Below are some samples of the reports you have available to you in Commando.
HL7 Message Reports: Sample 1 shows you a report generated for a simple HL7 message showing only the fields that contain data (4 pages). Compare this with the Sample 2 report that shows the SAME message but includes all of the version 2.3 segment/field details as well as the data (25 pages).
MSH-Message header segment (20 fields)
MSH-03: Sending Application (3 components) namespace id: SOMEAPP MSH-04: Sending Facility (3 components) namespace id: SOMEAPP MSH-05: Receiving Application (3 components) namespace id: YOURAPP MSH-06: Receiving Facility (3 components) namespace id: YOURAPP MSH-07: Date/Time Of Message (2 components) time stamp data: 20031111163831+0000 degree of precision (optional): S MSH-08: Security (1 component) Value: NO SECURITY MSH-09: Message Type (4 components) component 1: ADT component 2: A08 MSH-10: Message Control ID (1 component) Value: MISYS000611811 MSH-11: Processing ID (2 components) processing id: T MSH-12: Version ID (3 components) version id: 2.3 MSH-13: Sequence Number (1 component) Value: 000000000611811 MSH-15: Accept Acknowledgment Type (1 component) Value: AL
EVN-Event type segment (6 fields)
EVN-01: Event Type Code (1 component) Value: A08 EVN-02: Recorded Date/Time (2 components) time stamp data: 20031111163831+0000 degree of precision (optional): S EVN-04: Event Reason Code (1 component) Value: 00102 EVN-05: Operator ID (7 components) id number: 00002
PID-Patient identification segment (30 fields)
PID-02: Patient ID (6 components) id: 234166342 PID-03: Patient Identifier List (6 components) id: 0190737 PID-04: Alternate Patient ID - PID (6 components) id: 234166342 PID-05: Patient Name (7 components) family name (last name): OYLE given name (first name): OLIVE middle initial or name: M PID-07: Date/Time of Birth (2 components) time stamp data: 19760824 PID-08: Sex (1 component) Value: F PID-11: Patient Address (9 components) street address: 5008 SOMEPLACE RD other designation: APT215 city: FT WORTH state or province: TX zip or postal code: 76132-0000 PID-13: Phone Number - Home (8 components) telecommunications use code: (817)555-1212 PID-14: Phone Number - Business (8 components) telecommunications use code: (214)555-1212X00019 PID-18: Patient Account Number (6 components) id: 234166342 PID-19: SSN Number - Patient (1 component) Value: 234166342
PV1-Patient visit segment (52 fields)
PV1-02: Patient Class (1 component) Value: P PV1-03: Assigned Patient Location (9 components) point of care: room: bed: facility: 00002 PV1-04: Admission Type (1 component) Value: R PV1-06: Prior Patient Location (9 components) point of care: 00019 PV1-07: Attending Doctor (7 components) id number: 06543 family name (last name): HOOPER given name (first name): DENNIS middle initial or name: L PV1-20: Financial Class (2 components) financial class: 00111
DG1-Diagnosis segment (19 fields)
DG1-01: Set ID - DG1 (1 component) Value: 0001 DG1-02: Diagnosis Coding Method (1 component) Value: I9 DG1-04: Diagnosis Description (1 component) Value: NODX DG1-06: Diagnosis Type (1 component) Value: W DG1-15: Diagnosis Priority (1 component) Value: 01 DG1-16: Diagnosing Clinician (7 components) id number: 06543 family name (last name): HOOPER given name (first name): DENNIS middle initial or name: L
GT1-Guarantor segment (55 fields)
GT1-01: Set ID - GT1 (1 component) Value: 0001 GT1-03: Guarantor Name (7 components) family name (last name): OYLE given name (first name): OLIVE middle initial or name: M GT1-05: Guarantor Address (9 components) street address: 5008 SOMEPLACE RD other designation: APT215 city: FT WORTH state or province: TX zip or postal code: 76132-0000 GT1-06: Guarantor Ph Num-Home (8 components) telecommunications use code: (817)555-1212 GT1-07: Guarantor Ph Num-Business (8 components) telecommunications use code: (214)555-1212X00019
IN1-Insurance segment (49 fields)
IN1-01: Set ID - IN1 (1 component) Value: 0001 IN1-02: Insurance Plan ID (6 components) identifier: 0000008 IN1-03: Insurance Company ID (6 components) id: 0000114 IN1-04: Insurance Company Name (8 components) organization name: UNITED HEALTH 87726 IN1-05: Insurance Company Address (9 components) street address: P O BOX 740800 other designation: city: ATLANTA state or province: GA zip or postal code: 30374-0800 IN1-07: Insurance Co Phone Number (8 components) telecommunications use code: (800)842-5724 IN1-12: Plan Effective Date (1 component) Value: 20000401 IN1-15: Plan Type (1 component) Value: P IN1-16: Name Of Insured (7 components) family name (last name): OYLE given name (first name): OLIVE middle initial or name: M IN1-17: Insured's Relationship To Patient (6 components) identifier: 00002 IN1-18: Insured's Date Of Birth (2 components) time stamp data: 19760824 IN1-19: Insured's Address (9 components) street address: 5008 SOMEPLACE RD other designation: APT215 city: FT WORTH state or province: TX zip or postal code: 76132-0000 IN1-20: Assignment Of Benefits (1 component) Value: Y IN1-21: Coordination Of Benefits (1 component) Value: Y IN1-27: Release Information Code (1 component) Value: A IN1-36: Policy Number (1 component) Value: 234166342 IN1-43: Insured's Sex (1 component) Value: F
IN2-Insurance additional information segment (72 fields)
IN2-02: Insured's Social Security Number (1 component) Value: 234166342 IN2-03: Insured's Employer's Name and ID (7 components) id number: 0009999 family name (last name): UNKNOWN IN2-05: Mail Claim Party (1 component) Value: I
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MSH-Message header segment (20 fields)
MSH-01: Field Separator [ST] (MaxLen: [1] 1 Component) [ST] Value: MSH-02: Encoding Characters [ST] (MaxLen: [4] 1 Component) [ST] Value: MSH-03: Sending Application [HD] (MaxLen: [180] Table: [361] 3 Components) [IS] namespace id: SOMEAPP [ST] universal id: [ID] universal id type: MSH-04: Sending Facility [HD] (MaxLen: [180] Table: [362] 3 Components) [IS] namespace id: SOMEAPP [ST] universal id: [ID] universal id type: MSH-05: Receiving Application [HD] (MaxLen: [180] Table: [361] 3 Components) [IS] namespace id: YOURAPP [ST] universal id: [ID] universal id type: MSH-06: Receiving Facility [HD] (MaxLen: [180] Table: [362] 3 Components) [IS] namespace id: YOURAPP [ST] universal id: [ID] universal id type: MSH-07: Date/Time Of Message [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: 20031111163831+0000 [ST] degree of precision (optional): S MSH-08: Security [ST] (MaxLen: [40] 1 Component) [ST] Value: NO SECURITY MSH-09: Message Type [CM] (MaxLen: [7] Table: [76] 4 Components) [ST] component 1: ADT [ST] component 2: A08 [ST] component 3: [ST] component 4: MSH-10: Message Control ID [ST] (MaxLen: [20] 1 Component) [ST] Value: MISYS000611811 MSH-11: Processing ID [PT] (MaxLen: [3] 2 Components) [ID] processing id: T [ID] processing mode: MSH-12: Version ID [VID] (MaxLen: [60] Table: [104] 3 Components) [ID] version id: 2.3 [CE] internationalization code: [CE] international version id: MSH-13: Sequence Number [NM] (MaxLen: [15] 1 Component) [ST] Value: 000000000611811 MSH-14: Continuation Pointer [ST] (MaxLen: [180] 1 Component) [ST] Value: MSH-15: Accept Acknowledgment Type [ID] (MaxLen: [2] Table: [155] 1 Component) [ST] Value: AL MSH-16: Application Acknowledgment Type [ID] (MaxLen: [2] Table: [155] 1 Component) [ST] Value: MSH-17: Country Code [ID] (MaxLen: [2] 1 Component) [ST] Value: MSH-18: Character Set [ID] (MaxLen: [16] Table: [211] 1 Component) [ST] Value: MSH-19: Principal Language Of Message [CE] (MaxLen: [60] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: MSH-20: Alternate Character Set Handling Scheme [ID] (MaxLen: [20] Table: [356] 1 Component) [ST] Value:
EVN-Event type segment (6 fields)
EVN-01: Event Type Code [ID] (MaxLen: [3] Table: [3] 1 Component) [ST] Value: A08 EVN-02: Recorded Date/Time [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: 20031111163831+0000 [ST] degree of precision (optional): S EVN-03: Date/Time Planned Event [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional): EVN-04: Event Reason Code [IS] (MaxLen: [3] Table: [62] 1 Component) [ST] Value: 00102 EVN-05: Operator ID [XCN] (MaxLen: [60] Table: [188] 7 Components) [ST] id number: 00002 [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix: [ST] prefix: [ST] degree: EVN-06: Event Occurred [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional):
PID-Patient identification segment (30 fields)
PID-01: Set ID - PID [SI] (MaxLen: [4] 1 Component) [ST] Value: PID-02: Patient ID [CX] (MaxLen: [20] 6 Components) Annotation: sssss [ST] id: 234166342 [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: PID-03: Patient Identifier List [CX] (MaxLen: [20] 6 Components) [ST] id: 0190737 [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: PID-04: Alternate Patient ID - PID [CX] (MaxLen: [20] 6 Components) [ST] id: 234166342 [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: PID-05: Patient Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): OYLE [ST] given name (first name): OLIVE [ST] middle initial or name: M [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: PID-06: Mother's Maiden Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: PID-07: Date/Time of Birth [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: 19760824 [ST] degree of precision (optional): PID-08: Sex [IS] (MaxLen: [1] Table: [1] 1 Component) [ST] Value: F PID-09: Patient Alias [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: PID-10: Race [CE] (MaxLen: [80] Table: [5] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PID-11: Patient Address [XAD] (MaxLen: [106] 9 Components) [ST] street address: 5008 SOMEPLACE RD [ST] other designation: APT215 [ST] city: FT WORTH [ST] state or province: TX [ST] zip or postal code: 76132-0000 [ID] country: [ID] address type: [ST] other geographic designation: [ST] country ??: PID-12: County Code [IS] (MaxLen: [4] Table: [289] 1 Component) [ST] Value: PID-13: Phone Number - Home [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: (817)555-1212 [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: PID-14: Phone Number - Business [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: (214)555-1212X00019 [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: PID-15: Primary Language [CE] (MaxLen: [60] Table: [296] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PID-16: Marital Status [CE] (MaxLen: [80] Table: [2] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PID-17: Religion [CE] (MaxLen: [80] Table: [6] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PID-18: Patient Account Number [CX] (MaxLen: [20] 6 Components) [ST] id: 234166342 [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: PID-19: SSN Number - Patient [ST] (MaxLen: [16] 1 Component) [ST] Value: 234166342 PID-20: Driver's License Number - Patient [DLN] (MaxLen: [25] 3 Components) [ST] license number: [IS] issuing state, province, country: [DT] expiration date: PID-21: Mother's Identifier [CX] (MaxLen: [20] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: PID-22: Ethnic Group [CE] (MaxLen: [80] Table: [189] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PID-23: Birth Place [ST] (MaxLen: [60] 1 Component) [ST] Value: PID-24: Multiple Birth Indicator [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: PID-25: Birth Order [NM] (MaxLen: [2] 1 Component) [ST] Value: PID-26: Citizenship [CE] (MaxLen: [80] Table: [171] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PID-27: Veterans Military Status [CE] (MaxLen: [60] Table: [172] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PID-28: Nationality [CE] (MaxLen: [80] Table: [212] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PID-29: Patient Death Date and Time [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional): PID-30: Patient Death Indicator [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value:
PV1-Patient visit segment (52 fields)
PV1-01: Set ID - PV1 [SI] (MaxLen: [4] 1 Component) [ST] Value: PV1-02: Patient Class [IS] (MaxLen: [1] Table: [4] 1 Component) [ST] Value: P PV1-03: Assigned Patient Location [PL] (MaxLen: [80] 9 Components) [IS] point of care: [IS] room: [IS] bed: [IS] facility: 00002 [IS] location status: [IS] person location type: [IS] building: [IS] floor: [ST] location description: PV1-04: Admission Type [IS] (MaxLen: [2] Table: [7] 1 Component) [ST] Value: R PV1-05: Preadmit Number [CX] (MaxLen: [20] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: PV1-06: Prior Patient Location [PL] (MaxLen: [80] 9 Components) [IS] point of care: 00019 [IS] room: [IS] bed: [IS] facility: [IS] location status: [IS] person location type: [IS] building: [IS] floor: [ST] location description: PV1-07: Attending Doctor [XCN] (MaxLen: [60] Table: [10] 7 Components) [ST] id number: 06543 [ST] family name (last name): HOOPER [ST] given name (first name): DENNIS [ST] middle initial or name: L [ST] suffix: [ST] prefix: [ST] degree: PV1-08: Referring Doctor [XCN] (MaxLen: [60] Table: [10] 7 Components) [ST] id number: [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix: [ST] prefix: [ST] degree: PV1-09: Consulting Doctor [XCN] (MaxLen: [60] Table: [10] 7 Components) [ST] id number: [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix: [ST] prefix: [ST] degree: PV1-10: Hospital Service [IS] (MaxLen: [3] Table: [69] 1 Component) [ST] Value: PV1-11: Temporary Location [PL] (MaxLen: [80] 9 Components) [IS] point of care: [IS] room: [IS] bed: [IS] facility: [IS] location status: [IS] person location type: [IS] building: [IS] floor: [ST] location description: PV1-12: Preadmit Test Indicator [IS] (MaxLen: [2] Table: [87] 1 Component) [ST] Value: PV1-13: Re-admission Indicator [IS] (MaxLen: [2] Table: [92] 1 Component) [ST] Value: PV1-14: Admit Source [IS] (MaxLen: [3] Table: [23] 1 Component) [ST] Value: PV1-15: Ambulatory Status [IS] (MaxLen: [2] Table: [9] 1 Component) [ST] Value: PV1-16: VIP Indicator [IS] (MaxLen: [2] Table: [99] 1 Component) [ST] Value: PV1-17: Admitting Doctor [XCN] (MaxLen: [60] Table: [10] 7 Components) [ST] id number: [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix: [ST] prefix: [ST] degree: PV1-18: Patient Type [IS] (MaxLen: [2] Table: [18] 1 Component) [ST] Value: PV1-19: Visit Number [CX] (MaxLen: [20] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: PV1-20: Financial Class [FC] (MaxLen: [50] Table: [64] 2 Components) [ID] financial class: 00111 [TS] effective date: PV1-21: Charge Price Indicator [IS] (MaxLen: [2] Table: [32] 1 Component) [ST] Value: PV1-22: Courtesy Code [IS] (MaxLen: [2] Table: [45] 1 Component) [ST] Value: PV1-23: Credit Rating [IS] (MaxLen: [2] Table: [46] 1 Component) [ST] Value: PV1-24: Contract Code [IS] (MaxLen: [2] Table: [44] 1 Component) [ST] Value: PV1-25: Contract Effective Date [DT] (MaxLen: [8] 1 Component) [ST] Value: PV1-26: Contract Amount [NM] (MaxLen: [12] 1 Component) [ST] Value: PV1-27: Contract Period [NM] (MaxLen: [3] 1 Component) [ST] Value: PV1-28: Interest Code [IS] (MaxLen: [2] Table: [73] 1 Component) [ST] Value: PV1-29: Transfer to Bad Debt Code [IS] (MaxLen: [1] Table: [110] 1 Component) [ST] Value: PV1-30: Transfer to Bad Debt Date [DT] (MaxLen: [8] 1 Component) [ST] Value: PV1-31: Bad Debt Agency Code [IS] (MaxLen: [10] Table: [21] 1 Component) [ST] Value: PV1-32: Bad Debt Transfer Amount [NM] (MaxLen: [12] 1 Component) [ST] Value: PV1-33: Bad Debt Recovery Amount [NM] (MaxLen: [12] 1 Component) [ST] Value: PV1-34: Delete Account Indicator [IS] (MaxLen: [1] Table: [111] 1 Component) [ST] Value: PV1-35: Delete Account Date [DT] (MaxLen: [8] 1 Component) [ST] Value: PV1-36: Discharge Disposition [IS] (MaxLen: [3] Table: [112] 1 Component) [ST] Value: PV1-37: Discharged to Location [CM] (MaxLen: [25] Table: [113] 4 Components) [ST] component 1: [ST] component 2: [ST] component 3: [ST] component 4: PV1-38: Diet Type [CE] (MaxLen: [80] Table: [114] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: PV1-39: Servicing Facility [IS] (MaxLen: [2] Table: [115] 1 Component) [ST] Value: PV1-40: Bed Status [IS] (MaxLen: [1] Table: [116] 1 Component) [ST] Value: PV1-41: Account Status [IS] (MaxLen: [2] Table: [117] 1 Component) [ST] Value: PV1-42: Pending Location [PL] (MaxLen: [80] 9 Components) [IS] point of care: [IS] room: [IS] bed: [IS] facility: [IS] location status: [IS] person location type: [IS] building: [IS] floor: [ST] location description: PV1-43: Prior Temporary Location [PL] (MaxLen: [80] 9 Components) [IS] point of care: [IS] room: [IS] bed: [IS] facility: [IS] location status: [IS] person location type: [IS] building: [IS] floor: [ST] location description: PV1-44: Admit Date/Time [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional): PV1-45: Discharge Date/Time [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional): PV1-46: Current Patient Balance [NM] (MaxLen: [12] 1 Component) [ST] Value: PV1-47: Total Charges [NM] (MaxLen: [12] 1 Component) [ST] Value: PV1-48: Total Adjustments [NM] (MaxLen: [12] 1 Component) [ST] Value: PV1-49: Total Payments [NM] (MaxLen: [12] 1 Component) [ST] Value: PV1-50: Alternate Visit ID [CX] (MaxLen: [20] Table: [203] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: PV1-51: Visit Indicator [IS] (MaxLen: [1] Table: [326] 1 Component) [ST] Value: PV1-52: Other Healthcare Provider [XCN] (MaxLen: [60] Table: [10] 7 Components) [ST] id number: [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix: [ST] prefix: [ST] degree:
DG1-Diagnosis segment (19 fields)
DG1-01: Set ID - DG1 [SI] (MaxLen: [4] 1 Component) [ST] Value: 0001 DG1-02: Diagnosis Coding Method [ID] (MaxLen: [2] Table: [53] 1 Component) [ST] Value: I9 DG1-03: Diagnosis Code - DG1 [CE] (MaxLen: [60] Table: [51] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: DG1-04: Diagnosis Description [ST] (MaxLen: [40] 1 Component) [ST] Value: NODX DG1-05: Diagnosis Date/Time [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional): DG1-06: Diagnosis Type [IS] (MaxLen: [2] Table: [52] 1 Component) [ST] Value: W DG1-07: Major Diagnostic Category [CE] (MaxLen: [60] Table: [118] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: DG1-08: Diagnostic Related Group [CE] (MaxLen: [60] Table: [55] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: DG1-09: DRG Approval Indicator [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: DG1-10: DRG Grouper Review Code [IS] (MaxLen: [2] Table: [56] 1 Component) [ST] Value: DG1-11: Outlier Type [CE] (MaxLen: [60] Table: [83] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: DG1-12: Outlier Days [NM] (MaxLen: [3] 1 Component) [ST] Value: DG1-13: Outlier Cost [CP] (MaxLen: [12] 6 Components) [MO] price: [ID] price type: [NM] from value: [NM] to value: [CE] range units: [ID] range type: DG1-14: Grouper Version And Type [ST] (MaxLen: [4] 1 Component) [ST] Value: DG1-15: Diagnosis Priority [ID] (MaxLen: [2] Table: [359] 1 Component) [ST] Value: 01 DG1-16: Diagnosing Clinician [XCN] (MaxLen: [60] 7 Components) [ST] id number: 06543 [ST] family name (last name): HOOPER [ST] given name (first name): DENNIS [ST] middle initial or name: L [ST] suffix: [ST] prefix: [ST] degree: DG1-17: Diagnosis Classification [IS] (MaxLen: [3] Table: [228] 1 Component) [ST] Value: DG1-18: Confidential Indicator [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: DG1-19: Attestation Date/Time [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional):
GT1-Guarantor segment (55 fields)
GT1-01: Set ID - GT1 [SI] (MaxLen: [4] 1 Component) [ST] Value: 0001 GT1-02: Guarantor Number [CX] (MaxLen: [59] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: GT1-03: Guarantor Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): OYLE [ST] given name (first name): OLIVE [ST] middle initial or name: M [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: GT1-04: Guarantor Spouse Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: GT1-05: Guarantor Address [XAD] (MaxLen: [106] 9 Components) [ST] street address: 5008 SOMEPLACE RD [ST] other designation: APT215 [ST] city: FT WORTH [ST] state or province: TX [ST] zip or postal code: 76132-0000 [ID] country: [ID] address type: [ST] other geographic designation: [ST] country ??: GT1-06: Guarantor Ph Num-Home [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: (817)555-1212 [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: GT1-07: Guarantor Ph Num-Business [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: (214)555-1212X00019 [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: GT1-08: Guarantor Date/Time Of Birth [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional): GT1-09: Guarantor Sex [IS] (MaxLen: [1] Table: [1] 1 Component) [ST] Value: GT1-10: Guarantor Type [IS] (MaxLen: [2] Table: [68] 1 Component) [ST] Value: GT1-11: Guarantor Relationship [CE] (MaxLen: [80] Table: [63] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-12: Guarantor SSN [ST] (MaxLen: [11] 1 Component) [ST] Value: GT1-13: Guarantor Date - Begin [DT] (MaxLen: [8] 1 Component) [ST] Value: GT1-14: Guarantor Date - End [DT] (MaxLen: [8] 1 Component) [ST] Value: GT1-15: Guarantor Priority [NM] (MaxLen: [2] 1 Component) [ST] Value: GT1-16: Guarantor Employer Name [XPN] (MaxLen: [130] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: GT1-17: Guarantor Employer Address [XAD] (MaxLen: [106] 9 Components) [ST] street address: [ST] other designation: [ST] city: [ST] state or province: [ST] zip or postal code: [ID] country: [ID] address type: [ST] other geographic designation: [ST] country ??: GT1-18: Guarantor Employer Phone Number [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: GT1-19: Guarantor Employee ID Number [CX] (MaxLen: [20] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: GT1-20: Guarantor Employment Status [IS] (MaxLen: [2] Table: [66] 1 Component) [ST] Value: GT1-21: Guarantor Organization Name [XON] (MaxLen: [130] 8 Components) [ST] organization name: [IS] organization name type code: [NM] id number: [NM] check digit: [ID] code identifying check digit scheme used: [HD] assigning authority: [IS] identifier type code: [HD] assigning facility id: GT1-22: Guarantor Billing Hold Flag [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: GT1-23: Guarantor Credit Rating Code [CE] (MaxLen: [80] Table: [341] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-24: Guarantor Death Date And Time [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional): GT1-25: Guarantor Death Flag [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: GT1-26: Guarantor Charge Adjustment Code [CE] (MaxLen: [80] Table: [218] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-27: Guarantor Household Annual Income [CP] (MaxLen: [10] 6 Components) [MO] price: [ID] price type: [NM] from value: [NM] to value: [CE] range units: [ID] range type: GT1-28: Guarantor Household Size [NM] (MaxLen: [3] 1 Component) [ST] Value: GT1-29: Guarantor Employer ID Number [CX] (MaxLen: [20] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: GT1-30: Guarantor Marital Status Code [CE] (MaxLen: [80] Table: [2] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-31: Guarantor Hire Effective Date [DT] (MaxLen: [8] 1 Component) [ST] Value: GT1-32: Employment Stop Date [DT] (MaxLen: [8] 1 Component) [ST] Value: GT1-33: Living Dependency [IS] (MaxLen: [2] Table: [223] 1 Component) [ST] Value: GT1-34: Ambulatory Status [IS] (MaxLen: [2] Table: [9] 1 Component) [ST] Value: GT1-35: Citizenship [CE] (MaxLen: [80] Table: [171] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-36: Primary Language [CE] (MaxLen: [60] Table: [296] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-37: Living Arrangement [IS] (MaxLen: [2] Table: [220] 1 Component) [ST] Value: GT1-38: Publicity Code [CE] (MaxLen: [80] Table: [215] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-39: Protection Indicator [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: GT1-40: Student Indicator [IS] (MaxLen: [2] Table: [231] 1 Component) [ST] Value: GT1-41: Religion [CE] (MaxLen: [80] Table: [6] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-42: Mother's Maiden Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: GT1-43: Nationality [CE] (MaxLen: [80] Table: [212] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-44: Ethnic Group [CE] (MaxLen: [80] Table: [189] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-45: Contact Person's Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: GT1-46: Contact Person's Telephone Number [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: GT1-47: Contact Reason [CE] (MaxLen: [80] Table: [222] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: GT1-48: Contact Relationship [IS] (MaxLen: [2] Table: [63] 1 Component) [ST] Value: GT1-49: Job Title [ST] (MaxLen: [20] 1 Component) [ST] Value: GT1-50: Job Code/Class [JCC] (MaxLen: [20] Table: [327] 2 Components) [IS] job code: [IS] job class: GT1-51: Guarantor Employer's Organization Name [XON] (MaxLen: [130] 8 Components) [ST] organization name: [IS] organization name type code: [NM] id number: [NM] check digit: [ID] code identifying check digit scheme used: [HD] assigning authority: [IS] identifier type code: [HD] assigning facility id: GT1-52: Handicap [IS] (MaxLen: [2] Table: [295] 1 Component) [ST] Value: GT1-53: Job Status [IS] (MaxLen: [2] Table: [311] 1 Component) [ST] Value: GT1-54: Guarantor Financial Class [FC] (MaxLen: [50] Table: [64] 2 Components) [ID] financial class: [TS] effective date: GT1-55: Guarantor Race [CE] (MaxLen: [80] Table: [5] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system:
IN1-Insurance segment (49 fields)
IN1-01: Set ID - IN1 [SI] (MaxLen: [4] 1 Component) [ST] Value: 0001 IN1-02: Insurance Plan ID [CE] (MaxLen: [60] Table: [72] 6 Components) [ST] identifier: 0000008 [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN1-03: Insurance Company ID [CX] (MaxLen: [59] 6 Components) [ST] id: 0000114 [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: IN1-04: Insurance Company Name [XON] (MaxLen: [130] 8 Components) [ST] organization name: UNITED HEALTH 87726 [IS] organization name type code: [NM] id number: [NM] check digit: [ID] code identifying check digit scheme used: [HD] assigning authority: [IS] identifier type code: [HD] assigning facility id: IN1-05: Insurance Company Address [XAD] (MaxLen: [106] 9 Components) [ST] street address: P O BOX 740800 [ST] other designation: [ST] city: ATLANTA [ST] state or province: GA [ST] zip or postal code: 30374-0800 [ID] country: [ID] address type: [ST] other geographic designation: [ST] country ??: IN1-06: Insurance Co Contact Person [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: IN1-07: Insurance Co Phone Number [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: (800)842-5724 [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: IN1-08: Group Number [ST] (MaxLen: [12] 1 Component) [ST] Value: IN1-09: Group Name [XON] (MaxLen: [130] 8 Components) [ST] organization name: [IS] organization name type code: [NM] id number: [NM] check digit: [ID] code identifying check digit scheme used: [HD] assigning authority: [IS] identifier type code: [HD] assigning facility id: IN1-10: Insured's Group Emp ID [CX] (MaxLen: [12] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: IN1-11: Insured's Group Emp Name [XON] (MaxLen: [130] 8 Components) [ST] organization name: [IS] organization name type code: [NM] id number: [NM] check digit: [ID] code identifying check digit scheme used: [HD] assigning authority: [IS] identifier type code: [HD] assigning facility id: IN1-12: Plan Effective Date [DT] (MaxLen: [8] 1 Component) [ST] Value: 20000401 IN1-13: Plan Expiration Date [DT] (MaxLen: [8] 1 Component) [ST] Value: IN1-14: Authorization Information [CM] (MaxLen: [55] 4 Components) [ST] component 1: [ST] component 2: [ST] component 3: [ST] component 4: IN1-15: Plan Type [IS] (MaxLen: [3] Table: [86] 1 Component) [ST] Value: P IN1-16: Name Of Insured [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): OYLE [ST] given name (first name): OLIVE [ST] middle initial or name: M [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: IN1-17: Insured's Relationship To Patient [CE] (MaxLen: [80] Table: [63] 6 Components) [ST] identifier: 00002 [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN1-18: Insured's Date Of Birth [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: 19760824 [ST] degree of precision (optional): IN1-19: Insured's Address [XAD] (MaxLen: [106] 9 Components) [ST] street address: 5008 SOMEPLACE RD [ST] other designation: APT215 [ST] city: FT WORTH [ST] state or province: TX [ST] zip or postal code: 76132-0000 [ID] country: [ID] address type: [ST] other geographic designation: [ST] country ??: IN1-20: Assignment Of Benefits [IS] (MaxLen: [2] Table: [135] 1 Component) [ST] Value: Y IN1-21: Coordination Of Benefits [IS] (MaxLen: [2] Table: [173] 1 Component) [ST] Value: Y IN1-22: Coord Of Ben. Priority [ST] (MaxLen: [2] 1 Component) [ST] Value: IN1-23: Notice Of Admission Flag [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN1-24: Notice Of Admission Date [DT] (MaxLen: [8] 1 Component) [ST] Value: IN1-25: Report Of Eligibility Flag [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN1-26: Report Of Eligibility Date [DT] (MaxLen: [8] 1 Component) [ST] Value: IN1-27: Release Information Code [IS] (MaxLen: [2] Table: [93] 1 Component) [ST] Value: A IN1-28: Pre-Admit Cert (PAC) [ST] (MaxLen: [15] 1 Component) [ST] Value: IN1-29: Verification Date/Time [TS] (MaxLen: [26] 2 Components) [ST] time stamp data: [ST] degree of precision (optional): IN1-30: Verification By [XCN] (MaxLen: [60] 7 Components) [ST] id number: [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix: [ST] prefix: [ST] degree: IN1-31: Type Of Agreement Code [IS] (MaxLen: [2] Table: [98] 1 Component) [ST] Value: IN1-32: Billing Status [IS] (MaxLen: [2] Table: [22] 1 Component) [ST] Value: IN1-33: Lifetime Reserve Days [NM] (MaxLen: [4] 1 Component) [ST] Value: IN1-34: Delay Before L.R. Day [NM] (MaxLen: [4] 1 Component) [ST] Value: IN1-35: Company Plan Code [IS] (MaxLen: [8] Table: [42] 1 Component) [ST] Value: IN1-36: Policy Number [ST] (MaxLen: [15] 1 Component) [ST] Value: 234166342 IN1-37: Policy Deductible [CP] (MaxLen: [12] 6 Components) [MO] price: [ID] price type: [NM] from value: [NM] to value: [CE] range units: [ID] range type: IN1-38: Policy Limit - Amount [CP] (MaxLen: [12] 6 Components) [MO] price: [ID] price type: [NM] from value: [NM] to value: [CE] range units: [ID] range type: IN1-39: Policy Limit - Days [NM] (MaxLen: [4] 1 Component) [ST] Value: IN1-40: Room Rate - Semi-Private [CP] (MaxLen: [12] 6 Components) [MO] price: [ID] price type: [NM] from value: [NM] to value: [CE] range units: [ID] range type: IN1-41: Room Rate - Private [CP] (MaxLen: [12] 6 Components) [MO] price: [ID] price type: [NM] from value: [NM] to value: [CE] range units: [ID] range type: IN1-42: Insured's Employment Status [CE] (MaxLen: [60] Table: [66] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN1-43: Insured's Sex [IS] (MaxLen: [1] Table: [1] 1 Component) [ST] Value: F IN1-44: Insured's Employer's Address [XAD] (MaxLen: [106] 9 Components) [ST] street address: [ST] other designation: [ST] city: [ST] state or province: [ST] zip or postal code: [ID] country: [ID] address type: [ST] other geographic designation: [ST] country ??: IN1-45: Verification Status [ST] (MaxLen: [2] 1 Component) [ST] Value: IN1-46: Prior Insurance Plan ID [IS] (MaxLen: [8] Table: [72] 1 Component) [ST] Value: IN1-47: Coverage Type [IS] (MaxLen: [3] Table: [309] 1 Component) [ST] Value: IN1-48: Handicap [IS] (MaxLen: [2] Table: [295] 1 Component) [ST] Value: IN1-49: Insured's ID Number [CX] (MaxLen: [12] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility:
IN2-Insurance additional information segment (72 fields)
IN2-01: Insured's Employee ID [CX] (MaxLen: [59] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: IN2-02: Insured's Social Security Number [ST] (MaxLen: [11] 1 Component) [ST] Value: 234166342 IN2-03: Insured's Employer's Name and ID [XCN] (MaxLen: [130] 7 Components) [ST] id number: 0009999 [ST] family name (last name): UNKNOWN [ST] given name (first name): [ST] middle initial or name: [ST] suffix: [ST] prefix: [ST] degree: IN2-04: Employer Information Data [IS] (MaxLen: [1] Table: [139] 1 Component) [ST] Value: IN2-05: Mail Claim Party [IS] (MaxLen: [1] Table: [137] 1 Component) [ST] Value: I IN2-06: Medicare Health Ins Card Number [ST] (MaxLen: [15] 1 Component) [ST] Value: IN2-07: Medicaid Case Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: IN2-08: Medicaid Case Number [ST] (MaxLen: [15] 1 Component) [ST] Value: IN2-09: Military Sponsor Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: IN2-10: Military ID Number [ST] (MaxLen: [20] 1 Component) [ST] Value: IN2-11: Dependent Of Military Recipient [CE] (MaxLen: [80] Table: [342] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-12: Military Organization [ST] (MaxLen: [25] 1 Component) [ST] Value: IN2-13: Military Station [ST] (MaxLen: [25] 1 Component) [ST] Value: IN2-14: Military Service [IS] (MaxLen: [14] Table: [140] 1 Component) [ST] Value: IN2-15: Military Rank/Grade [IS] (MaxLen: [2] Table: [141] 1 Component) [ST] Value: IN2-16: Military Status [IS] (MaxLen: [3] Table: [142] 1 Component) [ST] Value: IN2-17: Military Retire Date [DT] (MaxLen: [8] 1 Component) [ST] Value: IN2-18: Military Non-Avail Cert On File [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN2-19: Baby Coverage [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN2-20: Combine Baby Bill [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN2-21: Blood Deductible [ST] (MaxLen: [1] 1 Component) [ST] Value: IN2-22: Special Coverage Approval Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: IN2-23: Special Coverage Approval Title [ST] (MaxLen: [30] 1 Component) [ST] Value: IN2-24: Non-Covered Insurance Code [IS] (MaxLen: [8] Table: [143] 1 Component) [ST] Value: IN2-25: Payor ID [CX] (MaxLen: [59] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: IN2-26: Payor Subscriber ID [CX] (MaxLen: [59] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: IN2-27: Eligibility Source [IS] (MaxLen: [1] Table: [144] 1 Component) [ST] Value: IN2-28: Room Coverage Type/Amount [CM] (MaxLen: [25] Table: [145] 4 Components) [ST] component 1: [ST] component 2: [ST] component 3: [ST] component 4: IN2-29: Policy Type/Amount [CM] (MaxLen: [25] Table: [147] 4 Components) [ST] component 1: [ST] component 2: [ST] component 3: [ST] component 4: IN2-30: Daily Deductible [CM] (MaxLen: [25] 4 Components) [ST] component 1: [ST] component 2: [ST] component 3: [ST] component 4: IN2-31: Living Dependency [IS] (MaxLen: [2] Table: [223] 1 Component) [ST] Value: IN2-32: Ambulatory Status [IS] (MaxLen: [2] Table: [9] 1 Component) [ST] Value: IN2-33: Citizenship [CE] (MaxLen: [80] Table: [171] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-34: Primary Language [CE] (MaxLen: [60] Table: [296] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-35: Living Arrangement [IS] (MaxLen: [2] Table: [220] 1 Component) [ST] Value: IN2-36: Publicity Code [CE] (MaxLen: [80] Table: [215] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-37: Protection Indicator [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN2-38: Student Indicator [IS] (MaxLen: [2] Table: [231] 1 Component) [ST] Value: IN2-39: Religion [CE] (MaxLen: [80] Table: [6] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-40: Mother's Maiden Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: IN2-41: Nationality [CE] (MaxLen: [80] Table: [212] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-42: Ethnic Group [CE] (MaxLen: [80] Table: [189] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-43: Marital Status [CE] (MaxLen: [80] Table: [2] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-44: Insured's Employment Start Date [DT] (MaxLen: [8] 1 Component) [ST] Value: IN2-45: Employment Stop Date [DT] (MaxLen: [8] 1 Component) [ST] Value: IN2-46: Job Title [ST] (MaxLen: [20] 1 Component) [ST] Value: IN2-47: Job Code/Class [JCC] (MaxLen: [20] Table: [327] 2 Components) [IS] job code: [IS] job class: IN2-48: Job Status [IS] (MaxLen: [2] Table: [311] 1 Component) [ST] Value: IN2-49: Employer Contact Person Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: IN2-50: Employer Contact Person Phone Number [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: IN2-51: Employer Contact Reason [IS] (MaxLen: [2] Table: [222] 1 Component) [ST] Value: IN2-52: Insured's Contact Person's Name [XPN] (MaxLen: [48] 7 Components) [ST] family name (last name): [ST] given name (first name): [ST] middle initial or name: [ST] suffix (jr, sr, etc): [ST] prefix (mr, mrs, dr etc): [ST] degree (md, phd etc): [ID] name type code: IN2-53: Insured's Contact Person Phone Number [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: IN2-54: Insured's Contact Person Reason [IS] (MaxLen: [2] Table: [222] 1 Component) [ST] Value: IN2-55: Relationship To The Patient Start Date [DT] (MaxLen: [8] 1 Component) [ST] Value: IN2-56: Relationship To The Patient Stop Date [DT] (MaxLen: [8] 1 Component) [ST] Value: IN2-57: Insurance Co. Contact Reason [IS] (MaxLen: [2] Table: [232] 1 Component) [ST] Value: IN2-58: Insurance Co Contact Phone Number [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: IN2-59: Policy Scope [IS] (MaxLen: [2] Table: [312] 1 Component) [ST] Value: IN2-60: Policy Source [IS] (MaxLen: [2] Table: [313] 1 Component) [ST] Value: IN2-61: Patient Member Number [CX] (MaxLen: [60] 6 Components) [ST] id: [ST] check digit: [ID] code identifying the check digit scheme employed: [HD] assigning authority: [IS] identifyer type code: [HD] assigning facility: IN2-62: Guarantor's Relationship To Insured [CE] (MaxLen: [80] Table: [63] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-63: Insured's Phone Number - Home [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: IN2-64: Insured's Employer Phone Number [XTN] (MaxLen: [40] 8 Components) [ID] telecommunications use code: [ID] telecommunications equipment type: [ST] email address: [NM] country code: [NM] area/city code: [NM] phone number: [NM] extension: [ST] any text: IN2-65: Military Handicapped Program [CE] (MaxLen: [60] Table: [343] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-66: Suspend Flag [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN2-67: Copay Limit Flag [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN2-68: Stoploss Limit Flag [ID] (MaxLen: [1] Table: [136] 1 Component) [ST] Value: IN2-69: Insured Organization Name And ID [XON] (MaxLen: [130] 8 Components) [ST] organization name: [IS] organization name type code: [NM] id number: [NM] check digit: [ID] code identifying check digit scheme used: [HD] assigning authority: [IS] identifier type code: [HD] assigning facility id: IN2-70: Insured Employer Organization Name And ID [XON] (MaxLen: [130] 8 Components) [ST] organization name: [IS] organization name type code: [NM] id number: [NM] check digit: [ID] code identifying check digit scheme used: [HD] assigning authority: [IS] identifier type code: [HD] assigning facility id: IN2-71: Race [CE] (MaxLen: [80] Table: [5] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system: IN2-72: HCFA Patient's Relationship to Insured [CE] (MaxLen: [60] Table: [344] 6 Components) [ST] identifier: [ST] text: [ST] name of coding system: [ST] alternate identifier: [ST] alternate text: [ST] name of alternate coding system:
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Segment: PID-Patient identification segment 30 Fields
# Description Len Type Table #Comp
1 Set ID - PID 4 SI 0 1 2 Patient ID 20 CX 0 6 3 Patient Identifier List 20 CX 0 6 4 Alternate Patient ID - PID 20 CX 0 6 5 Patient Name 48 XPN 0 7 6 Mother's Maiden Name 48 XPN 0 7 7 Date/Time of Birth 26 TS 0 2 8 Sex 1 IS 1 1 9 Patient Alias 48 XPN 0 7 10 Race 80 CE 5 6 11 Patient Address 106 XAD 0 9 12 County Code 4 IS 289 1 13 Phone Number - Home 40 XTN 0 8 14 Phone Number - Business 40 XTN 0 8 15 Primary Language 60 CE 296 6 16 Marital Status 80 CE 2 6 17 Religion 80 CE 6 6 18 Patient Account Number 20 CX 0 6 19 SSN Number - Patient 16 ST 0 1 20 Driver's License Number - Patient 25 DLN 0 3 21 Mother's Identifier 20 CX 0 6 22 Ethnic Group 80 CE 189 6 23 Birth Place 60 ST 0 1 24 Multiple Birth Indicator 1 ID 136 1 25 Birth Order 2 NM 0 1 26 Citizenship 80 CE 171 6 27 Veterans Military Status 60 CE 172 6 28 Nationality 80 CE 212 6 29 Patient Death Date and Time 26 TS 0 2 30 Patient Death Indicator 1 ID 136 1
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