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.
| 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 | |||||
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
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.
Y DOB Required
N DOB Not Required
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.
Y Patient Gender Required
N Patient Gender Not Rquired
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.
Y Patient’s relationship to insured Required
N Patient’s relationship to insured Not Required
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.
Y Patient’s relationship to insured Required
N Patient’s relationship to insured Not Required
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.
Y Diagnosis Required
N Diagnosis Not Required
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.
Y Services Required
N Services Not Required
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.
Y Patient’s name Required
N Patient’s name Not Required
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.
Y Patient’s Address Required
N Patient’s Address Not Required
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.
Y Subscribers name Required
N Subscribers name Not Required
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.
Y Workman compensation idenfication Required
N Workman compensation idenfication Not Required
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.
Y Subscribers bill type Required
N Subscribers bill type Not Required
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.
Y Commerical carrier name and address Required
N Commerical carrier name and address Not Required
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
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
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