SITUATIONAL            SBR02           1069      Individual Relationship Code                                      O     ID      2/2
                                                                           Code indicating the relationship between two individuals or entities

                                                                           ALIAS: Relationship Code

                                                                           SEMANTIC  SBR02 specifies the relationship to the person insured.

                        1416                                               NSF Reference:
                                                                           DA0-17.0
                         1416

                        2698                                               Required when the subscriber is the same person as the patient. If
                                                                           the subscriber is not the same person as the patient, do not use
                                                                           this element.

                                                                                   CODE       DEFINITION

                                                                           18                 Self

                         SITUATIONAL            SBR03           127       Reference Identification                                         O    AN        1/30
                                                                           Reference information as defined for a particular Transaction Set or as specified
                                                                           by the Reference Identification Qualifier

                                                                           INDUSTRY Insured Group or Policy Number

                                                                           ALIAS: Group or Policy Number

                                                                           SEMANTIC  SBR03 is policy or group number.

                        2398                                               NSF Reference:
                                                                           DA0-10.0
                         2398
                                                                           Required if the subscriber’s payer identification includes Group or
                         1096
                                                                           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).

                         SITUATIONAL            SBR04           93        Name                                                             O    AN        1/60
                                                                           Free-form name

                                                                           INDUSTRY Insured Group Name

                                                                           ALIAS: Group or Plan Name

                                                                           SEMANTIC  SBR04 is plan name.

                        2399                                               NSF Reference:
                                                                           DA0-11.0
                         2399
                                                                           Required if the subscriber’s payer identification includes a Group
                         1240
                                                                           or Plan Name.

                         SITUATIONAL            SBR05           1336      Insurance Type Code                                              O      ID      1/3
                                                                           Code identifying the type of insurance policy within a specific insurance program

                                                                           ALIAS: Insurance type code

                        1417                                               NSF Reference:
                                                                           DA0-06.0
                         1417

                        1386                                               Required when the destination payer (Loop 2010BB) is Medicare
                                                                           and Medicare is not the primary payer (SBR01 equals “S” or “T”).

                                                                                   CODE       DEFINITION

                                                                           12                 Medicare Secondary Working Aged Beneficiary or
                                                                                               Spouse with Employer Group Health Plan