| Pos |
Segment |
M/C |
Repeat |
Repr. |
Notes |
| 010 |
|
5267 |
Service type code |
M |
1 |
an..3 |
|
| 020 |
|
7517 |
Benefit and coverage code |
M |
1 |
an..3 |
|
| 030 |
|
3507 |
Benefit coverage constituents code |
C |
1 |
an..3 |
|
| 040 |
|
2151 |
Period type code |
C |
1 |
an..3 |
|
| 050 |
|
E017 |
MONETARY AMOUNT |
C |
1 |
|
|
|
|
5025 |
Monetary amount type code qualifier |
C |
|
an..3 |
|
|
|
5004 |
Monetary amount |
C |
|
n..35 |
|
|
|
6345 |
Currency identification code |
C |
|
an..3 |
|
|
|
6343 |
Currency type code qualifier |
C |
|
an..3 |
|
|
|
4405 |
Status description code |
C |
|
an..3 |
|
| 060 |
|
5482 |
Percentage |
C |
1 |
n..10 |
|
| 070 |
|
6063 |
Quantity type code qualifier |
C |
1 |
an..3 |
|
| 080 |
|
6060 |
Quantity |
C |
1 |
an..35 |
|
| 090 |
|
9607 |
Yes or no indicator code |
C |
2 |
an..3 |
|
| 100 |
|
4497 |
Insurance cover type code |
C |
1 |
an..3 |
|
| 110 |
|
4440 |
Free text |
C |
1 |
an..512 |
|