IN1: Insurance

The card a patient hands over at reception: who the insurer is, the policy number, and whose policy it is, because it is not always the patient's own. IN1 is that card, and a patient with two cards produces two IN1 segments.

IN1 carries one insurance policy for the patient. It names the payer, the plan, the person who holds the policy and how that person relates to the patient.

The shape of one line

Where IN1 appears

IN1 appears in 30 of the 202 message structures the standard defines.

A whole message

MSH|^~\&|EPIC|STJOSEPH|BILLING|STJOSEPH|20240314093015||ADT^A01^ADT_A01|MSG00017|P|2.5.1
EVN||20240314093000
PID|1||1000345678^^^STJOSEPH^MR||CARTWRIGHT^ELEANOR^MAY^^^^L||19510822|F
PV1|1|I|3W^312^A^STJOSEPH||||1447312^OKONKWO^ADAEZE^^^^MD|||MED
IN1|1|MCARE^MEDICARE PART A^L|MCR001|CENTERS FOR MEDICARE AND MEDICAID|7500 SECURITY BLVD^^BALTIMORE^MD^21244^USA||^WPN^PH^^1^800^6334227|||||20200901||||CARTWRIGHT^ELEANOR^MAY^^^^L|SEL|19510822|41 ORCHARD LANE^APT 2B^PORTLAND^OR^97202^USA^H|||1||||||||||||||1EG4TE5MK73
IN1|2|BCBSOR^BLUE CROSS BLUE SHIELD OF OREGON^L|GRP44821|BCBS OREGON|PO BOX 1271^^PORTLAND^OR^97207^USA||^WPN^PH^^1^503^5551200|GRP44821|RETIREE SUPPLEMENT|||20210101||||CARTWRIGHT^HAROLD^JAMES^^^^L|SPO|19480117|41 ORCHARD LANE^APT 2B^PORTLAND^OR^97202^USA^H|||2||||||||||||||XOB449120366

Every field

Open this IN1 message in HL7 Studio

Field notes

• IN1-1Set ID - IN1

  Set ID, numbering the IN1 segments. It matters more here than in most segments, because it carries the ordering of the policies and a receiver has to know which one to bill first. It is not a coordination-of-benefits priority in its own right, though it is very often used as one, and IN1-22 is the field that actually states the priority.

  Open IN1-1 in HL7 Studio

• IN1-2Insurance Plan ID

  Insurance plan identifier, meaning the plan itself and not the company that sells it. It is required in v2.5.1. Where a site has no distinct plan concept the sender will usually put the payer code here, which makes IN1-2 and IN1-3 carry the same value and hides the distinction.

  Open IN1-2 in HL7 Studio

• IN1-3Insurance Company ID

  Insurance company identifier, the payer. It repeats, which is how a policy administered by one company and underwritten by another is expressed. Most senders use one repetition.

  Open IN1-3 in HL7 Studio

• IN1-8Group Number

  Group number, and IN1-9 the group name. These are what identify an employer-sponsored plan and are what a payer will ask for when a claim is queried. They are absent for individual and government policies, and treating them as required will reject valid Medicare coverage.

  Open IN1-8 in HL7 Studio

• IN1-12Plan Effective Date

  Plan effective date, and IN1-13 the plan expiration date. A policy with an expiration date in the past is not currently in force, and a receiver that stores coverage without checking these will bill a lapsed policy. An empty expiration date means open ended, not expired.

  Open IN1-12 in HL7 Studio

• IN1-16Name Of Insured

  Name of insured, the person who holds the policy. It is not necessarily the patient. IN1-17 gives the relationship and IN1-18 the insured's date of birth, which is what a payer eligibility check needs when the patient is a dependent.

  Open IN1-16 in HL7 Studio

• IN1-17Insured’s Relationship To Patient

  Insured's relationship to patient, bound to table 0063. SEL means the patient is the subscriber, SPO a spouse, CHD a child. This field decides whether the patient's own demographics or the insured's should be sent to the payer, and getting it wrong produces eligibility denials that look like coverage problems.

  Open IN1-17 in HL7 Studio

• IN1-22Coord Of Ben. Priority

  Coordination of benefits priority, stating whether this policy is primary, secondary or tertiary. Where it is populated it is authoritative and IN1-1 is not. Where it is empty, the order of the IN1 segments is the only signal available, which is why the ordering matters.

  Open IN1-22 in HL7 Studio

• IN1-36Policy Number

  Policy number, the member identifier the payer knows the subscriber by. This is the number printed on the card and the one a claim is submitted with. It is distinct from IN1-2 and IN1-8, and it is the field most often mislabelled in an interface specification.

  Open IN1-36 in HL7 Studio

• IN1-49Insured’s ID Number

  Insured's identifier, an additional identifier for the insured person within the payer or the provider organisation. It supplements IN1-36 and does not replace it; where both are populated they answer different questions.

  Open IN1-49 in HL7 Studio

Mapping to FHIR

Each IN1 becomes one FHIR Coverage. The payer becomes Coverage.payor, which is a reference to an Organization and so needs that Organization to exist or be created; the policy number becomes Coverage.subscriberId; and the relationship in IN1-17 becomes Coverage.relationship, which is the field that says whether Coverage.beneficiary and Coverage.subscriber are the same person. Coordination of benefits priority becomes Coverage.order, and where IN1-22 is empty the set ID is the fallback.

Parsing pitfalls

• The subscriber assumed to be the patient

  IN1-17 exists because they often are not. A child on a parent's policy needs the parent's name and date of birth sent for eligibility, and sending the patient's produces a denial that reads as though the coverage does not exist.

• Coverage priority taken from the set ID

  IN1-22 states the coordination of benefits order and overrides the segment ordering. Reading IN1-1 when IN1-22 is populated will bill the secondary payer first on any feed where the segments are not sorted.

• Expired policies stored as active

  IN1-13 is regularly populated on ADT feeds for patients whose coverage has lapsed. Storing coverage without checking the effective and expiration dates leaves stale policies attached to the patient indefinitely.

• The plan, group and policy numbers confused

  IN1-2 identifies the plan, IN1-8 the employer group, IN1-36 the member. Three different fields that all look like account numbers, and an interface specification that names them loosely will have them swapped in implementation.

• Coverage replaced wholesale on an update

  An A08 carrying IN1 segments is stating the current set of policies. Appending them creates duplicates, and blindly deleting and reinserting loses any local annotation. Match on payer and policy number and reconcile.

Related

• IN2additional insurance detail that would not fit in IN1
• IN3certification and precertification for the policy
• PIDthe patient the coverage applies to
• GT1the guarantor, who is financially responsible where insurance does not cover

Message types carrying IN1

IN1 appears in 30 message structures, belonging to 21 message types.

• ADR
• ADT5
• BAR2
• DFT2
• OMB
• OMD
• OMG
• OMI
• OML3
• OMN
• OMP
• OMS
• ORM
• RDE
• REF
• RPA
• RPI2
• RQA
• RQI
• VXR
• VXU