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#	Data Element Name	DataType	Usage	Vocabulary	Cardinality	Item #	Length	C.LEN	Flags
PM1
1	Health Plan ID	CWE	R	0072 Insurance Plan ID	[1..1]	00368
2	Insurance Company ID	CX	R		[1..*]	00428
3	Insurance Company Name	XON	O		[0..*]	00429
4	Insurance Company Address	XAD	O		[0..*]	00430
5	Insurance Co Contact Person	XPN	O		[0..*]	00431
6	Insurance Co Phone Number	XTN	O		[0..*]	00432
7	Group Number	ST	O		[0..1]	00433		12	#
8	Group Name	XON	O		[0..*]	00434
9	Plan Effective Date	DT	O		[0..1]	00437
10	Plan Expiration Date	DT	O		[0..1]	00438
11	Patient DOB Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03454
12	Patient Gender Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03455
13	Patient Relationship Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03456
14	Patient Signature Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03457
15	Diagnosis Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03458
16	Service Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03459
17	Patient Name Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03460
18	Patient Address Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03461
19	Subscribers Name Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03462
20	Workman's Comp Indicator	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03463
21	Bill Type Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03464
22	Commercial Carrier Name and Address Required	ID	O	0136(R) Yes/no Indicator(Required)	[0..1]	03465
23	Policy Number Pattern	ST	O		[0..1]	03466
24	Group Number Pattern	ST	O		[0..1]	03467

PM1-1: Health Plan ID (CWE) 00368

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

PM1-8: Group Name (XON) 00434

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

PM1-9: Plan Effective Date (DT) 00437

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

PM1-10: Plan Expiration Date (DT) 00438

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.

• Y    DOB Required

• N    DOB Not Required

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.

• Y    Patient Gender Required

• N    Patient Gender Not Rquired

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.

• Y    Patient’s relationship to insured Required

• N    Patient’s relationship to insured Not Required

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.

• Y    Patient’s relationship to insured Required

• N    Patient’s relationship to insured Not Required

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.

• Y    Diagnosis Required

• N    Diagnosis Not Required

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.

• Y    Services Required

• N    Services Not Required

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.

• Y    Patient’s name Required

• N    Patient’s name Not Required

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.

• Y    Patient’s Address Required

• N    Patient’s Address Not Required

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.

• Y    Subscribers name Required

• N    Subscribers name Not Required

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.

• Y    Workman compensation idenfication Required

• N    Workman compensation idenfication Not Required

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.

• Y    Subscribers bill type Required

• N    Subscribers bill type Not Required

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.

• Y    Commerical carrier name and address Required

• N    Commerical carrier name and address Not Required

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