INS

Member Level Detail

Pos: 010	Max: 1
Detail - Optional
Loop: 2000	Elements: 13

Ref

Id

Element Name

Req

Type

Min/Max

Usage

INS01

1073

Yes/No Condition or Response Code
Description: Code indicating a Yes or No condition or response
Industry: Insured Indicator
Alias: Subscriber Indicator

M

ID

1/1

Required

Code

Name

N

No

Y

Yes

INS02

1069

Individual Relationship Code
Description: Code indicating the relationship between two individuals or entities
This value should be 18 for the subscriber.
For dependents, use this value to identify the relationship to the subscriber. For example, a daughter would be value 19.

M

ID

2/2

Required

Code

Name

01

Spouse

03

Father or Mother

04

Grandfather or Grandmother

05

Grandson or Granddaughter

06

Uncle or Aunt

07

Nephew or Niece

08

Cousin

09

Adopted Child

10

Foster Child

11

Son-in-law or Daughter-in-law

12

Brother-in-law or Sister-in-law

13

Mother-in-law or Father-in-law

14

Brother or Sister

15

Ward

17

Stepson or Stepdaughter

18

Self

19

Child

23

Sponsored Dependent

Dependents between the ages of 19 and 25 not attending school; age qualifications may vary depending on policy.

24

Dependent of a Minor Dependent

25

Ex-spouse

26

Guardian

31

Court Appointed Guardian

32

Mother

33

Father

38

Collateral Dependent

Relative related by blood or marriage who resides in the home and is dependent on the insured for a major portion of their support.

48

Stepfather

49

Stepmother

53

Life Partner

This is a partner that acts like a spouse without a legal marriage committment.

INS03

875

Maintenance Type Code
Description: Code identifying the specific type of item maintenance
For further information about full file audits versus change only transactions see section 2.6 (Updates versus Full File Audits) of this guide.

O

ID

3/3

Required

Code

Name

001

Change

Use this code to indicate a change to an existing subscriber/dependent record.

021

Addition

Use this code to add a subscriber or dependent.

024

Cancellation or Termination

Use this code for cancellation, termination, or deletion of a subscriber or dependent.

025

Reinstatement

Use this code for reinstatement of a cancelled subscriber/dependent record.

030

Audit or Compare

Use this code when sending a full roster to verify that the sponsor and payer databases are synchronized. See section 2.6, Updates versus Full File Audits, for additional information

INS04

1203

Maintenance Reason Code
Description: Code identifying the reason for the maintenance change
Recommended: To be sent unless the trading partner agreement between the sponsor and payer allow this data element to not be sent.

O

ID

2/3

Situational

Code

Name

01

Divorce

02

Birth

03

Death

04

Retirement

05

Adoption

06

Strike

07

Termination of Benefits

08

Termination of Employment

09

Consolidation Omnibus Budget Reconciliation Act (COBRA)

10

Consolidation Omnibus Budget Reconciliation Act (COBRA) Premium Paid

11

Surviving Spouse

14

Voluntary Withdrawal

15

Primary Care Provider (PCP) Change

16

Quit

17

Fired

18

Suspended

20

Active

21

Disability

22

Plan Change

This is used when a member changes from one Plan to a different Plan. This is not intended to identify changes to a Plan.

25

Change in Identifying Data Elements

Use this code when a change has been made to the primary elements that identify an individual. Such primary elements include the following: first name, last name, Social Security Number, date of birth, and employee identification number.

26

Declined Coverage

The subscriber declined a previously active coverage.

27

Pre-Enrollment

This code can be used to enroll newborns prior to receiving the newborn’s application.

28

Initial Enrollment

29

Benefit Selection

This is used when a member changes benefits within a Plan.

31

Legal Separation

32

Marriage

33

Personnel Data

Use this code for any data change that is not included in any of the other allowed codes. An example would be change in Coordination of Benefits information.

37

Leave of Absence with Benefits

38

Leave of Absence without Benefits

39

Lay Off with Benefits

40

Lay Off without Benefits

41

Re-enrollment

43

Change of Location

Use this code to indicate a change of address.

AI

No Reason Given

XN

Notification Only

To be used in complete enrollment transmissions. This is used when INS03 is equal to 030 (Audit/Compare).

XT

Transfer

This is used when an employee has an organizational change (i.e. a location change within the organization) with no change in benefits or Plan.

INS05

1216

Benefit Status Code
Description: The type of coverage under which benefits are paid

O

ID

1/1

Required

Code

Name

A

Active

C

Consolidated Omnibus Budget Reconciliation Act (COBRA)

S

Surviving Insured

T

Tax Equity and Fiscal Responsibility Act (TEFRA)

INS06

1218

Medicare Plan Code
Description: Code identifying the Medicare Plan
This element is REQUIRED if a member is being enrolled or disenrolled in Medicare, is currently enrolled in Medicare or has terminated or changed their Medicare enrollment.

O

ID

1/1

Situational

Code

Name

A

Medicare Part A

B

Medicare Part B

C

Medicare Part A and B

D

Medicare

Medicare - Part Unknown

E

No Medicare

INS07

1219

Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code
Description: A Qualifying Event is any of the following which results in loss of coverage for a Qualified Beneficiary
Industry: Consolidated Omnibus Budget Reconciliation Act (COBRA) Qualifying Event Code
This element is REQUIRED if a member is being enrolled in or is enrolled for a benefit covered by COBRA.

O

ID

1/2

Situational

Code

Name

1

Termination of Employment

2

Reduction of work hours

3

Medicare

4

Death

5

Divorce

6

Separation

7

Ineligible Child

8

Bankruptcy of a Retired Employee

INS08

584

Employment Status Code
Description: Code showing the general employment status of an employee/claimant
Required for subscriber.
If this insurance enrollment is through a non Imployment based program such as Medicare or Medicaid then this data element will contain the status of the subscriber in that program, rather than their employment status. Codes for non employment based programs will be limited to “FT”, Full Time, “PT”, Part-Time, and “TE”, Terminated.

O

ID

2/2

Situational

Code

Name

AO

Active Military - Overseas

AU

Active Military - USA

FT

Full-time

Full time active employee

L1

Leave of Absence

PT

Part-time

Part time Active Employee

RT

Retired

TE

Terminated

INS09

1220

Student Status Code
Description: Code indicating the student status of the patient if 19 years of age or older, not handicapped and not the insured
Only use the Student Status Code when describing a non-spouse dependent whose age requires a qualifying condition for enrollment (e.g., being an active student). See the Plan contract for details of the age requirements for student status usage.
All valid standard codes are used.

O

ID

1/1

Situational

INS10

1073

Yes/No Condition or Response Code
Description: Code indicating a Yes or No condition or response
Industry: Handicap Indicator
This element is REQUIRED if the member is handicapped or to correct previous report of handicapped status.

O

ID

1/1

Situational

Code

Name

N

No

Y

Yes

INS11

1250

Date Time Period Format Qualifier
Description: Code indicating the date format, time format, or date and time format
Send when required by X12 syntax.

C

ID

2/3

Situational

Code

Name

D8

Date Expressed in Format CCYYMMDD

INS12

1251

Date Time Period
Description: Expression of a date, a time, or range of dates, times or dates and times
Industry: Insured Individual Death Date
Use this date for the date of death of the subscriber/dependent.
This does not replace the use of the termination date within the 2300 loop.

C

AN

1/35

Situational

INS17

1470

Number
Description: A generic number
Industry: Birth Sequence Number
Required if reporting family members with the same birth date, when needed for proper reporting, tracking or response to benefits.

O

N0

1/9

Situational

1.

P1112 - If either INS11,INS12 is present, then all are required

1.

INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.

2.

INS10 is the handicapped status indicator. A "Y" value indicates an individual is handicapped; an "N" value indicates an individual is not handicapped.

3.

INS12 is the date of death.

4.

INS14, INS15, and INS16 identify where the employee works.

5.

INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).

Notes:

1. Subscriber information must preceed dependent information in a transmission, or the subscriber information must have been submitted to the receiver in a previous transmission.
2. No more than 10,000 INS segments can occur in a single 834 transaction. Multiple transactions within a single interchange can be used to transfer information on larger numbers of members.

Example:

INS*Y*18*021*28*A*E**FT~