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PM1 - Payer Master File Segment

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 Segment
Seq# DataElement Description Must Implement Flags Cardinality Length C.LEN Vocabulary DataType
PM1
1 00368 Health Plan ID SHALL [1..1] CWE
2 00428 Insurance Company ID SHALL [1..*] CX
3 00429 Insurance Company Name [0..*] XON
4 00430 Insurance Company Address [0..*] XAD
5 00431 Insurance Co Contact Person [0..*] XPN
6 00432 Insurance Co Phone Number [0..*] XTN
7 00433 Group Number = [0..1] 12 ST
8 00434 Group Name [0..*] XON
9 00437 Plan Effective Date [0..1] DT
10 00438 Plan Expiration Date [0..1] DT
11 03454 Patient DOB Required [0..1] ID
12 03455 Patient Gender Required [0..1] ID
13 03456 Patient Relationship Required [0..1] ID
14 03457 Patient Signature Required [0..1] ID
15 03458 Diagnosis Required [0..1] ID
16 03459 Service Required [0..1] ID
17 03460 Patient Name Required [0..1] ID
18 03461 Patient Address Required [0..1] ID
19 03462 Subscribers Name Required [0..1] ID
20 03463 Workman's Comp Indicator [0..1] ID
21 03464 Bill Type Required [0..1] ID
22 03465 Commercial Carrier Name and Address Required [0..1] ID
23 03466 Policy Number Pattern [0..1] ST
24 03467 Group Number Pattern [0..1] ST

PM1-1: Health Plan ID (CWE) 00368

(Definition from FT1.14 in Ch. 6)

Definition: This field contains the identifier of the primary insurance plan with which this transaction should be associated. Refer to User-defined Table 0072 - Insurance Plan ID in Chapter 2C, Code Tables, for suggested values.

(Definition from IN1.2 in Ch. 6)

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 Delete Indication values in each subsequent element. If the respective systems can support it, a Delete Indication value can be sent in the plan field.

The assigning authority for IN1-2, Health Plan ID is assumed to be the Entity named in IN1-3, Insurance Company ID.

(Definition from PM1.1 in Ch. 8)

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.

PM1-2: Insurance Company ID (CX) 00428

(Definition from IN1.3 in Ch. 6)

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.

(Definition from PM1.2 in Ch. 8)

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.

PM1-3: Insurance Company Name (XON) 00429

(Definition from IN1.4 in Ch. 6)

Definition: This field contains the name of the insurance company. Multiple names for the same insurance company may be sent in this field. Specification of meaning based on sequence is deprecated.

(Definition from PM1.3 in Ch. 8)

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

PM1-4: Insurance Company Address (XAD) 00430

(Definition from IN1.5 in Ch. 6)

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.

(Definition from PM1.4 in Ch. 8)

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.

PM1-5: Insurance Co Contact Person (XPN) 00431

(Definition from IN1.6 in Ch. 6)

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.

(Definition from PM1.5 in Ch. 8)

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.

PM1-6: Insurance Co Phone Number (XTN) 00432

(Definition from IN1.7 in Ch. 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.

(Definition from PM1.6 in Ch. 8)

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.

PM1-7: Group Number (ST) 00433

(Definition from IN1.8 in Ch. 6)

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

(Definition from PM1.7 in Ch. 8)

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

PM1-8: Group Name (XON) 00434

(Definition from IN1.9 in Ch. 6)

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

(Definition from PM1.8 in Ch. 8)

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

PM1-9: Plan Effective Date (DT) 00437

(Definition from IN1.12 in Ch. 6)

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

(Definition from PM1.9 in Ch. 8)

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

PM1-10: Plan Expiration Date (DT) 00438

(Definition from IN1.13 in Ch. 6)

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

(Definition from PM1.10 in Ch. 8)

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

PM1-11: Patient DOB Required (ID) 03454

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.

PM1-12: Patient Gender Required (ID) 03455

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.

PM1-13: Patient Relationship Required (ID) 03456

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.

PM1-14: Patient Signature Required (ID) 03457

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.

PM1-15: Diagnosis Required (ID) 03458

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.

PM1-16: Service Required (ID) 03459

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.

PM1-17: Patient Name Required (ID) 03460

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.

PM1-18: Patient Address Required (ID) 03461

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.

PM1-19: Subscribers Name Required (ID) 03462

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.

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

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.

PM1-21: Bill Type Required (ID) 03464

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.

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

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.

PM1-23: Policy Number Pattern (ST) 03466

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

PM1-24: Group Number Pattern (ST) 03467

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