[ X12 Examples ]
Com1 Software 271 Eligibility Response Example
Posted: Thursday, August 15 2024 1:02:28 PM
Com1 Software, Inc.
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271 Eligibility Response Example
271 Eligibility Response source file.
ISA*00* *00* *ZZ*SENDER *ZZ*RECEIVER *080319*2327*U*00501*002721171*0*P*:~ GS*HC*SENDER*RECEIVER*20080319*2327*27211711*X*005010X279A1~ ST*271*1234~ BHT*0022*11*10001234*19990501*1319~ HL*1**20*1~ NM1*PR*2*ABCCOMPANY*****PI*842610001~ HL*2*1*21*1~ NM1*1P*1*JONES*MARCUS****SV*0202034~ REF*N5*129~ HL*3*2*22*1~ TRN*2*93175-012547*9877281234~ NM1*IL*1*SMITH*ROBERTB***MI*11122333301~ REF*1L*599119~ N3*29 FREMONT ST*APT# 1~ N4*PEACE*NY*10023~ DMG*D8*19430519*M~ HL*4*3*23*0~ TRN*2*93175-012547*9877281234*RADIOLOGY~ NM1*03*1*SMITH*MARY LOU~ REF*SY*003221234~ N3*29 FREMONT ST*APT # 1~ N4*PEACE*NY*10023~ DMG*D8*19881014*F~ INS*N*19~ DTP*472*D8*19950624~ EB*1*FAM*30*GP~ EB*B**81*GP***15****Y~ EB*L~ REF*18*01111111A~ LS*2120~ NM1*P3*1*BROWN*TOM*D**JR*SV*222333444~ PER*IC*BILLING DEPT*TE*2065556666~ LE*2120~ LS*2120~ NM1*P4*2*BC/BS*****PI*12~ N3*PO BOX 111 CLAIMS DEPT.~ N4*PARMA*OH*44144-4444~ PER*IC*PROVIDER SERVICES*TE*8001111111~ LE*2120~ HL*3*2*22*0~ TRN*2*93175-012547*9877281234~ NM1*IL*1*SMITH*ROBERT*B***MI*11122333301~ REF*1L*599119~ DMG*D8*19430519*M~ DTP*472*RD8*19990501-19990515~ DTP*346*D8*19950624~ DTP*102*D8*19950624~ EB*1*FAM*30*GP~ EB*1*IND*35~ EB*1*IND*47~ EB*1*IND*86~ EB*1*IND*88~ EB*1*IND*98~ EB*1*IND*AL~ EB*1*IND*MH~ EB*1*IND*UC~ MSG*Test Message line 1~ MSG*Test Line 2~ REF*18*22222222A~ REF*6P*111111~ LS*2120~ NM1*P4*2*CARE PLACE*****PI*H1111~ N3*123 STREET~ N4*NEW YORK*NY*10001~ PER*IC*PROVIDER SERVICES*TE*8001231234~ LE*2120~ EB*R*IND*30~ REF*18*33333333~ LS*2120~ NM1*P4*2*MEDICARE*****PI*1234567~ LE*2120~ LS*2120~ NM1*P4*2*Testnamexx*****PI*PP~ N3*P.O. BOX 111111~ N4*FAIRLAWN*OH*44123~ LE*2120~ SE*30*1234~ GE*1*27211711~ IEA*1*002721171~
Basic Inline
Base Mapping for the 271
********** Com1 Software Parser Map ********** Generated :08/14/17 12:35:31 ********** (c) 1992-2015 COM1 SOFTWARE DEVELOPMENT ************************************************** ********* File Name : 005010X279B.cfg ********* X12 Version 5010 ********* 271 Eligibility Response Configuration ************************************************** X12TRANSACTIONTYPE=271 VERSION=5010 KEYHEADERFIELD=HL,,,20 KEYFIELD=HL,,,22 KEYLINEFIELD=EB FIELD=HLCTL,16,HL,22,4,3 FIELD=INFOSOURCEENITITYCODE,16,NM1,,,2,,,,1 FIELD=INFOSOURCENAME,16,NM1,,,3,,INFOSOURCEENITITYCODE,,1 FIELD=INFOSOURCEIDCODE,16,NM1,,,8,,INFOSOURCEENITITYCODE,,1 FIELD=INFOSOURCEID,16,NM1,,,9,,INFOSOURCEENITITYCODE,,1 FIELD=TPANAME,16,NM1,2B,2,3,,INFOSOURCEENITITYCODE,,1 FIELD=EMPLOYERNAME,16,NM1,36,2,3,,INFOSOURCEENITITYCODE,,1 FIELD=GATEWAYPROVNAME,16,NM1,GP,2,3,,INFOSOURCEENITITYCODE,,1 FIELD=PLANSPONSORNAME,16,NM1,P5,2,3,,INFOSOURCEENITITYCODE,,1 FIELD=PAYERNAME,16,NM1,PR,2,3,,INFOSOURCEENITITYCODE,,1 FIELD=EMPLOYERID,16,NM1,24,8,8,,INFOSOURCEENITITYCODE,,1 FIELD=ETIN,16,NM1,46,8,8,,INFOSOURCEENITITYCODE,,1 FIELD=TAXID,16,NM1,FI,8,8,,INFOSOURCEENITITYCODE,,1 FIELD=NAIC,16,NM1,NI,8,8,,INFOSOURCEENITITYCODE,,1 FIELD=PAYERID,16,NM1,PI,8,8,,INFOSOURCEENITITYCODE,,1 FIELD=HCFAPLANID,16,NM1,XV,8,8,,INFOSOURCEENITITYCODE,,1 FIELD=HCFAPROVID,16,NM1,XX,8,8,,INFOSOURCEENITITYCODE,,1 FIELD=INFORECEIVERENITITYCODE,16,NM1,,,2,,INFOSOURCEENITITYCODE,,1 FIELD=INFORECEIVERNAME,16,NM1,,,3,,INFORECEIVERENITITYCODE,,1 FIELD=INFORECEIVERIDCODE,16,NM1,,,8,,INFORECEIVERENITITYCODE,,1 FIELD=INFORECEIVERID,16,NM1,,,9,,INFORECEIVERENITITYCODE,,1 FIELD=INFORECEIVERCONTACT,16,PER,,,2,,INFORECEIVERENITITYCODE,,1 FIELD=INFORECEIVERCONTACTTYPE,16,PER,,,3,,INFORECEIVERENITITYCODE,,1 FIELD=INFORECEIVERCONTACTNUMBER,16,PER,,,4,,INFORECEIVERENITITYCODE,,1 FIELD=TPARECEIVERNAME,16,NM1,2B,2,3,,INFORECEIVERENITITYCODE,,1 FIELD=EMPLOYERRECEIVERNAME,16,NM1,36,2,3,,INFORECEIVERENITITYCODE,,1 FIELD=HOPITALNAME,16,NM1,80,2,3,,INFORECEIVERENITITYCODE,,1 FIELD=FACILITYNAME,16,NM1,FA,2,3,,INFORECEIVERENITITYCODE,,1 FIELD=GATEWAYPROVRECEIVERNAME,16,NM1,GP,2,3,,INFORECEIVERENITITYCODE,,1 FIELD=PLANSPONSORRECEIVERNAME,16,NM1,P5,2,3,,INFORECEIVERENITITYCODE,,1 FIELD=PAYERRECEIVERNAME,16,NM1,PR,2,3,,INFORECEIVERENITITYCODE,,1 FIELD=EIN,16,NM1,24,8,8,,INFORECEIVERENITITYCODE,,1 FIELD=SSN,16,NM1,34,8,8,,INFORECEIVERENITITYCODE,,1 FIELD=FEDTAXID,16,NM1,FI,8,8,,INFORECEIVERENITITYCODE,,1 FIELD=RECEIVEPAYERID,16,NM1,PI,8,8,,INFORECEIVERENITITYCODE,,1 FIELD=PHARMACYPRONUM,16,NM1,PP,8,8,,INFORECEIVERENITITYCODE,,1 FIELD=SERVICEPROVNUM,16,NM1,SV,8,8,,INFORECEIVERENITITYCODE,,1 FIELD=HCFARECEIVERPROVID,16,NM1,XX,8,8,,INFORECEIVERENITITYCODE,,1 FIELD=PROVIDERLNAME,16,NM1,1P,2,3,,INFORECEIVERENITITYCODE,,1 FIELD=PROVIDERFNAME,16,NM1,1P,2,4,,INFORECEIVERENITITYCODE,,1 FIELD=PROVIDERPLANNETWORKID,16,REF,N5,2,2,,INFORECEIVERENITITYCODE,,1 FIELD=PROVIDERID,16,NM1,1P,2,8,,INFORECEIVERENITITYCODE,,1 FIELD=TRACETYPE,16,TRN,,,1 FIELD=REFTRACENUMBER,16,TRN,2,,2 FIELD=REFTRACEORIGINCOID,16,TRN,2,,3 FIELD=REFTRACEADDID,16,TRN,2,,4 FIELD=SUBTRACENUMBER,16,TRN,1,,2 FIELD=SUBTRACEORIGINCOID,16,TRN,1,,3 FIELD=SUBTRACEADDID,16,TRN,1,,4 FIELD=SUBID,16,NM1,IL,2,8 FIELD=SUBLNAME,32,NM1,IL,2,3,,SUBID FIELD=SUBFNAME,32,NM1,IL,2,4,,SUBID FIELD=SUBMI,1,NM1,IL,2,5,,SUBID FIELD=SUBADDR1,30,N3,,,1,,SUBID FIELD=SUBADDR2,30,N3,,,2,,SUBID FIELD=SUBCITY,30,N4,,,1,,SUBID FIELD=SUBST,2,N4,,,2,,SUBID FIELD=SUBZIP,10,N4,,,3,,SUBID FIELD=SUBSEX,1,DMG,,,3,,SUBID FIELD=SUBMSTATUS,1,DMG,,,4,,SUBID FIELD=SUBDOB,10,DMG,,,2,,SUBID FIELD=SUBISSUEDATE,32,DTP,102,2,3,,SUBID FIELD=SUBEFFECTIVEDATE,32,DTP,152,2,3,,SUBID FIELD=SUBPLANDATE,32,DTP,291,2,3,,SUBID FIELD=SUBCOBRABEGINDATE,32,DTP,340,2,3,,SUBID FIELD=SUBCOBRAENDDATE,32,DTP,341,2,3,,SUBID FIELD=SUBPREMIUMPAIDBEGINDATE,32,DTP,342,2,3,,SUBID FIELD=SUBPREMIEMPAIDENDDATE,32,DTP,343,2,3,,SUBID FIELD=SUBPLANBEGINDATE,32,DTP,346,2,3,,SUBID FIELD=SUBPLANENDDATE,32,DTP,347,2,3,,SUBID FIELD=SUBEROLLMENTDATE,32,DTP,382,2,3,,SUBID FIELD=SUBDEATHDATE,32,DTP,442,2,3,,SUBID FIELD=SUBCERTDATE,32,DTP,458,2,3,,SUBID FIELD=SUBPOLICYEFFECTIVEDATE,32,DTP,539,2,3,,SUBID FIELD=SUBPOLICYEXPIRATIONDATE,32,DTP,540,2,3,,SUBID FIELD=SUBELIGIBILITYDATE,32,DTP,307,2,3,,SUBID FIELD=SUBADMISSIONDATE,32,DTP,435,2,3,,SUBID FIELD=SUBSERVICEDATE,32,DTP,472,2,3,,SUBID FIELD=SUBADDEDDATE,32,DTP,318,2,3,,SUBID FIELD=SUBELIGIBILITYBEGINDATE,32,DTP,356,2,3,,SUBID FIELD=SUBELIGABILITYENDDATE,32,DTP,357,2,3,,SUBID FIELD=SUBLASTUPDATEDATE,32,DTP,636,2,3,,SUBID FIELD=SUBSTATUSDATE,32,DTP,771,2,3,,SUBID FIELD=DEPTRACETYPE,16,TRN,,,1 FIELD=DEPTRACENUMBER,16,TRN,,,2 FIELD=DEPTRACEORIGINCOID,16,TRN,,,3 FIELD=DEPTRACEADDID,16,TRN,,,4 FIELD=DEPID,16,NM1,03,2,8,,SUBID FIELD=DEPLNAME,32,NM1,03,2,3,,DEPID FIELD=DEPFNAME,32,NM1,03,2,4,,DEPID FIELD=DEPMI,1,NM1,03,2,5,,DEPID FIELD=DEPADDR1SUBADDR1,30,N3,,,1,,DEPID FIELD=DEPADDR2SUBADDR2,30,N3,,,2,,DEPID FIELD=DEPCITY,30,N4,,,1,,DEPID FIELD=DEPST,2,N4,,,2,,DEPID FIELD=DEPZIP,10,N4,,,2,,DEPID FIELD=DEPSEX,1,DMG,,,3,,DEPID FIELD=DEPMSTAT,1,DMG,,,4,,DEPID FIELD=DEPDOB,10,DMG,,,2,,DEPID FIELD=DEPELIGIBILITYDATE,32,DTP,307,2,3,,DEPID FIELD=DEPADMISSIONDATE,32,DTP,435,2,3,,DEPID FIELD=DEPSERVICEDATE,32,DTP,472,2,3,,DEPID FIELD=DEPPERIODSTARTDATE,32,DTP,193,2,3,,DEPID FIELD=DEPPERIODENDDATE,32,DTP,194,2,3,,DEPID FIELD=DEPCOMPLETIONDATE,32,DTP,198,2,3,,DEPID FIELD=DEPCOBDATE,32,DTP,290,2,3,,DEPID FIELD=DEPBENEFITDATE,32,DTP,292,2,3,,DEPID FIELD=DEPLASVISITDATE,32,DTP,304,2,3,,DEPID FIELD=DEPADDEDDATE,32,DTP,318,2,3,,DEPID FIELD=DEPBENEFITBEGINDATE,32,DTP,348,2,3,,DEPID FIELD=DEPBENEFITENDDATE,32,DTP,349,2,3,,DEPID FIELD=DEPELIGIBILITYBEGINDATE,32,DTP,356,2,3,,DEPID FIELD=DEPELIGABILITYENDDATE,32,DTP,357,2,3,,DEPID FIELD=DEPLASTUPDATEDATE,32,DTP,636,2,3,,DEPID FIELD=DEPSTATUSDATE,32,DTP,771,2,3,,DEPID FIELD=MESSAGE1,16,MSG,,,1,,SUBID,1 FIELD=BENEFIT1,16,EB,,,1,,SUBID,,,1 FIELD=COVERAGELEVEL1,16,EB,,,2,,SUBID,,,1 FIELD=SERVICETYPE1,16,EB,,,3,,SUBID,,,1 FIELD=INSURANCETYPE1,16,EB,,,4,,SUBID,,,1 FIELD=PLANDESC1,16,EB,,,5,,SUBID,,,1 FIELD=TIMEPERIOD1,16,EB,,,6,,SUBID,,,1 FIELD=AMOUNT1,16,EB,,,7,,SUBID,,,1 FIELD=PERCENT1,16,EB,,,8,,SUBID,,,1 FIELD=QTYQUAL1,16,EB,,,9,,SUBID,,,1 FIELD=QUANTITY1,16,EB,,,10,,SUBID,,,1 FIELD=PLANNUMBER1,16,REF,18,2,2,,SUBID,,,1 FIELD=GROUPNUMBER1,16,REF,6P,2,2,,SUBID,,,1 FIELD=PCPID1,16,NM1,P3,2,8,,SUBID,,,1 FIELD=PCPLNAME1,32,NM1,P3,2,3,,SUBID,,,1 FIELD=PCPFNAME1,32,NM1,P3,2,4,,SUBID,,,1 FIELD=PCPMI1,1,NM1,P3,2,5,,SUBID,,,1 FIELD=PCPADDR1SUBADDR11,30,N3,,,1,,PCPLNAME1,,,1 FIELD=PCPADDR2SUBADDR21,30,N3,,,2,,PCPLNAME1,,,1 FIELD=PCPCITY1,30,N4,,,1,,PCPLNAME1,,,1 FIELD=PCPST1,2,N4,,,2,,PCPLNAME1,,,1 FIELD=PCPZIP1,10,N4,,,2,,PCPLNAME1,,,1 FIELD=PCPCONTACT1,10,PER,,,2,,PCPLNAME1,,,1 FIELD=PCPCONTACTNUMBER1,10,PER,,,4,,PCPLNAME1,,,1 FIELD=PRIORINSID1,16,NM1,P4,2,8,,SUBID,,,1 FIELD=PRIORINSLNAME1,32,NM1,P4,2,3,,SUBID,,,1 FIELD=PRIORINSFNAME1,32,NM1,P4,2,4,,SUBID,,,1 FIELD=PRIORINSMI1,1,NM1,P4,2,5,,SUBID,,,1 FIELD=PRIORINSADDR1SUBADDR11,30,N3,,,1,,PRIORINSLNAME1,,,1 FIELD=PRIORINSADDR2SUBADDR21,30,N3,,,2,,PRIORINSLNAME1,,,1 FIELD=PRIORINSCITY1,30,N4,,,1,,PRIORINSLNAME1,,,1 FIELD=PRIORINSST1,2,N4,,,2,,PRIORINSLNAME1,,,1 FIELD=PRIORINSZIP1,10,N4,,,2,,PRIORINSLNAME1,,,1 FIELD=PRIORINSCONTACT1,10,PER,,,2,,PRIORINSLNAME1,,,1 FIELD=PRIORINSCONTACTNUMBER1,10,PER,,,4,,PRIORINSLNAME1,,,1 FIELD=BENEFIT2,16,EB,,,1,,SUBID,,,2 FIELD=COVERAGELEVEL2,16,EB,,,2,,SUBID,,,2 FIELD=SERVICETYPE2,16,EB,,,3,,SUBID,,,2 FIELD=INSURANCETYPE2,16,EB,,,4,,SUBID,,,2 FIELD=PLANDESC2,16,EB,,,5,,SUBID,,,2 FIELD=TIMEPERIOD2,16,EB,,,6,,SUBID,,,2 FIELD=AMOUNT2,16,EB,,,7,,SUBID,,,2 FIELD=PERCENT2,16,EB,,,8,,SUBID,,,2 FIELD=QTYQUAL2,16,EB,,,9,,SUBID,,,2 FIELD=QUANTITY2,16,EB,,,10,,SUBID,,,2 FIELD=PLANNUMBER2,16,REF,18,2,2,,SUBID,,,2 FIELD=GROUPNUMBER2,16,REF,6P,2,2,,SUBID,,,2 FIELD=PCPID2,16,NM1,P3,2,8,,SUBID,,,2 FIELD=PCPLNAME2,32,NM1,P3,2,3,,SUBID,,,2 FIELD=PCPFNAME2,32,NM1,P3,2,4,,SUBID,,,2 FIELD=PCPMI2,1,NM1,P3,2,5,,SUBID,,,2 FIELD=PCPADDR1SUBADDR12,30,N3,,,1,,PCPLNAME2,,,2 FIELD=PCPADDR2SUBADDR22,30,N3,,,2,,PCPLNAME2,,,2 FIELD=PCPCITY2,30,N4,,,1,,PCPLNAME2,,,2 FIELD=PCPST2,2,N4,,,2,,PCPLNAME2,,,2 FIELD=PCPZIP2,10,N4,,,2,,PCPLNAME2,,,2 FIELD=PCPCONTACT2,10,PER,,,2,,PCPLNAME2,,,2 FIELD=PCPCONTACTNUMBER2,10,PER,,,4,,PCPLNAME2,,,2 FIELD=PRIORINSID2,16,NM1,P4,2,8,,SUBID,,,2 FIELD=PRIORINSLNAME2,32,NM1,P4,2,3,,SUBID,,,2 FIELD=PRIORINSFNAME2,32,NM1,P4,2,4,,SUBID,,,2 FIELD=PRIORINSMI2,1,NM1,P4,2,5,,SUBID,,,2 FIELD=PRIORINSADDR1SUBADDR12,30,N3,,,1,,PRIORINSLNAME2,,,2 FIELD=PRIORINSADDR2SUBADDR22,30,N3,,,2,,PRIORINSLNAME2,,,2 FIELD=PRIORINSCITY2,30,N4,,,1,,PRIORINSLNAME2,,,2 FIELD=PRIORINSST2,2,N4,,,2,,PRIORINSLNAME2,,,2 FIELD=PRIORINSZIP2,10,N4,,,2,,PRIORINSLNAME2,,,2 FIELD=PRIORINSCONTACT2,10,PER,,,2,,PRIORINSLNAME2,,,2 FIELD=PRIORINSCONTACTNUMBER2,10,PER,,,4,,PRIORINSLNAME2,,,2 FIELD=BENEFIT3,16,EB,,,1,,SUBID,,,3 FIELD=COVERAGELEVEL3,16,EB,,,2,,SUBID,,,3 FIELD=SERVICETYPE3,16,EB,,,3,,SUBID,,,3 FIELD=INSURANCETYPE3,16,EB,,,4,,SUBID,,,3 FIELD=PLANDESC3,16,EB,,,5,,SUBID,,,3 FIELD=TIMEPERIOD3,16,EB,,,6,,SUBID,,,3 FIELD=AMOUNT3,16,EB,,,7,,SUBID,,,3 FIELD=PERCENT3,16,EB,,,8,,SUBID,,,3 FIELD=QTYQUAL3,16,EB,,,9,,SUBID,,,3 FIELD=QUANTITY3,16,EB,,,10,,SUBID,,,3 FIELD=PLANNUMBER3,16,REF,18,2,2,,SUBID,,,3 FIELD=GROUPNUMBER3,16,REF,6P,2,2,,SUBID,,,3 FIELD=PCPID3,16,NM1,P3,2,8,,SUBID,,,3 FIELD=PCPLNAME3,32,NM1,P3,2,3,,SUBID,,,3 FIELD=PCPFNAME3,32,NM1,P3,2,4,,SUBID,,,3 FIELD=PCPMI3,1,NM1,P3,2,5,,SUBID,,,3 FIELD=PCPADDR1SUBADDR13,30,N3,,,1,,PCPLNAME3,,,3 FIELD=PCPADDR2SUBADDR23,30,N3,,,2,,PCPLNAME3,,,3 FIELD=PCPCITY3,30,N4,,,1,,PCPLNAME3,,,3 FIELD=PCPST3,2,N4,,,2,,PCPLNAME3,,,3 FIELD=PCPZIP3,10,N4,,,2,,PCPLNAME3,,,3 FIELD=PCPCONTACT3,10,PER,,,2,,PCPLNAME3,,,3 FIELD=PCPCONTACTNUMBER3,10,PER,,,4,,PCPLNAME3,,,3 FIELD=PRIORINSID3,16,NM1,P4,2,8,,SUBID,,,3 FIELD=PRIORINSLNAME3,32,NM1,P4,2,3,,SUBID,,,3 FIELD=PRIORINSFNAME3,32,NM1,P4,2,4,,SUBID,,,3 FIELD=PRIORINSMI3,1,NM1,P4,2,5,,SUBID,,,3 FIELD=PRIORINSADDR1SUBADDR13,30,N3,,,1,,PRIORINSLNAME3,,,3 FIELD=PRIORINSADDR2SUBADDR23,30,N3,,,2,,PRIORINSLNAME3,,,3 FIELD=PRIORINSCITY3,30,N4,,,1,,PRIORINSLNAME3,,,3 FIELD=PRIORINSST3,2,N4,,,2,,PRIORINSLNAME3,,,3 FIELD=PRIORINSZIP3,10,N4,,,2,,PRIORINSLNAME3,,,3 FIELD=PRIORINSCONTACT3,10,PER,,,2,,PRIORINSLNAME3,,,3 FIELD=PRIORINSCONTACTNUMBER3,10,PER,,,4,,PRIORINSLNAME3,,,3 FIELD=BENEFIT4,16,EB,,,1,,SUBID,,,4 FIELD=COVERAGELEVEL4,16,EB,,,2,,SUBID,,,4 FIELD=SERVICETYPE4,16,EB,,,3,,SUBID,,,4 FIELD=INSURANCETYPE4,16,EB,,,4,,SUBID,,,4 FIELD=PLANDESC4,16,EB,,,5,,SUBID,,,4 FIELD=TIMEPERIOD4,16,EB,,,6,,SUBID,,,4 FIELD=AMOUNT4,16,EB,,,7,,SUBID,,,4 FIELD=PERCENT4,16,EB,,,8,,SUBID,,,4 FIELD=QTYQUAL4,16,EB,,,9,,SUBID,,,4 FIELD=QUANTITY4,16,EB,,,10,,SUBID,,,4 FIELD=PLANNUMBER4,16,REF,18,2,2,,SUBID,,,4 FIELD=GROUPNUMBER4,16,REF,6P,2,2,,SUBID,,,4 FIELD=PCPID4,16,NM1,P3,2,8,,SUBID,,,4 FIELD=PCPLNAME4,32,NM1,P3,2,3,,SUBID,,,4 FIELD=PCPFNAME4,32,NM1,P3,2,4,,SUBID,,,4 FIELD=PCPMI4,1,NM1,P3,2,5,,SUBID,,,4 FIELD=PCPADDR1SUBADDR14,30,N3,,,1,,PCPLNAME4,,,4 FIELD=PCPADDR2SUBADDR24,30,N3,,,2,,PCPLNAME4,,,4 FIELD=PCPCITY4,30,N4,,,1,,PCPLNAME4,,,4 FIELD=PCPST4,2,N4,,,2,,PCPLNAME4,,,4 FIELD=PCPZIP4,10,N4,,,2,,PCPLNAME4,,,4 FIELD=PCPCONTACT4,10,PER,,,2,,PCPLNAME4,,,4 FIELD=PCPCONTACTNUMBER4,10,PER,,,4,,PCPLNAME4,,,4 FIELD=PRIORINSID4,16,NM1,P4,2,8,,SUBID,,,4 FIELD=PRIORINSLNAME4,32,NM1,P4,2,3,,SUBID,,,4 FIELD=PRIORINSFNAME4,32,NM1,P4,2,4,,SUBID,,,4 FIELD=PRIORINSMI4,1,NM1,P4,2,5,,SUBID,,,4 FIELD=PRIORINSADDR1SUBADDR14,30,N3,,,1,,PRIORINSLNAME4,,,4 FIELD=PRIORINSADDR2SUBADDR24,30,N3,,,2,,PRIORINSLNAME4,,,4 FIELD=PRIORINSCITY4,30,N4,,,1,,PRIORINSLNAME4,,,4 FIELD=PRIORINSST4,2,N4,,,2,,PRIORINSLNAME4,,,4 FIELD=PRIORINSZIP4,10,N4,,,2,,PRIORINSLNAME4,,,4 FIELD=PRIORINSCONTACT4,10,PER,,,2,,PRIORINSLNAME4,,,4 FIELD=PRIORINSCONTACTNUMBER4,10,PER,,,4,,PRIORINSLNAME4,,,4 FIELD=BENEFIT5,16,EB,,,1,,SUBID,,,5 FIELD=COVERAGELEVEL5,16,EB,,,2,,SUBID,,,5 FIELD=SERVICETYPE5,16,EB,,,3,,SUBID,,,5 FIELD=INSURANCETYPE5,16,EB,,,4,,SUBID,,,5 FIELD=PLANDESC5,16,EB,,,5,,SUBID,,,5 FIELD=TIMEPERIOD5,16,EB,,,6,,SUBID,,,5 FIELD=AMOUNT5,16,EB,,,7,,SUBID,,,5 FIELD=PERCENT5,16,EB,,,8,,SUBID,,,5 FIELD=QTYQUAL5,16,EB,,,9,,SUBID,,,5 FIELD=QUANTITY5,16,EB,,,10,,SUBID,,,5 FIELD=PLANNUMBER5,16,REF,18,2,2,,SUBID,,,5 FIELD=GROUPNUMBER5,16,REF,6P,2,2,,SUBID,,,5 FIELD=PCPID5,16,NM1,P3,2,8,,SUBID,,,5 FIELD=PCPLNAME5,32,NM1,P3,2,3,,SUBID,,,5 FIELD=PCPFNAME5,32,NM1,P3,2,4,,SUBID,,,5 FIELD=PCPMI5,1,NM1,P3,2,5,,SUBID,,,5 FIELD=PCPADDR1SUBADDR15,30,N3,,,1,,PCPLNAME5,,,5 FIELD=PCPADDR2SUBADDR25,30,N3,,,2,,PCPLNAME5,,,5 FIELD=PCPCITY5,30,N4,,,1,,PCPLNAME5,,,5 FIELD=PCPST5,2,N4,,,2,,PCPLNAME5,,,5 FIELD=PCPZIP5,10,N4,,,2,,PCPLNAME5,,,5 FIELD=PCPCONTACT5,10,PER,,,2,,PCPLNAME5,,,5 FIELD=PCPCONTACTNUMBER5,10,PER,,,4,,PCPLNAME5,,,5 FIELD=PRIORINSID5,16,NM1,P4,2,8,,SUBID,,,5 FIELD=PRIORINSLNAME5,32,NM1,P4,2,3,,SUBID,,,5 FIELD=PRIORINSFNAME5,32,NM1,P4,2,4,,SUBID,,,5 FIELD=PRIORINSMI5,1,NM1,P4,2,5,,SUBID,,,5 FIELD=PRIORINSADDR1SUBADDR15,30,N3,,,1,,PRIORINSLNAME5,,,5 FIELD=PRIORINSADDR2SUBADDR25,30,N3,,,2,,PRIORINSLNAME5,,,5 FIELD=PRIORINSCITY5,30,N4,,,1,,PRIORINSLNAME5,,,5 FIELD=PRIORINSST5,2,N4,,,2,,PRIORINSLNAME5,,,5 FIELD=PRIORINSZIP5,10,N4,,,2,,PRIORINSLNAME5,,,5 FIELD=PRIORINSCONTACT5,10,PER,,,2,,PRIORINSLNAME5,,,5 FIELD=PRIORINSCONTACTNUMBER5,10,PER,,,4,,PRIORINSLNAME5,,,5 FIELD=BENEFIT6,16,EB,,,1,,SUBID,,,6 FIELD=COVERAGELEVEL6,16,EB,,,2,,SUBID,,,6 FIELD=SERVICETYPE6,16,EB,,,3,,SUBID,,,6 FIELD=INSURANCETYPE6,16,EB,,,4,,SUBID,,,6 FIELD=PLANDESC6,16,EB,,,5,,SUBID,,,6 FIELD=TIMEPERIOD6,16,EB,,,6,,SUBID,,,6 FIELD=AMOUNT6,16,EB,,,7,,SUBID,,,6 FIELD=PERCENT6,16,EB,,,8,,SUBID,,,6 FIELD=QTYQUAL6,16,EB,,,9,,SUBID,,,6 FIELD=QUANTITY6,16,EB,,,10,,SUBID,,,6 FIELD=PLANNUMBER6,16,REF,18,2,2,,SUBID,,,6 FIELD=GROUPNUMBER6,16,REF,6P,2,2,,SUBID,,,6 FIELD=PCPID6,16,NM1,P3,2,8,,SUBID,,,6 FIELD=PCPLNAME6,32,NM1,P3,2,3,,SUBID,,,6 FIELD=PCPFNAME6,32,NM1,P3,2,4,,SUBID,,,6 FIELD=PCPMI6,1,NM1,P3,2,5,,SUBID,,,6 FIELD=PCPADDR1SUBADDR16,30,N3,,,1,,PCPLNAME6,,,6 FIELD=PCPADDR2SUBADDR26,30,N3,,,2,,PCPLNAME6,,,6 FIELD=PCPCITY6,30,N4,,,1,,PCPLNAME6,,,6 FIELD=PCPST6,2,N4,,,2,,PCPLNAME6,,,6 FIELD=PCPZIP6,10,N4,,,2,,PCPLNAME6,,,6 FIELD=PCPCONTACT6,10,PER,,,2,,PCPLNAME6,,,6 FIELD=PCPCONTACTNUMBER6,10,PER,,,4,,PCPLNAME6,,,6 FIELD=PRIORINSID6,16,NM1,P4,2,8,,SUBID,,,6 FIELD=PRIORINSLNAME6,32,NM1,P4,2,3,,SUBID,,,6 FIELD=PRIORINSFNAME6,32,NM1,P4,2,4,,SUBID,,,6 FIELD=PRIORINSMI6,1,NM1,P4,2,5,,SUBID,,,6 FIELD=PRIORINSADDR1SUBADDR16,30,N3,,,1,,PRIORINSLNAME6,,,6 FIELD=PRIORINSADDR2SUBADDR26,30,N3,,,2,,PRIORINSLNAME6,,,6 FIELD=PRIORINSCITY6,30,N4,,,1,,PRIORINSLNAME6,,,6 FIELD=PRIORINSST6,2,N4,,,2,,PRIORINSLNAME6,,,6 FIELD=PRIORINSZIP6,10,N4,,,2,,PRIORINSLNAME6,,,6 FIELD=PRIORINSCONTACT6,10,PER,,,2,,PRIORINSLNAME6,,,6 FIELD=PRIORINSCONTACTNUMBER6,10,PER,,,4,,PRIORINSLNAME6,,,6 FIELD=BENEFIT7,16,EB,,,1,,SUBID,,,7 FIELD=COVERAGELEVEL7,16,EB,,,2,,SUBID,,,7 FIELD=SERVICETYPE7,16,EB,,,3,,SUBID,,,7 FIELD=INSURANCETYPE7,16,EB,,,4,,SUBID,,,7 FIELD=PLANDESC7,16,EB,,,5,,SUBID,,,7 FIELD=TIMEPERIOD7,16,EB,,,6,,SUBID,,,7 FIELD=AMOUNT7,16,EB,,,7,,SUBID,,,7 FIELD=PERCENT7,16,EB,,,8,,SUBID,,,7 FIELD=QTYQUAL7,16,EB,,,9,,SUBID,,,7 FIELD=QUANTITY7,16,EB,,,10,,SUBID,,,7 FIELD=PLANNUMBER7,16,REF,18,2,2,,SUBID,,,7 FIELD=GROUPNUMBER7,16,REF,6P,2,2,,SUBID,,,7 FIELD=PCPID7,16,NM1,P3,2,8,,SUBID,,,7 FIELD=PCPLNAME7,32,NM1,P3,2,3,,SUBID,,,7 FIELD=PCPFNAME7,32,NM1,P3,2,4,,SUBID,,,7 FIELD=PCPMI7,1,NM1,P3,2,5,,SUBID,,,7 FIELD=PCPADDR1SUBADDR17,30,N3,,,1,,PCPLNAME7,,,7 FIELD=PCPADDR2SUBADDR27,30,N3,,,2,,PCPLNAME7,,,7 FIELD=PCPCITY7,30,N4,,,1,,PCPLNAME7,,,7 FIELD=PCPST7,2,N4,,,2,,PCPLNAME7,,,7 FIELD=PCPZIP7,10,N4,,,2,,PCPLNAME7,,,7 FIELD=PCPCONTACT7,10,PER,,,2,,PCPLNAME7,,,7 FIELD=PCPCONTACTNUMBER7,10,PER,,,4,,PCPLNAME7,,,7 FIELD=PRIORINSID7,16,NM1,P4,2,8,,SUBID,,,7 FIELD=PRIORINSLNAME7,32,NM1,P4,2,3,,SUBID,,,7 FIELD=PRIORINSFNAME7,32,NM1,P4,2,4,,SUBID,,,7 FIELD=PRIORINSMI7,1,NM1,P4,2,5,,SUBID,,,7 FIELD=PRIORINSADDR1SUBADDR17,30,N3,,,1,,PRIORINSLNAME7,,,7 FIELD=PRIORINSADDR2SUBADDR27,30,N3,,,2,,PRIORINSLNAME7,,,7 FIELD=PRIORINSCITY7,30,N4,,,1,,PRIORINSLNAME7,,,7 FIELD=PRIORINSST7,2,N4,,,2,,PRIORINSLNAME7,,,7 FIELD=PRIORINSZIP7,10,N4,,,2,,PRIORINSLNAME7,,,7 FIELD=PRIORINSCONTACT7,10,PER,,,2,,PRIORINSLNAME7,,,7 FIELD=PRIORINSCONTACTNUMBER7,10,PER,,,4,,PRIORINSLNAME7,,,7 FIELD=BENEFIT8,16,EB,,,1,,SUBID,,,8 FIELD=COVERAGELEVEL8,16,EB,,,2,,SUBID,,,8 FIELD=SERVICETYPE8,16,EB,,,3,,SUBID,,,8 FIELD=INSURANCETYPE8,16,EB,,,4,,SUBID,,,8 FIELD=PLANDESC8,16,EB,,,5,,SUBID,,,8 FIELD=TIMEPERIOD8,16,EB,,,6,,SUBID,,,8 FIELD=AMOUNT8,16,EB,,,7,,SUBID,,,8 FIELD=PERCENT8,16,EB,,,8,,SUBID,,,8 FIELD=QTYQUAL8,16,EB,,,9,,SUBID,,,8 FIELD=QUANTITY8,16,EB,,,10,,SUBID,,,8 FIELD=PLANNUMBER8,16,REF,18,2,2,,SUBID,,,8 FIELD=GROUPNUMBER8,16,REF,6P,2,2,,SUBID,,,8 FIELD=PCPID8,16,NM1,P3,2,8,,SUBID,,,8 FIELD=PCPLNAME8,32,NM1,P3,2,3,,SUBID,,,8 FIELD=PCPFNAME8,32,NM1,P3,2,4,,SUBID,,,8 FIELD=PCPMI8,1,NM1,P3,2,5,,SUBID,,,8 FIELD=PCPADDR1SUBADDR18,30,N3,,,1,,PCPLNAME8,,,8 FIELD=PCPADDR2SUBADDR28,30,N3,,,2,,PCPLNAME8,,,8 FIELD=PCPCITY8,30,N4,,,1,,PCPLNAME8,,,8 FIELD=PCPST8,2,N4,,,2,,PCPLNAME8,,,8 FIELD=PCPZIP8,10,N4,,,2,,PCPLNAME8,,,8 FIELD=PCPCONTACT8,10,PER,,,2,,PCPLNAME8,,,8 FIELD=PCPCONTACTNUMBER8,10,PER,,,4,,PCPLNAME8,,,8 FIELD=PRIORINSID8,16,NM1,P4,2,8,,SUBID,,,8 FIELD=PRIORINSLNAME8,32,NM1,P4,2,3,,SUBID,,,8 FIELD=PRIORINSFNAME8,32,NM1,P4,2,4,,SUBID,,,8 FIELD=PRIORINSMI8,1,NM1,P4,2,5,,SUBID,,,8 FIELD=PRIORINSADDR1SUBADDR18,30,N3,,,1,,PRIORINSLNAME8,,,8 FIELD=PRIORINSADDR2SUBADDR28,30,N3,,,2,,PRIORINSLNAME8,,,8 FIELD=PRIORINSCITY8,30,N4,,,1,,PRIORINSLNAME8,,,8 FIELD=PRIORINSST8,2,N4,,,2,,PRIORINSLNAME8,,,8 FIELD=PRIORINSZIP8,10,N4,,,2,,PRIORINSLNAME8,,,8 FIELD=PRIORINSCONTACT8,10,PER,,,2,,PRIORINSLNAME8,,,8 FIELD=PRIORINSCONTACTNUMBER8,10,PER,,,4,,PRIORINSLNAME8,,,8 FIELD=BENEFIT9,16,EB,,,1,,SUBID,,,9 FIELD=COVERAGELEVEL9,16,EB,,,2,,SUBID,,,9 FIELD=SERVICETYPE9,16,EB,,,3,,SUBID,,,9 FIELD=INSURANCETYPE9,16,EB,,,4,,SUBID,,,9 FIELD=PLANDESC9,16,EB,,,5,,SUBID,,,9 FIELD=TIMEPERIOD9,16,EB,,,6,,SUBID,,,9 FIELD=AMOUNT9,16,EB,,,7,,SUBID,,,9 FIELD=PERCENT9,16,EB,,,8,,SUBID,,,9 FIELD=QTYQUAL9,16,EB,,,9,,SUBID,,,9 FIELD=QUANTITY9,16,EB,,,10,,SUBID,,,9 FIELD=PLANNUMBER9,16,REF,18,2,2,,SUBID,,,9 FIELD=GROUPNUMBER9,16,REF,6P,2,2,,SUBID,,,9 FIELD=PCPID9,16,NM1,P3,2,8,,SUBID,,,9 FIELD=PCPLNAME9,32,NM1,P3,2,3,,SUBID,,,9 FIELD=PCPFNAME9,32,NM1,P3,2,4,,SUBID,,,9 FIELD=PCPMI9,1,NM1,P3,2,5,,SUBID,,,9 FIELD=PCPADDR1SUBADDR19,30,N3,,,1,,PCPLNAME9,,,9 FIELD=PCPADDR2SUBADDR29,30,N3,,,2,,PCPLNAME9,,,9 FIELD=PCPCITY9,30,N4,,,1,,PCPLNAME9,,,9 FIELD=PCPST9,2,N4,,,2,,PCPLNAME9,,,9 FIELD=PCPZIP9,10,N4,,,2,,PCPLNAME9,,,9 FIELD=PCPCONTACT9,10,PER,,,2,,PCPLNAME9,,,9 FIELD=PCPCONTACTNUMBER9,10,PER,,,4,,PCPLNAME9,,,9 FIELD=PRIORINSID9,16,NM1,P4,2,8,,SUBID,,,9 FIELD=PRIORINSLNAME9,32,NM1,P4,2,3,,SUBID,,,9 FIELD=PRIORINSFNAME9,32,NM1,P4,2,4,,SUBID,,,9 FIELD=PRIORINSMI9,1,NM1,P4,2,5,,SUBID,,,9 FIELD=PRIORINSADDR1SUBADDR19,30,N3,,,1,,PRIORINSLNAME9,,,9 FIELD=PRIORINSADDR2SUBADDR29,30,N3,,,2,,PRIORINSLNAME9,,,9 FIELD=PRIORINSCITY9,30,N4,,,1,,PRIORINSLNAME9,,,9 FIELD=PRIORINSST9,2,N4,,,2,,PRIORINSLNAME9,,,9 FIELD=PRIORINSZIP9,10,N4,,,2,,PRIORINSLNAME9,,,9 FIELD=PRIORINSCONTACT9,10,PER,,,2,,PRIORINSLNAME9,,,9 FIELD=PRIORINSCONTACTNUMBER9,10,PER,,,4,,PRIORINSLNAME9,,,9 FIELD=BENEFIT10,16,EB,,,1,,SUBID,,,10 FIELD=COVERAGELEVEL10,16,EB,,,2,,SUBID,,,10 FIELD=SERVICETYPE10,16,EB,,,3,,SUBID,,,10 FIELD=INSURANCETYPE10,16,EB,,,4,,SUBID,,,10 FIELD=PLANDESC10,16,EB,,,5,,SUBID,,,10 FIELD=TIMEPERIOD10,16,EB,,,6,,SUBID,,,10 FIELD=AMOUNT10,16,EB,,,7,,SUBID,,,10 FIELD=PERCENT10,16,EB,,,8,,SUBID,,,10 FIELD=QTYQUAL10,16,EB,,,9,,SUBID,,,10 FIELD=QUANTITY10,16,EB,,,10,,SUBID,,,10 FIELD=PLANNUMBER10,16,REF,18,2,2,,SUBID,,,10 FIELD=GROUPNUMBER10,16,REF,6P,2,2,,SUBID,,,10 FIELD=PCPID10,16,NM1,P3,2,8,,SUBID,,,10 FIELD=PCPLNAME10,32,NM1,P3,2,3,,SUBID,,,10 FIELD=PCPFNAME10,32,NM1,P3,2,4,,SUBID,,,10 FIELD=PCPMI10,1,NM1,P3,2,5,,SUBID,,,10 FIELD=PCPADDR1SUBADDR110,30,N3,,,1,,PCPLNAME10,,,10 FIELD=PCPADDR2SUBADDR210,30,N3,,,2,,PCPLNAME10,,,10 FIELD=PCPCITY10,30,N4,,,1,,PCPLNAME10,,,10 FIELD=PCPST10,2,N4,,,2,,PCPLNAME10,,,10 FIELD=PCPZIP10,10,N4,,,2,,PCPLNAME10,,,10 FIELD=PCPCONTACT10,10,PER,,,2,,PCPLNAME10,,,10 FIELD=PCPCONTACTNUMBER10,10,PER,,,4,,PCPLNAME10,,,10 FIELD=PRIORINSID10,16,NM1,P4,2,8,,SUBID,,,10 FIELD=PRIORINSLNAME10,32,NM1,P4,2,3,,SUBID,,,10 FIELD=PRIORINSFNAME10,32,NM1,P4,2,4,,SUBID,,,10 FIELD=PRIORINSMI10,1,NM1,P4,2,5,,SUBID,,,10 FIELD=PRIORINSADDR1SUBADDR110,30,N3,,,1,,PRIORINSLNAME10,,,10 FIELD=PRIORINSADDR2SUBADDR210,30,N3,,,2,,PRIORINSLNAME10,,,10 FIELD=PRIORINSCITY10,30,N4,,,1,,PRIORINSLNAME10,,,10 FIELD=PRIORINSST10,2,N4,,,2,,PRIORINSLNAME10,,,10 FIELD=PRIORINSZIP10,10,N4,,,2,,PRIORINSLNAME10,,,10 FIELD=PRIORINSCONTACT10,10,PER,,,2,,PRIORINSLNAME10,,,10 FIELD=PRIORINSCONTACTNUMBER10,10,PER,,,4,,PRIORINSLNAME10,,,10