REF

Dependent Additional Identification

Pos: 140	Max: 9
Detail - Optional
Loop: 2110D	Elements: 3

Ref

Id

Element Name

Req

Type

Min/Max

Usage

REF01

128

Reference Identification Qualifier
Description: Code qualifying the Reference Identification
Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
Use “1L”, “1W”, “18", ”49", ‘‘6P’’, “A6", ”F6", ‘‘IG’’, “N6", and ”NQ" only in an EB loop with EB01 = “R”.

M

ID

2/3

Required

Code

Name

18

Plan Number

1L

Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes “IG” or “6P” when they can be determined.

1W

Member Identification Number

49

Family Unit Number

6P

Group Number

9F

Referral Number

A6

Employee Identification Number

F6

Health Insurance Claim (HIC) Number

G1

Prior Authorization Number

IG

Insurance Policy Number

N6

Plan Network Identification Number

NQ

Medicaid Recipient Identification Number

REF02

127

Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Industry: Dependent Eligibility or Benefit Identifier
Use this information for the reference number as qualified by the preceding data element (REF01).

C

AN

1/30

Required

REF03

352

Description
Description: A free-form description to clarify the related data elements and their content
Industry: Plan Sponsor Name
Use if available.

C

AN

1/80

Situational

1.

R0203 - At least one of REF02,REF03 is required

1.

REF04 contains data relating to the value cited in REF02.

Notes:

1. Use this segment to identify other or additional reference numbers for the entity identified. The type of reference number is determined by the qualifier in REF01.
2. Use this segment for reference identifiers related only to the EB loop that it is contained in (e.g. Other or Additional Payer’s identifiers).

Example:

REF*G1*653745725~