IDF Request - InstaMed Developer Portal

Eligibility fields for IDV version 1.1

Record ID: IMELI11

Field #	Field Name	Format	Min	Max	Req'd	Comment
1	Record ID	AN	7	7	Y	"IMELI11."
2	PayerIDQualifer	AN	1	2	C	If Payer ID is populated and Payer ID Qualifier is NULL, Payer ID Mapping will be triggered. See Appendix - D.
3	PayerID	AN	1	80	Y	*Note*: InstaMed Payer IDs are available in InstaMed Online under User Guide → InstaMed Payer List or by using Payer List Search in EDI Enrollment.
4	PayerName	AN	1	35	Y	Although required, payer naming convention does not impact flow of transaction; however, the payer name will determine reporting roll-ups within InstaMed Online.
5	SubscriberID	AN	2	80	O	MI – Policy #, 6P – Group #, SY – Social Security Number.
6	SubscriberLastName	AN	1	35	C
7	SubscriberFirstName	AN	1	25	C
8	SubscriberMiddleName	AN	1	25	O
9	SubscriberPrefix	AN	1		O
10	SubscriberSuffix	AN	1	10	O
11	SubscriberDateOfBirth	DT	1	35	C
12	AsOfDate	DT	1	35	C	If AsOfDate and FromDate & ToDate are not populated, date is set to system date.
13	PatientLastName	AN	1	35	C
14	PatientFirstName	AN	1	25	C
15	PatientMiddleName	AN	1	25	O
16	PatientPrefix	AN	1	10	O
17	PatientSuffix	AN	1		O
18	PatientDateOfBirth	DT	1	35	C
19	PatientRelationship	AN	1	35	O	01 – Spouse, 18 – Self, 19 – Child, 34 – Other Adult.
20	PatientGender	AN	1	1	C	F, M, U.
21	TraceNumber	AN	1	30	Y	Should be unique to ensure accurate response mapping.
22	ProviderIDQualifier	AN		2	O	Recommended – XX – NPI; Otherwise, SV – Provider ID, FI – Tax ID.
23	ProviderID	AN	1	80	O	Recommended – Group NPI.
24	ProviderLastName	AN	1	35	O
25	ProviderFirstName	AN	1	25	O
26	ProviderMiddleName	AN	1	25	O
27	GroupID	AN	1	30	O	Recommended – "[DEFAULT]" if no group ID applies.
28	MemberSSN	AN	1	30	C	Dependent on Payer Search Criteria.
29	MemberGroupNumber	AN	1	30	O
30	ProviderAddress1	AN	1	55	C
31	ProviderAddress2	AN	1	55	C
32	ProviderCity	AN	2	30	C	Required if Provider State or Zip are included.
33	ProviderState	AN	2	2	C	Required if Provider City or Zip are included.
34	ProviderZip	AN	3	15	C	Required if Provider City or State are included.
35	ProviderID2Qualifier	AN		2	O	ProviderID2Qualifier is required when ProviderID2 is populated.
36	ProviderID2	AN	1	80	O
37	SubscriberID2Qualifier	AN		2	O	SubscriberID2Qualifier when SubscriberID2 is populated.
38	SubscriberID2	AN	2	80	O
39	PatientAccountNumber	AN	2	80	O
40	PatientID1Qualifier	AN		2	O	PatientID1Qualifier when PatientID1 is populated.
41	PatientID1	AN	2	80	O
42	PatientID2Qualifier	AN		2	O	PatientID2Qualifier when PatientID2 is populated.
43	PatientID2	AN	2	80	O
44	FromDate	DT	1	35	O	Field is used when AsOfDate is not populated.
45	ToDate	DT	1	35	O	Field is used when AsOfDate is not populated.
46	ServiceTypeCode	AN	2	2	O	Default value is 30 if field is not populated.
47	Additional Field 1	Not used			O	Reserved for future use.
48	Additional Field 2	Not used			O	Reserved for future use.
49	Additional Field 3	Not used			O	Reserved for future use.
50	Additional Field 4	Not used			O	Reserved for future use.
51	Additional Field 5	Not used			O	Reserved for future use.
52	Additional Field 6	Not used			O	Reserved for future use.
53	Additional Field 7	Not used			O	Reserved for future use.
54	Additional Field 8	Not used			O	Reserved for future use.
55	Additional Field 9	Not used			O	Reserved for future use.
56	Additional Field 10	Not used			O	Reserved for future use.

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