Loops and Segments Table – Loop 2320 – Other Subscriber Information
Coordination of Benefits (COB) Payer Paid Amount and Allowed Amount.
Usage : Required
Element : AMT01
Value : D
Comment : Code to identify the primary paid amount.
Usage : Required
Element : AMT02
Value : Nil
Comment : Total amount paid by the primary payer.
Usage : Required
Element : AMT01
Value : B6
Comment : Code to identify the primary allowed amount.
Usage : Required
Element : AMT02
Value : Nil
Comment : Total amount allowed by the primary payer.
Subscriber Demographic Information.
Usage : Required
Element : DMG01
Value : D8
Comment : Code indicating the format of the date.
Usage : Required
Element : DMG02
Value : Nil
Comment : Date of birth (CCYYMMDD).
Usage : Required
Element : DMG03
Value :
F = Female
M = Male
U= Unknown
Comment : Code indicating the sex of the individual.
Other Insurance Coverage Information
Usage : Required
Element : OI03
Value :
N = No
Y = Yes
Comment : A “Y” value indicates insured or authorized person authorizes benefits to be assigned to the provider; an “N” value indicates benefits have not been assigned to the provider.
Usage : Situational
Element : OI04
Value :
B = Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file
C = Signed CMS Claim Form on file
M = Signed signature authorization form for CMS Claim Form block 13 on file
P = Signature generated by provider because the beneficiary was not physically present for services
S = Signed signature authorization form for CMS Claim Form block 12 on file
Comment : Indicates how the beneficiary or subscriber authorization signature was obtained and how it is being retained by the provider.
Usage : Required
Element : OI06
Value :
A = Appropriate Release of Information on File at Health Care Service Provider or at Utilization Review Organization
I= Informed Consent to Release Medical Information for Conditions or Diagnoses Regulated by Federal Statues
M = The Provider has Limited or Restricted Ability to Release Data Related to a Claim
N= No, Provider is Not Allowed to Release Data
O = On file at Payer or at Plan Sponsor
Y = Yes, Provider has a Signed Statement Permitting Release of Medical Billing Data Related to a Claim
Comment : Code indicating if the provider has on file a signed statement by the beneficiary authorizing the release of medical data to other organizations.