REF

Other Claim Related Identification

Pos: 040	Max: 5
Detail - Optional
Loop: 2100	Elements: 2

Ref

Id

Element Name

Req

Type

Min/Max

Usage

REF01

128

Reference Identification Qualifier
Description: Code qualifying the Reference Identification

M

ID

2/3

Required

Code

Name

1L

Group or Policy Number

1W

Member Identification Number

9A

Repriced Claim Reference Number

9C

Adjusted Repriced Claim Reference Number

A6

Employee Identification Number

BB

Authorization Number

CE

Class of Contract Code

EA

Medical Record Identification Number

F8

Original Reference Number

G1

Prior Authorization Number

G3

Predetermination of Benefits Identification Number

IG

Insurance Policy Number

SY

Social Security Number

REF02

127

Reference Identification
Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Industry: Other Claim Related Identifier

C

AN

1/30

Required

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 REF segment for reference numbers specific to the claim identified in the CLP segment. This is used to provide additional information used in the process of adjudicating this claim.

Example:

REF*EA*666123~