Estimated Closing Cost Amount

16Discount Fees Paid by Borrower Amount

17Closing Costs or Concessions Paid by Seller

18Prepaid Items Amount

19Federal Housing Administration, Mortgage Insurance Premium Funding Fee Financed Amount

1AVariance

1BVariance Adjustment Cost

1CVariance Adjustment Schedule

1DEscalation

1EFixed Price

1FLodging

1GMeals

1HTravel Expense

1JInsurance Expense

1KUnion Dues

1LRegular Income

1MIncome on Real Property

1NIncome from Social Security and/or other Government Assistance

1PTotal Monthly Income

1QElectric and/or Fuel Payment

1RWater and/or Sewer Payment

1STelephone Payment

1TMaintenance Expense

1UFood Expense

1VClothing Expense

1WLaundry Expense

1XMedical and/or Dental Expense

1YRecreation Expenses

1ZCharitable Contributions

20Federal Housing Administration, Mortgage Insurance Premium or Veteran's Administration Funding Fee Amount

21Original Cost of Property Amount

22Owner's Estimate of Value Amount

23Appraised Value Amount

24Gross Monthly Income Amount

25Assets at Bankruptcy

26Negotiated Cost

27Authorized Unpriced Work

28Target Price

29Estimated Price

2AHome Insurance Expense

2BLife Insurance Expense

2CHealth Insurance Expense

2DAutomobile Insurance Expense

2EValue of Property Claimed as Exempt

2FAutomobile Payment

2GOther Type of Installment Payment

2HOperating Expenses

2ITotal Projected Monthly Income

2JTotal Projected Monthly Expenses

2KExcess Income

2LValue of Personal Property

2MMonthly Overtime

2NTotal All Repairs

2PTotal Recommended Repairs

2QState Quarterly Total Gross Wages

2RState Quarterly Unemployment Insurance (UI) Total Wages

2SState Quarterly Unemployment Insurance (UI) Excess Wages

2TState Quarterly Unemployment Insurance (UI) Taxable Wages

2UState Quarterly Disability Insurance Taxable Wages

2VState Quarterly Tip Wages

2WAsset-Long Term

2XAsset-Short Term

2YBase Coverage

2ZCommission Retained

30Contract Ceiling

31Estimated Contract Ceiling

32Target Fee or Profit Amount

33Original Contract Target Cost

34Negotiated Contract Changes

35Current Target Cost

36Contract Budget Base (CBB)

37Current Budgeted Cost for Work Scheduled (BCWS)

38Current Budgeted Cost for Work Performed (BCWP)

39Current Actual Cost of Work Performed (ACWP)

3AAccounting

3BAccounts Payable

3CAccounts Receivable

3DAdvanced Dividends

3EAdvertising Expenses

3FAmortization

3GAmortization Costs

3HAmount of Decree

3IAsset Investment

3JAuthorized Capital

3KAvailable Reserves

3LBad Debt Allowance

3MBad Debts

3NBank Account(s)

3OLong Term Assets

3PLong Term Liabilities

3QLong Term Tangible Assets

3RLosses on Capital

3SMachines and Tools

3TMember Risk Capital

3UMiscellaneous After Tax Exempt

3VMortgage

3WNominal Capital

3XNominal Damages

3YNon-operational Fixed Assets

3ZExcess Amount Requested

40Current Schedule Variance (SV)

41Current Cost Variance (CV)

42Cumulative Budgeted Cost for Work Scheduled (BCWS)

43Cumulative Budgeted Cost for Work Performed (BCWP)

44Cumulative Actual Cost of Work Performed (ACWP)

45Cumulative Schedule Variance (SV)

46Cumulative Cost Variance (CV)

47Reprogram Cost Variance

48Reprogram Budget

49At Complete Budget (BAC)

4ANonissued Capital

4BNotes Payable

4CNotes Receivable

4DBank Debentures

4EBank Obligations

4FBuildings

4GBuildings Under Construction

4HCapital

4ICapital Associated with Principal

4JCapital of Other Subsidiaries

4KCapital Stock

4LCash

4MCapital Subsidies Received

4NCommercial Debt

4OCommercial Expenses

4PCommon Stock

4QConsequential Damages

4RCompensatory Damages

4SConvertible Debentures

4TCost of Goods Sold

4UCost of Sales

4VCost(s)

4WCurrent Assets

4XCurrent Liabilities

4YDamages

4ZDeferred Cost

50At Complete Latest Revised Estimate (LRE)

51At Complete Variance

52Total Allocated Budget

53Difference (Contract Budget Base - Total Allocated Budget)

54Forecast

55At Complete Forecast

56Current Cost Performance Index (CPIe) - Efficiency (BCWP/ACWP)

57Current Cost Performance Index (CPIp) - Planned (ACWP/BCWP)

58Current Schedule Performance Index (SPI)

59Cumulative Cost Performance Index (CPIe) - Efficiency (BCWP/ACWP)

5ADeferred Credit or Income

5BDeferred Taxation

5CDeposits

5DDepreciation

5EDepreciation of Fixed Assets

5FDepreciation of Revaluation of Fixed Assets

5GDirector's Remuneration

5HDividends

5IDoubtful Receivables

5JEquipment

5KEquipment Subsidies

5LEquities, Stocks

5MEquity

5NExceptional Item

5OExports

5PExternal Charge

5QExtraordinary Charge

5RExtraordinary Current Asset Write Downs

5SExtraordinary Result

5TFinancial Assets

5UFinancial Charges

5VFinancial Debt

5WFinancial Expenses

5XFinancial Income

5YFinished Goods

5ZFixed Asset Debts

60Cumulative Cost Performance Index (CPIp) - Planned (ACWP/BCWP)

61Cumulative Schedule Performance Index (SPI)

62To Complete Performance Index (TCPI) for Budget at Complete (BAC)

63To Complete Performance Index (TCPI) for Estimate At Complete (EAC)

64Initial Contract Price Target

65Initial Contract Price Ceiling

66Adjusted Contract Price Target

67Adjusted Contract Price Ceiling

68Funds Authorized to Date

69Accrued Expenditures

6AFixed Assets

6BFixed Assets for Sale

6CFixtures

6DFixtures and Equipment

6EFranchise

6FFranchise Tax Balance

6GFranchise Tax Paid

6HFree Reserves

6IFurniture

6JFuture Loan

6KGeneral Accounts

6LGeneral Expenses

6MGoodwill

6NGrants for Operating Costs

6OGroup Related Financial Income

6PIncome Stated in Advance

6QIncome Tax

6RIncome Tax, Corporate

6SIncome Tax, Noncorporate

6TInjunction

6UIntangible Depreciation

6VIntangibles

6WInterest of Third Party

6XInterest on Loans

6YOperating Income (Loss)

6ZOptional Reserves

70Open Commitments

71Forecast of Billings

72Estimated Termination Costs

73Accrued Expenditures plus Open Commitments

74Contract Work Authorized - Definitized

75Contract Work Authorized - Not Definitized

76Contract Work Authorized - Total

77Forecast of Work - Not Yet Authorized

78Forecast of Work - All Other

79Forecast of Work - Total

7AOrganizational Expenses

7BOutside Share in Profit or Loss

7COutstanding Debts against Board of Directors/Managers

7DOwing

7EOwing from Affiliates

7FOwing from Participants

7GOwing to Affiliates

7HOwing to Fiscal Office

7IOwing to National Social Security Office

7JOwing to Participants

7KOwn Work Capitalized

7LPaid in Capital

7MPar Value

7NParticipating Interest

7OPatents

7PPension Debts

7QPensions Provision

7RPreferred Stock

7SPrepaid Orders in Progress

7TPrior Results Carried Forward

7UProfit or Loss

7VProfit or Loss after Taxes

7WProfit or Loss before Taxes

7XProfit or Loss on Ordinary Activities after Tax

7YProgress Payments

7ZProposed Dividend

80Funding - Total Requirements

81Funds Carryover

82Net Funds Required

83Contract Work Authorized (with fee/profit) Actual or Projected

84Contract Work Authorized (with fee/profit) Actual or Projected - At Complete

85Best Case Estimate

86Worst Case Estimate

87Most Likely Estimate

88"As Is" Appraisal Amount

89"Subject To" Appraisal Amount

8AProvision for Depreciation of Stock or Inventory

8BProvision for Future Purchases

8CProvision for Risks

8DPunitive Damages

8EPurchase Price

8FPurchases

8GRaw Materials

8HReal Estate

8IReceivables

8JRegularization Account

8KResearch and Development

8LRestructuring Costs

8MResult

8NRetained Earnings

8ORevenues

8PSales

8QSales and Use Tax

8RSavings

8SSecured Liability

8TSecured Loans

8USelling Expenses

8VServices

8WShare Capital

8XShare in Profit or Loss of Minority Interest

8YShare Premium Capital

8ZShares in Affiliated Companies

90"Completion Per Plans" Appraisal Amount

91Site Value Amount

92Compensation

93Contribution

94Death Benefit

95Death Benefit Decrement

96Employee Account Balance

97Loan Repayment

98Prior W2

99Single Premium

9ASocial Charges

9BSocial Security (FICA)

9CSpecial Reserves

9DSpecially Secured Creditors

9ESpecific Performance

9FStarting Capital

9GStatutory Reserves

9HSubscribed Capital

9ISuit Amount

9JSupplies

9KSurplus of Revaluation

9LTangible Net Worth

9MTax Adjustments

9NTax Balance

9OTax Capital Amount

9PTax on Extraordinary Items

9QTax Recoverable

9RTaxed Reserves

9STrade Creditors

9TInventory (Stock)

9UInventory (Stock) Depreciation

9VInventory (Stock) Purchases

9WInvestment in Own Shares

9XInvestments

9YIssued Capital

9ZLabor Costs

A0Assistantship from Admitting Educational Institution

A1Average Negative Ledger Balance

A2Average Positive Collected Balance

A3Average Negative Collected Balance

A4Average Positive Ledger Balance

A5Disallowed - Estimated

A6Disallowed - Actual

A7Noncovered Charges - Estimated

A8Noncovered Charges - Actual

A9Allowed - Estimated

AAAllocated

ABAdjusted Collected Balance

ACAverage Collected Balance

ADAdjusted Total

AEArrearage

AFAverage Float

AGAdjusted Gross Income

AHLoan Balance Difference

AISale Amount

AJFunds Held by Mortgagee

AKAttorney Fees

ALAverage Ledger Balance

AMAmount Financed

ANBankruptcy Fee

AOAmount Override

APAmount Prior to Fractionalization

AQAverage Price Per Call

ARFees to Public Officials for Foreclosure

ASAverage Price Per Minute

ATTotal Received

AUCoverage Amount

AVActual Cash Value

AWReplacement Cost

AXPrevious Price

AYTitle Cost

AZOther Foreclosure and Acquisition Expenses

B0Bond

B1Benefit Amount

B2Bonuses and Commissions Divided Over 12 Months

B3Bonuses Divided Over 12 Months

B4Bonuses and Commissions

B5Budgeted

B6Allowed - Actual

B7Deductible - Estimated

B8Co-insurance - Estimated

B9Co-insurance - Actual

BABargain

BBMortgage Insurance Premiums

BCBilling Cycle Net Fee Position (Excess/Deficit)

BDBalance Due

BEDisbursements for Authorized Repair

BFHazard Insurance Premium

BGEviction Attorney Fees

BHEviction Expenses

BIProperty Taxes

BJDisbursements Not Shown Elsewhere

BKDisbursements for Protection and Preservation

BLDisbursements for Inspections and Boarding

BMAdjustments

BNRental Income

BORental Expense

BPAverage Net Collected Balance

BQBail

BRAdjusted Insured Loss Amount

BSMortgage Note Interest

BTBank Reject Total

BUOverhead Costs

BVUncollected Interest

BWAmount Due from Buyer at Closing

BXAmount Owed to Buyer at Closing

BYAdditional Closing Expenses

BZDeficiency Judgment Expenses

C0Current Expenditures

C1Co-Payment Amount

C2Child Rider Coverage

C3Prior Payment - Estimated

C4Prior Payment - Actual

C5Claim Amount Due - Estimated

C6Claim Amount Due - Actual

C7Payor Responsibility - Estimated

C8Payor Responsibility - Actual

C9Disallowed Cost Containment - Actual

CAContractor Cumulative to Date

CBCollected Balance Required

CCChargeback Claim Amount

CDOverpaid Section 235 Subsidy

CESummary Amount

CFAppraisal Fees

CGCommission Fees Deducted

CHChange Amount

CIFunds Held for Insured

CJOther Deductions

CKBack End Load

CLOutstanding Balance Current Lender

CMClaimant Requested Total

CNSpecial Assessments

COTaxes on Deed

CPStatutory Disbursements

CQNet Claim Amount

CRContractor at Complete

CSCommission Sales

CTContract

CUSubcontractor Cumulative to Date

CVSubcontractor at Complete

CWEarned Value

CXActual

CYCumulative Budget

CZCumulative Earned Value

D0Administration and Management Costs

D1Deferred Compensation Commissions

D2Deductible Amount

D3Deferred Compensation Commissions and Bonuses

D4Deferred Compensation

D5Dependent Care Contribution

D6Disallowed Cost Containment - Estimated

D7Dispensing Fee

D8Discount Amount

D9Cumulative Actual

DAOriginal Mortgage

DBUnapplied Section 235 Funds

DCUnapplied Buydown Fund

DDDirect Deposit

DEEstimate of Damage

DFAuthorized Bid

DGEscrow Balance

DHTotal Disbursements

DICharge Off

DJLiens Amount Original

DKRelease of Lien

DLDebit

DMAsset

DNLiability

DOSatisfaction

DPExemption

DQSettlement

DRAlimony Expense

DSAlimony Income

DTChild Support Expense

DUChild Support Income

DVSeparate Maintenance Expense

DWSeparate Maintenance Income

DXDeductible Waived

DYPer Day Limit

DZJob-related Expense

E0Administration and Management Indemnity Charge

E1Employer Year to Date Contribution

E2Employee Annual Pledge Amount

E3Employee Current Contribution

E4Employer Pledge Amount

E5Employer Current Contribution

E6Eligible Wage Amount

E7Employee Year to Date Contribution

E8Education Contribution

E9Initial Fee

EAEarnings Allowance

EBCollected Balance (Excess/Deficit)

ECAllowance (Excess/Deficit)

EDEstimated Cost of Attendance

EEOther Expense

EFEstimated Financial Aid

EGOther Income

EHAmount of Mortgages and Liens

EIMortgage Payment(s)

EJInsurance, Maintenance, Taxes and Miscellaneous

EKNet Rental Income

ELPresent Market Value

EMGross Rental Income

ENCancellation Fee

EOCapital Reserves

EPEmployer Annual Pledge Amount

EQCondominium Association Fees

ERHomeowner Association Fees

ESMortgage Insurance Proceeds

ETNet Proceeds from Sale of Real Estate Property

EUInsurance Proceeds (Primary Settlement)

EVPresale Proceeds

EWPledged Savings

EXAs Is Broker's Opinion

EYSubject To Broker's Opinion

EZUniform Commercial Code Filing Office Fee

F0Commercial Staff Labor Costs

F1Maximum Allowable Cost (MAC) Penalty Copay

F2Patient Responsibility - Actual

F3Patient Responsibility - Estimated

F4Postage Claimed

F5Patient Amount Paid

F6Provider Reserves

F7Sales Tax

F8Usual and Customary Charge - Estimated

F9Usual and Customary - Actual

FACoordination Fee

FBCalculation Fee

FCExpected Family Contribution

FDDirect Deposit Flipped to Check

FEFee

FFApplication Fee

FGLicensing Fee

FHRegulatory Fee

FIFirst Interest Payment Amount

FJWaiver Fee

FKOther Unlisted Amount

FLFloat

FMFair Market Value

FNFine

FOFees Paid

FPFees Paid Year to Date

FQFirm Contractor Share

FREstimated Government Share

FSExpense

FTEndorsement Premium Amount

FUCommercial Staff Indemnity Charge

FVFlat Fee Paid to Date

FWFlat Fee Paid Current Month

FXEndorsement

FYFirst Payment

FZEarned Income

G0Initial Adjustment Total

G1Indicated Value by Sales Comparison Approach

G2Indicated Value by Income Approach

G3Price per Unit Area

G4Reconciliation of Final Value Estimate

G5Estimated Monthly Market Rent

G6Adjusted Sales Price

G7Sales or Financing Concessions

G8Indicated Value by Cost Approach

G9As-is Value of Site Improvements

GADepreciated Value of Improvements

GBPrice, High Value

GCPrice, Low Value

GDPhysical Depreciation

GEFunctional Depreciation

GFExternal Depreciation

GGAdjusted Sales Price of Comparable Sales

GHPredominate Value

GIAverage Customer Income

GJAverage Neighborhood Income

GKAverage Customer Purchase

GLWeekly Dollar Sales

GMAverage Case Sales

GNBuy-down

GOCredit Line

GPAppraisal Repair Amount

GQBrokers Opinion Repair Amount

GRCredit Line Available

GSSubsequent Adjustments Total

GTGoods and Services Tax

GUTaxes Paid

GVGross Value

GWTotal Charge

GXTotal Credit

GYTotal Debit

GZTotal Finance Charge

H0Host Government (government of the institution) Financing for Education

H1Legal Reserves

H2Cancellation

H3Deposit Inception to Date

H4Deposit Year to Date

H5Dump in Remittance

H6Earnings

H7Life Insurance Cash Value

H8Structure Value

H9Original List Price

HACoin

HBCurrency

HCU.S. Treasury Checks

HDPostal Money Orders

HECity Checks

HFOther Checks

HGHome Government Financing for Education

HHAnnual Social Security Wages

HIAnnual Social Security Tips

HJAnnual Wages, Tips, and Other Compensation

HKSocial Security Employee Tax Withheld

HLFederal Income Tax Withheld

HMAdvance Earned Income Credit

HNCommission

HOVacation Pay

HPGross Pay Submitted

HQIntersell Commission Sales

HRTotal Payroll Approved

HSHoliday Pay

HTOvertime Pay

HURegular Pay

HVSick Pay

HWSpecial Pay

HXContract Price

HYCommercial Space Income

HZUtilities Paid by Owner

I0Life Insurance Coverage

I1Investment Income

I2Income

I3Price, Gross Living Area

I4Total Estimated Rent

I5Gross Annual Income

I6Custodian's Salary

I7Engineer's Salary

I8Elevator Operator's Salary

I9Indicated Value by Market Approach Estimate of Market Value

IAAdjusted Monthly Rent

IBInvestable Balance

ICAccrued Unpaid Interest To Be Capitalized

IDImport Duty Amount

IEExcise Tax Amount

IFInspection Fee

IGAdjustment for Gross Living Area

IHPredominant Price High

IIIrregular Interest Payment Amount

IJNet Adjusted Monthly Rent

IKIndicated Monthly Market Rent

ILPredominant Price Low

IMAdjustment for Rooms

INInstallment

IOAdjustment for Bedrooms

IPInterest Payable During Repayment Period

IQContingent Debt

IRInsurance Recovery

ISIndependent Scholarship

ITIncentive Fee

IUAccrued Unpaid Interest Not To Be Capitalized

IVUtilities Allowance

IWFurniture Allowance

IYDebentures

IZAccount High Balance

J0Limited Partnership Capital

J1Current Face Amount

J2Original Face Amount

J3Fixed Default Note Holder's Amount

J4Initial Monthly Payment

J5Original Principal and Interest Payment

J6Final Principal and Interest Payment

J7Conversion Fee

J8Ending Balance

J9Beginning Balance

JAAssessment

JBEquity Claimed as Exempt

JCCounter Claim

JDWeekly Benefit

JELease

JFAdministrative Load

JGAsset Cost Applicable to Entire Contract

JHAsset Cost Applicable to Portion of Contract

JIAnnual Fee

JJCost Basis

JKDisability Premium

JLEmployee Additional Contribution

JMEmployee Match Contribution

JNEmployer Contribution

JOFree Look Value

JPFree Withdrawal Value

JQFront End Load

JRGuaranteed Minimum Death Benefit

JSInterim Value

JTMonthly Rent

JUJudgment

JVLoan Value

JWMarket Value

JXMarket Value Adjusted Value

JYMarket Value Adjustment

JZNet Contract Value

K0Discounted Bills not Due

K1Unpaid Security Balance

K2Total Unpaid Security Balance

K3Veterans Affairs Funding Fee

K4Initial Target Fee

K5Minimum Fee

K6Maximum Fee

K7Price

K8Special Accounting Classification Reference Number (ACRN) Amount

K9New Price

KAEstimated Contract

KBEstimated Net Adjustment

KCObligated

KDUndefinitized

KEAnnual Revenue

KFNet Paid Amount

KGNet Collected Amount

KHDeduction Amount

KINet Variance Amount

KJMinimum Contract Amount

KKItem Gross Amount

KLCollected Amount

KMDisbursed Amount

KNGross Amount of Payment

KOCommitted Amount

KPPrincipal and Interest

KQIncremental Order Amount

KRLiability-Long Term

KSTaxes and Insurance

KTDefault Principal

KUDefault Interest

KVLiability-Short Term

KWDefault Taxes and Insurance

KXMiscellaneous Fee Collections

KYNot-To-Exceed Price

KZMortgagor's Monthly Obligations

L0Liquid Assets

L1Legal Contribution

L2Leasehold Insurance Amount

L3Total Unidentified Payments Rejected

L4Total Credits Received

L5Total Debits Received

L6Total Pre-advices Received

L7Total Prenotes Received

L8Total Post-advices Received

L9Total Debit for Settlement

LADefinitized

LBDefinitized Total

LCLessor's Cost

LDIncremental

LELoan Eligibility Amount

LFLoan Remittance or Repayment

LGLaundry Income

LHBaseline

LILine Item Unit Price

LJLegal and Audit

LKLoan Amount Requested

LLLump Sum

LMLimit

LNLien Payoff

LOMoney Purchase

LPList Price

LQMaximum Potential Liability

LRTotal Credit for Settlement

LSNet Settlement

LTTotal Award

LUOption Amount

LVPlanned Periodic Payment

LWTax and Insurance Escrow Fund Balance

LXLoan Expense

LYTotal Remaining Principal Balance for the Issuer

LZDelinquent Payment

M0Loans from Officers

M1Maximum Out of Pocket Amount

M2Medical Contribution

M3Tax rate expressed as a flat fee

M4Minimum amount of tax to be paid

M5Minimum amount to which tax rate is applied

M6Maximum amount of tax to be paid

M7Maximum amount to which tax rate is applied

M8Markup Amount

M9Net of Surrender Withdrawal

MAMaximum Amount

MBUndistributed Budget

MCCost of Money

MDMinimum Due

MEMinimum Default Note Holder's Cost

MFAdministrative Fees

MGMaximum Late Charge

MHMinimum Late Charge

MIMinimum Incentive Fee

MJMaximum Default Note Holder's Cost

MKGross to Pay

MLPrior Net Invoice Total

MMPayout

MNMonthly Limit

MOMinimum Order Value

MPMonthly Payment Amount

MQPost Tax Equity and Fiscal Responsibility Act (TEFRA) Cost Basis

MRManagement Reserve

MSPast-Due Taxes and Assessment Remaining Unpaid

MTPre Tax Equity and Fiscal Responsibility Act (TEFRA) Cost Basis

MUPremium Tax Paid on Surrender

MVPremium Tax Paid up Front

MWSales Loads

MXMaximum Incentive Fee

MYSurrender Value

MZValuation Price

N0Loans or Financial Borrowings

N1Net Worth

N2Individual Income Taxes and Other

N3Corporate Income and Excess Profits Tax

N4Excise Taxes

N5Estate and Gift Taxes

N6Carrier Tax Act Taxes

N7Federal Unemployment Tax Act Taxes

N8Miscellaneous Taxes

N9Withheld and Federal Insurance Contribution Act (FICA) Taxes

NANet Adjustment

NBNet Compensation Position

NCNegative Collected Balance

NDPer Person Monthly Limit

NENet Billed

NFMonthly Net Fee Position (Excess/Deficit)

NGMedicare Copayment

NHMedicare Deductible

NIMedicare Paid

NJOther Insurance Paid Amount

NKTotal in Force and Applied Coverage

NLNegative Ledger Balance

NMNon-collateralized Amount

NNTransaction Fee

NONon Commission Sales

NPNet to Pay Total

NQAdjusted Nonrecurring

NRNonrecurring

NSNet Savings Amount

NTUnit Value

NUReinsurance Amount

NVRenewal Amount

NWRetention Per Life

NXRetention Per Policy

NYNet Year to Date (Excess/Deficit)

NZEqualization Account

O0Extraordinary Income

O1Amount of First Mortgage Being Refinanced

O2Other Family Financing for Education

O3Intangible Assets Written Off

O4Interest Payable

O5Interest Receivable

O6Joint Venture Results

O7Long Term Debt

O8Long Term Provisions

O9Loss

OAPrincipal Balance Amount

OBOutstanding Loan Balance

OCOpening Bank Charges

ODDraft Amount

OEMiscellaneous Charges

OFContractor's Offer

OGCable Charge

OHHandling Charges

OINon-commission Charges

OJMerchandise

OKLetter of Credit Amount

OLOutstanding Balance Other Lender

OMOther Monthly Income

ONNegotiating Bank Charges

OOOverdrafts

OPOriginal Payment Total

OQPayroll Costs

ORLetter of Credit Remaining Amount

OSOther Salaries

OTCommission Amendment Charges

OUProfit

OVProfit and Loss Deficit

OWProfit after Extraordinary Items and before Tax

OXProfit after Tax and Before Extraordinary Items

OYPayment Commission

OZProfit Distributed to Employees

P0Parental Financing for Education

P1Partner's Calendar Year Salary

P2Prior Plan Year Gross Salary

P3Premium Amount

P4Prior Year's Wage

P5Partner's Tax Year Salary

P6Premium Due

P7Partner's K1 Tax Year Amount

P8Partner's K1 Calendar Year Amount

P9Current Mortgage Principal Balance

PAPayment Cancellation Total

PBBilled Amount

PCPositive Collected Balance

PDCredit

PEPlan Period Election

PFPrincipal

PGPayoff

PHPer Occurrence Deductible

PIPer Occurrence Monthly Limit

PJPast Due

PKPhotograph Fee

PLPositive Ledger Balance

PMLast Premium Amount

PNPrior Gross Invoice Total

POPercent Override

PPPayment Prior to Advance

PQAdvance Amount

PRPer Occurrence Limit

PSPer Occurrence per Day Limit

PTPer Occurrence Aggregate Limit

PUUnsecured Priority Claim

PVPrepetition Charges

PWPer Occurrence Maximum per Week Limit

PXPer Person Maximum per Week Limit

PYPer Person per Day Limit

PZOriginal Principal Balance

Q0Loans to Affiliated Companies

Q1Proposed

Q21035 Exchange

Q3401K Transfer

Q4Total Prenotes Accepted

Q5Total Prenotes Rejected

Q6Automatic Premium Deduction

Q7Total Post-advices Accepted

Q8Total Post-advices Rejected

Q9Cash With Application

QACombined

QBCredit Card

QCDeposit Fund

QDDirect Billing

QEDisc Premium

QFElectronic Funds Transfer (EFT)

QGGovernment Allotment

QHInitial Premium

QIIndividual Retirement Account 60 Day Rollover

QJIndividual Retirement Account Direct Transfer

QKIndividual Retirement Account Regular Contribution

QLKeogh/HR 10

QMKeogh/HR 10 Transfer

QNQuarterly Net Fee Position (Excess/Deficit)

QOList Billing

QPModal Premium

QQPayroll Taxes

QRParking Income

QSNon-Qualified (1035 Exchange)

QTPAC - Pre-Authorized Check

QUPayroll Deduction

QVPension

QWPremium Received With Application

QXProfit Sharing Trust

QYQualified

QZPayment Amount

R0Loans to Participants

R1Fixed, Liquidated Secured Debt

R2Contingent Secured Debt

R3Disputed Secured Debt

R4Unliquidated Secured Debt

R5Fixed, Liquidated Unsecured Debt

R6Contingent Unsecured Debt

R7Disputed Unsecured Debt

R8Unliquidated Unsecured Debt

R9At Time of Filing

RAAccelerated Royalty

RBPer Person Deductible

RCRefund Check

RDPer Person Limit

RERoyalty Due

RFRestitution

RGBudgeted Redemption

RHPer Person Aggregate Limit

RIResidual Value

RJRate Amount

RKProvision for Long Term Depreciation

RLRegular Remittance

RMRemittance Refund

RNResident Manager's Salary

ROProvisions

RPRepair

RQRecommended Amount

RRReserve Requirement Amount

RSReserves

RTLast Payment

RUTotal Debits Rejected

RVTotal Payments Rejected

RWTotal Delinquency

RXTotal Pre-advices Accepted

RYTotal Pre-advices Rejected

RZLender's Total Delinquency

S0Self-Financing for Education

S1Salary Amount

S2Salary with Bonuses

S3Salary with Commissions

S4Salary with Subchapter S Corporation Income

S5Salary with Partner's Bonuses

S6Subchapter S Corporation

S7Sole Proprietorship

S8Period Rental

S9Secured Claim Allowed

SACampaign Summary Amount

SBStated Amount

SCTotal Service Charge

SDSales Charge

SEService Charges Which Cannot Be Compensated by Balances

SFScholarship from Admitting Educational Institution

SGSponsor-Financing for Education

SHSurrender Charge

SISubsequent Interest Payment Amount

SJSurrender Full

SKSurrender Partial

SLSecurity Personnel's Salary

SMSupplemental

SNSales Administration Expense

SOSpecial Creditors Amount

SPSales Price

SQSpecial Debtors Amount

SRSecured Claim

SSCampaign Summary Amount to be Shared

STState

SUSurcharge

SVFixed Monthly Principal Payment

SWBase Award Fee

SXSeverance Tax

SYInitial Buydown Balance

SZCertification Fee

T0Third-Party Government-Financing for Education

T1Teacher

T2Total Claim Before Taxes

T3Total Submitted Charges

T4Total Current Balance

T5Total Claims

T6Claim

T7Total Credits Accepted

T8Total Credits Rejected

T9Total Debits Accepted

TATotal Annual Sales

TBTotal Annual Sales to Customer

TCProposed Cost

TDProposed Profit

TEProposed Fee

TFTotal Proposed Price

TGAlternate Proposed Price

THTotal Claim Allowed

TITitle Insurance Amount on Loan

TJTime and Expense Paid to Date

TKTotal Amount of Contract

TLTotal Prior Loan Amount Owed

TMTime and Expense Paid Current Month

TOTelephone Operator's Salary

TPTotal payment amount

TQSubsidies for Operating Costs

TRTarget Cost

TSTotal Sales

TTTotal Transaction Amount

TUTransportation Cost per Unit of Measure

TVLevel of Premium Insurance - Retention

TWTechnicians Indemnity Provision

TXTotal to Date

TYTotal at Complete

TZTransportation Cost Total

U0U.S. Government-Financing for Education

U1Unsecured, Priority Claim Allowed

U2Ingredient Cost Claimed

U3Miscellaneous Expenses

U4Present Value of Lot

U5Cost of Improvements

U6Alterations, Improvements, Repairs

U7Land

U8Refinance

U9Estimated Prepaid Items

UAUnliquidated Amount

UBUnpaid Principal Balance

UCUnspecified Aggregate Limit

UDUnsecured, Nonpriority Claim Allowed

UEMortgage Insurance

UFDiscount (If Borrower Paid)

UGTotal Unpaid Principal Balance for Stafford Loans

UHSubordinate Financing

UITotal Costs

UJOther Credits

UKBase Loan Amount (w/o financed Mortgage Insurance)

ULMortgage Insurance Financed

UMTotal Loan Amount

UNUnsecured, Nonpriority Claim

UOCash from or to Borrower

UPTotal Unpaid Principal Balance for Parental Loans for Students

UQMonthly Income

URUnearned Income

USTotal Unpaid Principal Balance for Supplemental Loans for Students

UTValue Added Sales

UUClearing House Settlement

UVDrawback

UWTotal Monthly Liabilities

UXUtilities, Furniture, and Amenities Included in Rent

UYTotal Assets

UZTotal Liquid Assets

V0Value Added

V1Tax and Insurance Escrow Fund

V2Interest Due to Investor

V3Total Principal Due to the Investor

V4Total Interest Due to the Investor

V5Total Curtailment Due to the Investor

V6Total Principal Payoff and Repurchase Due to the Investor

V7Total Interest Payoff and Repurchase Due to the Investor

V8Actual Outstanding Principal Balance

V9Face Amount

VATotal Current Rent or Mortgage Payment (Issue)

VBTotal Non-liquid Assets

VCAuthorized

VDActual Person Day Rate

VEEstimated Person Day Rate

VFTotal Monthly Expenses

VGCurrent Monthly Principal and Interest

VHLevy Amount

VICurrent Support

VJPast Due Support

VKMedical Support

VLNet Negative Amortization Amount

VMWithhold From Wages

VNCommission Basis

VOCommission Earned

VPCurrent Monthly Payment

VQCommission Netted

VRTotal Monthly Debt

VSOther Financing Payment

VTCurrent Value

VUClosing Cost

VVCapitalized Mortgage Amount

VWFirst Mortgage Monthly Principal and Interest

VXInterest Amount Paid to Date

VYMinimum Transfer

VZMaximum Transfer

W0Trade Debtors

W1W-2

W2W-2 with Bonuses

W3W-2 with Deferred Compensation

W4W-2 without Bonuses

W5Deposit Sub Total

W6Direct Rollover

W7Direct Transfer

W8Discounted

W9Secondary Finance

WAMinimum Deposit

WBSub-Agency Compensation

WCBuyers Agency Compensation

WDVariable Rate Compensation

WECompensation Bonus on Sale of Property

WFVeterans Affairs Loan Guarantee

WGSecurity Trade Amount

WHBalance Owing All Other Liens, Subject Property

WIOther Financing

WJDual Agency Compensation

WKPer Week Limit

WLLender's Opinion of Value

WMTotal Original Principal Balance

WNOther Agent Compensation

WODock Usage Fee

WPPool Usage Fee

WQClubhouse Fee

WROptional Service Fee

WSOther Association Fees

WTPrincipal, Interest, Taxes

WUPrincipal, Interest, Taxes and Insurance

WVTotal Points Paid at Closing

WWAmount that Would Have Been Paid in the Absence of Capitation

WXPoints Paid by Seller

WYLoan Withdrawal

WZSeverance Pay

X0Treble Damages

X1Transfer to Untaxed Reserves

X2Reissued

X3Rollover Amount

X4Annual Rental

X5Gross Monthly Rent

X6SEP - Self Employee Pension

X8Funding Amount

X9Tax Sheltered Annuity (403B Transfer)

XAMaximum Award Fee

XBMaturity Value

XCEarned Wages

XDBase Period Wage

XEWithdrawal

XFWithdrawal Inception to Date

XGWithdrawal Less Market Value Adjustment

XHWithdrawal Less Surrender

XIWithdrawal Less Taxes

XJWithdrawal Year to Date

XKUnavailable Reserves

XLUncalled Capital

XMUnemployment Contribution

XNUnlimited Capital, Minimum Fixed

XOUnpaid Capital

XPUnsecured Liabilities

XQValue Added Tax

XRValue of Shares

XSVehicles

XTVoluntary Reserves

XUWages

XVWithholding

XWOriginal Value

XXWorking Capital

XYSales Price Per Dwelling Unit

XZSales Price Per Room

Y0Self Insurance Amount

Y1Year to Date Eligible Salary

Y2Total Real Estate Owned

Y3Total Liabilities

Y4Total Liability Monthly Payments

Y5Total Real Estate Owned Market Value

Y6Total Real Estate Owned Gross Rental Income

Y7Total Real Estate Owned Mortgages and Liens

Y8Total Real Estate Owned Mortgage Payments

Y9Total Real Estate Owned Miscellaneous Expenses

YATotal Real Estate Owned Net Rental Income

YBActual Unpaid Principal Balance

YCScheduled Unpaid Principal Balance

YDPrincipal Due to Investor

YEConstant Principal and Interest

YFOther Fee Collection

YGBeginning Scheduled Unpaid Principal Balance

YHTax and Insurance Principal Balance

YINew Principal and Interest

YJCurtailment

YKPrepayment Penalty

YLPartial Annuitization

YMPartial Withdrawal

YNPost Tax Equity and Fiscal Responsibility Act (TEFRA) Gain

YOPre Tax Equity and Fiscal Responsibility Act (TEFRA) Gain

YPPolicy Amount

YQPayments in Advance

YRPayments in Arrears

YSCancelled

YTDenied

YUIn Process

YVRequested

YWPaid

YXPaid for This Facility

YYReturned

YZTotal Aggregate Limit

Z0Insertion Cost

Z1Repackaging Labor Cost

Z2Repackaging Material Cost

Z3Unit Cost of Discrepant Material

Z4Liquidation Principal

Z5Remaining Pool Balance

Z6Remaining Security Balance

Z7Program Cost

Z8Override to Handling Fee

Z9Production Cost

ZAFederal Medicare or Medicaid Claim Mandate - Category 1

ZBFederal Medicare or Medicaid Claim Mandate - Category 2

ZCFederal Medicare or Medicaid Claim Mandate - Category 3

ZDFederal Medicare or Medicaid Claim Mandate - Category 4

ZEFederal Medicare or Medicaid Claim Mandate - Category 5

ZFFederal Pension Mandate - Category 1

ZGFederal Pension Mandate - Category 2

ZHFederal Pension Mandate - Category 3

ZIFederal Pension Mandate - Category 4

ZJFederal Pension Mandate - Category 5

ZKFederal Medicare or Medicaid Payment Mandate - Category 1

ZLFederal Medicare or Medicaid Payment Mandate - Category 2

ZMFederal Medicare or Medicaid Payment Mandate - Category 3

ZNFederal Medicare or Medicaid Payment Mandate - Category 4

ZOFederal Medicare or Medicaid Payment Mandate - Category 5

ZPCoupon Face Value

ZQInitial Target Cost

ZRIncrease

ZSDecrease

ZTProrated Amount

ZULoan Charge

ZVMortgage Recording Fee

ZWDeed Recording Fee

ZXRelease Recording Fee

ZYAssumption

ZZMutually Defined

AA1Excess Funds

AA2Cumulative Total

AA3Reimbursable Amount

AA4Total Reimbursable Amount

AA5Direct Citation Amount

AA6Total Direct Citation Funds

AA7Chargeable Amount

AAATemporary Term Coverage

AABConditional Receipt Coverage

AACBinding Interim Coverage

AADApplication Amount

AAEApproved Amount

AAFUltimate Face Amount

AAGRequested Amount from All Reinsurers

AAHReplacement Amount

AAIScheduled Contribution

AAJScheduled Disbursement

AAKShort Term Investment

AALSubsequent Contribution

AAMSubsequent Distribution

AANTax-Federal

AAOTax-Local

AAPTax-State

AAQTrust Fund

AARCapital Leases

AASSurplus

AATRestated Assets

AAUOwing to Clients

AAVShareholder Loans

AAWAccumulated Deficit

AAXLoan from Parent Company

AAYContribution Not Subject to Repayment

AAZIncome Before Depreciation

ABAIncome After Depreciation

ABBProfit (Loss) Before Financial Items

ABCInterest Expenses

ABDProfit (Loss) Before Extraordinary Items

ABEProfit (Loss) After Financial Items

ABFIncome Before Allocations

ABGIncome from Sale of Fixed Assets

ABHContribution to Group

ABIDeferred Tax Assets

ABJBlocked Accounts

ABKNon-taxed Reserves

ABLPledged Assets

ABMRestricted Equity

ABNNon-restricted Equity

ABODepreciable Assets

ABPTaxable Assets

ABQIncome from Business

ABRIncome Subject to Taxes

ABSTaxable Amount of Real Estate

ABTEnding Principal Balance

ABUAverage Daily Principal Balance

ABVInterest Amount

ABWAdjustments for Difference in Average Daily Principal Balance

ABXBeginning Principal Balance

ABYLoan Principal Disbursements

ABZPrincipal Increases

ACAPrincipal of Loans Purchased

ACBPrincipal Cured

ACCPrincipal Sold

ACDPrincipal Insurance Claims

ACEPrincipal Guarantee Voided

ACFPrincipal Paid by Borrowers

ACGLoans in School and Grace

ACHLoans in Authorized Deferment

ACILoans Repay or Forebearance - Current or Less than 31 Days

ACJLoans Repay or Forebearance - 31 to 60 Days Past Due

ACKLoans Repay or Forebearance - 61 to 90 Days Past Due

ACLLoans Repay or Forebearance - 91 to 120 Days Past Due

ACMLoans Repay or Forebearance - 121 to 180 Days Past Due

ACNLoans Repay or Forebearance - 181 to 270 Days Past Due

ACOLoans Repay or Forebearance - 271 or More Days Past Due

ACPLoans Repay or Forebearance - Claims Filed, Not Yet Paid

ACQAgent Sales

ACRAmount Involved

ACSAssigned Capital

ACTCredit Line Utilized

ACUDirect Sales

ACVEarnings per Share

ACWInheritance

ACXInvested Capital

ACYLoan from Family Members

ACZNon Depreciable Assets

ADAPartially Paid Amount per Share

ADBPending Orders

ADCPersonal Loan

ADDPlant and Machinery

ADEPre-Tax Loss

ADFPre-Tax Profit

ADGRegistered Capital

ADHRevaluation Reserves

ADISocial Capital

ADJStatutory Profit

ADKTraining Pay

ADLRetroactive Pay

ADMExpected Reimbursement Amount

ADNPermit Cost

ADOMinimum

ADPAdditional Amount to Meet Minimum

ADQLabor Per Hour

ADRNon-recoverable Depreciation

ADSRecoverable Depreciation

ADTOverhead

ADUIndemnity Benefit

ADWReplacement Cost of Repairs

ADXActual Cash Value of Repairs

ADYRecoverable Depreciation of Repairs

ADZNon-recoverable Depreciation of Repairs

AEANon-indemnity Benefit

AEBActual Cash Value of Building

AECGovernment Share

AEDContractor Share

AEEAward Fee

AEFBase Fee

AEGTarget Profit Floor

AEHTarget Profit Ceiling

AEILabor Per Day

AEJDifference in Interest Due

AEKDifference in Prepayment Penalty

AELDifference in Principal Due

AEMAppropriation of Retained Earnings Less Reversals

AENAppropriations

AEOBillings and Costs-Profit Differential

AEPCommon Stock Par Value

AEQCost of Services Rendered

AERCreditors

AESDeclared Profit

AETDiscounted Notes

AEUEndorsed Notes

AEVGeneral Reserves

AEWImport Volume

AEXIncome Tax Credit

AEYLong-Term Deposits

AEZLong-Term Loans

AFAMinority Interest

AFBNon-Operating Expense

AFCNon-Operating Income

AFDOperating Profit or Loss

AFEPreferred Stock Par Value

AFFProfit After Tax and Minority Interest

AFGRetained Earnings to be Appropriated

AFHRevaluation Surplus or Deficit

AFIReversal of Voluntary Earned Surplus

AFJShare Price

AFKShort-Term Deposits

AFLShort-Term Loans

AFMTax Provisions

AFNUnallocated Profit

AFOVoluntary Earned Surplus

AFPCalculated Weekly Compensation Amount

AFQBenefit Type Gross Weekly Amount

AFRBenefit Type Net Weekly Amount

AFSEmployee Gross Wage

AFTGarage Gross Wages

AFUOfficer Compensation - Actual Flat

AFVOfficer Compensation - Statutory Maximum

AFWOfficer Compensation - Statutory Minimum

AFYPrevious Balance

AFZDisputed Amount

AGANon-Operating Income or Expense

AGBOperating Income or Expense

AGCIncome or Expense

AGDPurchase Authority

AGECapital Decrease

AGFCapital Increase

AGGDeed Capital

AGHTransferred Amount

AGIUnadjusted Sales Price

AGJSales Concessions

AGKProperty Value

AGMPartial Release Amount

AGNLien Filing Fee

AGOAdditional Repair Price

AGPQualified Tuition and Related Expenses

AGQQualified Financial Assistance

AGRAggregate Reimbursements or Refunds

AGSNew Loan Balance

AGTRaw Material Purchases

AGUWork in Progress Purchases

AGVOperating Cash Flow

AGWPayments for Outside Work

AGXSet Aside for Provisions

AGYFinancial Income or Expense

AGZExtraordinary Income or Expense

AHAUnfinished Production Carried Forward

AHBInstallation Materials Cost

AHCNew Mortgage Amount

AHDCapitalized Assets

AHEProfit Reserves

AHFShare in Profit or Loss in Other Companies

AHGMonetary Correction

AHIScheduled Repayment Amount

AHJAmounts Placed with Other Banks

AHKDue from Parent Company

AHLOwing from Subsidiary Companies

AHMCertificates of Deposit Amount

AHNPublicly Traded Shares Amount

AHONon Publicly Traded Shares Amount

AHPTrading Securities Amount

AHQInvestment Securities Amount

AHREarnings Per Share Minus Dividends

AHSActive Partner Capital

AJCAdjusted Claim

ANCAccrued Income

APTAmount of Purchase Exempt From Tax or Fee

ASPAnnual Sales or Premiums

ATFAmount of Tax or Fee Exemption

AVEAverage

BAANet Taxable Income

BABOriginal Amount of Instrument

BACAddition to Tax

BADReinstatement Fee

BAEPermit Fee Due

BAFPermit Fee with Extension

BAGNet Annual Permit Fee Due

BAHPermit Fee Penalty Due

BAIPermit Fee Interest Due

BAJTotal Permit Fee Due

BAKFranchise Tax

BALUnclaimed Franchise Tax Credit

BAMNet Franchise Tax Due

BANFranchise Tax Penalty Due

BAOTotal Franchise Tax Due

BAPTotal Amount Due

BAQOverpayment

BARAmount to be Refunded

BASGross In-State Receipts

BATGross Receipts

BAUOccupation Fee

BAVTotal Assessed Value

BAWTotal Value of All Property

BAXValue of In-State Property

BAYTotal Value of Out-of-State Property

BAZTotal Par Value

BBATotal Assessable Capital Stock

BBBApportioned Value

BBCEstimated In-State Real Property Value

BBDPar Value of In-State Assets

BBEIn-State Business Revenue

BBFSubscription Price

BBGValue of Authorized Shares

BBHOrdinance Amount

BBICapital for a Cooperative

BBJDirectors Legal Obligation Debt

BBKSilent Partner Capital

BLDBridge Loan Not Deposited

BOABorrower Advance

BORBorrowed Amount

BTRBetterment

BXPBills of Exchange Payable

CJLCollections, Judgments, and Liens

COACorporate Assets

CPOClosing Costs Paid by Any Other Party Other Than Seller or Buyer

CPSClosing Costs Paid by Seller

CRCContainer Replacement Cost

CRLContainer Replacement Labor Cost

CRMContainer Replacement Material Cost

D4DDollar For Dollar Deductions

DEIDelayed Interest

DFADeferred Assets

DLQDelinquent Taxes

DPFDiscount Points Financed

DPNDiscount Points Not Financed

DPPDefaulted Tax Plan Payment

DVPDevelopment Properties

EAAAdministrative Expenses

EABAir Travel Expenses

EACAmount Forgiven

EADAmount Guaranteed

EAEAmount Over Fair Market Value

EAFAmount Owed

EAGAmount Payable

EAHAmount Raised

EAIAmount Received

EAJAmount Refunded

EAKAmount Rescinded

EALAnonymous Contribution

EAMBalance Owed

EANBank Charges

EAOBank Loan

EAPBrochure Expenses

EAQBus Travel Expenses

EARConsultant Expenses

EASCorrected Amount

EATDisability Expenses

EAUDisposed Amount

EAVDraw Amount

EAWElection Expenses

EAXEndorsement Amount

EAYEntertainment Expenses

EAZExcess Expenses

EBAExpected Expenditure Amount

EBBExpenditure Amount

EBCFamily Care Expenses

EBDFederal Share Amount

EBEFiling Fee

EBGIn-Kind Contribution

EBHIncurred Amount

EBILoan Amount Plus Interest

EBJLoan Balance

EBKMatching Contribution

EBLMeeting Expenses

EBMMiscellaneous Income

EBNMiscellaneous Receipts

EBONew Loan Amount

EBPNew Unpaid Expenditure

EBQNewsletter Expenses

EBRNewspaper Advertising Expenses

EBSNomination Expenses

EBTNon-Federal Share

EBUOffice Expenses

EBVOffice Rental

EBWOriginal Asset Value

EBXOriginal Loan Amount

EBYParty Expenses

EBZPayment

ECAPersonal Expenses

ECBPersonal Funds

ECCPledged Amount

ECDPostage Expenses

ECEPrinting Expenses

ECFPublic Funds

ECGRadio Advertising Expenses

ECHReimbursed Amount

ECIReported Amount

ECJRetainer

ECKSign Expenses

ECLSub-Contract Value

ECMTax Receipts

ECNTaxi Travel Expenses

ECOTelecommunication Expenses

ECPTelevision Advertising Expenses

ECQUnpaid Expenditure

ECRUtilities Expenses

ECSTotal

ECTSubtotal

ECUGrand Total

ECVIncidental Expenses

ECWTransportation Expenses

ECXGift Value

ECYFood and Refreshments

ECZPolling Expenses

ED4Tuition and Required Fees

EDBBooks and Supplies

EIPMaintenance Expense on Income Producing Property

ENPMaintenance Expense on Non-Income Producing Property

ENTEntitlement Amount

ERNEarnest Money

ETDEver To Date (ETD) Claim Loss

EXCExploration Costs

FARFederal Housing Administration (FHA) Appraiser Required Repairs and Improvements

FBAFinal Balance

FLAFirst Lien Advance

FOAForeign Assets

GARGarnishments

GATAnnual Tax

GCBCorrected Tax Bill

GCLGross Claim

GFDGifts Not Deposited

GFTGift Amount

GRCGross Contribution

GRDGrants Not Deposited

GRRGross Restoration

GRTGrant Amount

GSPGood Standing Tax Plan Payment

GTSTotal Supplemental Tax Due

GUITax Installment Due

GUPTax Installment Paid

GUSTotal Supplemental Tax Paid

HDAHome Equity Line of Credit Draw Amount

HOAHead Office Account

HZCHazardous Clean-up Cost

IBLInter-Bank Loans

INBInstallment Balance After the Current Installment is Applied

IPDInterest per Diem

ISSInterest Since Claim Submission

IVPInvestment Property

LDRLand Rights

LOWLower Fund

LPCTotal Subject Property Liens Paid by Closing

LPFLease Purchase Funds

LPYLease Payments

LSPTotal Liabilities to be Paid at Closing Not Including Subject Property Liens

LSTLoss on Sale Of Property

MADMiscellaneous Adjustment

MMAModified Mortgage Amount

NBFNet Benefit

NBONet Worth of Business Owned

NCTNet Contribution

NPPNo Tax Plan Payment

NRENet Restoration Expenses

OEQOffice Equipment

OLAOther Liability Amounts

PADPolicy Advance

PANPenalty and Interest

PBGProfit (Loss) Before Grants

PCAProcessing Allowance

PCCPrior Contract Cost Basis

PCPPrevious Claim Payments

PCSPrior Contract Surrender Charge

PCVPrior Contract Value

PEXProfit (Loss) after Extraordinary Items and Tax

PGRProposed Gross Rent for the Subject Property

PPNPending Net Sale Proceeds from Non-Real Estate Assets

PPRPending Net Sale Proceeds from Real Estate Assets

PRDProperty Damage

PRLPartial Payroll Payment

RPCRepackaging Cost

SAASystem Adjusted Amount

SAGSurplus (Deficit) after Grant

SALSalvage

SFDSecured Borrowed Funds Not Deposited

SOFSetoff

SSCShares in Subsidiary Companies

TBCTotal Buyer Closing Costs

TCSTotal Commission from Primary and Secondary Sources

TDATotal Depository Accounts

TENTotal Maintenance Expense on All Non-Income Producing Properties

TEPTotal Maintenance Expense on All Income Producing Properties

TGDTotal Gifts Not Deposited

TISTotal Self-employed Income from Primary and Secondary Sources

TLATotal Other Liquid Assets

TLVTotal Life Insurance Net Cash Value

TMMTotal Monetary Markup Amount

TOLTotal Omitted Liabilities

TPATotal Previous Adjusted Claim

TPRTotal Net Proceeds from Real Estate Assets

TPSTotal Paid as Submitted

TRFTotal Retirement Funds

TRITotal Non-rental Income

TRLTotal Resubordinated Liabilities

TRPTotal Liabilities for Rental Properties

TSBTotal Stocks and Bonds

U8LTax Payment Refinanced by Same Lender

UAAUser Adjusted Amount

UEPUpdated Expenses on Presale

UFDUnsecured Borrowed Funds Not Deposited

UHIUnsecured Home Improvements

UIPUpdated Interest on Presale

UNKUnknown Tax Plan Payment

UPFUpper Fund

VESVested/Earned Upper Fund

VSIValue of Securities at Issue Date

VSMValue of Securities at Maturity

AMT02

Monetary Amount

MRMIN 1 MAX 18ID: 782

Monetary amount

AMT03

Credit/Debit Flag Code

OIDMIN 1 MAX 1ID: 478

Code indicating whether amount is a credit or debit

CCredit

DDebit

HLH

Health Information

OMax: 1Area: 2Seq: 1300

To provide health information

HLH01

Health-Related Code

OIDMIN 1 MAX 1ID: 1212

Code indicating a specific health situation

NNone

SSubstance Abuse

TTobacco Use

UUnknown

XTobacco Use and Substance Abuse

HLH02

Height

ORMIN 1 MAX 8ID: 65

Vertical dimension of an object measured when the object is in the upright position

HLH03

Weight

ORMIN 1 MAX 10ID: 81

Numeric value of weight

HLH04

Weight

ORMIN 1 MAX 10ID: 81

Numeric value of weight

HLH05

Description

OANMIN 1 MAX 80ID: 352

A free-form description to clarify the related data elements and their content

HLH06

Current Health Condition Code

OIDMIN 1 MAX 1ID: 1213

Code indicating current health condition of the individual

1Acute

2Stable

3Chronic

4Systemic

5Localized

6Mild Disease

7Normal, Healthy

8Severe Systemic disease

9Severe Systemic Disease that is a Constant Threat to Life

EExcellent

FFair

GGood

PPoor

HLH07

Description

OANMIN 1 MAX 80ID: 352

A free-form description to clarify the related data elements and their content

Loop: DSB_loop

Repeat: 4

DSB

Disability Information

OMax: 1Area: 2Seq: 2000

To supply disability information

DSB01

Disability Type Code

MIDMIN 1 MAX 1ID: 1146

Code identifying the disability status of the individual

1Short Term Disability

2Long Term Disability

3Permanent or Total Disability

4No Disability

5Partial Disability

ZMutually Defined

DSB02

Quantity

ORMIN 1 MAX 15ID: 380

Numeric value of quantity

DSB03

Occupation Code

OIDMIN 4 MAX 6ID: 1149

Code identifying the occupation of an individual

DSB04

Work Intensity Code

OIDMIN 1 MAX 1ID: 1154

Code identifying the level of intensity of work

HHeavy

LLight

MMedium

RRegular

DSB05

Product Option Code

OIDMIN 1 MAX 2ID: 1161

Code indicating an option chosen for the product

1Pretax

2Post-tax

3Qualified

4Non-qualified

5401K

6Individual Retirement Account

7Keogh

8Simplified Employee Pension

9Single Premium

AFirst to Die

BLast to Die

CChild Rider

DDiscontinue One-Bill Submission

NBenefit Continuation

OOne-Bill Submission

SSalary Continuation

10Flexible Premium

11Variable Premium

12Fixed Premium

13Registered under the Income Tax Act of Canada

14Non-Registered under the Income Tax Act of Canada

15Registered Spousal Case

28Exclusive

29Shopped

30Lead Reinsurer

31Facultative Excess

BABank Account

GAGovernment Allocation

NCOne-Bill Submission Not Chosen

PDPayroll Deduction

DSB06

Monetary Amount

ORMIN 1 MAX 18ID: 782

Monetary amount

DSB07

Product/Service ID Qualifier

CIDMIN 2 MAX 2ID: 235

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

DSB08

Medical Code Value

CANMIN 1 MAX 15ID: 1137

Code value for describing a medical condition or procedure

DTP

Date or Time or Period

OMax: 10Area: 2Seq: 2100

To specify any or all of a date, a time, or a time period

DTP01

Date/Time Qualifier

MIDMIN 3 MAX 3ID: 374

Code specifying type of date or time, or both date and time

436Insurance Card

931Reinsurance Effective

AAOLast Insurance Medical

221Penalty Begin

336Employment Begin

338Medicare Begin

340Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin

346Plan Begin

348Benefit Begin

350Education Begin

352Primary Care Provider Begin

354Illness Begin

356Eligibility Begin

358Cycle Begin

473Medicaid Begin

482Pregnancy Begin

485Injury Begin

AEAMedicare Part A Eligibility Begin Date

AEEMedicare Part B Eligibility Begin Date

AELEmployees Temporarily Laid Off Begin Period

091Report End

151Service Period End

155Adjustment Period End

197End

194Period End

233Claim Statement Period End

268End Date of Support

337Employment End

339Medicare End

341Consolidated Omnibus Budget Reconciliation Act (COBRA) End

347Plan End

349Benefit End

351Education End

353Primary Care Provider End

355Illness End

357Eligibility End

361Initial Disability Period End

483Pregnancy End

486Injury End

DTP02

Date Time Period Format Qualifier

MIDMIN 2 MAX 3ID: 1250

Code indicating the date format, time format, or date and time format

DTP03

Date Time Period

MANMIN 1 MAX 35ID: 1251

Expression of a date, a time, or range of dates, times or dates and times

Loop: HD_loop

Repeat: 99

Health Coverage

OMax: 1Area: 2Seq: 2600

To provide information on health coverage

HD01

Maintenance Type Code

MIDMIN 3 MAX 3ID: 875

Code identifying the specific type of item maintenance

001Change

002Delete

006Membership Type

050Original

051Denial

030Audit or Compare

026Correction

HD02

Maintenance Reason Code

OIDMIN 2 MAX 3ID: 1203

Code identifying the reason for the maintenance change

HD03

Insurance Line Code

OIDMIN 2 MAX 3ID: 1205

Code identifying a group of insurance products

ACBasic Life

AFSupplemental Life

AGPreventative Care/Wellness

AH24 Hour Care

AIWorkers Compensation

AJMedicare Risk

AKMental Health

AMAlternative Medicine

APPaid Up Life

ARDependent Life

AUAcupuncture

BCDeath and Dismemberment

BESupplemental Death and Dismemberment

BHWeekly Indemnity

BKWeekly Indemnity - New York Employees

CCChiropractic Care

CVEmployee Comprehensive

HEHearing

LLLifestyle Life (Individualized Basic Life)

MMMajor Medical

NQNon-Qualified

ULUniversal Life

URUtilization Review

403403(B) Tax Sheltered Annuity

AAADurable Medical Equipment

AABFoot Care

AACSubstance Abuse

ADDAccidental Death or Dismemberment

CHU403(C) Church Exempt Annuity Plans Covered by ERISA

CLFContributory Life

DCPDental Capitation

DENDental

EMP408(K) Employer Sponsored Qualified Defined Distribution Plans Funded with Individual IRA's

EPOExclusive Provider Organization

FACFacility

FSAFlexible Spending

GDC457(B) Government Deferred Compensation

HLTHealth

HMOHealth Maintenance Organization

IRAGroup Individual Retirement Account

IRC408(B) Individual Retirement Account (IRA) Annuity Contract

LTCLong-Term Care

LTDLong-Term Disability

MODMail Order Drug

NGD457(F) Non-Government Deferred Compensation

PDGPrescription Drug

POSPoint of Service

PPOPreferred Provider Organization

PRAPractitioners

PSPProfit-Sharing Plan

QDA401(K) Qualified Cash or Deferred Arrangement

QDC401(A) Qualified Defined Contribution

STDShort-Term Disability

VISVision

ZZZMutually Defined

HD04

Plan Coverage Description

OANMIN 1 MAX 50ID: 1204

A description or number that identifies the plan or coverage

HD05

Coverage Level Code

OIDMIN 3 MAX 3ID: 1207

Code indicating the level of coverage being provided for this insured

CHDChildren Only

DEPDependents Only

E1DEmployee and One Dependent

E2DEmployee and Two Dependents

E3DEmployee and Three Dependents

E5DEmployee and One or More Dependents

E6DEmployee and Two or More Dependents

E7DEmployee and Three or More Dependents

E8DEmployee and Four or More Dependents

E9DEmployee and Five or More Dependents

ECHEmployee and Children

EMPEmployee Only

ESPEmployee and Spouse

FAMFamily

INDIndividual

S1CSubscriber and 1 child

S5CSubscriber and 1 or more children

S6CSubscriber and 2 or more children

SPCSpouse and Children

SPOSpouse Only

SS1Subscriber, spouse, and 1 child

SS5Subscriber, spouse, and 1 or more children

SS6Subscriber, spouse, and 2 or more children

SSPSubscriber and spouse

TWOTwo Party

HD06

Count

ON0MIN 1 MAX 9ID: 609

Occurrence counter

HD07

Count

ON0MIN 1 MAX 9ID: 609

Occurrence counter

HD08

Underwriting Decision Code

OIDMIN 1 MAX 1ID: 1209

Code indicating the decision made by the underwriter

AApproved

BApproved after Reevaluation

CConditioned

DDeclined

ICertified

NNot Medically Underwritten

SSuspended

HD09

Yes/No Condition or Response Code

OIDMIN 1 MAX 1ID: 1073

Code indicating a Yes or No condition or response

NNo

UUnknown

WNot Applicable

YYes

HD10

Drug House Code

OIDMIN 2 MAX 3ID: 1211

Code indicating a drug house with which the insurance plan is affiliated

AMAmericas

NPNational Pharmacy

ZZMutually Defined

BAXBaxter-Travenol

FLRFlex Rx

HCSHealth Case Services

PCSPharmaceutical Card System (PCS)

THRThrift

HD11

Yes/No Condition or Response Code

OIDMIN 1 MAX 1ID: 1073

Code indicating a Yes or No condition or response

NNo

UUnknown

WNot Applicable

YYes

DTP

Date or Time or Period

OMax: 10Area: 2Seq: 2700

To specify any or all of a date, a time, or a time period

DTP01

Date/Time Qualifier

MIDMIN 3 MAX 3ID: 374

Code specifying type of date or time, or both date and time

302Maintenance

303Maintenance Effective

BAMMaintenance Procedures Review

CDTMaintenance Comment

300Enrollment Signature Date

382Enrollment

539Policy Effective

540Policy Expiration

979Policy Surrender

ADKPolicy Effective on or before

ADNPolicy Effective on or after

292Benefit

348Benefit Begin

349Benefit End

288Consolidated Omnibus Budget Reconciliation Act (COBRA)

301Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event

340Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin

341Consolidated Omnibus Budget Reconciliation Act (COBRA) End

543Last Premium Paid Date

DTP02

Date Time Period Format Qualifier

MIDMIN 2 MAX 3ID: 1250

Code indicating the date format, time format, or date and time format

D8Date Expressed in Format CCYYMMDD

DTP03

Date Time Period

MANMIN 1 MAX 35ID: 1251

Expression of a date, a time, or range of dates, times or dates and times

REF

Reference Information

OMax: 5Area: 2Seq: 2900

To specify identifying information

REF01

Reference Identification Qualifier

MIDMIN 2 MAX 3ID: 128

Code qualifying the Reference Identification

1LGroup or Policy Number

24Short-term Disability Policy Number

2CLong-term Disability Policy Number

0KPolicy Form Identifying Number

38Master Policy Number

66Previous Policy Number

69Dental Insurance Policy Number

A8Flexible Spending Account (FSA) Insurance Policy Number

A4Disability Insurance Policy Number

AZHealth Insurance Policy Number

B7Life Insurance Policy Number

BARetirement Plan Policy Number

IGInsurance Policy Number

NWAssociated Policy Number

POLPolicy Number

REF02

Reference Identification

CANMIN 1 MAX 50ID: 127

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

REF03

Description

CANMIN 1 MAX 80ID: 352

A free-form description to clarify the related data elements and their content

Loop: LX_loop

Repeat: 30

Transaction Set Line Number

OMax: 1Area: 2Seq: 3100

To reference a line number in a transaction set

LX01

Assigned Number

MN0MIN 1 MAX 6ID: 554

Number assigned for differentiation within a transaction set

NM1

Individual or Organizational Name

OMax: 1Area: 2Seq: 3200

To supply the full name of an individual or organizational entity

NM101

Entity Identifier Code

MIDMIN 2 MAX 3ID: 98

Code identifying an organizational entity, a physical location, property or an individual

ODDoctor of Optometry

QODoctor of Osteopathy

QYMedical Doctor

QNDentist

00Alternate Insurer

P3Primary Care Provider

1PProvider

NM102

Entity Type Qualifier

MIDMIN 1 MAX 1ID: 1065

Code qualifying the type of entity

1Person

6Organization

3Unknown

CCustodial

NM103

Name Last or Organization Name

CANMIN 1 MAX 60ID: 1035

Individual last name or organizational name

NM104

Name First

OANMIN 1 MAX 35ID: 1036

Individual first name

NM105

Name Middle

OANMIN 1 MAX 25ID: 1037

Individual middle name or initial

NM106

Name Prefix

OANMIN 1 MAX 10ID: 1038

Prefix to individual name

NM107

Name Suffix

OANMIN 1 MAX 10ID: 1039

Suffix to individual name

NM108

Identification Code Qualifier

CIDMIN 1 MAX 2ID: 66

Code designating the system/method of code structure used for Identification Code (67)

NM109

Identification Code

CANMIN 2 MAX 80ID: 67

Code identifying a party or other code

NM110

Entity Relationship Code

CIDMIN 2 MAX 2ID: 706

Code describing entity relationship

01Parent

02Child

03Corporation

04Subsidiary

05Wholly-Owned Subsidiary

06Division

07Company

08Doing Business As

09Component

10Partnership

11Partner

12Member

13Association

14Headquarters

15Profit Center

16Cost Center

17Product Line

18Union

19Group

20Department

21Multinational Corporation

22Sibling

23Affiliate

24Direct Affiliate

25Established Patient

26Not Established Patient

27Domestic Partner

29Power of Attorney Delegee

30Significant Other

31Ultimate Parent Company

32Branch

33Owned

34Managed

35Leased

36Group Affiliate

37Owner Affiliate

38Owner

39Related for U.S. Customs Purposes

40Related for U.S. Bureau of the Census Purposes

41Spouse

42Adoptive Parent

43Bank

44Brother

45Business Associate

46Daughter

47Dependent

48Employee

49Employer

50Father

51Fianc�e

52Foreman

53Foster Parent

54Friend

55Grand Child

56Grand Parent

57Guardian

58Inforce Policyholder

59Institution

60Minister

61Mother

62Neighbor

63Non Family

64None

65Other

66Other Family

67Self

68Sister

69Step Child

70Supervisor

71Teacher

72Unknown

73Business Name

74Counselor

75Sanctioning Organization

76Sponsoring Organization

77Same Job as Applicant

78Stockholder

79Attorney

80Aunt

81Brother-in-law

82Cousin

83Daughter-in-law

84Family

85Father-in-law

86Financial Interest

87Marketing Unit

88Mother-in-law

89Nephew

90Niece

91Officer

92Principal Customer

93Principal Supplier

94Sister-in-law

95Son

96Son-in-law

97Uncle

98Descendant

99Director

AAPrincipal Stockholder

ABInsured Entity

ACAllied Professional

ADAncillary Referral

AEContact

AFContract

AGHealth Care Facility Affiliation

AHIndependent Physician/Practice Association (IPA) Affiliation

AIReferral Lab Provider

AJManaged Care Organization Affiliation

AKMedical Director

ALHealth Care Network Affiliation

AMOffice Manager

ANOn-call Physician

AOPhysician Hospital Organization (PHO) Affiliation

APProvider in Practice

AQReferred by Provider

ARReferred to Provider

ASReferral X-ray Provider

ATParent-in-law

AUStep Parent

AVFormer Spouse

AWWard

CPCustodial Parent

OPObligated Parent

PIPrincipal

NM111

Entity Identifier Code

OIDMIN 2 MAX 3ID: 98

Code identifying an organizational entity, a physical location, property or an individual

NM112

Name Last or Organization Name

OANMIN 1 MAX 60ID: 1035

Individual last name or organizational name

Loop: COB_loop

Repeat: 5

COB

Coordination of Benefits

OMax: 1Area: 2Seq: 4000

To supply information on coordination of benefits

COB01

Payer Responsibility Sequence Number Code

OIDMIN 1 MAX 1ID: 1138

Code identifying the insurance carrier's level of responsibility for a payment of a claim

APayer Responsibility Four

BPayer Responsibility Five

CPayer Responsibility Six

DPayer Responsibility Seven

EPayer Responsibility Eight

FPayer Responsibility Nine

GPayer Responsibility Ten

HPayer Responsibility Eleven

NUnconfirmed

ONoncapitated Agreement

PPrimary

SSecondary

TTertiary

UUnknown

COB02

Reference Identification

OANMIN 1 MAX 50ID: 127

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

COB03

Coordination of Benefits Code

OIDMIN 1 MAX 1ID: 1143

Code identifying whether there is a coordination of benefits

1Coordination of Benefits

2Coordination of Benefits applies to Spouse Only

3Coordination of Benefits applies to Spouse and Dependents

4Coordination of Benefits applies to Dependents Only

5Unknown

6No Coordination of Benefits

7Coordination of Benefits Applies to Subscriber Only

8Conflict in Coordination of Benefit

9Coordination of Benefits Applies to Whole Family

COB04

Service Type Code

OIDMIN 1 MAX 2ID: 1365

Code identifying the classification of service

1Medical Care

2Surgical

3Consultation

4Diagnostic X-Ray

5Diagnostic Lab

6Radiation Therapy

7Anesthesia

8Surgical Assistance

9Other Medical

BNon-escrow or Non-impound Service

CEscrow or Impound Service

10Blood Charges

11Used Durable Medical Equipment

12Durable Medical Equipment Purchase

13Ambulatory Service Center Facility

14Renal Supplies in the Home

15Alternate Method Dialysis

16Chronic Renal Disease (CRD) Equipment

17Pre-Admission Testing

18Durable Medical Equipment Rental

19Pneumonia Vaccine

20Second Surgical Opinion

21Third Surgical Opinion

22Social Work

23Diagnostic Dental

24Periodontics

25Restorative

26Endodontics

27Maxillofacial Prosthetics

28Adjunctive Dental Services

30Health Benefit Plan Coverage

31Benefit Disclaimer

32Plan Waiting Period

33Chiropractic

34Chiropractic Office Visits

35Dental Care

36Dental Crowns

37Dental Accident

38Orthodontics

39Prosthodontics

40Oral Surgery

41Routine (Preventive) Dental

42Home Health Care

43Home Health Prescriptions

44Home Health Visits

45Hospice

46Respite Care

47Hospital

48Hospital - Inpatient

49Hospital - Room and Board

50Hospital - Outpatient

51Hospital - Emergency Accident

52Hospital - Emergency Medical

53Hospital - Ambulatory Surgical

54Long Term Care

55Major Medical

56Medically Related Transportation

57Air Transportation

58Cabulance

59Licensed Ambulance

60General Benefits

61In-vitro Fertilization

62MRI/CAT Scan

63Donor Procedures

64Acupuncture

65Newborn Care

66Pathology

67Smoking Cessation

68Well Baby Care

69Maternity

70Transplants

71Audiology Exam

72Inhalation Therapy

73Diagnostic Medical

74Private Duty Nursing

75Prosthetic Device

76Dialysis

77Otological Exam

78Chemotherapy

79Allergy Testing

80Immunizations

81Routine Physical

82Family Planning

83Infertility

84Abortion

85AIDS

86Emergency Services

87Cancer

88Pharmacy

89Free Standing Prescription Drug

90Mail Order Prescription Drug

91Brand Name Prescription Drug

92Generic Prescription Drug

93Podiatry

94Podiatry - Office Visits

95Podiatry - Nursing Home Visits

96Professional (Physician)

97Anesthesiologist

98Professional (Physician) Visit - Office

99Professional (Physician) Visit - Inpatient

A0Professional (Physician) Visit - Outpatient

A1Professional (Physician) Visit - Nursing Home

A2Professional (Physician) Visit - Skilled Nursing Facility

A3Professional (Physician) Visit - Home

A4Psychiatric

A5Psychiatric - Room and Board

A6Psychotherapy

A7Psychiatric - Inpatient

A8Psychiatric - Outpatient

A9Rehabilitation

AARehabilitation - Room and Board

ABRehabilitation - Inpatient

ACRehabilitation - Outpatient

ADOccupational Therapy

AEPhysical Medicine

AFSpeech Therapy

AGSkilled Nursing Care

AHSkilled Nursing Care - Room and Board

AISubstance Abuse

AJAlcoholism

AKDrug Addiction

ALVision (Optometry)

AMFrames

ANRoutine Exam

AOLenses

AQNonmedically Necessary Physical

ARExperimental Drug Therapy

B1Burn Care

B2Brand Name Prescription Drug - Formulary

B3Brand Name Prescription Drug - Non-Formulary

BAIndependent Medical Evaluation

BBPartial Hospitalization (Psychiatric)

BCDay Care (Psychiatric)

BDCognitive Therapy

BEMassage Therapy

BFPulmonary Rehabilitation

BGCardiac Rehabilitation

BHPediatric

BINursery

BJSkin

BKOrthopedic

BLCardiac

BMLymphatic

BNGastrointestinal

BPEndocrine

BQNeurology

BREye

BSInvasive Procedures

BTGynecological

BUObstetrical

BVObstetrical/Gynecological

BWMail Order Prescription Drug: Brand Name

BXMail Order Prescription Drug: Generic

BYPhysician Visit - Office: Sick

BZPhysician Visit - Office: Well

C1Coronary Care

CAPrivate Duty Nursing - Inpatient

CBPrivate Duty Nursing - Home

CCSurgical Benefits - Professional (Physician)

CDSurgical Benefits - Facility

CEMental Health Provider - Inpatient

CFMental Health Provider - Outpatient

CGMental Health Facility - Inpatient

CHMental Health Facility - Outpatient

CISubstance Abuse Facility - Inpatient

CJSubstance Abuse Facility - Outpatient

CKScreening X-ray

CLScreening laboratory

CMMammogram, High Risk Patient

CNMammogram, Low Risk Patient

COFlu Vaccination

CPEyewear and Eyewear Accessories

CQCase Management

DGDermatology

DMDurable Medical Equipment

DSDiabetic Supplies

GFGeneric Prescription Drug - Formulary

GNGeneric Prescription Drug - Non-Formulary

GYAllergy

ICIntensive Care

MHMental Health

NINeonatal Intensive Care

ONOncology

PTPhysical Therapy

PUPulmonary

RNRenal

RTResidential Psychiatric Treatment

TCTransitional Care

TNTransitional Nursery Care

UCUrgent Care

DTP

Date or Time or Period

OMax: 2Area: 2Seq: 4070

To specify any or all of a date, a time, or a time period

DTP01

Date/Time Qualifier

MIDMIN 3 MAX 3ID: 374

Code specifying type of date or time, or both date and time

338Medicare Begin

336Employment Begin

340Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin

346Plan Begin

348Benefit Begin

350Education Begin

354Illness Begin

356Eligibility Begin

358Cycle Begin

473Medicaid Begin

482Pregnancy Begin

485Injury Begin

197End

194Period End

337Employment End

339Medicare End

341Consolidated Omnibus Budget Reconciliation Act (COBRA) End

347Plan End

349Benefit End

351Education End

355Illness End

357Eligibility End

353Primary Care Provider End

359Cycle End

474Medicaid End

483Pregnancy End

486Injury End

DTP02

Date Time Period Format Qualifier

MIDMIN 2 MAX 3ID: 1250

Code indicating the date format, time format, or date and time format

D8Date Expressed in Format CCYYMMDD

DTP03

Date Time Period

MANMIN 1 MAX 35ID: 1251

Expression of a date, a time, or range of dates, times or dates and times

Transaction Set Trailer

MMax: 1Area: 2Seq: 6900

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

SE01

Number of Included Segments

MN0MIN 1 MAX 10ID: 96

Total number of segments included in a transaction set including ST and SE segments

SE02

Transaction Set Control Number

MANMIN 4 MAX 9ID: 329

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Healthcare Leader X12 834 Benefit Enrollment and Maintenance