| seq | type | opt | description | value |
|---|---|---|---|---|
| 1 | O | Insurance Rank | ’1’ - Primary ‘2’ - Secondary | |
| 2 | O | Insurance company ID | Electronic Payer ID if available, otherwise practice-specific insurance company ID assigned by Elation | |
| 3 | O | Insurance company ID | Electronic Payer ID if available, otherwise practice-specific insurance company ID assigned by Elation | |
| 4 | O | Insurance Company Name | ||
| 5.1 | O | Insurance Company Address (Line 1) | ||
| 5.2 | O | Insurance Company Address (Line 2) | ||
| 5.3 | O | Insurance Company City | ||
| 5.4 | O | Insurance Company State | ||
| 5.5 | O | Insurance Company Zip Code | ||
| 8 | O | Insurance Group Number | ||
| 9 | O | Insurance Plan Name | ||
| 16.1 | O | Last Name of Insured | ||
| 16.2 | O | First Name of Insured | ||
| 17 | O | Insured’s Relationship to Patient | ’1’ - Self ‘2’ - Spouse ‘3’ - Other | |
| 19.1 | O | Insured’s Street Address | ||
| 19.3 | O | Insured’s City | ||
| 19.4 | O | Insured’s State | ||
| 19.5 | O | Insured’s Zip | ||
| 36 | O | Policy Number |
IN1|1|811258067747182|811258067747182|DC MEDICARE|P.O. BOX 890396^^CAMP HILL^PA^170890398|||111111|PPO Plan||||||||1|||||||||||||||||||AABB1122
IN1|2|60054|60054|AETNA|1800 ELM ST^^CARMEL^IN^460821935||||||||||||1|||||||||||||||||||CCDD334455