| 1 | ▶insureds_employee_id | CX | Optional | Yes | - |
| 1.1 | ├.id_number | ST | Optional | No | - |
| 1.2 | ├.identifier_check_digit | ST | Optional | No | - |
| 1.3 | ├.check_digit_scheme | ID | Optional | No | - |
| 1.4 | ├.assigning_authority | HD | Optional | No | - |
| 1.5 | ├.identifier_type_code | ID | Optional | No | - |
| 1.6 | ├.assigning_facility | HD | Optional | No | - |
| 1.7 | ├.effective_date | DT | Optional | No | - |
| 1.8 | ├.expiration_date | DT | Optional | No | - |
| 1.9 | ├.assigning_jurisdiction | CWE | Optional | No | - |
| 1.10 | ├.assigning_agency_or_department | CWE | Optional | No | - |
| 1.11 | ├.security_check | ST | Optional | No | - |
| 1.12 | └.security_check_scheme | ID | Optional | No | - |
| 2 | insureds_social_security_number | ST | Optional | No | - |
| 3 | ▶insureds_employers_name_and_id | XCN | Optional | Yes | - |
| 3.1 | ├.person_identifier | ST | Optional | No | - |
| 3.2 | ├.family_name | FN | Optional | No | - |
| 3.3 | ├.given_name | ST | Optional | No | - |
| 3.4 | ├.second_and_further_given_names_or_initials_thereof | ST | Optional | No | - |
| 3.5 | ├.suffix | ST | Optional | No | - |
| 3.6 | ├.prefix | ST | Optional | No | - |
| 3.7 | ├.degree | ST | Optional | No | - |
| 3.8 | ├.source_table | CWE | Optional | No | - |
| 3.9 | ├.assigning_authority | HD | Optional | No | - |
| 3.10 | ├.name_type_code | ID | Optional | No | - |
| 3.11 | ├.identifier_check_digit | ST | Optional | No | - |
| 3.12 | ├.check_digit_scheme | ID | Optional | No | - |
| 3.13 | ├.identifier_type_code | ID | Optional | No | - |
| 3.14 | ├.assigning_facility | HD | Optional | No | - |
| 3.15 | ├.name_representation_code | ID | Optional | No | - |
| 3.16 | ├.name_context | CWE | Optional | No | - |
| 3.17 | ├.name_validity_range | DR | Optional | No | - |
| 3.18 | ├.name_assembly_order | ID | Optional | No | - |
| 3.19 | ├.effective_date | DTM | Optional | No | - |
| 3.20 | ├.expiration_date | DTM | Optional | No | - |
| 3.21 | ├.professional_suffix | ST | Optional | No | - |
| 3.22 | ├.assigning_jurisdiction | CWE | Optional | No | - |
| 3.23 | ├.assigning_agency_or_department | CWE | Optional | No | - |
| 3.24 | ├.security_check | ST | Optional | No | - |
| 3.25 | └.security_check_scheme | ID | Optional | No | - |
| 4 | ▶employer_information_data | CWE | Optional | No | HL70139 |
| 4.1 | ├.identifier | ST | Optional | No | - |
| 4.2 | ├.text | ST | Optional | No | - |
| 4.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 4.4 | ├.alternate_identifier | ST | Optional | No | - |
| 4.5 | ├.alternate_text | ST | Optional | No | - |
| 4.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 4.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 4.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 4.9 | ├.original_text | ST | Optional | No | - |
| 4.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 4.11 | ├.second_alternate_text | ST | Optional | No | - |
| 4.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 4.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 4.14 | ├.coding_system_oid | ST | Optional | No | - |
| 4.15 | ├.value_set_oid | ST | Optional | No | - |
| 4.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 4.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 4.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 4.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 4.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 4.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 4.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 5 | ▶mail_claim_party | CWE | Optional | Yes | HL70137 |
| 5.1 | ├.identifier | ST | Optional | No | - |
| 5.2 | ├.text | ST | Optional | No | - |
| 5.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 5.4 | ├.alternate_identifier | ST | Optional | No | - |
| 5.5 | ├.alternate_text | ST | Optional | No | - |
| 5.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 5.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 5.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 5.9 | ├.original_text | ST | Optional | No | - |
| 5.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 5.11 | ├.second_alternate_text | ST | Optional | No | - |
| 5.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 5.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 5.14 | ├.coding_system_oid | ST | Optional | No | - |
| 5.15 | ├.value_set_oid | ST | Optional | No | - |
| 5.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 5.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 5.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 5.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 5.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 5.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 5.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 6 | medicare_health_ins_card_number | ST | Optional | No | - |
| 7 | ▶medicaid_case_name | XPN | Optional | Yes | - |
| 7.1 | ├.family_name | FN | Optional | No | - |
| 7.2 | ├.given_name | ST | Optional | No | - |
| 7.3 | ├.second_and_further_given_names_or_initials_thereof | ST | Optional | No | - |
| 7.4 | ├.suffix | ST | Optional | No | - |
| 7.5 | ├.prefix | ST | Optional | No | - |
| 7.6 | ├.degree | ST | Optional | No | - |
| 7.7 | ├.name_type_code | ID | Optional | No | - |
| 7.8 | ├.name_representation_code | ID | Optional | No | - |
| 7.9 | ├.name_context | CWE | Optional | No | - |
| 7.10 | ├.name_validity_range | DR | Optional | No | - |
| 7.11 | ├.name_assembly_order | ID | Optional | No | - |
| 7.12 | ├.effective_date | DTM | Optional | No | - |
| 7.13 | ├.expiration_date | DTM | Optional | No | - |
| 7.14 | ├.professional_suffix | ST | Optional | No | - |
| 7.15 | └.called_by | ST | Optional | No | - |
| 8 | medicaid_case_number | ST | Optional | No | - |
| 9 | ▶military_sponsor_name | XPN | Optional | Yes | - |
| 9.1 | ├.family_name | FN | Optional | No | - |
| 9.2 | ├.given_name | ST | Optional | No | - |
| 9.3 | ├.second_and_further_given_names_or_initials_thereof | ST | Optional | No | - |
| 9.4 | ├.suffix | ST | Optional | No | - |
| 9.5 | ├.prefix | ST | Optional | No | - |
| 9.6 | ├.degree | ST | Optional | No | - |
| 9.7 | ├.name_type_code | ID | Optional | No | - |
| 9.8 | ├.name_representation_code | ID | Optional | No | - |
| 9.9 | ├.name_context | CWE | Optional | No | - |
| 9.10 | ├.name_validity_range | DR | Optional | No | - |
| 9.11 | ├.name_assembly_order | ID | Optional | No | - |
| 9.12 | ├.effective_date | DTM | Optional | No | - |
| 9.13 | ├.expiration_date | DTM | Optional | No | - |
| 9.14 | ├.professional_suffix | ST | Optional | No | - |
| 9.15 | └.called_by | ST | Optional | No | - |
| 10 | military_id_number | ST | Optional | No | - |
| 11 | ▶dependent_of_military_recipient | CWE | Optional | No | HL70342 |
| 11.1 | ├.identifier | ST | Optional | No | - |
| 11.2 | ├.text | ST | Optional | No | - |
| 11.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 11.4 | ├.alternate_identifier | ST | Optional | No | - |
| 11.5 | ├.alternate_text | ST | Optional | No | - |
| 11.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 11.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 11.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 11.9 | ├.original_text | ST | Optional | No | - |
| 11.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 11.11 | ├.second_alternate_text | ST | Optional | No | - |
| 11.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 11.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 11.14 | ├.coding_system_oid | ST | Optional | No | - |
| 11.15 | ├.value_set_oid | ST | Optional | No | - |
| 11.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 11.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 11.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 11.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 11.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 11.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 11.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 12 | military_organization | ST | Optional | No | - |
| 13 | military_station | ST | Optional | No | - |
| 14 | ▶military_service | CWE | Optional | No | HL70140 |
| 14.1 | ├.identifier | ST | Optional | No | - |
| 14.2 | ├.text | ST | Optional | No | - |
| 14.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 14.4 | ├.alternate_identifier | ST | Optional | No | - |
| 14.5 | ├.alternate_text | ST | Optional | No | - |
| 14.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 14.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 14.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 14.9 | ├.original_text | ST | Optional | No | - |
| 14.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 14.11 | ├.second_alternate_text | ST | Optional | No | - |
| 14.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 14.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 14.14 | ├.coding_system_oid | ST | Optional | No | - |
| 14.15 | ├.value_set_oid | ST | Optional | No | - |
| 14.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 14.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 14.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 14.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 14.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 14.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 14.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 15 | ▶military_rank_grade | CWE | Optional | No | HL70141 |
| 15.1 | ├.identifier | ST | Optional | No | - |
| 15.2 | ├.text | ST | Optional | No | - |
| 15.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 15.4 | ├.alternate_identifier | ST | Optional | No | - |
| 15.5 | ├.alternate_text | ST | Optional | No | - |
| 15.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 15.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 15.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 15.9 | ├.original_text | ST | Optional | No | - |
| 15.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 15.11 | ├.second_alternate_text | ST | Optional | No | - |
| 15.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 15.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 15.14 | ├.coding_system_oid | ST | Optional | No | - |
| 15.15 | ├.value_set_oid | ST | Optional | No | - |
| 15.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 15.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 15.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 15.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 15.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 15.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 15.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 16 | ▶military_status | CWE | Optional | No | HL70142 |
| 16.1 | ├.identifier | ST | Optional | No | - |
| 16.2 | ├.text | ST | Optional | No | - |
| 16.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 16.4 | ├.alternate_identifier | ST | Optional | No | - |
| 16.5 | ├.alternate_text | ST | Optional | No | - |
| 16.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 16.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 16.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 16.9 | ├.original_text | ST | Optional | No | - |
| 16.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 16.11 | ├.second_alternate_text | ST | Optional | No | - |
| 16.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 16.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 16.14 | ├.coding_system_oid | ST | Optional | No | - |
| 16.15 | ├.value_set_oid | ST | Optional | No | - |
| 16.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 16.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 16.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 16.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 16.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 16.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 16.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 17 | military_retire_date | DT | Optional | No | - |
| 18 | military_non_avail_cert_on_file | ID | Optional | No | HL70136 |
| 19 | baby_coverage | ID | Optional | No | HL70136 |
| 20 | combine_baby_bill | ID | Optional | No | HL70136 |
| 21 | blood_deductible | ST | Optional | No | - |
| 22 | ▶special_coverage_approval_name | XPN | Optional | Yes | - |
| 22.1 | ├.family_name | FN | Optional | No | - |
| 22.2 | ├.given_name | ST | Optional | No | - |
| 22.3 | ├.second_and_further_given_names_or_initials_thereof | ST | Optional | No | - |
| 22.4 | ├.suffix | ST | Optional | No | - |
| 22.5 | ├.prefix | ST | Optional | No | - |
| 22.6 | ├.degree | ST | Optional | No | - |
| 22.7 | ├.name_type_code | ID | Optional | No | - |
| 22.8 | ├.name_representation_code | ID | Optional | No | - |
| 22.9 | ├.name_context | CWE | Optional | No | - |
| 22.10 | ├.name_validity_range | DR | Optional | No | - |
| 22.11 | ├.name_assembly_order | ID | Optional | No | - |
| 22.12 | ├.effective_date | DTM | Optional | No | - |
| 22.13 | ├.expiration_date | DTM | Optional | No | - |
| 22.14 | ├.professional_suffix | ST | Optional | No | - |
| 22.15 | └.called_by | ST | Optional | No | - |
| 23 | special_coverage_approval_title | ST | Optional | No | - |
| 24 | ▶non_covered_insurance_code | CWE | Optional | Yes | HL70143 |
| 24.1 | ├.identifier | ST | Optional | No | - |
| 24.2 | ├.text | ST | Optional | No | - |
| 24.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 24.4 | ├.alternate_identifier | ST | Optional | No | - |
| 24.5 | ├.alternate_text | ST | Optional | No | - |
| 24.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 24.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 24.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 24.9 | ├.original_text | ST | Optional | No | - |
| 24.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 24.11 | ├.second_alternate_text | ST | Optional | No | - |
| 24.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 24.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 24.14 | ├.coding_system_oid | ST | Optional | No | - |
| 24.15 | ├.value_set_oid | ST | Optional | No | - |
| 24.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 24.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 24.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 24.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 24.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 24.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 24.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 25 | ▶payor_id | CX | Optional | Yes | - |
| 25.1 | ├.id_number | ST | Optional | No | - |
| 25.2 | ├.identifier_check_digit | ST | Optional | No | - |
| 25.3 | ├.check_digit_scheme | ID | Optional | No | - |
| 25.4 | ├.assigning_authority | HD | Optional | No | - |
| 25.5 | ├.identifier_type_code | ID | Optional | No | - |
| 25.6 | ├.assigning_facility | HD | Optional | No | - |
| 25.7 | ├.effective_date | DT | Optional | No | - |
| 25.8 | ├.expiration_date | DT | Optional | No | - |
| 25.9 | ├.assigning_jurisdiction | CWE | Optional | No | - |
| 25.10 | ├.assigning_agency_or_department | CWE | Optional | No | - |
| 25.11 | ├.security_check | ST | Optional | No | - |
| 25.12 | └.security_check_scheme | ID | Optional | No | - |
| 26 | ▶payor_subscriber_id | CX | Optional | Yes | - |
| 26.1 | ├.id_number | ST | Optional | No | - |
| 26.2 | ├.identifier_check_digit | ST | Optional | No | - |
| 26.3 | ├.check_digit_scheme | ID | Optional | No | - |
| 26.4 | ├.assigning_authority | HD | Optional | No | - |
| 26.5 | ├.identifier_type_code | ID | Optional | No | - |
| 26.6 | ├.assigning_facility | HD | Optional | No | - |
| 26.7 | ├.effective_date | DT | Optional | No | - |
| 26.8 | ├.expiration_date | DT | Optional | No | - |
| 26.9 | ├.assigning_jurisdiction | CWE | Optional | No | - |
| 26.10 | ├.assigning_agency_or_department | CWE | Optional | No | - |
| 26.11 | ├.security_check | ST | Optional | No | - |
| 26.12 | └.security_check_scheme | ID | Optional | No | - |
| 27 | ▶eligibility_source | CWE | Optional | No | HL70144 |
| 27.1 | ├.identifier | ST | Optional | No | - |
| 27.2 | ├.text | ST | Optional | No | - |
| 27.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 27.4 | ├.alternate_identifier | ST | Optional | No | - |
| 27.5 | ├.alternate_text | ST | Optional | No | - |
| 27.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 27.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 27.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 27.9 | ├.original_text | ST | Optional | No | - |
| 27.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 27.11 | ├.second_alternate_text | ST | Optional | No | - |
| 27.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 27.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 27.14 | ├.coding_system_oid | ST | Optional | No | - |
| 27.15 | ├.value_set_oid | ST | Optional | No | - |
| 27.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 27.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 27.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 27.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 27.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 27.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 27.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 28 | ▶room_coverage_type_amount | RMC | Optional | Yes | - |
| 28.1 | ├.room_type | CWE | Optional | No | - |
| 28.2 | ├.amount_type | CWE | Optional | No | - |
| 28.3 | ├.coverage_amount | NM | Optional | No | - |
| 28.4 | └.money_or_percentage | ST | Optional | No | - |
| 29 | ▶policy_type_amount | PTA | Optional | Yes | - |
| 29.1 | ├.policy_type | CWE | Optional | No | - |
| 29.2 | ├.amount_class | CWE | Optional | No | - |
| 29.3 | ├.money_or_percentage_quantity | NM | Optional | No | - |
| 29.4 | └.money_or_percentage | ST | Optional | No | - |
| 30 | ▶daily_deductible | DDI | Optional | No | - |
| 30.1 | ├.delay_days | NM | Optional | No | - |
| 30.2 | ├.monetary_amount | MO | Optional | No | - |
| 30.3 | └.number_of_days | NM | Optional | No | - |
| 31 | ▶living_dependency | CWE | Optional | No | HL70223 |
| 31.1 | ├.identifier | ST | Optional | No | - |
| 31.2 | ├.text | ST | Optional | No | - |
| 31.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 31.4 | ├.alternate_identifier | ST | Optional | No | - |
| 31.5 | ├.alternate_text | ST | Optional | No | - |
| 31.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 31.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 31.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 31.9 | ├.original_text | ST | Optional | No | - |
| 31.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 31.11 | ├.second_alternate_text | ST | Optional | No | - |
| 31.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 31.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 31.14 | ├.coding_system_oid | ST | Optional | No | - |
| 31.15 | ├.value_set_oid | ST | Optional | No | - |
| 31.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 31.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 31.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 31.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 31.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 31.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 31.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 32 | ▶ambulatory_status | CWE | Optional | Yes | HL70009 |
| 32.1 | ├.identifier | ST | Optional | No | - |
| 32.2 | ├.text | ST | Optional | No | - |
| 32.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 32.4 | ├.alternate_identifier | ST | Optional | No | - |
| 32.5 | ├.alternate_text | ST | Optional | No | - |
| 32.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 32.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 32.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 32.9 | ├.original_text | ST | Optional | No | - |
| 32.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 32.11 | ├.second_alternate_text | ST | Optional | No | - |
| 32.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 32.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 32.14 | ├.coding_system_oid | ST | Optional | No | - |
| 32.15 | ├.value_set_oid | ST | Optional | No | - |
| 32.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 32.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 32.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 32.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 32.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 32.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 32.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 33 | ▶citizenship | CWE | Optional | Yes | HL70171 |
| 33.1 | ├.identifier | ST | Optional | No | - |
| 33.2 | ├.text | ST | Optional | No | - |
| 33.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 33.4 | ├.alternate_identifier | ST | Optional | No | - |
| 33.5 | ├.alternate_text | ST | Optional | No | - |
| 33.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 33.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 33.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 33.9 | ├.original_text | ST | Optional | No | - |
| 33.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 33.11 | ├.second_alternate_text | ST | Optional | No | - |
| 33.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 33.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 33.14 | ├.coding_system_oid | ST | Optional | No | - |
| 33.15 | ├.value_set_oid | ST | Optional | No | - |
| 33.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 33.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 33.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 33.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 33.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 33.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 33.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 34 | ▶primary_language | CWE | Optional | No | HL70296 |
| 34.1 | ├.identifier | ST | Optional | No | - |
| 34.2 | ├.text | ST | Optional | No | - |
| 34.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 34.4 | ├.alternate_identifier | ST | Optional | No | - |
| 34.5 | ├.alternate_text | ST | Optional | No | - |
| 34.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 34.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 34.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 34.9 | ├.original_text | ST | Optional | No | - |
| 34.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 34.11 | ├.second_alternate_text | ST | Optional | No | - |
| 34.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 34.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 34.14 | ├.coding_system_oid | ST | Optional | No | - |
| 34.15 | ├.value_set_oid | ST | Optional | No | - |
| 34.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 34.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 34.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 34.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 34.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 34.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 34.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 35 | ▶living_arrangement | CWE | Optional | No | HL70220 |
| 35.1 | ├.identifier | ST | Optional | No | - |
| 35.2 | ├.text | ST | Optional | No | - |
| 35.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 35.4 | ├.alternate_identifier | ST | Optional | No | - |
| 35.5 | ├.alternate_text | ST | Optional | No | - |
| 35.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 35.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 35.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 35.9 | ├.original_text | ST | Optional | No | - |
| 35.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 35.11 | ├.second_alternate_text | ST | Optional | No | - |
| 35.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 35.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 35.14 | ├.coding_system_oid | ST | Optional | No | - |
| 35.15 | ├.value_set_oid | ST | Optional | No | - |
| 35.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 35.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 35.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 35.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 35.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 35.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 35.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 36 | ▶publicity_code | CWE | Optional | No | HL70215 |
| 36.1 | ├.identifier | ST | Optional | No | - |
| 36.2 | ├.text | ST | Optional | No | - |
| 36.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 36.4 | ├.alternate_identifier | ST | Optional | No | - |
| 36.5 | ├.alternate_text | ST | Optional | No | - |
| 36.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 36.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 36.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 36.9 | ├.original_text | ST | Optional | No | - |
| 36.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 36.11 | ├.second_alternate_text | ST | Optional | No | - |
| 36.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 36.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 36.14 | ├.coding_system_oid | ST | Optional | No | - |
| 36.15 | ├.value_set_oid | ST | Optional | No | - |
| 36.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 36.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 36.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 36.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 36.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 36.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 36.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 37 | protection_indicator | ID | Optional | No | HL70136 |
| 38 | ▶student_indicator | CWE | Optional | No | HL70231 |
| 38.1 | ├.identifier | ST | Optional | No | - |
| 38.2 | ├.text | ST | Optional | No | - |
| 38.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 38.4 | ├.alternate_identifier | ST | Optional | No | - |
| 38.5 | ├.alternate_text | ST | Optional | No | - |
| 38.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 38.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 38.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 38.9 | ├.original_text | ST | Optional | No | - |
| 38.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 38.11 | ├.second_alternate_text | ST | Optional | No | - |
| 38.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 38.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 38.14 | ├.coding_system_oid | ST | Optional | No | - |
| 38.15 | ├.value_set_oid | ST | Optional | No | - |
| 38.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 38.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 38.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 38.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 38.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 38.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 38.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 39 | ▶religion | CWE | Optional | No | HL70006 |
| 39.1 | ├.identifier | ST | Optional | No | - |
| 39.2 | ├.text | ST | Optional | No | - |
| 39.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 39.4 | ├.alternate_identifier | ST | Optional | No | - |
| 39.5 | ├.alternate_text | ST | Optional | No | - |
| 39.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 39.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 39.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 39.9 | ├.original_text | ST | Optional | No | - |
| 39.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 39.11 | ├.second_alternate_text | ST | Optional | No | - |
| 39.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 39.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 39.14 | ├.coding_system_oid | ST | Optional | No | - |
| 39.15 | ├.value_set_oid | ST | Optional | No | - |
| 39.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 39.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 39.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 39.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 39.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 39.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 39.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 40 | ▶mothers_maiden_name | XPN | Optional | Yes | - |
| 40.1 | ├.family_name | FN | Optional | No | - |
| 40.2 | ├.given_name | ST | Optional | No | - |
| 40.3 | ├.second_and_further_given_names_or_initials_thereof | ST | Optional | No | - |
| 40.4 | ├.suffix | ST | Optional | No | - |
| 40.5 | ├.prefix | ST | Optional | No | - |
| 40.6 | ├.degree | ST | Optional | No | - |
| 40.7 | ├.name_type_code | ID | Optional | No | - |
| 40.8 | ├.name_representation_code | ID | Optional | No | - |
| 40.9 | ├.name_context | CWE | Optional | No | - |
| 40.10 | ├.name_validity_range | DR | Optional | No | - |
| 40.11 | ├.name_assembly_order | ID | Optional | No | - |
| 40.12 | ├.effective_date | DTM | Optional | No | - |
| 40.13 | ├.expiration_date | DTM | Optional | No | - |
| 40.14 | ├.professional_suffix | ST | Optional | No | - |
| 40.15 | └.called_by | ST | Optional | No | - |
| 41 | ▶nationality | CWE | Optional | No | HL70212 |
| 41.1 | ├.identifier | ST | Optional | No | - |
| 41.2 | ├.text | ST | Optional | No | - |
| 41.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 41.4 | ├.alternate_identifier | ST | Optional | No | - |
| 41.5 | ├.alternate_text | ST | Optional | No | - |
| 41.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 41.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 41.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 41.9 | ├.original_text | ST | Optional | No | - |
| 41.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 41.11 | ├.second_alternate_text | ST | Optional | No | - |
| 41.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 41.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 41.14 | ├.coding_system_oid | ST | Optional | No | - |
| 41.15 | ├.value_set_oid | ST | Optional | No | - |
| 41.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 41.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 41.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 41.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 41.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 41.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 41.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 42 | ▶ethnic_group | CWE | Optional | Yes | HL70189 |
| 42.1 | ├.identifier | ST | Optional | No | - |
| 42.2 | ├.text | ST | Optional | No | - |
| 42.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 42.4 | ├.alternate_identifier | ST | Optional | No | - |
| 42.5 | ├.alternate_text | ST | Optional | No | - |
| 42.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 42.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 42.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 42.9 | ├.original_text | ST | Optional | No | - |
| 42.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 42.11 | ├.second_alternate_text | ST | Optional | No | - |
| 42.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 42.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 42.14 | ├.coding_system_oid | ST | Optional | No | - |
| 42.15 | ├.value_set_oid | ST | Optional | No | - |
| 42.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 42.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 42.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 42.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 42.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 42.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 42.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 43 | ▶marital_status | CWE | Optional | Yes | HL70002 |
| 43.1 | ├.identifier | ST | Optional | No | - |
| 43.2 | ├.text | ST | Optional | No | - |
| 43.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 43.4 | ├.alternate_identifier | ST | Optional | No | - |
| 43.5 | ├.alternate_text | ST | Optional | No | - |
| 43.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 43.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 43.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 43.9 | ├.original_text | ST | Optional | No | - |
| 43.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 43.11 | ├.second_alternate_text | ST | Optional | No | - |
| 43.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 43.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 43.14 | ├.coding_system_oid | ST | Optional | No | - |
| 43.15 | ├.value_set_oid | ST | Optional | No | - |
| 43.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 43.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 43.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 43.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 43.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 43.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 43.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 44 | insureds_employment_start_date | DT | Optional | No | - |
| 45 | employment_stop_date | DT | Optional | No | - |
| 46 | job_title | ST | Optional | No | - |
| 47 | ▶job_code_class | JCC | Optional | No | - |
| 47.1 | ├.job_code | CWE | Optional | No | - |
| 47.2 | ├.job_class | CWE | Optional | No | - |
| 47.3 | └.job_description_text | ID | Optional | No | - |
| 48 | ▶job_status | CWE | Optional | No | HL70311 |
| 48.1 | ├.identifier | ST | Optional | No | - |
| 48.2 | ├.text | ST | Optional | No | - |
| 48.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 48.4 | ├.alternate_identifier | ST | Optional | No | - |
| 48.5 | ├.alternate_text | ST | Optional | No | - |
| 48.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 48.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 48.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 48.9 | ├.original_text | ST | Optional | No | - |
| 48.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 48.11 | ├.second_alternate_text | ST | Optional | No | - |
| 48.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 48.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 48.14 | ├.coding_system_oid | ST | Optional | No | - |
| 48.15 | ├.value_set_oid | ST | Optional | No | - |
| 48.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 48.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 48.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 48.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 48.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 48.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 48.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 49 | ▶employer_contact_person_name | XPN | Optional | Yes | - |
| 49.1 | ├.family_name | FN | Optional | No | - |
| 49.2 | ├.given_name | ST | Optional | No | - |
| 49.3 | ├.second_and_further_given_names_or_initials_thereof | ST | Optional | No | - |
| 49.4 | ├.suffix | ST | Optional | No | - |
| 49.5 | ├.prefix | ST | Optional | No | - |
| 49.6 | ├.degree | ST | Optional | No | - |
| 49.7 | ├.name_type_code | ID | Optional | No | - |
| 49.8 | ├.name_representation_code | ID | Optional | No | - |
| 49.9 | ├.name_context | CWE | Optional | No | - |
| 49.10 | ├.name_validity_range | DR | Optional | No | - |
| 49.11 | ├.name_assembly_order | ID | Optional | No | - |
| 49.12 | ├.effective_date | DTM | Optional | No | - |
| 49.13 | ├.expiration_date | DTM | Optional | No | - |
| 49.14 | ├.professional_suffix | ST | Optional | No | - |
| 49.15 | └.called_by | ST | Optional | No | - |
| 50 | ▶employer_contact_person_phone_number | XTN | Optional | Yes | - |
| 50.1 | ├.telephone_number | ST | Optional | No | - |
| 50.2 | ├.telecommunication_use_code | ID | Optional | No | - |
| 50.3 | ├.telecommunication_equipment_type | ID | Optional | No | - |
| 50.4 | ├.communication_address | ST | Optional | No | - |
| 50.5 | ├.country_code | SNM | Optional | No | - |
| 50.6 | ├.area_city_code | SNM | Optional | No | - |
| 50.7 | ├.local_number | SNM | Optional | No | - |
| 50.8 | ├.extension | SNM | Optional | No | - |
| 50.9 | ├.any_text | ST | Optional | No | - |
| 50.10 | ├.extension_prefix | ST | Optional | No | - |
| 50.11 | ├.speed_dial_code | ST | Optional | No | - |
| 50.12 | ├.unformatted_telephone_number | ST | Optional | No | - |
| 50.13 | ├.effective_start_date | DTM | Optional | No | - |
| 50.14 | ├.expiration_date | DTM | Optional | No | - |
| 50.15 | ├.expiration_reason | CWE | Optional | No | - |
| 50.16 | ├.protection_code | CWE | Optional | No | - |
| 50.17 | ├.shared_telecommunication_identifier | EI | Optional | No | - |
| 50.18 | └.preference_order | NM | Optional | No | - |
| 51 | ▶employer_contact_reason | CWE | Optional | No | HL70222 |
| 51.1 | ├.identifier | ST | Optional | No | - |
| 51.2 | ├.text | ST | Optional | No | - |
| 51.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 51.4 | ├.alternate_identifier | ST | Optional | No | - |
| 51.5 | ├.alternate_text | ST | Optional | No | - |
| 51.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 51.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 51.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 51.9 | ├.original_text | ST | Optional | No | - |
| 51.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 51.11 | ├.second_alternate_text | ST | Optional | No | - |
| 51.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 51.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 51.14 | ├.coding_system_oid | ST | Optional | No | - |
| 51.15 | ├.value_set_oid | ST | Optional | No | - |
| 51.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 51.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 51.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 51.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 51.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 51.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 51.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 52 | ▶insureds_contact_persons_name | XPN | Optional | Yes | - |
| 52.1 | ├.family_name | FN | Optional | No | - |
| 52.2 | ├.given_name | ST | Optional | No | - |
| 52.3 | ├.second_and_further_given_names_or_initials_thereof | ST | Optional | No | - |
| 52.4 | ├.suffix | ST | Optional | No | - |
| 52.5 | ├.prefix | ST | Optional | No | - |
| 52.6 | ├.degree | ST | Optional | No | - |
| 52.7 | ├.name_type_code | ID | Optional | No | - |
| 52.8 | ├.name_representation_code | ID | Optional | No | - |
| 52.9 | ├.name_context | CWE | Optional | No | - |
| 52.10 | ├.name_validity_range | DR | Optional | No | - |
| 52.11 | ├.name_assembly_order | ID | Optional | No | - |
| 52.12 | ├.effective_date | DTM | Optional | No | - |
| 52.13 | ├.expiration_date | DTM | Optional | No | - |
| 52.14 | ├.professional_suffix | ST | Optional | No | - |
| 52.15 | └.called_by | ST | Optional | No | - |
| 53 | ▶insureds_contact_person_phone_number | XTN | Optional | Yes | - |
| 53.1 | ├.telephone_number | ST | Optional | No | - |
| 53.2 | ├.telecommunication_use_code | ID | Optional | No | - |
| 53.3 | ├.telecommunication_equipment_type | ID | Optional | No | - |
| 53.4 | ├.communication_address | ST | Optional | No | - |
| 53.5 | ├.country_code | SNM | Optional | No | - |
| 53.6 | ├.area_city_code | SNM | Optional | No | - |
| 53.7 | ├.local_number | SNM | Optional | No | - |
| 53.8 | ├.extension | SNM | Optional | No | - |
| 53.9 | ├.any_text | ST | Optional | No | - |
| 53.10 | ├.extension_prefix | ST | Optional | No | - |
| 53.11 | ├.speed_dial_code | ST | Optional | No | - |
| 53.12 | ├.unformatted_telephone_number | ST | Optional | No | - |
| 53.13 | ├.effective_start_date | DTM | Optional | No | - |
| 53.14 | ├.expiration_date | DTM | Optional | No | - |
| 53.15 | ├.expiration_reason | CWE | Optional | No | - |
| 53.16 | ├.protection_code | CWE | Optional | No | - |
| 53.17 | ├.shared_telecommunication_identifier | EI | Optional | No | - |
| 53.18 | └.preference_order | NM | Optional | No | - |
| 54 | ▶insureds_contact_person_reason | CWE | Optional | Yes | HL70222 |
| 54.1 | ├.identifier | ST | Optional | No | - |
| 54.2 | ├.text | ST | Optional | No | - |
| 54.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 54.4 | ├.alternate_identifier | ST | Optional | No | - |
| 54.5 | ├.alternate_text | ST | Optional | No | - |
| 54.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 54.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 54.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 54.9 | ├.original_text | ST | Optional | No | - |
| 54.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 54.11 | ├.second_alternate_text | ST | Optional | No | - |
| 54.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 54.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 54.14 | ├.coding_system_oid | ST | Optional | No | - |
| 54.15 | ├.value_set_oid | ST | Optional | No | - |
| 54.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 54.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 54.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 54.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 54.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 54.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 54.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 55 | relationship_to_the_patient_start_date | DT | Optional | No | - |
| 56 | relationship_to_the_patient_stop_date | DT | Optional | Yes | - |
| 57 | ▶insurance_co_contact_reason | CWE | Optional | No | HL70232 |
| 57.1 | ├.identifier | ST | Optional | No | - |
| 57.2 | ├.text | ST | Optional | No | - |
| 57.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 57.4 | ├.alternate_identifier | ST | Optional | No | - |
| 57.5 | ├.alternate_text | ST | Optional | No | - |
| 57.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 57.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 57.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 57.9 | ├.original_text | ST | Optional | No | - |
| 57.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 57.11 | ├.second_alternate_text | ST | Optional | No | - |
| 57.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 57.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 57.14 | ├.coding_system_oid | ST | Optional | No | - |
| 57.15 | ├.value_set_oid | ST | Optional | No | - |
| 57.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 57.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 57.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 57.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 57.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 57.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 57.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 58 | ▶insurance_co_contact_phone_number | XTN | Optional | Yes | - |
| 58.1 | ├.telephone_number | ST | Optional | No | - |
| 58.2 | ├.telecommunication_use_code | ID | Optional | No | - |
| 58.3 | ├.telecommunication_equipment_type | ID | Optional | No | - |
| 58.4 | ├.communication_address | ST | Optional | No | - |
| 58.5 | ├.country_code | SNM | Optional | No | - |
| 58.6 | ├.area_city_code | SNM | Optional | No | - |
| 58.7 | ├.local_number | SNM | Optional | No | - |
| 58.8 | ├.extension | SNM | Optional | No | - |
| 58.9 | ├.any_text | ST | Optional | No | - |
| 58.10 | ├.extension_prefix | ST | Optional | No | - |
| 58.11 | ├.speed_dial_code | ST | Optional | No | - |
| 58.12 | ├.unformatted_telephone_number | ST | Optional | No | - |
| 58.13 | ├.effective_start_date | DTM | Optional | No | - |
| 58.14 | ├.expiration_date | DTM | Optional | No | - |
| 58.15 | ├.expiration_reason | CWE | Optional | No | - |
| 58.16 | ├.protection_code | CWE | Optional | No | - |
| 58.17 | ├.shared_telecommunication_identifier | EI | Optional | No | - |
| 58.18 | └.preference_order | NM | Optional | No | - |
| 59 | ▶policy_scope | CWE | Optional | No | HL70312 |
| 59.1 | ├.identifier | ST | Optional | No | - |
| 59.2 | ├.text | ST | Optional | No | - |
| 59.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 59.4 | ├.alternate_identifier | ST | Optional | No | - |
| 59.5 | ├.alternate_text | ST | Optional | No | - |
| 59.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 59.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 59.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 59.9 | ├.original_text | ST | Optional | No | - |
| 59.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 59.11 | ├.second_alternate_text | ST | Optional | No | - |
| 59.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 59.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 59.14 | ├.coding_system_oid | ST | Optional | No | - |
| 59.15 | ├.value_set_oid | ST | Optional | No | - |
| 59.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 59.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 59.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 59.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 59.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 59.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 59.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 60 | ▶policy_source | CWE | Optional | No | HL70313 |
| 60.1 | ├.identifier | ST | Optional | No | - |
| 60.2 | ├.text | ST | Optional | No | - |
| 60.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 60.4 | ├.alternate_identifier | ST | Optional | No | - |
| 60.5 | ├.alternate_text | ST | Optional | No | - |
| 60.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 60.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 60.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 60.9 | ├.original_text | ST | Optional | No | - |
| 60.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 60.11 | ├.second_alternate_text | ST | Optional | No | - |
| 60.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 60.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 60.14 | ├.coding_system_oid | ST | Optional | No | - |
| 60.15 | ├.value_set_oid | ST | Optional | No | - |
| 60.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 60.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 60.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 60.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 60.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 60.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 60.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 61 | ▶patient_member_number | CX | Optional | No | - |
| 61.1 | ├.id_number | ST | Optional | No | - |
| 61.2 | ├.identifier_check_digit | ST | Optional | No | - |
| 61.3 | ├.check_digit_scheme | ID | Optional | No | - |
| 61.4 | ├.assigning_authority | HD | Optional | No | - |
| 61.5 | ├.identifier_type_code | ID | Optional | No | - |
| 61.6 | ├.assigning_facility | HD | Optional | No | - |
| 61.7 | ├.effective_date | DT | Optional | No | - |
| 61.8 | ├.expiration_date | DT | Optional | No | - |
| 61.9 | ├.assigning_jurisdiction | CWE | Optional | No | - |
| 61.10 | ├.assigning_agency_or_department | CWE | Optional | No | - |
| 61.11 | ├.security_check | ST | Optional | No | - |
| 61.12 | └.security_check_scheme | ID | Optional | No | - |
| 62 | ▶guarantors_relationship_to_insured | CWE | Optional | No | HL70063 |
| 62.1 | ├.identifier | ST | Optional | No | - |
| 62.2 | ├.text | ST | Optional | No | - |
| 62.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 62.4 | ├.alternate_identifier | ST | Optional | No | - |
| 62.5 | ├.alternate_text | ST | Optional | No | - |
| 62.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 62.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 62.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 62.9 | ├.original_text | ST | Optional | No | - |
| 62.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 62.11 | ├.second_alternate_text | ST | Optional | No | - |
| 62.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 62.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 62.14 | ├.coding_system_oid | ST | Optional | No | - |
| 62.15 | ├.value_set_oid | ST | Optional | No | - |
| 62.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 62.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 62.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 62.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 62.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 62.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 62.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 63 | ▶insureds_phone_number_home | XTN | Optional | Yes | - |
| 63.1 | ├.telephone_number | ST | Optional | No | - |
| 63.2 | ├.telecommunication_use_code | ID | Optional | No | - |
| 63.3 | ├.telecommunication_equipment_type | ID | Optional | No | - |
| 63.4 | ├.communication_address | ST | Optional | No | - |
| 63.5 | ├.country_code | SNM | Optional | No | - |
| 63.6 | ├.area_city_code | SNM | Optional | No | - |
| 63.7 | ├.local_number | SNM | Optional | No | - |
| 63.8 | ├.extension | SNM | Optional | No | - |
| 63.9 | ├.any_text | ST | Optional | No | - |
| 63.10 | ├.extension_prefix | ST | Optional | No | - |
| 63.11 | ├.speed_dial_code | ST | Optional | No | - |
| 63.12 | ├.unformatted_telephone_number | ST | Optional | No | - |
| 63.13 | ├.effective_start_date | DTM | Optional | No | - |
| 63.14 | ├.expiration_date | DTM | Optional | No | - |
| 63.15 | ├.expiration_reason | CWE | Optional | No | - |
| 63.16 | ├.protection_code | CWE | Optional | No | - |
| 63.17 | ├.shared_telecommunication_identifier | EI | Optional | No | - |
| 63.18 | └.preference_order | NM | Optional | No | - |
| 64 | ▶insureds_employer_phone_number | XTN | Optional | Yes | - |
| 64.1 | ├.telephone_number | ST | Optional | No | - |
| 64.2 | ├.telecommunication_use_code | ID | Optional | No | - |
| 64.3 | ├.telecommunication_equipment_type | ID | Optional | No | - |
| 64.4 | ├.communication_address | ST | Optional | No | - |
| 64.5 | ├.country_code | SNM | Optional | No | - |
| 64.6 | ├.area_city_code | SNM | Optional | No | - |
| 64.7 | ├.local_number | SNM | Optional | No | - |
| 64.8 | ├.extension | SNM | Optional | No | - |
| 64.9 | ├.any_text | ST | Optional | No | - |
| 64.10 | ├.extension_prefix | ST | Optional | No | - |
| 64.11 | ├.speed_dial_code | ST | Optional | No | - |
| 64.12 | ├.unformatted_telephone_number | ST | Optional | No | - |
| 64.13 | ├.effective_start_date | DTM | Optional | No | - |
| 64.14 | ├.expiration_date | DTM | Optional | No | - |
| 64.15 | ├.expiration_reason | CWE | Optional | No | - |
| 64.16 | ├.protection_code | CWE | Optional | No | - |
| 64.17 | ├.shared_telecommunication_identifier | EI | Optional | No | - |
| 64.18 | └.preference_order | NM | Optional | No | - |
| 65 | ▶military_handicapped_program | CWE | Optional | No | HL70343 |
| 65.1 | ├.identifier | ST | Optional | No | - |
| 65.2 | ├.text | ST | Optional | No | - |
| 65.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 65.4 | ├.alternate_identifier | ST | Optional | No | - |
| 65.5 | ├.alternate_text | ST | Optional | No | - |
| 65.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 65.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 65.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 65.9 | ├.original_text | ST | Optional | No | - |
| 65.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 65.11 | ├.second_alternate_text | ST | Optional | No | - |
| 65.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 65.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 65.14 | ├.coding_system_oid | ST | Optional | No | - |
| 65.15 | ├.value_set_oid | ST | Optional | No | - |
| 65.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 65.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 65.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 65.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 65.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 65.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 65.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 66 | suspend_flag | ID | Optional | No | HL70136 |
| 67 | copay_limit_flag | ID | Optional | No | HL70136 |
| 68 | stoploss_limit_flag | ID | Optional | No | HL70136 |
| 69 | ▶insured_organization_name_and_id | XON | Optional | Yes | - |
| 69.1 | ├.organization_name | ST | Optional | No | - |
| 69.2 | ├.organization_name_type_code | CWE | Optional | No | - |
| 69.3 | ├.id_number | NM | Optional | No | - |
| 69.4 | ├.identifier_check_digit | ST | Optional | No | - |
| 69.5 | ├.check_digit_scheme | ID | Optional | No | - |
| 69.6 | ├.assigning_authority | HD | Optional | No | - |
| 69.7 | ├.identifier_type_code | ID | Optional | No | - |
| 69.8 | ├.assigning_facility | HD | Optional | No | - |
| 69.9 | ├.name_representation_code | ID | Optional | No | - |
| 69.10 | └.organization_identifier | ST | Optional | No | - |
| 70 | ▶insured_employer_organization_name_and_id | XON | Optional | Yes | - |
| 70.1 | ├.organization_name | ST | Optional | No | - |
| 70.2 | ├.organization_name_type_code | CWE | Optional | No | - |
| 70.3 | ├.id_number | NM | Optional | No | - |
| 70.4 | ├.identifier_check_digit | ST | Optional | No | - |
| 70.5 | ├.check_digit_scheme | ID | Optional | No | - |
| 70.6 | ├.assigning_authority | HD | Optional | No | - |
| 70.7 | ├.identifier_type_code | ID | Optional | No | - |
| 70.8 | ├.assigning_facility | HD | Optional | No | - |
| 70.9 | ├.name_representation_code | ID | Optional | No | - |
| 70.10 | └.organization_identifier | ST | Optional | No | - |
| 71 | ▶race | CWE | Optional | Yes | HL70005 |
| 71.1 | ├.identifier | ST | Optional | No | - |
| 71.2 | ├.text | ST | Optional | No | - |
| 71.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 71.4 | ├.alternate_identifier | ST | Optional | No | - |
| 71.5 | ├.alternate_text | ST | Optional | No | - |
| 71.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 71.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 71.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 71.9 | ├.original_text | ST | Optional | No | - |
| 71.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 71.11 | ├.second_alternate_text | ST | Optional | No | - |
| 71.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 71.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 71.14 | ├.coding_system_oid | ST | Optional | No | - |
| 71.15 | ├.value_set_oid | ST | Optional | No | - |
| 71.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 71.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 71.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 71.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 71.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 71.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 71.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 72 | ▶patients_relationship_to_insured | CWE | Optional | No | HL70344 |
| 72.1 | ├.identifier | ST | Optional | No | - |
| 72.2 | ├.text | ST | Optional | No | - |
| 72.3 | ├.name_of_coding_system | ID | Optional | No | - |
| 72.4 | ├.alternate_identifier | ST | Optional | No | - |
| 72.5 | ├.alternate_text | ST | Optional | No | - |
| 72.6 | ├.name_of_alternate_coding_system | ID | Optional | No | - |
| 72.7 | ├.coding_system_version_id | ST | Optional | No | - |
| 72.8 | ├.alternate_coding_system_version_id | ST | Optional | No | - |
| 72.9 | ├.original_text | ST | Optional | No | - |
| 72.10 | ├.second_alternate_identifier | ST | Optional | No | - |
| 72.11 | ├.second_alternate_text | ST | Optional | No | - |
| 72.12 | ├.name_of_second_alternate_coding_system | ID | Optional | No | - |
| 72.13 | ├.second_alternate_coding_system_version_id | ST | Optional | No | - |
| 72.14 | ├.coding_system_oid | ST | Optional | No | - |
| 72.15 | ├.value_set_oid | ST | Optional | No | - |
| 72.16 | ├.value_set_version_id | DTM | Optional | No | - |
| 72.17 | ├.alternate_coding_system_oid | ST | Optional | No | - |
| 72.18 | ├.alternate_value_set_oid | ST | Optional | No | - |
| 72.19 | ├.alternate_value_set_version_id | DTM | Optional | No | - |
| 72.20 | ├.second_alternate_coding_system_oid | ST | Optional | No | - |
| 72.21 | ├.second_alternate_value_set_oid | ST | Optional | No | - |
| 72.22 | └.second_alternate_value_set_version_id | DTM | Optional | No | - |
| 73 | ▶co_pay_amount | CP | Optional | No | - |
| 73.1 | ├.price | MO | Optional | No | - |
| 73.2 | ├.price_type | ID | Optional | No | - |
| 73.3 | ├.from_value | NM | Optional | No | - |
| 73.4 | ├.to_value | NM | Optional | No | - |
| 73.5 | ├.range_units | CWE | Optional | No | - |
| 73.6 | └.range_type | ID | Optional | No | - |