50 2100C NM102 Entity Type 1,2 1= Person Qualifier 2= Nonperson entity 50 2100C NM103 Name Last or Provider Organization Last or Name Name 50 2100C NM104 Name First Provider Required when the value in NM102 = “1" First Name 51 2100C NM108 Identification XX XX = NPI Code Qualifier 51 2100C NM109 Identification Provider Enter NPI Code Identifier 54 2000D DMG Subscriber Demographic Information 54 2000D DMG01 Date Time D8 D8 = Date expressed Period Format in format Qualifier CCYYMMDD 55 2000D DMG02 Date Time Date of Birth Period 55 2000D DMG03 Gender Code F,M F = Female M = Male 56 2100D NM1 Subscriber Name 56 2100D NM101 Entity Identifier IL IL = Insured or Subscriber Code TR3 Loop ID Page Reference Name Codes Length Expected Value # 56 2100D NM102 Entity Type 1 1 = Person Qualifier 57 2100D NM103 Name Last or last name Subscriber’s Organization Name 57 2100D NM104 Name First first name Subscriber’s 57 2100D NM108 Identification MI MI Code Qualifier 57 2100D NM109 Identification Subscriber Identifier Code 58 2200D TRN Claim Status Tracking Number 58 2200D TRN01 Trace Type Code 1 1 = Current Transaction Trace Numbers 58 2200D TRN02 Reference Claims status tracking number Identification
50 2100C NM102 Entity Type Qualifier 1,2 1= Person 2= Nonperson entity 50 2100C NM103 Name Last or Organization Name Provider Last or Name 50 2100C NM104 Name First Provider First Name Required when the value in NM102 = “1" 51 2100C NM108 Identification Code Qualifier XX XX = NPI 51 2100C NM109 Identification Code Provider Identifier Enter NPI 54 2000D DMG Subscriber Demographic Information 54 2000D DMG01 Date Time Period Format Qualifier D8 D8 = Date expressed in format CCYYMMDD 55 2000D DMG02 Date Time Period Date of Birth 55 2000D DMG03 Gender Code F,M F = Female M = Male 56 2100D NM1 Subscriber Name 56 2100D NM101 Entity Identifier Code IL IL = Insured or Subscriber TR3 Page # Loop ID Reference Name Codes Length Expected Value 56 2100D NM102 Entity Type Qualifier 1 1 = Person 57 2100D NM103 Name Last or Organization Name Subscriber’s last name 57 2100D NM104 Name First Subscriber’s first name 57 2100D NM108 Identification Code Qualifier MI MI 57 2100D NM109 Identification Code Subscriber Identifier 58 2200D TRN Claim Status Tracking Number 58 2200D TRN01 Trace Type Code 1 1 = Current Transaction Trace Numbers 58 2200D TRN02 Reference Identification Claims status tracking number
PHC_EDI_CORE_276_277_CG.docx