Page # Id Reference Name Codes Length Notes/Comments 142 2300 HD05 Coverage Level Code For 2 Tier: 3/3 The preferred values are based on EMP Employee Only (S) the group contract. – FAM Family (F) – For 3 Tier: EMP Employee Only (S) – E1D Employee and One Dependent (Child) (D) – ESP Employee and Spouse (D) – E6D Employee and Two or More Dependents (M) – For 4 Tier: EMP Employee Only (S) – ECH Employee and Children (K) – ESP Employee and Spouse (P) – FAM Family (F) – For Composite: FAM Composite (T) – 143 2300 DTP01 Date/Time Qualifier 303 Maintenance Effective (Change Date) 3/3 Required when enrolling a member – 348 Benefit Begin (Effective Date) or when there is a change to the – 349 Benefit End (Termination Date/Last Day of dates. – Coverage) 144 2300 DTP03 Date Time Period 1/35 Coverage Period 146 2300 REF01 Reference Identification 1L Group Number 2/3 This should only be used for groups – Qualifier with both Dental and Vision Groups with only Dental or Only vision should send in the 2000 loop. 147 2300 REF02 Reference Identification 1/50 The 18 digit Group Number assigned by Delta Dental 164 2320 COB01 Payer Responsibility P Primary 1/1 Provide if available – Sequence Number Code S Secondary – T Tertiary – 164 2320 COB02 Reference Identification 1/50 Insured Group or Policy Number 164 2320 COB03 Coordination of Benefits 1 Coordination of Benefits 1/1 – Code 6 No Coordination Of Benefits –
Page # Id Reference Name Codes Length Notes/Comments 142 2300 HD05 Coverage Level Code For 2 Tier: EMP – Employee Only (S) FAM – Family (F) For 3 Tier: EMP – Employee Only (S) E1D – Employee and One Dependent (Child) (D) ESP – Employee and Spouse (D) E6D – Employee and Two or More Dependents (M) For 4 Tier: EMP – Employee Only (S) ECH – Employee and Children (K) ESP – Employee and Spouse (P) FAM – Family (F) For Composite: FAM – Composite (T) 3/3 The preferred values are based on the group contract. 143 2300 DTP01 Date/Time Qualifier 303 – Maintenance Effective (Change Date) 348 – Benefit Begin (Effective Date) 349 – Benefit End (Termination Date/Last Day of Coverage) 3/3 Required when enrolling a member or when there is a change to the dates. 144 2300 DTP03 Date Time Period 1/35 Coverage Period 146 2300 REF01 Reference Identification Qualifier 1L – Group Number 2/3 This should only be used for groups with both Dental and Vision Groups with only Dental or Only vision should send in the 2000 loop. 147 2300 REF02 Reference Identification 1/50 The 18 digit Group Number assigned by Delta Dental 164 2320 COB01 Payer Responsibility Sequence Number Code P – Primary S – Secondary T – Tertiary 1/1 Provide if available 164 2320 COB02 Reference Identification 1/50 Insured Group or Policy Number 164 2320 COB03 Coordination of Benefits Code 1 – Coordination of Benefits 6 – No Coordination Of Benefits 1/1
5010_-_834_companion_Guide_Delta_Dental_Arizona.docx