| Field Description | Field ID |
| Tertiary Payer Name | @INS3 |
| Tertiary Policy Group # | @INS3GRP |
| Tertiary Policy Member ID | @INS3MEM |
| Tertiary Payer Address 1 | @INS3ADDR |
| Tertiary Payer Address 2 | @INS3ADDR2 |
| Tertiary Payer City | @INS3CITY |
| Tertiary Payer State | @INS3STATE |
| Tertiary Payer Zip | @INS3ZIP |
| Tertiary Payer Phone | @INS3PH |
| Tertiary Payer Copay | @TCOP |
| Tertiary Policy Co-Insurance | @TCOINS |
| Tertiary Patient Deductible | @TDEDUCT |