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18.8.121 PM1 - Payer Master File Segment (8.8.17)

The Technical Steward for the PM1 segment is Orders and Observations.

The PM1 segment contains per insurance company (payer) the policies specific to their organization. Trailing this segment in the message structure are either the Limited Coverage Policy or the Approved Coverage Policy. If an insurance company is listed they have limited coverage. Note, the first 10 fields come directly from the IN1 segment.

HL7 Attribute Table - PM1 - Payer Master File

Base Framework
Seq#Data ElementDescriptionFlagsImplementCardinalityLengthC.LENVocabularyData Type
PM1
100368Health Plan ID  SHOULD[1..1] InsurancePlanId (CD)
CWE

Coded with Exceptions

200428Insurance Company ID SHOULD[1..*] 
CX

Extended Composite ID with Check Digit

300429Insurance Company Name MAY[0..*] 
XON

Extended Composite Name and Identification Number for Organizations

400430Insurance Company Address MAY[0..*] 
XAD

Extended Address

500431Insurance Co Contact Person MAY[0..*] 
XPN

Extended Person Name

600432Insurance Co Phone Number MAY[0..*] 
XTN

Extended Telecommunication Number

700433Group Number
=

Truncation not allowed!

MAY[0..1] 12
ST

String Data

800434Group Name MAY[0..*] 
XON

Extended Composite Name and Identification Number for Organizations

900437Plan Effective Date MAY[0..1] 
DT

Date

1000438Plan Expiration Date MAY[0..1] 
DT

Date

1103454Patient DOB Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1203455Patient Gender Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1303456Patient Relationship Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1403457Patient Signature Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1503458Diagnosis Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1603459Service Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1703460Patient Name Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1803461Patient Address Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1903462Subscribers Name Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

2003463Workman's Comp Indicator MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

2103464Bill Type Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

2203465Commercial Carrier Name and Address Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

2303466Policy Number Pattern MAY[0..1] 
ST

String Data

2403467Group Number Pattern MAY[0..1] 
ST

String Data

Seq#Data ElementDescriptionFlagsImplementCardinalityLengthC.LENVocabularyData Type
PM1
100368Health Plan ID  SHALL[1..1] InsurancePlanId (CD)
CWE

Coded with Exceptions

200428Insurance Company ID SHALL[1..*] 
CX

Extended Composite ID with Check Digit

300429Insurance Company Name MAY[0..*] 
XON

Extended Composite Name and Identification Number for Organizations

400430Insurance Company Address MAY[0..*] 
XAD

Extended Address

500431Insurance Co Contact Person MAY[0..*] 
XPN

Extended Person Name

600432Insurance Co Phone Number MAY[0..*] 
XTN

Extended Telecommunication Number

700433Group Number
=

Truncation not allowed!

MAY[0..1] 12
ST

String Data

800434Group Name MAY[0..*] 
XON

Extended Composite Name and Identification Number for Organizations

900437Plan Effective Date MAY[0..1] 
DT

Date

1000438Plan Expiration Date MAY[0..1] 
DT

Date

1103454Patient DOB Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1203455Patient Gender Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1303456Patient Relationship Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1403457Patient Signature Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1503458Diagnosis Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1603459Service Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1703460Patient Name Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1803461Patient Address Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

1903462Subscribers Name Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

2003463Workman's Comp Indicator MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

2103464Bill Type Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

2203465Commercial Carrier Name and Address Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

2303466Policy Number Pattern MAY[0..1] 
ST

String Data

2403467Group Number Pattern MAY[0..1] 
ST

String Data

Base FrameworkBase Standard Profile
Seq#Data ElementDescriptionFlagsImplementCardinalityLengthC.LENVocabularyData TypeImplementVocabulary
PM1 
100368Health Plan ID  SHOULD[1..1] InsurancePlanId (CD)
CWE

Coded with Exceptions

SHALL
200428Insurance Company ID SHOULD[1..*] 
CX

Extended Composite ID with Check Digit

SHALL
300429Insurance Company Name MAY[0..*] 
XON

Extended Composite Name and Identification Number for Organizations

MAY
400430Insurance Company Address MAY[0..*] 
XAD

Extended Address

MAY
500431Insurance Co Contact Person MAY[0..*] 
XPN

Extended Person Name

MAY
600432Insurance Co Phone Number MAY[0..*] 
XTN

Extended Telecommunication Number

MAY
700433Group Number
=

Truncation not allowed!

MAY[0..1] 12
ST

String Data

MAY
800434Group Name MAY[0..*] 
XON

Extended Composite Name and Identification Number for Organizations

MAY
900437Plan Effective Date MAY[0..1] 
DT

Date

MAY
1000438Plan Expiration Date MAY[0..1] 
DT

Date

MAY
1103454Patient DOB Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
1203455Patient Gender Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
1303456Patient Relationship Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
1403457Patient Signature Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
1503458Diagnosis Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
1603459Service Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
1703460Patient Name Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
1803461Patient Address Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
1903462Subscribers Name Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
2003463Workman's Comp Indicator MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
2103464Bill Type Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
2203465Commercial Carrier Name and Address Required MAY[0..1] univ: Yes/noIndicator (CD) hl7VS-yes-no-Indicator (VS) expandedYes-NoIndicator (CS)
ID

Coded Value for HL7 Defined Tables

MAY 
2303466Policy Number Pattern MAY[0..1] 
ST

String Data

MAY
2403467Group Number Pattern MAY[0..1] 
ST

String Data

MAY
Base Framework Base Standard Profile
Seq# Data Element Description Flags Optionality Repetition Length C.LEN Table Data Type Optionality Table
PM1  
1 00368 Health Plan ID   O     (0072)
CWE

Coded with Exceptions

R  
2 00428 Insurance Company ID   O Y    
CX

Extended Composite ID with Check Digit

R  
3 00429 Insurance Company Name   O Y    
XON

Extended Composite Name and Identification Number for Organizations

   
4 00430 Insurance Company Address   O Y    
XAD

Extended Address

   
5 00431 Insurance Co Contact Person   O Y    
XPN

Extended Person Name

   
6 00432 Insurance Co Phone Number   O Y    
XTN

Extended Telecommunication Number

   
7 00433 Group Number   O     12=  
ST

String Data

   
8 00434 Group Name   O Y    
XON

Extended Composite Name and Identification Number for Organizations

   
9 00437 Plan Effective Date   O      
DT

Date

   
10 00438 Plan Expiration Date   O      
DT

Date

   
11 03454 Patient DOB Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
12 03455 Patient Gender Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
13 03456 Patient Relationship Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
14 03457 Patient Signature Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
15 03458 Diagnosis Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
16 03459 Service Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
17 03460 Patient Name Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
18 03461 Patient Address Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
19 03462 Subscribers Name Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
20 03463 Workman's Comp Indicator   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
21 03464 Bill Type Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
22 03465 Commercial Carrier Name and Address Required   O      
ID

Coded Value for HL7 Defined Tables

  (0136)
23 03466 Policy Number Pattern   O      
ST

String Data

   
24 03467 Group Number Pattern   O      
ST

String Data

   
Seq# Data Element Description Optionality Repetition Length C.LEN Table Data Type
PM1
1 00368 Health Plan ID R     (0072)
CWE

Coded with Exceptions

2 00428 Insurance Company ID R Y    
CX

Extended Composite ID with Check Digit

3 00429 Insurance Company Name O Y    
XON

Extended Composite Name and Identification Number for Organizations

4 00430 Insurance Company Address O Y    
XAD

Extended Address

5 00431 Insurance Co Contact Person O Y    
XPN

Extended Person Name

6 00432 Insurance Co Phone Number O Y    
XTN

Extended Telecommunication Number

7 00433 Group Number O     12=  
ST

String Data

8 00434 Group Name O Y    
XON

Extended Composite Name and Identification Number for Organizations

9 00437 Plan Effective Date O      
DT

Date

10 00438 Plan Expiration Date O      
DT

Date

11 03454 Patient DOB Required O     (0136)
ID

Coded Value for HL7 Defined Tables

12 03455 Patient Gender Required O     (0136)
ID

Coded Value for HL7 Defined Tables

13 03456 Patient Relationship Required O     (0136)
ID

Coded Value for HL7 Defined Tables

14 03457 Patient Signature Required O     (0136)
ID

Coded Value for HL7 Defined Tables

15 03458 Diagnosis Required O     (0136)
ID

Coded Value for HL7 Defined Tables

16 03459 Service Required O     (0136)
ID

Coded Value for HL7 Defined Tables

17 03460 Patient Name Required O     (0136)
ID

Coded Value for HL7 Defined Tables

18 03461 Patient Address Required O     (0136)
ID

Coded Value for HL7 Defined Tables

19 03462 Subscribers Name Required O     (0136)
ID

Coded Value for HL7 Defined Tables

20 03463 Workman's Comp Indicator O     (0136)
ID

Coded Value for HL7 Defined Tables

21 03464 Bill Type Required O     (0136)
ID

Coded Value for HL7 Defined Tables

22 03465 Commercial Carrier Name and Address Required O     (0136)
ID

Coded Value for HL7 Defined Tables

23 03466 Policy Number Pattern O      
ST

String Data

24 03467 Group Number Pattern O      
ST

String Data

18.8.121.1 PMI Field Definitions (8.8.17.0)

18.8.121.2 PM1-1 Health Plan ID (CWE) 00368 (8.8.17.1)

Definition: This field contains a unique identifier for the insurance plan. Refer to User-defined Table 0072 - Insurance Plan ID in Chapter 2C, Code Tables, for suggested values. To eliminate a plan, the plan could be sent with null values in each subsequent element. If the respective systems can support it, a null value can be sent in the plan field.

The assigning authority for PM1-1, Health Plan ID is assumed to be the Entity named in PM1-2, Insurance Company ID.

18.8.121.3 PM1-2 Insurance Company ID (CX) 00428 (8.8.17.2)

Definition: This field contains unique identifiers for the insurance company. The assigning authority and identifier type code are strongly recommended for all CX data types.

18.8.121.4 PM1-3 Insurance Company Name (XON) 00429 (8.8.17.3)

Definition: This field contains the name of the insurance company. Multiple names for the same insurance company may be sent in this field.

18.8.121.5 PM1-4 Insurance Company Address (XAD) 00430 (8.8.17.4)

Definition: This field contains the address of the insurance company. Multiple addresses for the same insurance company may be sent in this field. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

18.8.121.6 PM1-5 Insurance Co Contact Person (XPN) 00431 (8.8.17.5)

Definition: This field contains the name of the person who should be contacted at the insurance company. Multiple names for the same contact person may be sent in this field. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

18.8.121.7 PM1-6 Insurance Co Phone Number (XTN) 00432 (8.8.17.6)

Definition: This field contains the phone number of the insurance company. Multiple phone numbers for the same insurance company may be sent in this field. As of v 2.7, no assumptions can be made based on position or sequence. Specification of meaning based on sequence is deprecated.

18.8.121.8 PM1-7 Group Number (ST) 00433 (8.8.17.7)

Definition: This field contains the group number of the insured's insurance.

18.8.121.9 PM1-8 Group Name (XON) 00434 (8.8.17.8)

Definition: This field contains the group name of the insured's insurance.

18.8.121.10 PM1-9 Plan Effective Date (DT) 00437 (8.8.17.9)

Definition: This field contains the date that the insurance goes into effect.

18.8.121.11 PM1-10 Plan Expiration Date (DT) 00438 (8.8.17.10)

Definition: This field indicates the last date of service that the insurance will cover or be responsible for.

18.8.121.12 PM1-11 Patient DOB Required (ID) 03454 (8.8.17.11)

Definition: This field indicates whether this insurance carrier requires the patient DOB. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.13 PM1-12 Patient Gender Required (ID) 03455 (8.8.17.12)

Definition: This field indicates whether this insurance carrier requires the patient Gender. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.14 PM1-13 Patient Relationship Required (ID) 03456 (8.8.17.13)

Definition: This field indicates whether this insurance carrier requires the patient’s Relationship to insured. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.15 PM1-14 Patient Signature Required (ID) 03457 (8.8.17.14)

Definition: This field indicates whether this insurance carrier requires the patient Signature. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.16 PM1-15 Diagnosis Required (ID) 03458 (8.8.17.15)

Definition: This field indicates whether this insurance carrier requires a diagnosis. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.17 PM1-16 Service Required (ID) 03459 (8.8.17.16)

Definition: This field indicates whether this insurance carrier requires services to be listed. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.18 PM1-17 Patient Name Required (ID) 03460 (8.8.17.17)

Definition: This field indicates whether this insurance carrier requires a patient name on all requests. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.19 PM1-18 Patient Address Required (ID) 03461 (8.8.17.18)

Definition: This field indicates whether this insurance carrier requires a patient address on all requests. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.20 PM1-19 Subscribers Name Required (ID) 03462 (8.8.17.19)

Definition: This field indicates whether this insurance carrier requires subscribers name on all requests. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.21 PM1-20 Workman's Comp Indicator (ID) 03463 (8.8.17.20)

Definition: This field indicates whether this insurance carrier requires workman compensation to be identified. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.22 PM1-21 Bill Type Required (ID) 03464 (8.8.17.21)

Definition: This field indicates whether this insurance carrier requires subscribers bill type. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.23 PM1-22 Commercial Carrier Name and Address Required (ID) 03465 (8.8.17.22)

Definition: This field indicates whether this insurance carrier requires commerical carrier name and address. Refer to HL7 Table 0136 - Yes/no Indicator in Chapter 2C, Code Tables, for valid values.

18.8.121.24 PM1-23 Policy Number Pattern (ST) 03466 (8.8.17.23)

Definition: This field contains the policy number pattern. This describes what the policy number should look like. There will likely be multiple patterns to identify the Policy number. It is recommended that Edit patterns are a sequence of the characters ‘A’ for alpha, ‘N’ for numeric, ‘X’ for alphanumeric, ‘B’ for blank, and ‘*’ for wildcard. Digits positionally refer to the two-character edit pattern list in the corresponding list field.

Edit pattern lists are a sequence characters to respresent the format and size of the Policy Number.

Example 1: The policy number has 3 numbers, 1 blank, 5 numbers and it would be defined in a Pattern as NNNBNNNNN

Example 2: The policy number has 2 numerics, 2 characters for state, 1 blank 5 Alphanumerics and would be represented as NNCCBXXXXX

18.8.121.25 PM1-24 Group Number Pattern (ST) 03467 (8.8.17.24)

Definition: This field contains the Group number pattern. This describes what the group number should look like. There will likely be multiple patterns to identify the group number. It is recommended that Edit patterns are a sequence of the characters ‘A’ for alpha, ‘N’ for numeric, ‘X’ for alphanumeric, ‘B’ for blank, and ‘*’ for wildcard. Digits positionally refer to the two-character edit pattern list in the corresponding list field.

Edit pattern lists are a sequence characters to respresent the format and size of the Group Number.

Example 1: The group number has 3 numbers, 1 blank, 5 numbers and it would be defined in a Pattern as NNNBNNNNN

Example 2: The group number has 2 numerics, 2 characters for state, 1 blank 5 Alphanumerics and would be represented as NNCCBXXXXX