Recent Updates
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Updated on: Dec 07, 2022
Insurance Plan Name or Program Name
Populating the Other Insured's Plan Name or Program Name: If Box 11d is marked Yes, fields 9 and 9a-d will need to be completed. Loop 2320, Segment/Data Element SBR04
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Updated on: Dec 07, 2022
Reserved for NUCC Use
(Previously Other Insured's Date of Birth, Sex)
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Updated on: Dec 07, 2022
Other Insured's Policy or Group Number
Populating the other insured's policy or group number: If Box 11d is marked Yes, fields 9 and 9a-d will need to be completed. Loop 2320, Segment/Data Element SBR03
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Updated on: Dec 07, 2022
Other Insured's Name
Populating the Insured's Name: If Box 11d is marked Yes, fields 9 and 9a-d will need to be completed.
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Updated on: Dec 07, 2022
Insured's Address
Populating the Insured's information Loop 2010BA, Segment/Data Element N301, N302, N401, N402, N403
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Updated on: Dec 07, 2022
Patient Relation to Insured
Patient Relation to Insured Loop 2000B, Loop 2000C, Segment/Data Element SBR02, PAT01
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Updated on: Dec 07, 2022
Patient's Address
Patient's Address Loop 2010CA, Segment/Data Element N302, N401, N402, N403
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Updated on: Dec 07, 2022
Insured's Name
Populating the Insured's Name Loop 2010BA, Segment/Data Element NM103, NM104, NM105, NM107
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Updated on: Dec 07, 2022
Patient's Birth Date
Loop 2010CA or Loop 2010BA, Degment/Data Element DMG02, DMG03
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Updated on: Dec 07, 2022
Patient's Name
Loop 2010CA or Loop 2010BA, Segment/Data Element NM103, NM104, NM105, NM107