| Element/Gruppe | No/Code | Beschreibung | Opt/Mand. |
|---|
| Element | 5267 | Code specifying the type of service. | Mandatory |
| Element | 7517 | Code used to identify the benefit and coverage. | Mandatory |
| Element | 3507 | Code used to identify who is included in the benefit coverage. | Optional |
| Element | 2151 | Code specifying the type of period. | Optional |
| Gruppe | E017 | Amount of goods or services stated as a monetary amount in a specified currency. | Optional |
| Element | 5482 | To specify a percentage. | Optional |
| Element | 6063 | Code qualifying the type of quantity. | Optional |
| Element | 6060 | Alphanumeric representation of a quantity. | Optional |
| Element | 9607 | Code specifying either a yes or no. | Optional |
| Element | 4497 | Code specifying the meaning of the insurance cover. | Optional |
| Element | 4440 | Free form text. | Optional |
