IDF Request

Eligibility fields for IDV version 1.1

Record ID: IMELI11

Field #Field NameFormatMinMaxReq'dComment
1Record IDAN77Y"IMELI11."
2PayerIDQualiferAN12CIf Payer ID is populated and Payer ID Qualifier is NULL, Payer ID Mapping will be triggered. See Appendix - D.
3PayerIDAN180YNote: InstaMed Payer IDs are available in InstaMed Online under User Guide InstaMed Payer List or by using Payer List Search in EDI Enrollment.
4PayerNameAN135YAlthough required, payer naming convention does not impact flow of transaction; however, the payer name will determine reporting roll-ups within InstaMed Online.
5SubscriberIDAN280OMI – Policy #, 6P – Group #, SY – Social Security Number.
6SubscriberLastNameAN135C
7SubscriberFirstNameAN125C
8SubscriberMiddleNameAN125O
9SubscriberPrefixAN1O
10SubscriberSuffixAN110O
11SubscriberDateOfBirthDT135C
12AsOfDateDT135CIf AsOfDate and FromDate & ToDate are not populated, date is set to system date.
13PatientLastNameAN135C
14PatientFirstNameAN125C
15PatientMiddleNameAN125O
16PatientPrefixAN110O
17PatientSuffixAN1O
18PatientDateOfBirthDT135C
19PatientRelationshipAN135O01 – Spouse, 18 – Self, 19 – Child, 34 – Other Adult.
20PatientGenderAN11CF, M, U.
21TraceNumberAN130YShould be unique to ensure accurate response mapping.
22ProviderIDQualifierAN2ORecommended – XX – NPI; Otherwise, SV – Provider ID, FI – Tax ID.
23ProviderIDAN180ORecommended – Group NPI.
24ProviderLastNameAN135O
25ProviderFirstNameAN125O
26ProviderMiddleNameAN125O
27GroupIDAN130ORecommended – "[DEFAULT]" if no group ID applies.
28MemberSSNAN130CDependent on Payer Search Criteria.
29MemberGroupNumberAN130O
30ProviderAddress1AN155C
31ProviderAddress2AN155C
32ProviderCityAN230CRequired if Provider State or Zip are included.
33ProviderStateAN22CRequired if Provider City or Zip are included.
34ProviderZipAN315CRequired if Provider City or State are included.
35ProviderID2QualifierAN2OProviderID2Qualifier is required when ProviderID2 is populated.
36ProviderID2AN180O
37SubscriberID2QualifierAN2OSubscriberID2Qualifier when SubscriberID2 is populated.
38SubscriberID2AN280O
39PatientAccountNumberAN280O
40PatientID1QualifierAN2OPatientID1Qualifier when PatientID1 is populated.
41PatientID1AN280O
42PatientID2QualifierAN2OPatientID2Qualifier when PatientID2 is populated.
43PatientID2AN280O
44FromDateDT135OField is used when AsOfDate is not populated.
45ToDateDT135OField is used when AsOfDate is not populated.
46ServiceTypeCodeAN22ODefault value is 30 if field is not populated.
47Additional Field 1Not usedOReserved for future use.
48Additional Field 2Not usedOReserved for future use.
49Additional Field 3Not usedOReserved for future use.
50Additional Field 4Not usedOReserved for future use.
51Additional Field 5Not usedOReserved for future use.
52Additional Field 6Not usedOReserved for future use.
53Additional Field 7Not usedOReserved for future use.
54Additional Field 8Not usedOReserved for future use.
55Additional Field 9Not usedOReserved for future use.
56Additional Field 10Not usedOReserved for future use.