| Field Description | Field ID |
| Primary Payer Group Number | @IN1GRP |
| Primary Payer Member Number | @IN1MEM |
| Primary Payer Name | @TIN1 |
| Secondary Payer Group Number | @IN2GRP |
| Secondary Payer Member Number | @IN2MEM |
| Secondary Payer Name | @TIN2 |
| Primary Payer Address 1 | @AINADDR1 |
| Primary Payer Address 2 | @AINADDR2 |
| Primary Payer City | @AIN1CITY |
| Primary Payer Phone | @AIN1PH |
| Primary Payer State | @AIN1STATE |
| Primary Payer Zip Code | @AIN1ZIP |
| Secondary Payer Address 1 | @AIN2ADDR1 |
| Secondary Payer Address 2 | @AIN2ADDR2 |
| Secondary Payer City | @AIN2CITY |
| Secondary Payer Phone | @AIN2PH |
| Secondary Payer State | @AIN2STATE |
| Secondary Payer Zip Code | @AUB2ZIP |