| EligibilityBenefitInfo | AN | 1 | 2 | |
| CoverageLevel | AN | 3 | 3 | |
| TraceNumber | AN | 1 | 30 | |
| RequestValidationIndicator | AN | 1 | 10 | |
| RequestValidationRejectReasonCode | AN | 1 | 10 | |
| RequestValidationRejectDescription | AN | 1 | 80 | |
| InformationSourceName | AN | 1 | 80 | |
| InformationSourceID | AN | 1 | 80 | |
| InformationSourceIDQualifier | AN | 1 | 10 | |
| SubscriberLastName | AN | 1 | 35 | |
| SubscriberFirstName | AN | 1 | 25 | |
| SubscriberMiddleName | AN | 1 | 25 | |
| SubscriberBirthDate | DATE | 1 | 10 | |
| RelationshipCode | AN | 1 | 10 | |
| RelationshipDescription | AN | 1 | 80 | |
| SubscriberID1 | AN | 1 | 80 | |
| SubscriberIDQualifier1 | AN | 1 | 10 | |
| SubscriberID2 | AN | 1 | 80 | |
| SubscriberIDQualifier2 | AN | 1 | 10 | |
| SubscriberID3 | AN | 1 | 80 | |
| SubscriberIDQualifier3 | AN | 1 | 10 | |
| SubscriberDates | DT | | | |
| SubscriberEligibilityBenefits | AN | | | |
| PatientLastName | AN | 1 | 35 | |
| PatientFirstName | AN | 1 | 25 | |
| PatientMiddleName | AN | 1 | 25 | |
| PatientBirthDate | DATE | 1 | 10 | |
| PatientGender | AN | 1 | 1 | |
| PatientID1 | AN | 1 | 80 | |
| PatientIDQualifier1 | AN | 1 | 10 | |
| PatientID2 | AN | 1 | 80 | |
| PatientIDQualifier2 | AN | 1 | 10 | |
| PatientDates | DT | | | |
| PatientEligibilityBenefits | AN | | | |
| ResponseDetailText | AN | 1 | | |
| PlanCoverage | AN | 1 | 80 | |
| PlanCoverageNote | AN | 1 | 255 | |
| PlanNumber | AN | 1 | 255 | |
| OtherPayer | AN | 1 | 80 | |
| OtherPayerPlanNumber | AN | 1 | 80 | |
| PrimaryCareProvider | AN | 1 | 255 | |
| EligibilityDate | DT | 1 | 10 | |
| OfficeVisitCopay | DEC | 1 | 15 | |
| PatientPrefix | AN | 1 | 25 | |
| PatientSuffix | AN | 1 | 25 | |
| SubscriberGroupNumber | AN | 1 | 80 | |
| PatientDateOfBirth | DATE | 1 | 10 | |
| PatientRelationship | AN | 1 | 10 | |
| SubscriberPrefix | AN | 1 | 10 | |
| SubscriberSuffix | AN | 1 | 10 | |
| PatientAddress | Address Data Table | | | Street1, Street2, Street3, City, State, Zip, Country, Company. |
| RejectCode | AN | 1 | 10 | |
| RejectReason | AN | 1 | 80 | |
| EligibilityExpiration | DATE | 1 | 10 | |
