SBR

Other Subscriber Information

Pos: 290	Max: 1
Detail - Optional
Loop: 2320	Elements: 5

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
NSF Reference: DA0-02.0

M

ID

1/1

Required

Code

Name

P

Primary

S

Secondary

T

Tertiary

SBR02

1069

Individual Relationship Code
Description: Code indicating the relationship between two individuals or entities
NSF Reference: DA0-17.0
Use this code to specify the relationship to the person insured.

O

ID

2/2

Required

Code

Name

01

Spouse

18

Self

19

Child

20

Employee

21

Unknown

22

Handicapped Dependent

29

Significant Other

76

Dependent

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
NSF Reference: DA0-10.0
Required if the subscriber’s payer identification includes Group or Plan Number. This data element is intended to carry the subscriber’s Group Number, not the number that uniquely identifies the subscriber (Subscriber ID, Loop 2010BA-NM109).

O

AN

1/30

Situational

SBR04

93

Name
Description: Free-form name
Industry: Policy Name
Alias: Plan Name
Required if the Subscriber’s payer identification includes Plan Name.

O

AN

1/60

Situational

SBR09

1032

Claim Filing Indicator Code
Description: Code identifying type of claim
NSF Reference: DA0-05.0
Required prior to mandated use of PlanID. Not used after PlanID is mandated.

O

ID

1/2

Situational

Code

Name

09

Self-pay

11

Other Non-Federal Programs

12

Preferred Provider Organization (PPO)

13

Point of Service (POS)

14

Exclusive Provider Organization (EPO)

15

Indemnity Insurance

16

Health Maintenance Organization (HMO) Medicare Risk

17

Dental Maintenance Organization

BL

Blue Cross/Blue Shield

CH

Champus

CI

Commercial Insurance Co.

DS

Disability

FI

Federal Employees Program

HM

Health Maintenance Organization

LM

Liability Medical

MB

Medicare Part B

MC

Medicaid

MH

Managed Care Non-HMO

OF

Other Federal Program

SA

Self-administered Group

VA

Veteran Administration Plan

Refers to Veteran’s Affairs Plan.

WC

Workers' Compensation Health Claim

ZZ

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 syntatically required loop. If the loop is used, then it is a “required” segment. See Appendix A for further details on ASC X12 nomenclature X12 syntax rules.
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 its respective 2330 loops.

Example:

SBR*P*01*003450*GOLDEN PLUS*****CI~