# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | insurance type | 0;1 | POINTER | 36 | B | Choose from the available listing the name(s) of the insurance company(ies) under which this applicant is covered. |
.18 | group plan | 0;18 | POINTER | 355.3 | Select the plan under which this patient is covered by the specified insurance company. If this is a group plan then there may already be an entry for this plan that you may select. Or, you may add a new plan. If this is an individual plan then it will be associated with only this patient. | |
.2 | coordination of benefits | 0;20 | SET OF CODES | 1:PRIMARY 2:SECONDARY 3:TERTIARY | ||
1 | *subscriber id | 0;2 | FREE TEXT | Enter the Subscriber's Primary ID number. This number is assigned by the payer and can be found on the subscriber's insurance card. This field is scheduled for deletion in May 2015. | ||
1.01 | date entered | 1;1 | DATE-TIME | This is the date this entry was added. It will be created by the system whenever a new policy is added. Entries created prior the installation of IB v2.0 will not have an entry in this field. | ||
1.02 | entered by | 1;2 | POINTER | 200 | This the user who added this entry. It will be entered by the system whenever a new policy is added. Entries created prior the installation of IB v2.0 will not have an entry in this field. | |
1.03 | date last verified | 1;3 | DATE-TIME | Insurance coverage is generally verified by calling the insurer and requesting an explanation of benefits. When coverage has been verified the person verifying the coverage should use the options to verify the coverage in VISTA. This is the date that this policy for this patient was last verified with the insurance company. It is important to update the verification date regularly so that other users will know how current the information in VISTA is. | ||
1.04 | verified by | 1;4 | POINTER | 200 | This is the user that last contacted the insurance company to verify the policy. It is updated by using the appropriate DHCP options. It is important to update the verification date and user so that other users will know the insurance policy information is current. | |
1.05 | date last edited | 1;5 | DATE-TIME | This is the date this policy was last edited. This field is updated by the computer whenever anyone edits this patient's policy information. | ||
1.06 | last edited by | 1;6 | POINTER | 200 | This is the user that last edited the policy. This field is updated by the computer whenever anyone edits this patients policy information. | |
1.08 | comment - patient policy | 1;8 | FREE TEXT | This is a place to record a short comment about this patients policy. It is specific to this patient and to this policy. The answer must be 3 to 80 characters. | ||
1.09 | source of information | 1;9 | POINTER | 355.12 | Enter the last source of this information. If the insurance information was obtained by patient interview, then enter interview, etc. If the information was initially or previously obtained by one source but updated by another source, then enter the most recent source of the information. The data in this field will be initially set to INTERVIEW with IB v2. The data may be passed to Accounts Receivable and/or the MCCR NDB. If this field is being edited through the use of the pre-registration software, the default for this field will be set to PRE-REGISTRATION. | |
1.1 | date of source of information | 1;10 | DATE-TIME | |||
2 | *group number | 0;3 | FREE TEXT | Enter any other appropriate number which identifies this policy, i.e., group number/code, under which this applicant is covered. Answer must be between 1 and 17 characters. This field is moved to the HEALTH INSURANCE POLICY file (355.3) beginning with IB v2.0. It will be deleted with the first release 18 months after the release of IB V2. | ||
2.01 | send bill to employer | 2;1 | BOOLEAN | 1:YES 0:NO | If the employer of the person who holds this policy requires that they pre-processed for the insurance policy then enter 'YES'. You will then be allowed to enter the company name and address that these bills should be sent to. The bills will then automatically use this address. If the employer does not require this, or unknown, enter 'NO'. The bills will then be sent to the insurance company. If the policy is held by other than the patient then this will not be the patient's employer but the employer of the person who is insured. | |
2.015 | subscriber's employer name | 2;9 | FREE TEXT | This is the name of the employer that will appear on the UB-04 if the bills should be sent to the employer for pre-processing. | ||
2.02 | employer claims street address | 2;2 | FREE TEXT | This is the street address of the employer who should receive claims to be pre-processed before the are forwarded to the insurance carrier. The answer should be 3 to 30 characters. | ||
2.03 | employ claim st address line 2 | 2;3 | FREE TEXT | This is line 2 of the street address for employers who pre-process insurance claims before they are forwarded to the insurance carrier for processing. Answer must be 3-30 characters. | ||
2.04 | employ claim st address line 3 | 2;4 | FREE TEXT | This is line 3 of the street address for employers who pre-process insurance claims before they are forwarded to the insurance carrier for processing. Answer must be 3-30 characters. | ||
2.05 | employer claims city | 2;5 | FREE TEXT | If the employer of the person who holds this policy pre-processes insurance claims prior to forwarding to the insurance carrier enter the city that claim should be sent to. This will be printed on the claim form. Answer must be 3 to 20 characters. | ||
2.06 | employer claims state | 2;6 | POINTER | 5 | If the employer of the person who holds this policy pre-processes insurance claims prior to forwarding to the insurance carrier enter the state that the claim should be sent to. This will be printed on the claim form. Answer must be 3 to 20 characters. | |
2.07 | employer claims zip code | 2;7 | FREE TEXT | Enter the zip code of the mailing address for this employer. Answer with either the 5 digit zip code (format 12345) or with the 9 digit zip code (in format 123456789 or 12345-6789). | ||
2.08 | employer claims phone | 2;8 | FREE TEXT | Enter the phone number of the employer. This should be the phone number of the person to contact regarding insurance claims. | ||
2.1 | esghp | 2;10 | BOOLEAN | 1:YES 0:NO | Enter 'Yes' if this policy is part of a plan that is sponsored or provided by the insured's current or past employer. | |
2.11 | employment status | 2;11 | SET OF CODES | 1:FULL TIME 2:PART TIME 3:NOT EMPLOYED 4:SELF EMPLOYED 5:RETIRED 6:ACTIVE MILITARY 9:UNKNOWN | If this is an Employer Sponsored Group Health Plan then this should be the employment status of the insured with the employer that sponsors the plan. | |
2.12 | retirement date | 2;12 | DATE-TIME | If this is an Employer Sponsored Group Health Plan then this should be the date the insured retired from the employer that sponsors the plan. | ||
3 | insurance expiration date | 0;4 | DATE-TIME | If this insurance policy under which this applicant is covered expires on a specified date enter that date, otherwise, leave this field blank. | ||
3.01 | insured's dob | 3;1 | DATE-TIME | The field is used to store the date of birth of the insured person. The field value may be printed in block 11a of the CMS-1500 claim form. This is a required field for billing ChampUS patients. | ||
3.02 | insured's branch | 3;2 | POINTER | 23 | This field may be used to store the service branch of the insured person. The field will be used primarily for CHAMPUS policies, where the subscriber, or sponsor, may be an active duty member of the military. The field value may be printed in block 11b of the CMS-1500 claim form. | |
3.03 | insured's rank | 3;3 | FREE TEXT | This field contains the insured person's military rank. The field will be used primarily for CHAMPUS policies, where the subscriber, or sponsor, may be an active duty member of the military. The field value may be printed in block 11c of the CMS-1500 claim form. | ||
3.04 | policy not billable | 3;4 | BOOLEAN | 0:NO 1:YES | This field is used primarily for CHAMPUS policies. If the patient is covered under CHAMPUS, but it is known that claims should never be submitted to the CHAMPUS Fiscal Intermediary, then entering YES in this field will cause Pharmacy claims to the FI not to be created. | |
3.05 | insured's ssn | 3;5 | FREE TEXT | This field contains the policyholder's social security number, if it is different than the Subscriber ID. For CHAMPUS policies, this value may be automatically inserted into this field from the PATIENT (#2) or SPONSOR PERSON (#355.82) files. | ||
3.06 | insured's street 1 | 3;6 | FREE TEXT | This field contains the first street address of the policyholder. | ||
3.07 | insured's street 2 | 3;7 | FREE TEXT | This field contains the second line of the street address of the policyholder. | ||
3.08 | insured's city | 3;8 | FREE TEXT | This field contains the city of the policyholder. | ||
3.09 | insured's state | 3;9 | POINTER | 5 | This field contains the state of the policyholder. | |
3.1 | insured's zip | 3;10 | FREE TEXT | This field contains the zip code of the policyholder. | ||
3.11 | insured's phone | 3;11 | FREE TEXT | This field contains the phone number of the policyholder. | ||
3.12 | insured's sex | 3;12 | SET OF CODES | F:FEMALE M:MALE | This field is used in insurance billing to help verify the policy coverage when the bill is submitted to the carrier. If the patient is the policy holder, this value should match the patient's sex. If the patient's spouse or other relative is the policy holder, the appropriate value should be determined and entered. | |
3.13 | insured's country | 3;13 | FREE TEXT | This field contains the country code of the policyholder. | ||
3.14 | insured's country subdivision | 3;14 | FREE TEXT | This field contains the country subdivision code of the policyholder. | ||
4.01 | primary care provider | 4;1 | FREE TEXT | This is the patient's Primary Care Provider within their managed care network that may refer the patient to the VA. | ||
4.02 | primary provider phone | 4;2 | FREE TEXT | This is the phone number of the Primary Care Provider that may refer the patient to the VA. | ||
4.03 | pt. relationship - hipaa(+) | 4;3 | SET OF CODES | 01:SPOUSE 18:SELF 19:CHILD 20:EMPLOYEE 29:SIGNIFICANT OTHER 32:MOTHER 33:FATHER 39:ORGAN DONOR 41:INJURED PLAINTIFF 53:LIFE PARTNER G8:OTHER RELATIONSHIP | Enter the code which best describes the patient's relationship to the person who holds this policy (or insured). | |
4.04 | eiv auto-update | 4;4 | BOOLEAN | 0:NO 1:YES | Flag that determines how the last update to INSURANCE TYPE sub-file was done. Value of "YES" means that data was last updated via eIV auto-update, value of "NO" means that data was last updated via other means. | |
4.05 | pharmacy relationship code | 4;5 | POINTER | 9002313.19 | This is the relationship of the patient to the cardholder. Code Description ---- ----------- 0 Not Specified 1 Cardholder - The individual that is enrolled in and receives benefits from a health plan 2 Spouse - Patient is the husband/wife/partner of the cardholder 3 Child - Patient is a child of the cardholder 4 Other - Relationship to cardholder is not precise | |
4.06 | pharmacy person code | 4;6 | FREE TEXT | This is the code that is assigned by the payer to identify the patient. The payer may use a unique person code to identify each specific person on the pharmacy insurance policy. This code may also describe the patient's relationship to the cardholder. Enrollment Standard Examples: 001 = Cardholder 002 = Spouse 003 - 999 = Dependents and Others (including second spouses, etc.) | ||
5.01 | patient id | 5;1 | FREE TEXT | This is the patient's primary ID number for this insurance company. Enter this field when the patient and the subscriber are different and the patient has been given a unique ID number. If issued by this payer, the number should be present on the patient's insurance card. This data will print in box 8a on the UB-04 for institutional claims when the patient and the subscriber are different. | ||
5.02 | subscriber's sec qualifier(1) | 5;2 | SET OF CODES | 23:Client Number IG:Insurance Policy Number SY:Social Security Number | Enter the subscriber secondary ID qualifier# 1. The qualifier describes the type of ID number. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare. | |
5.03 | subscriber's sec id(1) | 5;3 | FREE TEXT | Enter the subscriber's secondary ID #1. You may enter up to 3 secondary ID's and qualifiers. | ||
5.04 | subscriber's sec qualifier(2) | 5;4 | SET OF CODES | 23:Client Number IG:Insurance Policy Number SY:Social Security Number | Enter the subscriber secondary ID qualifier# 2. The qualifier describes the type of ID number. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare. | |
5.05 | subscriber's sec id(2) | 5;5 | FREE TEXT | Enter the subscriber's secondary ID #2. You may enter up to 3 secondary ID's and qualifiers. | ||
5.06 | subscriber's sec qualifier(3) | 5;6 | SET OF CODES | 23:Client Number IG:Insurance Policy Number SY:Social Security Number | Enter the subscriber secondary ID qualifier# 3. The qualifier describes the type of ID number. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare. | |
5.07 | subscriber's sec id(3) | 5;7 | FREE TEXT | Enter the subscriber's secondary ID #3. You may enter up to 3 secondary ID's and qualifiers. | ||
5.08 | patient's sec qualifier(1) | 5;8 | SET OF CODES | 23:Client Number IG:Insurance Policy Number SY:Social Security Number | Enter the patient secondary ID qualifier# 1. The qualifier describes the type of ID number. This should only be used when the patient and the subscriber are different. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare. | |
5.09 | patient's secondary id(1) | 5;9 | FREE TEXT | Enter the patient secondary ID #1. You may enter up to 3 secondary ID's and qualifiers. This should only be used when the patient and the subscriber are different. | ||
5.1 | patient's sec qualifier(2) | 5;10 | SET OF CODES | 23:Client Number IG:Insurance Policy Number SY:Social Security Number | Enter the patient secondary ID qualifier# 2. The qualifier describes the type of ID number. This should only be used when the patient and the subscriber are different. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare. | |
5.11 | patient's secondary id(2) | 5;11 | FREE TEXT | Enter the patient secondary ID #2. You may enter up to 3 secondary ID's and qualifiers. This should only be used when the patient and the subscriber are different. | ||
5.12 | patient's sec qualifier(3) | 5;12 | SET OF CODES | 23:Client Number IG:Insurance Policy Number SY:Social Security Number | Enter the patient secondary ID qualifier# 3. The qualifier describes the type of ID number. This should only be used when the patient and the subscriber are different. Up to 3 secondary ID's and qualifiers may be entered, but you cannot use the same qualifier more than once. SY is not a valid qualifier when the payer is Medicare. | |
5.13 | patient's secondary id(3) | 5;13 | FREE TEXT | Enter the patient secondary ID #3. You may enter up to 3 secondary ID's and qualifiers. This should only be used when the patient and the subscriber are different. | ||
6 | whose insurance(+) | 0;6 | SET OF CODES | v:VETERAN s:SPOUSE o:OTHER | Enter 'v' if this insurance policy is held by the veteran (applicant), 's' if the veteran is married and the spouse holds the policy, or 'o' if someone other than the veteran or his/her spouse hold the policy, i.e., employer. | |
7.01 | name of insured(+) | 7;1 | FREE TEXT | Enter the name of the individual for which this insurance policy was issued. If the patient and the insurance subscriber are the same, then this field will be defaulted from the patient name field. The name must contain a comma and be entered in Last,First format. | ||
7.02 | subscriber id | 7;2 | FREE TEXT | Enter the Subscriber's Primary ID number. This number is assigned by the payer and can be found on the subscriber's insurance card. | ||
8 | effective date of policy | 0;8 | DATE-TIME | Enter the date that this insurance policy initially went into effect (the date the patient acquired this policy). | ||
8.01 | requested service date | 8;1 | DATE-TIME | This is the Eligibility/Service Date that is received on the eIV Response message. If it is not present on the Response message then this is the Eligibility Date that was sent on the Inquiry message. | ||
8.02 | requested service type | 8;2 | POINTER | 365.013 | This is the Service Type that is received on the Response message. | |
9 | group reference information | 9;0 | MULTIPLE | 2.3129 | Subscriber/Dependent additional identification data. | |
10 | group provider info | 10;0 | MULTIPLE | 2.332 | Entries in this sub-file identify the characteristics of a provider. | |
11 | health care code information | 11;0 | MULTIPLE | 2.31211 | To supply information related to the delivery of health care. | |
12.01 | military info status code | 12;1 | POINTER | 365.039 | Code to indicate the status of the military information sent by the payer. | |
12.02 | military employment status | 12;2 | POINTER | 365.046 | Code showing the general military employment status of an employee/claimant. | |
12.03 | military govt affiliation code | 12;3 | POINTER | 365.041 | Code specifying the military service affiliation. | |
12.04 | military personnel description | 12;4 | FREE TEXT | This field further identifies the exact military unit. | ||
12.05 | military service rank code | 12;5 | POINTER | 365.042 | Code specifying the military service rank. | |
12.06 | date time period format qual | 12;6 | POINTER | 365.032 | Code qualifier indicating the date format, time format, or date and time format respective of the DATE TIME PERIOD field (#12.07). | |
12.07 | date time period | 12;7 | FREE TEXT | Expression of a date or range of dates that indicates the date span of military service. | ||
15 | *group name | 0;15 | FREE TEXT | If this insurance policy is a group policy, enter the name of the group. This field is moved to the HEALTH INSURANCE POLICY file (355.3) beginning with IB v2.0. It will be deleted with the first release 18 months after the release of IB V2. | ||
16 | pt. relationship to insured(+) | 0;16 | SET OF CODES | 01:PATIENT 02:SPOUSE 03:NATURAL CHILD 08:EMPLOYEE 09:DO NOT USE 11:ORGAN DONOR 15:INJURED PLANTIFF 18:DO NOT USE 32:MOTHER 33:FATHER 34:SIGNIFICANT OTHER 35:LIFE PARTNER 36:OTHER RELATIONSHIP | Select the relationship code that describes the relationship this patient has to the holder of this insurance policy. If the policy belongs to the patient enter '01' for patient. If the policy belongs to the spouse enter '02' for spouse, etc. | |
17 | *name of insured(+) | 0;17 | FREE TEXT | Enter the name of the individual for which this insurance policy was issued. If the patient and the insurance subscriber are the same, then this field will be defaulted from the patient name field. The name must contain a comma and be entered in Last,First format. This field is scheduled for deletion in May 2015. | ||
20 | new group name | COMPUTED | This computed field will yield the Group Name from file# 355.3 based on the current Group Plan in field# .18. | |||
21 | new group number | COMPUTED | This computed field will yield the Group Number from file# 355.3 based on the current Group Plan in field# .18. | |||
60 | eligibility/benefit | 6;0 | MULTIPLE | 2.322 | This multiple contains all of the eligibility and benefit data for a specific insured person returned from the Payer. |
Error: Invalid Global File Type: 2.312