X12 270 Health Care Eligibility Benefit Inquiry (X279A1)
This X12 Transaction Set contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Inquiry Transaction Set (270) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to inquire about the eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or a dependent under the subscriber's policy. The transaction set is intended to be used by all lines of insurance such as Health, Life, and Property and Casualty.
- ~ Segment
- * Element
- > Component
- ^ Repetition
Interchange Control Header
To start and identify an interchange of zero or more functional groups and interchange-related control segments
Code identifying the type of information in the Authorization Information
- 00
- No Authorization Information Present (No Meaningful Information in I02)
Information used for additional identification or authorization of the interchange sender or the data in the interchange; the type of information is set by the Authorization Information Qualifier (I01)
Code identifying the type of information in the Security Information
- 00
- No Security Information Present (No Meaningful Information in I04)
This is used for identifying the security information about the interchange sender or the data in the interchange; the type of information is set by the Security Information Qualifier (I03)
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
- ZZ
- Mutually Defined
Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element
Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified
- 01
- Duns (Dun & Bradstreet)
Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them
Type is not applicable; the repetition separator is a delimiter and not a data element; this field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure; this value must be different than the data element separator, component element separator, and the segment terminator
- ^
- Repetition Separator
Code specifying the version number of the interchange control segments
- 00501
- Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
A control number assigned by the interchange sender
Code indicating sender's request for an interchange acknowledgment
- 0
- No Interchange Acknowledgment Requested
- 1
- Interchange Acknowledgment Requested (TA1)
Code indicating whether data enclosed by this interchange envelope is test, production or information
- I
- Information
- P
- Production Data
- T
- Test Data
Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator
- >
- Component Element Separator
Functional Group Header
To indicate the beginning of a functional group and to provide control information
Code identifying a group of application related transaction sets
- HS
- Eligibility, Coverage or Benefit Inquiry (270)
Code identifying party sending transmission; codes agreed to by trading partners
Code identifying party receiving transmission; codes agreed to by trading partners
BCCA
DEN
030240928
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
Assigned number originated and maintained by the sender
Code identifying the issuer of the standard; this code is used in conjunction with Data Element 480
- T
- Transportation Data Coordinating Committee (TDCC)
- X
- Accredited Standards Committee X12
Code indicating the version, release, subrelease, and industry identifier of the EDI standard being used, including the GS and GE segments; if code in DE455 in GS segment is X, then in DE 480 positions 1-3 are the version number; positions 4-6 are the release and subrelease, level of the version; and positions 7-12 are the industry or trade association identifiers (optionally assigned by user); if code in DE455 in GS segment is T, then other formats are allowed
- 005010X279A1
Heading
Transaction Set Header
To indicate the start of a transaction set and to assign a control number
- Use this control segment to mark the start of a transaction set. One ST segment exists for every transaction set that occurs within a functional group.
Code uniquely identifying a Transaction Set
- The transaction set identifier (ST01) is used by the translation routines of the interchange partners to select the appropriate transaction set definition (e.g., 810 selects the Invoice Transaction Set).
- Use this code to identify the transaction set ID for the transaction set that will follow the ST segment. Each X12 standard has a transaction set identifier code that is unique to that transaction set.
- 270
- Eligibility, Coverage or Benefit Inquiry
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with the number, for example "0001", and increment from there. This number must be unique within a specific group and interchange, but can repeat in other groups and interchanges.
- Use the corresponding value in SE02 for this transaction set.
Reference assigned to identify Implementation Convention
- The implementation convention reference (ST03) is used by the translation routines of the interchange partners to select the appropriate implementation convention to match the transaction set definition. When used, this implementation convention reference takes precedence over the implementation reference specified in the GS08.
- This element must be populated with 005010X279A1.
- This element contains the same value as GS08. Some translator products strip off the ISA and GS segments prior to application (ST/SE) processing. Providing the information from the GS08 at this level will ensure that the appropriate application mapping is utilized at translation time.
- 005010X279A1
- Healthcare Eligibility, Coverage or Benefit
Beginning of Hierarchical Transaction
To define the business hierarchical structure of the transaction set and identify the business application purpose and reference data, i.e., number, date, and time
- Use this segment to start the transaction set and indicate the sequence of the hierarchical levels of information that will follow in Table 2.
Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set
- Use this code to specify the sequence of hierarchical levels that may appear in the transaction set. This code only indicates the sequence of the levels, not the requirement that all levels be present. For example, if code "0022" is used, the dependent level may or may not be present for each subscriber.
- 0022
- Information Source, Information Receiver, Subscriber, Dependent
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- BHT03 is the number assigned by the originator to identify the transaction within the originator's business application system.
- Due to the nature of batch transaction processing, the receiver of the 270 transaction (whether it is a clearinghouse or information source) may or may not be able to return the 270 BHT03 value in the 271 BHT03. See Section 1.4.6 Information Linkage for additional information and requirements.
- This element is to be used to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier is to be returned in the corresponding 271 transaction's BHT03. This identifier will only be returned by the last entity to handle the 270. This identifier will not be passed through the complete life of the transaction.
Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year
- BHT04 is the date the transaction was created within the business application system.
- Use this date for the date the transaction set was generated.
Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, or HHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S = integer seconds (00-59) and DD = decimal seconds; decimal seconds are expressed as follows: D = tenths (0-9) and DD = hundredths (00-99)
- BHT05 is the time the transaction was created within the business application system.
- Use this time for the time the transaction set was generated.
Code specifying the type of transaction
- Certain Medicaid programs support additional functionality for Spend Down. Use this code when necessary to further specify the type of transaction to a Medicaid program that supports this functionality.
- RT
- Spend Down
"Spend Down" is a term used by certain Medicaid programs when a recipient must pay a predetermined amount out of his or her own pocket before full coverage benefits are applied. In order to decrement the amount the recipient must pay out of pocket, a 270 transaction must be sent in with this code.
In the event that the service is not rendered and the Spend Down amount is returned to the recipient, an additional 270 must be sent in with a BHT02 with a code "01" to cancel the Spend Down.
Detail
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 20
- Information Source
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Source Name
To supply the full name of an individual or organizational entity
- Use this NM1 loop to identify an entity by name and/or identification number. This NM1 loop is used to identify the eligibility or benefit information source, (e.g., insurance company, HMO, IPA, employer).
Code identifying an organizational entity, a physical location, property or an individual
- 2B
- Third-Party Administrator
- 36
- Employer
- GP
- Gateway Provider
- P5
- Plan Sponsor
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- Use this code to indicate whether the entity is an individual person or an organization.
- 1
- Person
Use this code only if the information source is a Gateway Provider and an individual.
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Code designating the system/method of code structure used for Identification Code (67)
- Use code value "XX" if the information source is a provider and the CMS National Provider Identifier is mandated for use.
Use "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
- PI
- Payor Identification
Code identifying a party or other code
- 040
- Anthem Blue Cross
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 21
- Information Receiver
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Information Receiver Name
To supply the full name of an individual or organizational entity
- Use this segment to identify an entity by name and/or identification number. This NM1 loop is used to identify the eligibility/benefit information receiver (e.g., provider, medical group, employer, IPA, or hospital).
Code identifying an organizational entity, a physical location, property or an individual
- 1P
- Provider
- 2B
- Third-Party Administrator
- 36
- Employer
- 80
- Hospital
- FA
- Facility
- GP
- Gateway Provider
- P5
- Plan Sponsor
- PR
- Payer
Code qualifying the type of entity
- NM102 qualifies NM103.
- Use this code to indicate whether the entity is an individual person or an organization.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
Individual middle name or initial
Suffix to individual name
- Use this only if NM102 is "1".
Code designating the system/method of code structure used for Identification Code (67)
- Use this element to qualify the identification number submitted in NM109. This is the number that the information source associates with the information receiver. Because only one number can be submitted in NM109, the following hierarchy must be used. Additional identifiers are to be placed in the REF segment. If the information receiver is a provider and the National Provider ID is mandated for use and the provider is a covered health care provider under the mandate, code value "XX" must be used. Otherwise, one of the following codes may be used with the following hierarchy applied: Use the first code that applies: "SV", "PP", "FI", "34". The code "SV" is recommended to be used prior to the mandated use of the National Provider ID.
Use "PI" when Information Receiver is a payer and "XV" is not used.
Use "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
If the information receiver is an employer, use code value "24".
- 24
- Employer's Identification Number
Use this code only when the 270/271 transaction sets are used by an employer inquiring about eligibility and benefits of their employees.
- 34
- Social Security Number
Unless requested, do not send SSN (34 – Social Security Number)
- FI
- Federal Taxpayer's Identification Number
- PI
- Payor Identification
Use this code only when the 270/271 transaction sets are used between two payers.
- PP
- Pharmacy Processor Number
- SV
- Service Provider Number
Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.
- XV
- Centers for Medicare and Medicaid Services PlanID
- XX
- Centers for Medicare and Medicaid Services National Provider Identifier
Code identifying a party or other code
Unless requested, do not send SSN (34 – Social Security Number)
Information Receiver Additional Identification
To specify identifying information
- Use this segment when needed to convey other or additional identification numbers for the information receiver. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100B loop.
- Required when the information in 2100B NM1 is not sufficient to identify the information receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
Code qualifying the Reference Identification
- Use this code to specify or qualify the type of reference number that is following in REF02.
- Only one occurrence of each REF01 code value may be used in the 2100B loop.
- 0B
- State License Number
The state assigning the license number must be identified in REF03.
- 1C
- Medicare Provider Number
- 1D
- Medicaid Provider Number
- 1J
- Facility ID Number
- 4A
- Personal Identification Number (PIN)
- CT
- Contract Number
- EL
- Electronic device pin number
- EO
- Submitter Identification Number
- HPI
- Centers for Medicare and Medicaid Services National Provider Identifier
The Centers for Medicare and Medicaid Services National Provider Identifier may be used in this segment prior to being mandated for use.
- JD
- User Identification
- N5
- Provider Plan Network Identification Number
- N7
- Facility Network Identification Number
- Q4
- Prior Identifier Number
- SY
- Social Security Number
Unless requested, do not send SSN (SY – Social Security Number)
- TJ
- Federal Taxpayer's Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this reference number as qualified by the preceding data element (REF01).;
Unless requested, do not send SSN (SY – Social Security Number)
A free-form description to clarify the related data elements and their content
- Use this element for the two character state ID of the state assigning the identifier supplied in REF02. See Code source 22: States and Outlying Areas of the U.S.
Information Receiver Address
To specify the location of the named party
- Required when the information receiver is a provider who has multiple locations and it is needed to identify the location relative to the request. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
Information Receiver City, State, ZIP Code
To specify the geographic place of the named party
- Required when the information receiver is a provider who has multiple locations and it is needed to identify the location relative to the request. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Information Receiver Provider Information
To specify the identifying characteristics of a provider
- Required when the Information Receiver believes Provider Information is relevant to the request and is necessary to convey the provider's role in or taxonomy code related to the eligibility/benefit being inquired about and the provider is also the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
- For example, if the Information Receiver is also the Referring Provider, this PRV segment would be used to identify the provider's role.
- PRV02 qualifies PRV03.
Code identifying the type of provider
- AD
- Admitting
- AT
- Attending
- BI
- Billing
- CO
- Consulting
- CV
- Covering
- H
- Hospital
- HH
- Home Health Care
- LA
- Laboratory
- OT
- Other Physician
- P1
- Pharmacist
- P2
- Pharmacy
- PC
- Primary Care Physician
- PE
- Performing
- R
- Rural Health Clinic
- RF
- Referring
- SB
- Submitting
- SK
- Skilled Nursing Facility
- SU
- Supervising
Code qualifying the Reference Identification
- PXC
- Health Care Provider Taxonomy Code
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 22
- Subscriber
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
- 1
- Additional Subordinate HL Data Segment in This Hierarchical Structure.
Subscriber Trace Number
To uniquely identify a transaction to an application
- The information receiver may assign one TRN segment in this loop if the subscriber is the patient. A clearinghouse may assign one TRN segment in this loop if the subscriber is the patient. See Section 1.4.6 Information Linkage.
- This segment must not be used if the subscriber is not the patient. See section 1.4.2. Basic Concepts.
- Required when information receiver or clearinghouse intends to use the TRN segment as a tracing mechanism for the eligibility transaction and the subscriber is the patient. If not required by this implementation guide, do not send.
- Trace numbers assigned at the subscriber level are intended to allow tracing of an eligibility/benefit transaction when the subscriber is the patient.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- Use this number for the trace or reference number assigned by the information receiver or clearinghouse.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this number for the identification number of the company that assigned the trace or reference number specified in the previous data element (TRN02).
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
- This information allows the originating company to further identify a specific division or group within that organization that was responsible for assigning the trace or reference number.
Subscriber Name
To supply the full name of an individual or organizational entity
- Use this segment to identify an entity by name and/or identification number. Use this NM1 loop to identify the insured or subscriber.
- Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
- In worker's compensation or other property and casualty transactions, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
Code identifying an organizational entity, a physical location, property or an individual
- IL
- Insured or Subscriber
Code qualifying the type of entity
- NM102 qualifies NM103.
- Use this code to indicate whether the entity is an individual person or an organization.
- 1
- Person
- 2
- Non-Person Entity
Individual last name or organizational name
- Use this name for the subscriber's last name.
- Information sources cannot require subscriber's name suffix be sent as a part of the subscriber's last name.
First and Last name of the subscriber exactly as they appear on the Anthem ID card. Populated for finding match for subscriber.
Individual first name
- Use this name for the subscriber's first name.
First and Last name of the subscriber exactly as they appear on the Anthem ID card. Populated for finding match for subscriber.
Individual middle name or initial
- Use this name for the subscriber's middle name or initial.
Suffix to individual name
- Use this for the suffix to an individual's name; e.g., Sr., Jr. or III.
Code designating the system/method of code structure used for Identification Code (67)
- Use this element to qualify the identification number submitted in;NM109. This is the primary number that the information source associates with the subscriber.
- MI
- Member Identification Number
This code may only be used prior to the mandated use of code "II". This is the unique number the payer or information source uses to identify the insured (e.g., Health Insurance Claim Number, Medicaid Recipient ID Number, HMO Member ID, etc.).
Code identifying a party or other code
- Use this reference number as qualified by the preceding data element (NM108).
ID number exactly as it appears on the Anthem ID card, including any alpha prefix, which is required when present. Populated for finding match for subscriber.
Subscriber Additional Identification
To specify identifying information
- Use this segment when needed to convey identification numbers other than or in addition to the Member Identification Number. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100C loop.
- Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Numbers are to be provided in the NM1 segment as a Member Identification Number when it is the primary number an information source knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
- Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
- Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
OR
Required when this segment is used to transmit the Patient Account Number when REF01 = EJ (see Section 1.4.6).
OR
Required when this segment is used to transmit the Provider's Contract Number when REF01 = CT.
If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
Code qualifying the Reference Identification
- Use this code to specify or qualify the type of reference number that is following in REF02.
- Only one occurrence of each REF01 code value may be used in the 2100C loop.
Unless requested, do not send SSN (SY- Social Security Number)
- 6P
- Group Number
- SY
- Social Security Number
Unless requested, do not send SSN (SY- Social Security Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this reference number as qualified by the preceding data element (REF01).;
Subscriber Supplemental Identifier, Coverage within span dates will be returned for the group # submitted over coverage for other group numbers.
Subscriber Address
To specify the location of the named party
- Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.
Address information
- Use this information for the first line of the address information.
Address information
- Use this information for the second line of the address information.
Subscriber City, State, ZIP Code
To specify the geographic place of the named party
- Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Provider Information
To specify the identifying characteristics of a provider
- This segment must not be used to identify the information receiver or the information receiver's specialty type, unless the information is different from that sent in the 2100B loop.
- If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about when the provider is not the information receiver. For example, if the information receiver is a hospital and a referring provider must be identified, this is the segment where the referring provider would be identified.
- Required when the information source is known to process this information in creating a 271 response and the information receiver feels it is necessary to identify a specific provider or to associate a specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
- If identifying a specific provider, this segment contains reference identification numbers, all of which may be used up until the time the National Provider Identifier (NPI) is mandated for use. After the NPI is mandated, only the code for National Provider Identifier may be used.
- If identifying a type of specialty associated with the services identified in loop 2110C, use code PXC in PRV02 and the appropriate code in PRV03.
- PRV02 qualifies PRV03.
Code identifying the type of provider
- AD
- Admitting
- AT
- Attending
- BI
- Billing
- CO
- Consulting
- CV
- Covering
- H
- Hospital
- HH
- Home Health Care
- LA
- Laboratory
- OT
- Other Physician
- P1
- Pharmacist
- P2
- Pharmacy
- PC
- Primary Care Physician
- PE
- Performing
- R
- Rural Health Clinic
- RF
- Referring
- SK
- Skilled Nursing Facility
- SU
- Supervising
Code qualifying the Reference Identification
- If this segment is used to identify a specific provider and the National Provider ID is mandated for use, code value "HPI" must be used, otherwise one of the other code values may be used.
- If this segment is used to identify a type of specialty associated with the services identified in loop 2110C, use code PXC
Unless requested, do not send SSN (SY – Social Security Number)
- 9K
- Servicer
Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.
- D3
- National Council for Prescription Drug Programs Pharmacy Number
- EI
- Employer's Identification Number
- HPI
- Centers for Medicare and Medicaid Services National Provider Identifier
Required value when identifying a specific provider when the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.
- PXC
- Health Care Provider Taxonomy Code
- SY
- Social Security Number
Unless requested, do not send SSN (SY – Social Security Number)
- TJ
- Federal Taxpayer's Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this reference number as qualified by the preceding data element (PRV02).
Unless requested, do not send SSN (SY – Social Security Number)
Subscriber Demographic Information
To supply demographic information
- Use this segment when needed to convey birth date or gender demographic information for the subscriber.
- Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
- Required when the subscriber is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).
OR
Required when the subscriber is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- Use this code to indicate the format of the date of birth that follows in DMG02.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
- Use this date for the date of birth of the subscriber.
Code indicating the sex of the individual
- Use this code to indicate the subscriber's gender.
- F
- Female
- M
- Male
Multiple Birth Sequence Number
To provide benefit information on insured entities
- Required when the information receiver believes it is necessary to identify the birth sequence of the subscriber in the case of multiple births with the same birth date for an Alternate Search Option supported by the Information Source (See Section 1.4.8). If not required by this implementation guide, do not send.
- This segment must not be used if the subscriber is not part of a multiple birth.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- The value Y is used to satisfy X12 syntax.
- Y
- Yes
The value Y is used to satisfy X12 syntax. This data has no business purpose and must not be used to indicate if the insured is a subscriber.
Code indicating the relationship between two individuals or entities
- The value 18 is used only to satisfy X12 syntax.
- 18
- Self
The value 18 is used to satisfy X12 syntax. This data has no business purpose and must not be used to indicate the Individual's relationship to the insured.
A generic number
- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
- Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02.
Subscriber Health Care Diagnosis Code
To supply information related to the delivery of health care
- Use the HI segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the subscriber if that information cannot be returned in the 271 response.
- Use this segment to identify Diagnosis codes as they relate to the information provided in the EQ segments.
- Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
- Required when the information receiver believes the Diagnosis information is relevant to the inquiry, the information is available and if the information source supports or is believed to support this level of functionality. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data element has been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Subscriber Date
To specify any or all of a date, a time, or a time period
- Absence of a Plan date indicates the request is for the date the transaction is processed and the information source is to process the transaction in the same manner as if the processing date was sent.
- Use this segment to convey the plan date(s) for the subscriber or for the issue date of the subscriber's identification card for the information source.
- When using code "291" (Plan) at this level, it is implied that these dates apply to all of the Eligibility or Benefit Inquiry (EQ) loops that follow. If there is a need to supply a different Plan date for a specific EQ loop, it must be provided in the DTP segment within the EQ loop and it will only apply to that EQ loop.
- Required when the information receiver wishes to convey the plan date(s) for the subscriber in relation to the eligibility/benefit inquiry. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
OR
Required when utilizing a search option other than either the Primary Search Option or a Required Alternate Search Option identified in section 1.4.8 which requires the ID Card Issue Date. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
Code specifying type of date or time, or both date and time
- 291
- Plan
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- Use this date for the date(s) as qualified by the preceding data elements.
Please refer to the Phase 1 CORE Operating Rules, Section
154, Subsection 1.3: Eligibility Dates, for date requirements.
Subscriber Eligibility or Benefit Inquiry
To specify inquired eligibility or benefit information
- When the subscriber is not the patient, the 2110C EQ segment must not be used. When the transaction is used in a batch environment, it is possible to have both 2110C and 2110D EQ segments when the subscriber and dependent(s) are patients whose eligibility or benefits are being verified. See Section 1.4.3 Batch and Real Time for additional information.
- The 2110C EQ segment begins the 2110C loop.
- Required when the subscriber is the patient whose eligibility or benefits are being verified. If not required by this implementation guide, do not send.
- If the EQ segment is used, either EQ01 - Service Type Code or EQ02 - Composite Medical Procedure Identifier must be used. Only EQ01 or EQ02 is to be sent, not both.
An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01. An information source may support the use of Service Type Codes other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion.
An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes can be supplied in the 2100C HI segment and place of service in the 2110C III segment. - If an information source receives a Service Type Code "30" submitted in the 270 EQ01 or a Service Type Code that they do not support, the 2110C EB03 values identified in Section 1.4.7.1 Item #8 must also be returned if they are a covered benefit category at a plan level. Refer to Section 1.4.7 for additional information.
- EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
Code identifying the classification of service
- Position of data in the repeating data element conveys no significance.
- An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01.
- An information source may support the use of Service Type Codes from the list other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion. If an information source supports codes in addition to "30", the information source may provide a list of the supported codes from the list below to the information receiver. If no list is provided, an information receiver may transmit the most appropriate code.
- If an inquiry is submitted with a Service Type Code from the list other than "30" and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of "30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.
- EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
- Not used if EQ02 is used.
Use 30 for Health Benefit Coverage or other specific value listed in the Basic Instructions of this document. Only first value is used to determine response.
- 1
- Medical Care
- 2
- Surgical
- 4
- Diagnostic X-Ray
- 5
- Diagnostic Lab
- 6
- Radiation Therapy
- 7
- Anesthesia
- 8
- Surgical Assistance
- 12
- Durable Medical Equipment Purchase
- 13
- Ambulatory Service Center Facility
- 18
- Durable Medical Equipment Rental
- 20
- Second Surgical Opinion
- 30
- Health Benefit Plan Coverage
If only a single category of inquiry can be supported, use this code.
- 33
- Chiropractic
- 35
- Dental Care
- 40
- Oral Surgery
- 42
- Home Health Care
- 45
- Hospice
- 47
- Hospital
- 48
- Hospital - Inpatient
- 50
- Hospital - Outpatient
- 51
- Hospital - Emergency Accident
- 52
- Hospital - Emergency Medical
- 53
- Hospital - Ambulatory Surgical
- 60
- General Benefits
- 61
- In-vitro Fertilization
- 62
- MRI/CAT Scan
- 65
- Newborn Care
- 68
- Well Baby Care
- 69
- Maternity
- 73
- Diagnostic Medical
- 76
- Dialysis
- 78
- Chemotherapy
- 80
- Immunizations
- 81
- Routine Physical
- 82
- Family Planning
- 83
- Infertility
- 84
- Abortion
- 86
- Emergency Services
- 88
- Pharmacy
- 93
- Podiatry
- 98
- Professional (Physician) Visit - Office
- 99
- Professional (Physician) Visit - Inpatient
- A0
- Professional (Physician) Visit - Outpatient
- A3
- Professional (Physician) Visit - Home
- AG
- Skilled Nursing Care
- AI
- Substance Abuse
- AL
- Vision (Optometry)
- BG
- Cardiac Rehabilitation
- BH
- Pediatric
- BT
- Gynecological
- BU
- Obstetrical
- BV
- Obstetrical/Gynecological
- BY
- Physician Visit - Office: Sick
- BZ
- Physician Visit - Office: Well
- CE
- Mental Health Provider - Inpatient
- CF
- Mental Health Provider - Outpatient
- CG
- Mental Health Facility - Inpatient
- CH
- Mental Health Facility - Outpatient
- CI
- Substance Abuse Facility - Inpatient
- CJ
- Substance Abuse Facility - Outpatient
- CK
- Screening X-ray
- CL
- Screening laboratory
- CM
- Mammogram, High Risk Patient
- CN
- Mammogram, Low Risk Patient
- CO
- Flu Vaccination
- DM
- Durable Medical Equipment
- MH
- Mental Health
- UC
- Urgent Care
Required if utilizing a Medical Procedure Code inquiry when the information receiver believes that the information source supports this high level of functionality and EQ01 is not used. If not required by this implementation guide, do not send.
271 Response is based on value submitted in EQ01. Recommended to not submit value in EQ02.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- Use this code to qualify the type of specific Product/Service ID that will be used in EQ02-2.
- AD
- American Dental Association Codes
- CJ
- Current Procedural Terminology (CPT) Codes
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
- ID
- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
- N4
- National Drug Code in 5-4-2 Format
- ZZ
- Mutually Defined
Use this code only for International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS).
CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- Use this number for the product/service ID as identified by the preceding data element (EQ02-1).
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
- Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
- Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
- Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
- Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
Code indicating the level of coverage being provided for this insured
- It is at the sole discretion of the information source whether to support this functionality or not. If not supported, information source will process without this data element.
- FAM
- Family
Required when a 2100C HI segment is used. If not required by this implementation guide, do not send.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
- This first pointer designates the primary diagnosis for this EQ segment. Remaining diagnosis pointers indicate declining level of importance to the EQ segment. Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
Subscriber Spend Down Amount
To indicate the total monetary amount
- Use this segment only if it is necessary to report a Spend Down amount. Under certain Medicaid programs, individuals must indicate the dollar amount that they wish to apply towards their deductible. These programs require individuals to pay a certain amount towards their health care cost before Medicaid coverage starts.
- Required if Spend Down amount is being reported. If not required by this implementation guide, do not send.
Subscriber Spend Down Total Billed Amount
To indicate the total monetary amount
- Required if Spend Down amount is being reported in a separate 2110C AMT segment and the information source also requires the Spend Down Total Billed Amount. If not required by this implementation guide, do not send.
- Use this segment only if it is necessary to report the Spend Down Total Billed Amount in addition to the Spend Down Amount. See 2110C Subscriber Spend Down Amount segment for more information about Spend Down.
Subscriber Eligibility or Benefit Additional Inquiry Information
To report information
- Use the III segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment.
- Required when the information receiver believes the Facility Type information is relevant to the inquiry and the information is available. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- Use this code to specify the code that is following in the III02 is a Facility Type Code.
- ZZ
- Mutually Defined
Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of Service Codes for Professional Claims.
Code indicating a code from a specific industry code list
- Use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below; however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.
01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service
Subscriber Additional Information
To specify identifying information
- Required when the subscriber has received a referral or prior authorization number and the information receiver believes the information is relevant to the inquiry (such as for a benefit or procedure that requires a referral or prior authorization) and the information is available. If not required by this implementation guide do not send.
- Use this segment when it is necessary to provide a referral or prior authorization number for the benefit being inquired about.
Code qualifying the Reference Identification
- Use this code to specify or qualify the type of reference number that is following in REF02.
- 9F
- Referral Number
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this reference number as qualified by the preceding data element (REF01).;
Subscriber Eligibility/Benefit Date
To specify any or all of a date, a time, or a time period
- Use this segment to convey plan dates associated with the information contained in the corresponding EQ segment.
- This segment is only to be used to override dates provided in Loop 2100C when the date differs from the date provided in the DTP segment in Loop 2100C. Dates that apply to the entire request must be placed in the DTP segment in Loop 2100C. In order for a date to appear here, there must be a date or a date range in the corresponding 2100C loop.
- Required when the plan date(s) are different from the date(s) provided in the 2100C loop. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 291
- Plan
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- Use this code to specify the format of the date(s) or time(s) that follow in the next data element.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- Use this date for the date(s) as qualified by the preceding data elements.
Hierarchical Level
To identify dependencies among and the content of hierarchically related groups of data segments
A unique number assigned by the sender to identify a particular data segment in a hierarchical structure
- HL01 shall contain a unique alphanumeric number for each occurrence of the HL segment in the transaction set. For example, HL01 could be used to indicate the number of occurrences of the HL segment, in which case the value of HL01 would be "1" for the initial HL segment and would be incremented by one in each subsequent HL segment within the transaction.
Identification number of the next higher hierarchical data segment that the data segment being described is subordinate to
- HL02 identifies the hierarchical ID number of the HL segment to which the current HL segment is subordinate.
Code defining the characteristic of a level in a hierarchical structure
- HL03 indicates the context of the series of segments following the current HL segment up to the next occurrence of an HL segment in the transaction. For example, HL03 is used to indicate that subsequent segments in the HL loop form a logical grouping of data referring to shipment, order, or item-level information.
- 23
- Dependent
Code indicating if there are hierarchical child data segments subordinate to the level being described
- HL04 indicates whether or not there are subordinate (or child) HL segments related to the current HL segment.
- 0
- No Subordinate HL Segment in This Hierarchical Structure.
Dependent Trace Number
To uniquely identify a transaction to an application
- Trace numbers assigned at the dependent level are intended to allow tracing of an eligibility/benefit transaction when the dependent is the patient.
- The information receiver may assign one TRN segment in this loop if the dependent is the patient. A clearinghouse may assign one TRN segment in this loop if the dependent is the patient. See Section 1.4.6 Information Linkage.
- Required when information receiver or clearinghouse intends to use the TRN segment as a tracing mechanism for the eligibility transaction and the dependent is the patient. If not required by this implementation guide, do not send.
Code identifying which transaction is being referenced
- 1
- Current Transaction Trace Numbers
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN02 provides unique identification for the transaction.
- Use this number for the trace or reference number assigned by the information receiver or clearinghouse.
A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.
- TRN03 identifies an organization.
- Use this number for the identification number of the company that assigned the trace or reference number specified in the previous data element (TRN02).
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- TRN04 identifies a further subdivision within the organization.
- This information allows the originating company to further identify a specific division or group within that organization that was responsible for assigning the trace or reference number.
Dependent Name
To supply the full name of an individual or organizational entity
- Use this segment to identify an entity by name. This NM1 loop is used to identify the dependent of an insured or subscriber.
- Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
Code identifying an organizational entity, a physical location, property or an individual
- 03
- Dependent
Code qualifying the type of entity
- NM102 qualifies NM103.
- Use this code to indicate whether the entity is an individual person or an organization.
- 1
- Person
Individual last name or organizational name
- Use this name for the dependent's last name.
- Information sources cannot require dependent's name suffix be sent as a part of the dependent's last name.
First and Last name of the dependent exactly as they appear on the Anthem ID card. Populated for finding match for dependent.
Individual first name
- Use this name for the dependent's first name.
First and Last name of the dependent exactly as they appear on the Anthem ID card. Populated for finding match for dependent.
Individual middle name or initial
- Use this name for the dependent's middle name or initial.
Suffix to individual name
- Use this for the suffix to an individual's name; e.g., Sr., Jr. or III.
Dependent Additional Identification
To specify identifying information
- Use this segment when needed to convey identification numbers for the dependent. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100D loop.
- Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
- Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
OR
Required when this segment is used to transmit the Patient Account Number when REF01 = EJ (see Section 1.4.6).
OR
Required when this segment is used to transmit the Provider's Contract Number when REF01 = CT.
If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
Code qualifying the Reference Identification
- Use this code to specify or qualify the type of reference number that is following in REF02.
- Only one occurrence of each REF01 code value may be used in the 2100D loop.
Unless requested, do not send SSN (SY- Social Security Number)
- 6P
- Group Number
- SY
- Social Security Number
Unless requested, do not send SSN (SY- Social Security Number)
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this reference number as qualified by the preceding data element (REF01).;
Subscriber Supplemental Identifier
Coverage within span dates will be returned for the group number submitted over coverage for other group numbers.
Dependent Address
To specify the location of the named party
- Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.
Address information
- Use this information for the first line of the address information.
Address information
- Use this information for the second line of the address information.
Dependent City, State, ZIP Code
To specify the geographic place of the named party
- Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.
Free-form text for city name
- A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
Code (Standard State/Province) as defined by appropriate government agency
- N402 is required only if city name (N401) is in the U.S. or Canada.
Code defining international postal zone code excluding punctuation and blanks (zip code for United States)
Code identifying the country
- Use the alpha-2 country codes from Part 1 of ISO 3166.
Code identifying the country subdivision
- Use the country subdivision codes from Part 2 of ISO 3166.
Provider Information
To specify the identifying characteristics of a provider
- This segment must not be used to identify the information receiver or the information receiver's specialty type, unless the information is different from that sent in the 2100B loop.
- Required when the information source is known to process this information in creating a 271 response and the information receiver feels it is necessary to identify a specific provider or to associate a specialty type related to the service identified in the 2110D loop. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
- If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about when the provider is not the information receiver. For example, if the information receiver is a hospital and a referring provider must be identified, this is the segment where the referring provider would be identified.
- If identifying a specific provider, this segment contains reference;identification numbers, all of which may be used up until the time the;National Provider Identifier (NPI) is mandated for use. After the NPI is mandated, only the code for National Provider Identifier may be used.
- If identifying a type of specialty associated with the services identified in loop 2110D, use code PXC in PRV02 and the appropriate code in PRV03.
- PRV02 qualifies PRV03.
Code identifying the type of provider
- AD
- Admitting
- AT
- Attending
- BI
- Billing
- CO
- Consulting
- CV
- Covering
- H
- Hospital
- HH
- Home Health Care
- LA
- Laboratory
- OT
- Other Physician
- P1
- Pharmacist
- P2
- Pharmacy
- PC
- Primary Care Physician
- PE
- Performing
- R
- Rural Health Clinic
- RF
- Referring
- SK
- Skilled Nursing Facility
- SU
- Supervising
Code qualifying the Reference Identification
- If this segment is used to identify a specific provider and the National Provider ID is mandated for use, code value "HPI" must be used, otherwise one of the other code values may be used.
- If this segment is used to identify a type of specialty associated with the services identified in loop 2110D, use code PXC.
Unless requested, do not send SSN (SY – Social Security Number)
- 9K
- Servicer
Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.
- D3
- National Council for Prescription Drug Programs Pharmacy Number
- EI
- Employer's Identification Number
- HPI
- Centers for Medicare and Medicaid Services National Provider Identifier
Required value when identifying a specific provider when the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.
- PXC
- Health Care Provider Taxonomy Code
- SY
- Social Security Number
Unless requested, do not send SSN (SY – Social Security Number)
- TJ
- Federal Taxpayer's Identification Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this reference number as qualified by the preceding data element (PRV02).
Dependent Demographic Information
To supply demographic information
- Use this segment when needed to convey the birth date or gender demographic information for the dependent.
- Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
- Required when the dependent is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).
OR
Required when the dependent is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).
OR
Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
If not required by this implementation guide, do not send.
Code indicating the date format, time format, or date and time format
- Use this code to indicate the format of the date of birth that follows in DMG02.
- D8
- Date Expressed in Format CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- DMG02 is the date of birth.
- Use this date for the date of birth of the individual.;
Code indicating the sex of the individual
- Use this code to indicate the dependent's gender.
- F
- Female
- M
- Male
Dependent Relationship
To provide benefit information on insured entities
- Different types of health plans identify patients in different manners;depending upon how their eligibility is structured. However, two;approaches predominate.
The first approach is to assign each member of the family (and plan) a;unique ID number. This number can be used to identify and access;that individual's information independent of whether he or she is a;child, spouse, or the actual subscriber to the plan. The relationship of this individual to the actual subscriber or contract holder would be;one of spouse, child, self, etc.
The second approach is to assign the actual subscriber or contract;holder a unique ID number that is entered into the eligibility system.;Any related spouse, children, or dependents are identified through the;subscriber's ID and have no unique identification number of their;own. In this approach, the subscriber would be identified at the Loop;2100C subscriber or insured level and the actual patient (spouse,;child, etc.) would be identified at the Loop 2100D dependent level;under the subscriber.
- Required when the information receiver believes it is necessary to identify for an Alternate Search Option supported by the Information Source (See Section 1.4.8) the dependent's relationship to the insured and/or the birth sequence of the dependent in the case of multiple births with the same birth date. If not required by this implementation guide, do not send.
Code indicating a Yes or No condition or response
- INS01 indicates status of the insured. A "Y" value indicates the insured is a subscriber: an "N" value indicates the insured is a dependent.
- N
- No
Code indicating the relationship between two individuals or entities
- 01
- Spouse
- 19
- Child
- 34
- Other Adult
A generic number
- INS17 is the number assigned to each family member born with the same birth date. This number identifies birth sequence for multiple births allowing proper tracking and response of benefits for each dependent (i.e., twins, triplets, etc.).
Dependent Health Care Diagnosis Code
To supply information related to the delivery of health care
- Use the HI segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the dependent if that information cannot be returned in the 271 response.
- Required when the information receiver believes the Diagnosis information is relevant to the inquiry, the information is available and if the information source supports or is believed to support this level of functionality. If not required by this implementation guide, do not send.
- Use this segment to identify Diagnosis codes as they relate to the information provided in the EQ segments.
- Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABK
- International Classification of Diseases Clinical Modification (ICD-10-CM) Principal Diagnosis
- BK
- International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data element has been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Required when it is necessary to report an additional diagnosis and the preceding HI data elements have been used to report other diagnoses. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.
- ABF
- International Classification of Diseases Clinical Modification (ICD-10-CM) Diagnosis
- BF
- International Classification of Diseases Clinical Modification (ICD-9-CM) Diagnosis
Code indicating a code from a specific industry code list
- If C022-08 is used, then C022-02 represents the beginning value in a range of codes.
Dependent Date
To specify any or all of a date, a time, or a time period
- Absence of a Plan date indicates the request is for the date the transaction is processed and the information source is to process the transaction in the same manner as if the processing date was sent.
- Use this segment to convey the plan date(s) for the dependent or for the issue date of the dependent's identification card for the information source.
- When using code "291" (Plan) at this level, it is implied that these dates apply to all of the Eligibility or Benefit Inquiry (EQ) loops that follow. If there is a need to supply a different Plan date for a specific EQ loop, it must be provided in the DTP segment within the EQ loop and it will only apply to that EQ loop.
- Required when the information receiver wishes to convey the plan date(s) for the dependent in relation to the eligibility/benefit inquiry. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
OR
Required when utilizing a search option other than either the Primary Search Option or a Required Alternate Search Option identified in section 1.4.8 which requires the ID Card Issue Date. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
Code specifying type of date or time, or both date and time
- 291
- Plan
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- Use this code to specify the format of the date(s) or time(s) that follow in the next data element.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- Use this date for the date(s) as qualified by the preceding data elements.
Please refer to the Phase 1 CORE Operating Rules, Section
154, Subsection 1.3: Eligibility Dates, for date requirements.
Dependent Eligibility or Benefit Inquiry
To specify inquired eligibility or benefit information
- Use this segment to begin the eligibility/benefit inquiry looping structure.
- If the EQ segment is used, either EQ01 - Service Type Code or EQ02 - Composite Medical Procedure Identifier must be used. Only EQ01 or EQ02 is to be sent, not both.
An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01. An information source may support the use of Service Type Codes other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion.
An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes can be supplied in the 2100D HI segment and place of service in the 2110D III segment.
- If an information source receives a Service Type Code "30" submitted in the 270 EQ01 or a Service Type Code that they do not support, the 2110D EB03 values identified in Section 1.4.7.1 Item #8 must also be returned if they are a covered benefit category at a plan level. Refer to Section 1.4.7 for additional information.
- EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
Code identifying the classification of service
- Position of data in the repeating data element conveys no significance.
- An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01.
- An information source may support the use of Service Type Codes from the list other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion. If an information source supports codes in addition to "30", the information source may provide a list of the supported codes from the list below to the information receiver. If no list is provided, an information receiver may transmit the most appropriate code.
- If an inquiry is submitted with a Service Type Code from the list other than "30" and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of "30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.
- EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
- Not used if EQ02 is used.
Use 30 for Health Benefit Coverage or other specific value listed in the Basic Instructions of this document. Only first value is used to determine response.
- 1
- Medical Care
- 2
- Surgical
- 3
- Consultation
- 4
- Diagnostic X-Ray
- 5
- Diagnostic Lab
- 6
- Radiation Therapy
- 7
- Anesthesia
- 8
- Surgical Assistance
- 9
- Other Medical
- 10
- Blood Charges
- 11
- Used Durable Medical Equipment
- 12
- Durable Medical Equipment Purchase
- 13
- Ambulatory Service Center Facility
- 14
- Renal Supplies in the Home
- 15
- Alternate Method Dialysis
- 16
- Chronic Renal Disease (CRD) Equipment
- 17
- Pre-Admission Testing
- 18
- Durable Medical Equipment Rental
- 19
- Pneumonia Vaccine
- 20
- Second Surgical Opinion
- 21
- Third Surgical Opinion
- 22
- Social Work
- 23
- Diagnostic Dental
- 24
- Periodontics
- 25
- Restorative
- 26
- Endodontics
- 27
- Maxillofacial Prosthetics
- 28
- Adjunctive Dental Services
- 30
- Health Benefit Plan Coverage
If only a single category of inquiry can be supported, use this code.
- 32
- Plan Waiting Period
- 33
- Chiropractic
- 34
- Chiropractic Office Visits
- 35
- Dental Care
- 36
- Dental Crowns
- 37
- Dental Accident
- 38
- Orthodontics
- 39
- Prosthodontics
- 40
- Oral Surgery
- 41
- Routine (Preventive) Dental
- 42
- Home Health Care
- 43
- Home Health Prescriptions
- 44
- Home Health Visits
- 45
- Hospice
- 46
- Respite Care
- 47
- Hospital
- 48
- Hospital - Inpatient
- 49
- Hospital - Room and Board
- 50
- Hospital - Outpatient
- 51
- Hospital - Emergency Accident
- 52
- Hospital - Emergency Medical
- 53
- Hospital - Ambulatory Surgical
- 54
- Long Term Care
- 55
- Major Medical
- 56
- Medically Related Transportation
- 57
- Air Transportation
- 58
- Cabulance
- 59
- Licensed Ambulance
- 60
- General Benefits
- 61
- In-vitro Fertilization
- 62
- MRI/CAT Scan
- 63
- Donor Procedures
- 64
- Acupuncture
- 65
- Newborn Care
- 66
- Pathology
- 67
- Smoking Cessation
- 68
- Well Baby Care
- 69
- Maternity
- 70
- Transplants
- 71
- Audiology Exam
- 72
- Inhalation Therapy
- 73
- Diagnostic Medical
- 74
- Private Duty Nursing
- 75
- Prosthetic Device
- 76
- Dialysis
- 77
- Otological Exam
- 78
- Chemotherapy
- 79
- Allergy Testing
- 80
- Immunizations
- 81
- Routine Physical
- 82
- Family Planning
- 83
- Infertility
- 84
- Abortion
- 85
- AIDS
- 86
- Emergency Services
- 87
- Cancer
- 88
- Pharmacy
- 89
- Free Standing Prescription Drug
- 90
- Mail Order Prescription Drug
- 91
- Brand Name Prescription Drug
- 92
- Generic Prescription Drug
- 93
- Podiatry
- 94
- Podiatry - Office Visits
- 95
- Podiatry - Nursing Home Visits
- 96
- Professional (Physician)
- 97
- Anesthesiologist
- 98
- Professional (Physician) Visit - Office
- 99
- Professional (Physician) Visit - Inpatient
- A0
- Professional (Physician) Visit - Outpatient
- A1
- Professional (Physician) Visit - Nursing Home
- A2
- Professional (Physician) Visit - Skilled Nursing Facility
- A3
- Professional (Physician) Visit - Home
- A4
- Psychiatric
- A5
- Psychiatric - Room and Board
- A6
- Psychotherapy
- A7
- Psychiatric - Inpatient
- A8
- Psychiatric - Outpatient
- A9
- Rehabilitation
- AA
- Rehabilitation - Room and Board
- AB
- Rehabilitation - Inpatient
- AC
- Rehabilitation - Outpatient
- AD
- Occupational Therapy
- AE
- Physical Medicine
- AF
- Speech Therapy
- AG
- Skilled Nursing Care
- AH
- Skilled Nursing Care - Room and Board
- AI
- Substance Abuse
- AJ
- Alcoholism
- AK
- Drug Addiction
- AL
- Vision (Optometry)
- AM
- Frames
- AN
- Routine Exam
Use for Routine Vision Exam only.
- AO
- Lenses
- AQ
- Nonmedically Necessary Physical
- AR
- Experimental Drug Therapy
- B1
- Burn Care
- B2
- Brand Name Prescription Drug - Formulary
- B3
- Brand Name Prescription Drug - Non-Formulary
- BA
- Independent Medical Evaluation
- BB
- Partial Hospitalization (Psychiatric)
- BC
- Day Care (Psychiatric)
- BD
- Cognitive Therapy
- BE
- Massage Therapy
- BF
- Pulmonary Rehabilitation
- BG
- Cardiac Rehabilitation
- BH
- Pediatric
- BI
- Nursery
- BJ
- Skin
- BK
- Orthopedic
- BL
- Cardiac
- BM
- Lymphatic
- BN
- Gastrointestinal
- BP
- Endocrine
- BQ
- Neurology
- BR
- Eye
- BS
- Invasive Procedures
- BT
- Gynecological
- BU
- Obstetrical
- BV
- Obstetrical/Gynecological
- BW
- Mail Order Prescription Drug: Brand Name
- BX
- Mail Order Prescription Drug: Generic
- BY
- Physician Visit - Office: Sick
- BZ
- Physician Visit - Office: Well
- C1
- Coronary Care
- CA
- Private Duty Nursing - Inpatient
- CB
- Private Duty Nursing - Home
- CC
- Surgical Benefits - Professional (Physician)
- CD
- Surgical Benefits - Facility
- CE
- Mental Health Provider - Inpatient
- CF
- Mental Health Provider - Outpatient
- CG
- Mental Health Facility - Inpatient
- CH
- Mental Health Facility - Outpatient
- CI
- Substance Abuse Facility - Inpatient
- CJ
- Substance Abuse Facility - Outpatient
- CK
- Screening X-ray
- CL
- Screening laboratory
- CM
- Mammogram, High Risk Patient
- CN
- Mammogram, Low Risk Patient
- CO
- Flu Vaccination
- CP
- Eyewear and Eyewear Accessories
- CQ
- Case Management
- DG
- Dermatology
- DM
- Durable Medical Equipment
- DS
- Diabetic Supplies
- GF
- Generic Prescription Drug - Formulary
- GN
- Generic Prescription Drug - Non-Formulary
- GY
- Allergy
- IC
- Intensive Care
- MH
- Mental Health
- NI
- Neonatal Intensive Care
- ON
- Oncology
- PT
- Physical Therapy
- PU
- Pulmonary
- RN
- Renal
- RT
- Residential Psychiatric Treatment
- TC
- Transitional Care
- TN
- Transitional Nursery Care
- UC
- Urgent Care
Required if utilizing a Medical Procedure Code inquiry when the information receiver believes that the information source supports this high level of functionality and EQ01 is not used. If not required by this implementation guide, do not send.
271 Response is based on value submitted in EQ01. Recommended to not submit value in EQ02.
Code identifying the type/source of the descriptive number used in Product/Service ID (234)
- C003-01 qualifies C003-02 and C003-08.
- Use this code to qualify the type of specific Product/Service ID that will be used in EQ02-2.
- AD
- American Dental Association Codes
- CJ
- Current Procedural Terminology (CPT) Codes
- HC
- Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
- ID
- International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
- IV
- Home Infusion EDI Coalition (HIEC) Product/Service Code
- N4
- National Drug Code in 5-4-2 Format
- ZZ
- Mutually Defined
Use this code only for International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS).
CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
Identifying number for a product or service
- If C003-08 is used, then C003-02 represents the beginning value in the range in which the code occurs.
- Use this number for the product/service ID as identified by the preceding data element (EQ02-1).
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-03 modifies the value in C003-02 and C003-08.
- Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-04 modifies the value in C003-02 and C003-08.
- Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-05 modifies the value in C003-02 and C003-08.
- Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
This identifies special circumstances related to the performance of the service, as defined by trading partners
- C003-06 modifies the value in C003-02 and C003-08.
- Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
Required when a 2100D HI segment is used. If not required by this implementation guide, do not send.
A pointer to the diagnosis code in the order of importance to this service
- C004-01 identifies the primary diagnosis code for this service line.
- This first pointer designates the primary diagnosis for this EQ segment. Remaining diagnosis pointers indicate declining level of importance to the EQ segment. Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
A pointer to the diagnosis code in the order of importance to this service
- C004-02 identifies the second diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
A pointer to the diagnosis code in the order of importance to this service
- C004-03 identifies the third diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
A pointer to the diagnosis code in the order of importance to this service
- C004-04 identifies the fourth diagnosis code for this service line.
- Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
Dependent Eligibility or Benefit Additional Inquiry Information
To report information
- Use the III segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment.
- Required when the information receiver believes the Facility Type information is relevant to the inquiry and the information is available. If not required by this implementation guide, do not send.
Code identifying a specific industry code list
- Use this code to specify the code that is following in the III02 is a Facility Type Code.
- ZZ
- Mutually Defined
Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of Service Codes for Professional Claims.
Code indicating a code from a specific industry code list
- Use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below; however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.
01 Pharmacy
03 School
04 Homeless Shelter
05 Indian Health Service Free-standing Facility
06 Indian Health Service Provider-based Facility
07 Tribal 638 Free-standing Facility
08 Tribal 638 Provider-based Facility
11 Office
12 Home
13 Assisted Living Facility
14 Group Home
15 Mobile Unit
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room - Hospital
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
41 Ambulance - Land
42 Ambulance - Air or Water
49 Independent Clinic
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility - Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
57 Non-residential Substance Abuse Treatment Facility
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End-Stage Renal Disease Treatment Facility
71 Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other Place of Service
Dependent Additional Information
To specify identifying information
- Required when the dependent has received a referral or prior authorization number and the information receiver believes the information is relevant to the inquiry (such as for a benefit or procedure that requires a referral or prior authorization) and the information is available. If not required by this implementation guide do not send.
- Use this segment when it is necessary to provide a referral or prior authorization number for the benefit being inquired about.
Code qualifying the Reference Identification
- Use this code to specify or qualify the type of reference number that is following in REF02.
- 9F
- Referral Number
- G1
- Prior Authorization Number
Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier
- Use this reference number as qualified by the preceding data element (REF01).;
Dependent Eligibility/Benefit Date
To specify any or all of a date, a time, or a time period
- Use this segment to convey plan dates associated with the information contained in the corresponding EQ segment.
- This segment is only to be used to override dates provided in Loop 2100D when the date differs from the date provided in the DTP segment in Loop 2100D. Dates that apply to the entire request must be placed in the DTP segment in Loop 2100D. In order for a date to appear here, there must be a date or a date range in the corresponding 2100D loop.
- Required when the plan date(s) are different from the date(s) provided in the 2100C loop. If not required by this implementation guide, do not send.
Code specifying type of date or time, or both date and time
- 291
- Plan
Code indicating the date format, time format, or date and time format
- DTP02 is the date or time or period format that will appear in DTP03.
- Use this code to specify the format of the date(s) or time(s) that follow in the next data element.
- D8
- Date Expressed in Format CCYYMMDD
- RD8
- Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
Expression of a date, a time, or range of dates, times or dates and times
- Use this date for the date(s) as qualified by the preceding data elements.
Transaction Set Trailer
To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)
- Use this segment to mark the end of a transaction set and provide control information on the total number of segments included in the transaction set.
Total number of segments included in a transaction set including ST and SE segments
- Use this number to indicate the total number of segments included in the transaction set inclusive of the ST and SE segments.
Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set
- The transaction set control numbers in ST02 and SE02 must be identical. This unique number also aids in error resolution research. Start with a number, for example "0001", and increment from there. This number must be unique within a specific functional group (segments GS through GE) and interchange, but can repeat in other groups and interchanges.
Functional Group Trailer
To indicate the end of a functional group and to provide control information
Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element
Assigned number originated and maintained by the sender
Interchange Control Trailer
To define the end of an interchange of zero or more functional groups and interchange-related control segments
Example 1: Generic Request By a Clinic for the Patient’s (Subscriber) Eligibility
BHT*0022*13*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
HL*3*2*22*0~
TRN*1*93175-012547*9877281234~
NM1*IL*1*SMITH*ROBERT****MI*11122333301~
DMG*D8*19430519~
DTP*291*D8*20060501~
EQ*30~
SE*13*1234~
Example 2: Generic Request by a Physician for the Patient’s (Dependent) Eligibility
BHT*0022*13*10001235*20060501*1320~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*040~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS****SV*0202034~
HL*3*2*22*1~
NM1*IL*1******MI*11122333301~
HL*4*3*23*0~
TRN*1*93175-012547*9877281234~
NM1*03*1*SMITH*MARY~
DMG*D8*19781014~
DTP*291*D8*20060501~
EQ*30~
SE*15*1235~
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