SBR

Other Subscriber Information

Pos: 290

Max: 1

Detail - Optional

Loop: 2320

Elements: 5

User Option (Usage): Situational

To record information specific to the primary insured and the insurance carrier for that insured

Element Summary:

	Ref	Id	Element Name	Req	Type	Min/Max	Usage
	SBR01	1138	Payer Responsibility Sequence Number Code Description: Code identifying the insurance carrier's level of responsibility for a payment of a claim UB-92 Ref. [UB-Name]: 50 (A-C) [Payer Identification] 51 (A-C) [Provider Number] 52 (A-C) [Release of Information Certification Indicator] 53 (A-C) [Assignment of Benefits Certification Indicator] 54 (A-C) [Prior Payments - Payers and Patient] 55 (A-C) [Estimated Amount Due] 58 (A-C) [Insured’s Name] 59 (A-C) [Patient’s Relationship to Insured] 60 (A-C) [Certificate/Social Security Number/Health Insurance Claim/ Identification Number] 61 (A-C) [Insured Group Name] 62 (A-C) [Insurance Group Number] 63 (A-C) [Treatment Authorization Code] 64 (A-C) [Employment Status Code of the Insured] 65 (A-C) [Employer Name of the Insured] 66 (A-C) [Employer Location of the Insured] EMC v.6.0 Reference: Record Type 30 Field No. 2 (Sequence 01-03) Record Type 31 Field No. 2 (Sequence 01-03) Record Type 32 Field No. 2 (Sequence 01-03) Record Type 40 Field No. 5, 6, 7	M	ID	1/1	Required

Code

Name

Primary

Secondary

Tertiary

Used to indicate “payer of last resort”.

SBR02

1069

Individual Relationship Code
Description: Code indicating the relationship between two individuals or entities
UB-92 Ref. [UB-Name]: 59 (A-C) [Patient’s Relationship to Insured]
EMC v.6.0 Reference: Record Type 30 Field No. 18 (Sequence 01-03)
Use this code to specify the patient’s relationship to the person insured.

2/2

Required

Code

Name

Spouse

UB-92 Ref. [UB-Name]:

59 Code 02 [Spouse]

Grandfather or Grandmother

UB-92 Ref. [UB-Name]:

59 Code 19 [Grandparent]

Grandson or Granddaughter

UB-92 Ref. [UB-Name]:

59 Code 13 [Grandchild]

Nephew or Niece

UB-92 Ref. [UB-Name]:

59 Code 14 [Niece/Nephew]

Foster Child

UB-92 Ref. [UB-Name]:

59 Code 06 [Foster Child]

Ward

UB-92 Ref. [UB-Name]:

59 Code 07 [Ward of the Court]

Stepson or Stepdaughter

UB-92 Ref. [UB-Name]:

59 Code 05 [Step Child]

Self

UB-92 Ref. [UB-Name]:

59 Code 01 [Patient Is Insured]

Child

Description: Dependent between the ages of 0 and 19; age qualifications may vary depending on policy

UB-92 Ref. [UB-Name]:

59 Code 03 [Natural Child/Insured Financial Responsibility]

Employee

UB-92 Ref. [UB-Name]:

59 Code 08 [Employee]

Unknown

UB-92 Ref. [UB-Name]:

59 Code 09 [Unknown]

Handicapped Dependent

UB-92 Ref. [UB-Name]:

59 Code 10 [Handicapped Dependent]

Sponsored Dependent

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

UB-92 Ref. [UB-Name]:

59 Code 16 [Sponsored Dependent]

Dependent of a Minor Dependent

Description: A child not legally of age who has been granted adult status

UB-92 Ref. [UB-Name]:

59 Code 17 [Minor Dependent of a Minor Dependent]

Significant Other

Mother

Father

Emancipated Minor

Description: A person who has been judged by a court of competent jurisdiction to be allowed to act in his or her own interest; no adult is legally responsible for this minor; this may be declared as a result of marriage

Organ Donor

Description: Individual receiving medical service in order to donate organs for a transplant

UB-92 Ref. [UB-Name]:

59 Code 11 [Organ Donor]

Cadaver Donor

Description: Deceased individual donating body to be used for research or transplants

UB-92 Ref. [UB-Name]:

59 Code 12 [Cadaver Donor]

Injured Plaintiff

UB-92 Ref. [UB-Name]:

59 Code 15 [Injured Plaintiff]

Child Where Insured Has No Financial Responsibility

Description: Child is covered by the insured but the insured is not the legal guardian

UB-92 Ref. [UB-Name]:

59 Code 04 [Natural Child/Insured Does not Have Financial Responsibility]

Life Partner

UB-92 Ref. [UB-Name]:

59 Code 20 [Life Partner]

Other Relationship

SBR03	127	Reference Identification Description: Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier Industry: Insured Group or Policy Number UB-92 Ref. [UB-Name]: 62 (A-C) [Insurance Group Number] EMC v.6.0 Reference: Record Type 30 Field No. 10 (Sequence 01-03) Insurance Group No. Use this element to carry the subscriber’s group number but not the number that uniquely identifies the subscriber. The subscriber’s number should be carried in NM109. Using code IL in NM101 identifies the number in NM109 as the insured’s Identification Number.	O	AN	1/30	Situational
SBR04	93	Name Description: Free-form name Industry: Other Insured Group Name UB-92 Ref. [UB-Name]: 61 (A-C) [Insured Group Name] EMC v.6.0 Reference: Record Type 30 Field No. 11 (Sequence 01-03) Plan Name (Group Name) This data element is required when the Provider has the Plan Name (Group Name) within their files.	O	AN	1/60	Situational
SBR09	1032	Claim Filing Indicator Code Description: Code identifying type of claim EMC v.6.0 Reference: Record Type 30 Field No. 4 (Sequence 01-03. See SBR09 in LOOP 2000B for EMC code translation.) Required prior to mandated used of PlanID. Not used after PlanID is mandated.	O	ID	1/2	Situational

Code

Name

Self-pay

Central Certification

Other Non-Federal Programs

Preferred Provider Organization (PPO)

Point of Service (POS)

Exclusive Provider Organization (EPO)

Indemnity Insurance

Health Maintenance Organization (HMO) Medicare Risk

Automobile Medical

Blue Cross/Blue Shield

Champus

Commercial Insurance Co.

Disability

Health Maintenance Organization

Liability

Liability Medical

Medicare Part A

Medicare Part B

Medicaid

Other Federal Program

Title V

Veteran Administration Plan

Refers to Veterans Affairs Plan.

Workers' Compensation Health Claim

Mutually Defined

Unknown

1.	SBR02 specifies the relationship to the person insured.
2.	SBR03 is policy or group number.
3.	SBR04 is plan name.
4.	SBR07 is destination payer code. A "Y" value indicates the payer is the destination payer; an "N" value indicates the payer is not the destination payer.

Notes:

1. Required if other payers are known to potentially be involved in paying on this claim.
2. Because the usage of this segment is “Situational” this is not a syntactically required loop. If this loop is used, then this segment is a “Required” segment. See Appendix A for further details on ASC X12 nomenclature.
3. All information contained in the 2320 Loop applies only to the payer who is identified in the 2330B Loop of this iteration of the 2320 Loop. It is specific only to that payer. If information on additional payers is needed to be carried, run the 2320 Loop again with it’s respective 2330 Loops.

Example:

SBR*S*01*GR00786**MC****OF~