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Health Care Eligibility Benefit Response (X279A1)
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X12 271 Health Care Eligibility Benefit Response (X279A1)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Information Transaction Set (271) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to communicate information about or changes to eligibility, coverage or benefits from information sources (such as - insurers, sponsors, payors) to information receivers (such as - physicians, hospitals, repair facilities, third party administrators, governmental agencies). This information includes but is not limited to: benefit status, explanation of benefits, coverages, dependent coverage level, effective dates, amounts for co-insurance, co-pays, deductibles, exclusions and limitations.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI sample
  • Example 1b: Error Response from Payer to Clinic Not Eligible for Inquiries with Payer
View the latest version of this implementation guide as an interactive webpage
https://www.stedi.com/app/guides/view/health-partner-plans/health-care-eligibility-benefit-response-x279a1/01H16H334MDWERMA8J28N0FJQM
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Overview
ISA
-
Interchange Control Header
Max use 1
Required
GS
-
Functional Group Header
Max use 1
Required
heading
detail
Information Source Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
AAA
0250
Request Validation
Max use 9
Optional
Information Receiver Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
Subscriber Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Subscriber Trace Number
Max use 3
Optional
Subscriber Name Loop
NM1
0300
Subscriber Name
Max use 1
Required
REF
0400
Subscriber Additional Identification
Max use 9
Optional
N3
0600
Subscriber Address
Max use 1
Optional
N4
0700
Subscriber City, State, ZIP Code
Max use 1
Optional
AAA
0850
Subscriber Request Validation
Max use 9
Optional
PRV
0900
Provider Information
Max use 1
Optional
DMG
1000
Subscriber Demographic Information
Max use 1
Optional
INS
1100
Subscriber Relationship
Max use 1
Optional
HI
1150
Subscriber Health Care Diagnosis Code
Max use 1
Optional
DTP
1200
Subscriber Date
Max use 9
Optional
MPI
1275
Subscriber Military Personnel Information
Max use 1
Optional
Dependent Level Loop
HL
0100
Hierarchical Level
Max use 1
Required
TRN
0200
Dependent Trace Number
Max use 3
Optional
Dependent Name Loop
NM1
0300
Dependent Name
Max use 1
Required
REF
0400
Dependent Additional Identification
Max use 9
Optional
N3
0600
Dependent Address
Max use 1
Optional
N4
0700
Dependent City, State, ZIP Code
Max use 1
Optional
AAA
0850
Dependent Request Validation
Max use 9
Optional
PRV
0900
Provider Information
Max use 1
Optional
DMG
1000
Dependent Demographic Information
Max use 1
Optional
INS
1100
Dependent Relationship
Max use 1
Optional
HI
1150
Dependent Health Care Diagnosis Code
Max use 1
Optional
DTP
1200
Dependent Date
Max use 9
Optional
MPI
1275
Dependent Military Personnel Information
Max use 1
Optional
SE
4100
Transaction Set Trailer
Max use 1
Required
GE
-
Functional Group Trailer
Max use 1
Required
IEA
-
Interchange Control Trailer
Max use 1
Required
ISA

Interchange Control Header

RequiredMax use 1

To start and identify an interchange of zero or more functional groups and interchange-related control segments

Example
ISA-01
I01
Authorization Information Qualifier
Required
Identifier (ID)

Code identifying the type of information in the Authorization Information

00
No Authorization Information Present (No Meaningful Information in I02)
ISA-02
I02
Authorization Information
Required
String (AN)
Min 10Max 10

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)

ISA-03
I03
Security Information Qualifier
Required
Identifier (ID)

Code identifying the type of information in the Security Information

00
No Security Information Present (No Meaningful Information in I04)
ISA-04
I04
Security Information
Required
String (AN)
Min 10Max 10

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)

ISA-05
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

Codes
ISA-06
I06
Interchange Sender ID
Required
String (AN)
Min 15Max 15

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

ISA-07
I05
Interchange ID Qualifier
Required
Identifier (ID)
Min 2Max 2

Code indicating the system/method of code structure used to designate the sender or receiver ID element being qualified

Codes
ISA-08
I07
Interchange Receiver ID
Required
String (AN)
Min 15Max 15

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

ISA-09
I08
Interchange Date
Required
Date (DT)
YYMMDD format

Date of the interchange

ISA-10
I09
Interchange Time
Required
Time (TM)
HHMM format

Time of the interchange

ISA-11
I65
Repetition Separator
Required
String (AN)
Min 1Max 1

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
ISA-12
I11
Interchange Control Version Number
Required
Identifier (ID)

Code specifying the version number of the interchange control segments

00501
Standards Approved for Publication by ASC X12 Procedures Review Board through October 2003
ISA-13
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

ISA-14
I13
Acknowledgment Requested
Required
Identifier (ID)
Min 1Max 1

Code indicating sender's request for an interchange acknowledgment

0
No Interchange Acknowledgment Requested
1
Interchange Acknowledgment Requested (TA1)
ISA-15
I14
Interchange Usage Indicator
Required
Identifier (ID)
Min 1Max 1

Code indicating whether data enclosed by this interchange envelope is test, production or information

I
Information
P
Production Data
T
Test Data
ISA-16
I15
Component Element Separator
Required
String (AN)
Min 1Max 1

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
GS

Functional Group Header

RequiredMax use 1

To indicate the beginning of a functional group and to provide control information

Example
GS-01
479
Functional Identifier Code
Required
Identifier (ID)

Code identifying a group of application related transaction sets

HB
Eligibility, Coverage or Benefit Information (271)
GS-02
142
Application Sender's Code
Required
String (AN)
Min 2Max 15

Code identifying party sending transmission; codes agreed to by trading partners

GS-03
124
Application Receiver's Code
Required
String (AN)
Min 2Max 15

Code identifying party receiving transmission; codes agreed to by trading partners

GS-04
373
Date
Required
Date (DT)
CCYYMMDD format

Date expressed as CCYYMMDD where CC represents the first two digits of the calendar year

GS-05
337
Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

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)

GS-06
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

GS-07
455
Responsible Agency Code
Required
Identifier (ID)
Min 1Max 2

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
GS-08
480
Version / Release / Industry Identifier Code
Required
String (AN)

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

ST
0100
Heading > ST

Transaction Set Header

RequiredMax use 1

To indicate the start of a transaction set and to assign a control number

Usage notes
  • 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.
Example
ST-01
143
Transaction Set Identifier Code
Required
Identifier (ID)

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).
Usage notes
  • 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.
271
Eligibility, Coverage or Benefit Information
ST-02
329
Transaction Set Control Number
Required
Numeric (N)
Min 4Max 9

Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set

Usage notes
  • 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.
ST-03
1705
Implementation Convention Reference
Required
String (AN)

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.
Usage notes
  • 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
BHT
0200
Heading > BHT

Beginning of Hierarchical Transaction

RequiredMax use 1

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

Usage notes
  • Use this required segment to start the transaction set and indicate the sequence of the hierarchical levels of information that will follow in Table 2.
Example
BHT-01
1005
Hierarchical Structure Code
Required
Identifier (ID)

Code indicating the hierarchical application structure of a transaction set that utilizes the HL segment to define the structure of the transaction set

Usage notes
  • 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
BHT-02
353
Transaction Set Purpose Code
Required
Identifier (ID)

Code identifying purpose of transaction set

11
Response
BHT-03
127
Submitter Transaction Identifier
Optional
String (AN)
Min 1Max 50

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.
Usage notes
  • This information may be sent at the creator of the 271's discretion if using the transaction in a Batch mode and a Submitter Transaction Identifier was received in the 270 transaction BHT03, otherwise this is not used. 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 the identifier received in the BHT03 of the corresponding 270 transaction. This identifier is not to be passed through the complete life of the transaction, rather replaced with the identifier received in the 270.
BHT-04
373
Transaction Set Creation Date
Required
Date (DT)
CCYYMMDD format

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.
Usage notes
  • Use this date for the date the transaction set was generated.
BHT-05
337
Transaction Set Creation Time
Required
Time (TM)
HHMM, HHMMSS, HHMMSSD, or HHMMSSDD format

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.
Usage notes
  • Use this time for the time the transaction set was generated.
Heading end

Detail

2000A Information Source Level Loop
RequiredMax >1
HL
0100
Detail > Information Source Level Loop > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

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.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

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
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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.
AAA
0250
Detail > Information Source Level Loop > AAA

Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Use of this segment at this location in the HL is to identify reasons why a request cannot be processed based on the entities identified in ISA06, ISA08, GS02 or GS03.
  • Required when the request could not be processed at a system or application level based on the entities identified in ISA06, ISA08, GS02 or GS03 and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Y
Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

Usage notes
  • Use this code to indicate the reason why the transaction was unable to be processed successfully by the entity identified in either ISA08 or GS03.
04
Authorized Quantity Exceeded

Use this code to indicate that the transaction exceeds the number of patient requests allowed by the entity identified in either ISA08 or GS03. See section 1.4.3 Batch and Real Time for more information regarding the number of patient requests allowed in a transaction. This is not to be used to indicate that the number of patient requests exceeds the number allowed by the Information Source identified in Loop 2100A.

41
Authorization/Access Restrictions

Use this code to indicate that the entity identified in GS02 is not authorized to submit 270 transactions to the entity identified in either ISA08 or GS03. This is not to be used to indicate Authorization/Access Restrictions as related to the Information Source Identified in Loop 2100A.

42
Unable to Respond at Current Time

Use this code to indicate that the entity identified in either ISA08 or GS03 is unable to process the transaction at the current time. This indicates that there is a problem within the systems of the entity identified in either ISA08 or GS03 and is not related to any problem with the Information Source Identified in Loop 2100A.

79
Invalid Participant Identification

Use this code to indicate that the value in either GS02 or GS03 is invalid.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

Usage notes
  • Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).
C
Please Correct and Resubmit
N
Resubmission Not Allowed
P
Please Resubmit Original Transaction
R
Resubmission Allowed
S
Do Not Resubmit; Inquiry Initiated to a Third Party
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
2100A Information Source Name Loop
RequiredMax 1
NM1
0300
Detail > Information Source Level Loop > Information Source Name Loop > NM1

Information Source Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Use this segment to identify an entity by name and identification number. This NM1 loop is used to identify the eligibility or benefit information source (e.g., insurance company, HMO, IPA, employer).
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
Usage notes
  • Use this code to indicate whether the entity is an individual person or an organization.
1
Person
2
Non-Person Entity
NM1-03
1035
Information Source Last or Organization Name
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

Usage notes
  • Use this name for the organization name if NM102 is "2". Otherwise, this will be the individual's last name.
NM1-04
1036
Information Source First Name
Optional
String (AN)
Min 1Max 35

Individual first name

NM1-05
1037
Information Source Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Information Source Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • 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
46
Electronic Transmitter Identification Number (ETIN)
FI
Federal Taxpayer's Identification Number
NI
National Association of Insurance Commissioners (NAIC) Identification
PI
Payor Identification
XV
Centers for Medicare and Medicaid Services PlanID
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Information Source Primary Identifier
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

PER
0800
Detail > Information Source Level Loop > Information Source Name Loop > PER

Information Source Contact Information

OptionalMax use 3

To identify a person or office to whom administrative communications should be directed

Usage notes
  • If this segment is used, at a minimum either PER02 must be used or PER03 and PER04 must be used. It is recommended that at least PER02, PER03 and PER04 are sent if this segment is used.
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
  • Required when the Information Source desires to advise the Information Receiver on how to contact the Information Source about this eligibility response. If not required by this implementation guide, may be provided at the sender's discretion, but cannot be required by the receiver.
Example
If either Communication Number Qualifier (PER-03) or Information Source Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Information Source Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Information Source Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

Usage notes
  • Use this code to specify the type of person or group to which the contact number applies.
IC
Information Contact
PER-02
93
Information Source Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

Usage notes
  • Use this data element when the name of the individual to contact is not already defined or is different than the name within the prior name segment (e.g. N1 or NM1).
PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

Usage notes
  • Use this code to specify what type of communication number is following.
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-04
364
Information Source Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

Usage notes
  • Use this for the communication number or URL as qualified by the preceding data element.
  • The format for US domestic phone numbers is:
    AAABBBCCCC
    AAA = Area Code
    BBBCCCC = Local Number
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

Usage notes
  • Use this code to specify what type of communication number is following.
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-06
364
Information Source Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

Usage notes
  • The format for US domestic phone numbers is:
    AAABBBCCCC
    AAA = Area Code
    BBBCCCC = Local Number
  • Use this for the communication number or URL as qualified by the preceding data element.
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

Usage notes
  • Use this code to specify what type of communication number is following.
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
PER-08
364
Information Source Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

Usage notes
  • The format for US domestic phone numbers is:
    AAABBBCCCC
    AAA = Area Code
    BBBCCCC = Local Number
  • Use this for the communication number or URL as qualified by the preceding data element.
AAA
0850
Detail > Information Source Level Loop > Information Source Name Loop > AAA

Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request could not be processed at a system or application level when specifically related to the information source data contained in the original 270 transaction's information source name loop (Loop 2100A) or to indicate that the information source itself is experiencing system problems and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.
  • Use this segment to indicate problems in processing the transaction;specifically related to the information source data contained in the;original 270 transaction's information source name loop (Loop 2100A);or to indicate that the information source itself is experiencing system problems.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Y
Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

Usage notes
  • Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.
04
Authorized Quantity Exceeded

Use this code to indicate that the transaction exceeds the number of patient requests allowed by the Information Source identified in Loop 2100A. See section 1.4.3 Batch and Real Time for more information regarding the number of patient requests allowed in a transaction.

41
Authorization/Access Restrictions

Use this code to indicate that the entity identified in ISA06 or GS02 is not authorized to submit 270 transactions to the Information Source Identified in Loop 2100A.

42
Unable to Respond at Current Time

Use this code to indicate that Information Source Identified in Loop 2100A is unable to process the transaction at the current time. This indicates that there is a problem within the Information Source's system.

79
Invalid Participant Identification

Use this code to indicate that Information Source Identified in Loop 2100A is invalid. If the transaction is processed by a clearing house, VAN, etc., use this code to indicate that the Information Source Identified in Loop 2100A is not a valid identifier for Information Sources the clearing house, VAN, etc. have access to. If the transaction is sent directly to the Information Source, use this code to indicate that the Information Source Identified in Loop 2100A is not a valid identifier.

80
No Response received - Transaction Terminated

Use this code only if the transaction is processed by a clearing house, VAN, etc. Use this code to indicate that the transaction was sent to the Information Source identified in Loop 2100A however no response was received in the expected time frame.

This code must not be used by the Information Source identified in Loop 2100A.

T4
Payer Name or Identifier Missing

Use this code to indicate that either the name or identifier for Information Source Identified in Loop 2100A is missing.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

Usage notes
  • Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).
C
Please Correct and Resubmit
N
Resubmission Not Allowed
P
Please Resubmit Original Transaction
R
Resubmission Allowed
S
Do Not Resubmit; Inquiry Initiated to a Third Party
W
Please Wait 30 Days and Resubmit
X
Please Wait 10 Days and Resubmit
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
2100A Information Source Name Loop end
2000B Information Receiver Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

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.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

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.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

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
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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.
2100B Information Receiver Name Loop
RequiredMax 1
NM1
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > NM1

Information Receiver Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • 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, IPA, or hospital).
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

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
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
Usage notes
  • Use this code to indicate whether the entity is an individual person or an organization.
1
Person
2
Non-Person Entity
NM1-03
1035
Information Receiver Last or Organization Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

Usage notes
  • Use this name for the organization name if the entity type qualifier is a non-person entity. Otherwise, this will be the individual's last name.
NM1-04
1036
Information Receiver First Name
Optional
String (AN)
Min 1Max 35

Individual first name

Usage notes
  • Use this name only if NM102 is "1".
NM1-05
1037
Information Receiver Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

Usage notes
  • Use this name only if NM102 is "1".
NM1-07
1039
Information Receiver Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

Usage notes
  • Use name suffix only if NM102 is "1"; e.g., Sr., Jr., or III.
NM1-08
66
Identification Code Qualifier
Required
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • 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

The social security number may not be used for any Federally administered programs such as Medicare.

FI
Federal Taxpayer's Identification Number
PI
Payor Identification

Use this code only when the information receiver is a payer.

PP
Pharmacy Processor Number
SV
Service Provider Number

Use this code for the identification number assigned by the information source.

XV
Centers for Medicare and Medicaid Services PlanID
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Information Receiver Identification Number
Required
String (AN)
Min 2Max 80

Code identifying a party or other code

REF
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > REF

Information Receiver Additional Identification

OptionalMax use 9

To specify identifying information

Usage notes
  • 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 this information was used from the 270 transaction 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.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes
  • Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
  • 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

The social security number may not be used for any Federally administered programs such as Medicare.

TJ
Federal Taxpayer's Identification Number
REF-02
127
Information Receiver Additional Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Use this information for the reference number as qualified by the preceding data element (REF01).;
REF-03
352
Information Receiver Additional Identifier State
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

Usage notes
  • Use this element for the two character state code of the state assigning the identifier supplied in REF02.

See Code source 22: States and Outlying Areas of the U.S.

N3
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > N3

Information Receiver Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when this information was used from the 270 transaction 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.
Example
N3-01
166
Information Receiver Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this information for the first line of the address information.
N3-02
166
Information Receiver Additional Address Line
Optional
String (AN)
Min 1Max 55

Address information

N4
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > N4

Information Receiver City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when this information was used from the 270 transaction 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.
Example
Only one of Information Receiver State Code (N4-02) or Country Subdivision Code (N4-07) may be present
If Country Subdivision Code (N4-07) is present, then Country Code (N4-04) is required
N4-01
19
Information Receiver City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Information Receiver State Code
Optional
Identifier (ID)
Min 2Max 2

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.
N4-03
116
Information Receiver Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
AAA
0850
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > AAA

Information Receiver Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Use this segment to indicate problems in processing the transaction specifically related to the information receiver data contained in the original 270 transaction's information receiver name loop (Loop 2100B).
  • Required when the request could not be processed at a system or application level when specifically related to the information receiver data contained in the original 270 transaction's information receiver name loop (Loop 2100B) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Y
Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

Usage notes
  • Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.
15
Required application data missing

Use this code only when the information receiver's additional identification is missing.

41
Authorization/Access Restrictions
43
Invalid/Missing Provider Identification
44
Invalid/Missing Provider Name
45
Invalid/Missing Provider Specialty
46
Invalid/Missing Provider Phone Number
47
Invalid/Missing Provider State
48
Invalid/Missing Referring Provider Identification Number
50
Provider Ineligible for Inquiries
51
Provider Not on File
79
Invalid Participant Identification

Use this code only when the information receiver is not a provider or payer.

97
Invalid or Missing Provider Address
T4
Payer Name or Identifier Missing

Use this code only when the information receiver is a payer.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

Usage notes
  • Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).
C
Please Correct and Resubmit
N
Resubmission Not Allowed
R
Resubmission Allowed
S
Do Not Resubmit; Inquiry Initiated to a Third Party
W
Please Wait 30 Days and Resubmit
X
Please Wait 10 Days and Resubmit
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
PRV
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Information Receiver Name Loop > PRV

Information Receiver Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • This segment is used to convey additional information about a provider's role in the eligibility/benefit being inquired about and who is also the Information Receiver. For example, if the Information Receiver is also the Referring Provider, this PRV segment would be used to identify the provider's role. This PRV segment applies to all benefits returned for this Information Receiver unless overridden by a PRV segment in the 2100C, 2120C, 2100D or 2120D loops.
  • Required when the 270 request contained a 2100B PRV segment and the information contained in the PRV segment was used to determine the 271 response. If not required by this implementation guide, do not send.
Example
If either Reference Identification Qualifier (PRV-02) or Information Receiver Provider Taxonomy Code (PRV-03) is present, then the other is required
PRV-01
1221
Provider Code
Required
Identifier (ID)

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
PRV-02
128
Reference Identification Qualifier
Optional
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Information Receiver Provider Taxonomy Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Use this number for the reference number as qualified by the preceding data element (PRV02).
2100B Information Receiver Name Loop end
2000C Subscriber Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

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.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

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.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

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
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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.
TRN
0200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > TRN

Subscriber Trace Number

OptionalMax use 3

To uniquely identify a transaction to an application

Usage notes
  • An information source may receive up to two TRN segments in each loop 2000C of a 270 transaction and must return each of them in loop 2000C of the 271 transaction unless the person submitted in loop 2000C is determined to be a dependent, then the TRN segments must be returned in loop 2000D. See Section 1.4.2. The returned TRN segments will have a value of "2" in TRN01. See Section 1.4.6 Information Linkage for additional information.
  • Required when the 270 request contained one or two TRN segments and the subscriber is the patient (See Section 1.4.2.). One TRN segment for each TRN submitted in the 270 must be returned.
    OR
    Required when the Information Source needs to return a unique trace number for the current transaction.
    If not required by this implementation guide, do not send.
  • If the subscriber is the patient, an information source may add one TRN;segment to loop 2000C with a value of "1" in TRN01 and must identify;themselves in TRN03.
  • This segment must not be used if the subscriber is not the patient. See section 1.4.2. Basic Concepts.
  • If this transaction passes through a clearinghouse, the clearinghouse will receive from the information source the information receiver's TRN segment and the clearinghouse's TRN segment with a value of "2" in TRN01. Since the ultimate destination of the transaction is the information receiver, if the clearinghouse intends on passing their TRN segment to the information receiver, the clearinghouse must change the value in TRN01 to "1" of their TRN segment. This must be done since the trace number in the clearinghouse's TRN segment is not actually a referenced transaction trace number to the information receiver.
  • The trace number in the 271 transaction TRN02 must be returned exactly as submitted in the 270 transaction. For example, if the 270 transaction TRN02 was 012345678 it must be returned as 012345678 and not as 12345678.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers

The term "Current Transaction Trace Numbers" refers to trace or reference numbers assigned by the creator of the 271 transaction (the information source).

If a clearinghouse has assigned a TRN segment and intends on returning their TRN segment in the 271 response to the information receiver, they must convert the value in TRN01 to "1" (since it will be returned by the information source as a "2").

2
Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Numbers" refers to trace or reference numbers originally sent in the 270 transaction and now returned in the 271.

TRN-02
127
Trace Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • TRN02 provides unique identification for the transaction.
Usage notes
  • This element must contain the trace number submitted in TRN02 from the 270 transaction and must be returned exactly as submitted.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • If TRN01 is "1", use this information to identify the organization that assigned this trace number.
  • If TRN01 is "2", this is the value received in the original 270 transaction.
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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.
2100C Subscriber Name Loop
RequiredMax 1
NM1
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > NM1

Subscriber Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Use this segment to identify an entity by name and/or identification number. This NM1 loop is used to identify the insured or subscriber.
Example
If either Identification Code Qualifier (NM1-08) or Subscriber Primary Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

IL
Insured or Subscriber
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
2
Non-Person Entity
NM1-03
1035
Subscriber Last Name
Optional
String (AN)
Min 1Max 35

Individual last name or organizational name

Usage notes
  • Use this name for the subscriber's last name.
NM1-04
1036
Subscriber First Name
Optional
String (AN)
Min 1Max 25

Individual first name

Usage notes
  • Use this name for the subscriber's first name.
NM1-05
1037
Subscriber Middle Name or Initial
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

Usage notes
  • Use this name for the subscriber's middle name or initial.
NM1-07
1039
Subscriber Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

Usage notes
  • Use this for the suffix to an individual's name; e.g., Sr., Jr., or III.
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • Use this element to qualify the identification number submitted in;NM109. This is the primary number that the information source;associates with the subscriber.
ZZ
Mutually Defined
NM1-09
67
Subscriber Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • Use this code for the reference number as qualified by the preceding data element (NM108).

Member ID.

REF
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > REF

Subscriber Additional Identification

OptionalMax use 9

To specify identifying information

Usage notes
  • Required when the Information Source requires additional identifiers necessary to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7);
    OR
    Required when the 270 request contained a REF segment with a Patient Account Number in Loop 2100C/REF02 with REF01 equal EJ;
    OR
    Required when the 270 request contained a REF segment and the information provided in that REF segment was used to locate the individual in the information source's system (See Section 1.4.7).
    If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
  • If the 270 request contained a REF segment with a Patient Account Number in REF02 with REF01 equal EJ, then it must be returned in the 271 transaction using this segment if the patient is the Subscriber. The Patient Account Number in the 271 transaction must be returned exactly as submitted in the 270 transaction.
  • Use this segment to supply an identification number 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.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes
  • Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
  • Only one occurrence of each REF01 code value may be used in the 2100C loop.
1L
Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes IG or 6P when they can be determined.

1W
Member Identification Number

Use only if Loop 2100C NM108 contains II, and is prior to the mandated use of the HIPAA Unique Patient Identifier.

3H
Case Number
6P
Group Number
18
Plan Number
49
Family Unit Number

Required when the Information Source is a Pharmacy Benefit Manager (PBM) and the individual has a suffix to their member ID number that is required for use in the NCPDP Telecom Standard in the Insurance Segment in field 303-C3 Person Code. If not required by this implementation Guide, do not send.

NOTE: For all other uses, the Family Unit Number (suffix) is considered a part of the Member ID number and is used to uniquely identify the individual and must be returned at the end of the Member ID number in 2100C NM109 or in 2100C REF02 if REF01 is "1W".

CE
Class of Contract Code

This code is used in the 835 and may be returned if there is sufficient information contained in the 270 transaction to determine the applicable Class of Contract for claims processing.

CT
Contract Number

This code is to be used only to identify the provider's contract number of the provider identified in the PRV segment of Loop 2100C. This code is only to be used once the CMS National Provider Identifier has been mandated for use, and must be sent if required in the contract between the Information Receiver identified in Loop 2100B and the Information Source identified in Loop 2100A.

EA
Medical Record Identification Number
EJ
Patient Account Number
F6
Health Insurance Claim (HIC) Number

See segment note 3.

GH
Identification Card Serial Number

Use this code when the Identification Card has a number in addition to the Member Identification Number or Identity Card Number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member (e.g., on a monthly basis, replacement cards). This is particularly prevalent in the Medicaid environment.

HJ
Identity Card Number

Use this code when the Identity Card Number is different than the Member Identification Number. This is particularly prevalent in the Medicaid environment.

IF
Issue Number
IG
Insurance Policy Number
N6
Plan Network Identification Number
NQ
Medicaid Recipient Identification Number

See segment note 3.

Q4
Prior Identifier Number

This code is to be used when a corrected or new identification number is returned in NM109, the originally submitted identification number is to be returned in REF02. To be used in conjunction with code "001" in INS03 and code "25" in INS04.

SY
Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Y4
Agency Claim Number

This code is to only to be used when the information source is a Property and Casualty payer. Use this code to identify the Property and Casualty Claim Number associated with the subscriber. This code is not a HIPAA requirement as of this writing.

REF-02
127
Subscriber Supplemental Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Use this information for the reference number as qualified by the preceding data element (REF01).;
  • If REF01 is "EJ", the Patient Account Number from the 270 transaction must be returned exactly as submitted.
REF-03
352
Plan, Group or Plan Network Name
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

N3
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N3

Subscriber Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7),
    OR
    Required if a rejection response is generated and this segment was present in the 270 and is the cause of the rejection.
    If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.;
  • Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
  • Use this segment to identify address information for a subscriber.
Example
N3-01
166
Subscriber Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this information for the first line of the address information.
N3-02
166
Subscriber Address Line
Optional
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this information for the second line of the address information.
N4
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > N4

Subscriber City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7),
    OR
    Required if a rejection response is generated and this segment was present in the 270 and is the cause of the rejection.
    If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.;
  • Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
  • Use this segment to identify address information for a subscriber.
Example
Only one of Subscriber State Code (N4-02) or Subscriber Country Subdivision Code (N4-07) may be present
If Subscriber Country Subdivision Code (N4-07) is present, then Subscriber Country Code (N4-04) is required
N4-01
19
Subscriber City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Subscriber State Code
Optional
Identifier (ID)
Min 2Max 2

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.
N4-03
116
Subscriber Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Subscriber Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Subscriber Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
AAA
0850
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > AAA

Subscriber Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request could not be processed at a system or application level when specifically related to the data contained in the original 270 transaction's subscriber name loop (Loop 2100C) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.
  • Use this segment to indicate problems in processing the transaction;specifically related to the data contained in the original 270;transaction's subscriber name loop (Loop 2100C).
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

Usage notes
  • Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.
  • Use codes "43", "45", "47", "48", or "51" only in response to information that is in or should be in the PRV segment in the Subscriber Name loop (2100C).
  • See section 1.4.8 Search Options for data content criteria for the subscriber.
64
Invalid/Missing Patient ID
67
Patient Not Found
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

Usage notes
  • Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).
C
Please Correct and Resubmit
N
Resubmission Not Allowed
R
Resubmission Allowed

Use only when AAA03 is "42".

S
Do Not Resubmit; Inquiry Initiated to a Third Party
W
Please Wait 30 Days and Resubmit
X
Please Wait 10 Days and Resubmit
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

Use only when AAA03 is "42".

PRV
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > PRV

Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when the 270 request contained a 2100C PRV segment and the information contained in the PRV segment was used to determine the 271 response.;
    OR
    Required when needed either to identify a provider's role or to associate a specialty type related to the service identified in the 2110C loops. This PRV segment applies to all benefits in this 2100C loop unless overridden by a PRV segment in the 2120C loop.
    If not required by this implementation guide, do not send.
  • If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about or to convey the provider's Taxonomy Code 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 type of specialty associated with the services identified in loop 2110C, use code PXC in PRV02 and the appropriate code in PRV03.
  • If there is a PRV segment in 2100B, this PRV overrides it for this occurrence of the 2100C loop.
Example
If either Reference Identification Qualifier (PRV-02) or Provider Identifier (PRV-03) is present, then the other is required
PRV-01
1221
Provider Code
Required
Identifier (ID)

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
PRV-02
128
Reference Identification Qualifier
Optional
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Identifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Use this number for the reference number as qualified by the preceding data element (PRV02).
DMG
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DMG

Subscriber Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Use this segment to convey the birth date or gender demographic information for the subscriber.
  • Required when the Subscriber is the patient or when the Information Source requires this information to identify the Subscriber for subsequent EDI transactions (see Section 1.4.7), but not required if a rejection response is generated with a 2100C or 2110C AAA segment and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
Example
If either Date Time Period Format Qualifier (DMG-01) or Subscriber Birth Date (DMG-02) is present, then the other is required
DMG-01
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

Code indicating the date format, time format, or date and time format

Usage notes
  • Use this code to indicate the format of the date of birth that follows in DMG02.
D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Subscriber Birth Date
Optional
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • DMG02 is the date of birth.
Usage notes
  • Use this date for the date of birth of the subscriber.
DMG-03
1068
Subscriber Gender Code
Optional
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
INS
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

Subscriber Relationship

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • Required when acknowledging a change in the identifying elements for the subscriber from those submitted in the 270 or the Birth Sequence Number submitted in INS17 of the 270 was used to locate the Subscriber. If not required by this implementation guide, do not send.
Example
INS-01
1073
Insured Indicator
Required
Identifier (ID)

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.
Y
Yes
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

18
Self
INS-03
875
Maintenance Type Code
Optional
Identifier (ID)

Code identifying the specific type of item maintenance

001
Change
INS-04
1203
Maintenance Reason Code
Optional
Identifier (ID)

Code identifying the reason for the maintenance change

25
Change in Identifying Data Elements

Use this code to indicate that a change has been made to the primary elements that identify a specific person. Such elements are first name, last name, date of birth, identification numbers, and address.

INS-17
1470
Birth Sequence Number
Optional
Numeric (N0)
Min 1Max 9

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.).
Usage notes
  • Use to indicate the birth order in the event of multiple birth's in association with the birth date supplied in DMG02.
HI
1150
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > HI

Subscriber Health Care Diagnosis Code

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when an HI segment was received in the 270 and if the information source uses the information in the determination of the eligibility or benefit response for the subscriber. All information used from the HI segment of the 270 used in the determination of the eligibility or benefit response for the subscriber must be returned. If information was provided in an HI segment of 270 but was not used in the determination of the eligibility or benefits for the subscriber it must not be returned. 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.
    OR
    Required when needed to identify limitations in the benefits identified in the 2110C loops, such as if benefits are limited for a specific diagnosis code if the information source can support this high level functionality. If the information source cannot support this high level functionality, do not send.
  • Use the Diagnosis code pointers in 2110C EB14 to identify which diagnosis code or codes in this HI segment relates to the information provided in the EB segment.
  • Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-05
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-06
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-07
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-08
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
DTP
1200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > DTP

Subscriber Date

OptionalMax use 9

To specify any or all of a date, a time, or a time period

Usage notes
  • The dates represented may be in the past, the current date, or a future date. The dates may also be a single date or a span of dates. Which date(s) to use is determined by the format qualifier in DTP02.
  • Dates supplied in the 2100C DTP apply to the Subscriber and all 2110C loops unless overridden by an occurrence of a 2110C DTP with the same value in DTP01.
  • Required to identify the Plan (DTP01 = 291) or Plan Begin (DTP01 = 346) date when the individual has active coverage unless multiple plans apply to the individual or multiple plan periods apply, which must then be returned in the 2110C DTP (See Section 1.4.7);
    OR
    Required when needed to identify other relevant dates that apply to the Subscriber.
    If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

096
Discharge
102
Issue
152
Effective Date of Change
291
Plan
307
Eligibility
318
Added

Information Sources are encouraged to return Added date in the case of retroactive eligibility.

340
Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
341
Consolidated Omnibus Budget Reconciliation Act (COBRA) End
342
Premium Paid to Date Begin
343
Premium Paid to Date End
346
Plan Begin
347
Plan End
356
Eligibility Begin
357
Eligibility End
382
Enrollment
435
Admission
442
Date of Death
458
Certification
472
Service
539
Policy Effective
540
Policy Expiration
636
Date of Last Update
771
Status
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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.
Usage notes
  • Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Date Time Period
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

Usage notes
  • Use this date for the date(s) as qualified by the preceding data elements.
MPI
1275
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > MPI

Subscriber Military Personnel Information

OptionalMax use 1

To report military service data

Usage notes
  • Required when this transaction is processed by DOD or CHAMPUS/TRICARE and when necessary to convey the Subscriber's military service data If not required by this implementation guide, do not send.
Example
If either Date Time Period Format Qualifier (MPI-06) or Date Time Period (MPI-07) is present, then the other is required
MPI-01
1201
Information Status Code
Required
Identifier (ID)

A code to indicate the status of information

A
Partial
C
Current
L
Latest
O
Oldest
P
Prior
S
Second Most Current
T
Third Most Current
MPI-02
584
Employment Status Code
Required
Identifier (ID)

Code showing the general employment status of an employee/claimant

AE
Active Reserve
AO
Active Military - Overseas
AS
Academy Student
AT
Presidential Appointee
AU
Active Military - USA
CC
Contractor
DD
Dishonorably Discharged
HD
Honorably Discharged
IR
Inactive Reserves
LX
Leave of Absence: Military
PE
Plan to Enlist
RE
Recommissioned
RM
Retired Military - Overseas
RR
Retired Without Recall
RU
Retired Military - USA
MPI-03
1595
Government Service Affiliation Code
Required
Identifier (ID)

Code specifying the government service affiliation

A
Air Force
B
Air Force Reserves
C
Army
D
Army Reserves
E
Coast Guard
F
Marine Corps
G
Marine Corps Reserves
H
National Guard
I
Navy
J
Navy Reserves
K
Other
L
Peace Corp
M
Regular Armed Forces
N
Reserves
O
U.S. Public Health Service
Q
Foreign Military
R
American Red Cross
S
Department of Defense
U
United Services Organization
W
Military Sealift Command
MPI-04
352
Description
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • MPI04 is the actual response to further identify the exact military unit.
MPI-05
1596
Military Service Rank Code
Optional
Identifier (ID)

Code specifying the military service rank

A1
Admiral
A2
Airman
A3
Airman First Class
B1
Basic Airman
B2
Brigadier General
C1
Captain
C2
Chief Master Sergeant
C3
Chief Petty Officer
C4
Chief Warrant
C5
Colonel
C6
Commander
C7
Commodore
C8
Corporal
C9
Corporal Specialist 4
E1
Ensign
F1
First Lieutenant
F2
First Sergeant
F3
First Sergeant-Master Sergeant
F4
Fleet Admiral
G1
General
G4
Gunnery Sergeant
L1
Lance Corporal
L2
Lieutenant
L3
Lieutenant Colonel
L4
Lieutenant Commander
L5
Lieutenant General
L6
Lieutenant Junior Grade
M1
Major
M2
Major General
M3
Master Chief Petty Officer
M4
Master Gunnery Sergeant Major
M5
Master Sergeant
M6
Master Sergeant Specialist 8
P1
Petty Officer First Class
P2
Petty Officer Second Class
P3
Petty Officer Third Class
P4
Private
P5
Private First Class
R1
Rear Admiral
R2
Recruit
S1
Seaman
S2
Seaman Apprentice
S3
Seaman Recruit
S4
Second Lieutenant
S5
Senior Chief Petty Officer
S6
Senior Master Sergeant
S7
Sergeant
S8
Sergeant First Class Specialist 7
S9
Sergeant Major Specialist 9
SA
Sergeant Specialist 5
SB
Staff Sergeant
SC
Staff Sergeant Specialist 6
T1
Technical Sergeant
V1
Vice Admiral
W1
Warrant Officer
MPI-06
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
MPI-07
1251
Date Time Period
Optional
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • MPI07 indicates the date span of military service.
2110C Subscriber Eligibility or Benefit Information Loop
OptionalMax >1
EB
1300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > EB

Subscriber Eligibility or Benefit Information

RequiredMax use 1

To supply eligibility or benefit information

Usage notes
  • Required when the subscriber is the person whose eligibility or benefits are being described and the transaction is not rejected (see Section 1.4.10) or if the transaction needs to be rejected in this loop. If not required by this implementation guide, do not send.
  • See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what information must be returned if the subscriber is the person whose eligibility or benefits are being sent.
  • Either EB03 or EB13 may be used in the same EB segment, not both.
  • EB03 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 EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110C loop are identical.
  • A limit to the number of repeats of EB loops has not been established. In a batch environment there is no practical reason to limit the number of EB loop repeats. In a real time environment, consideration should be given to how many EB loops are generated given the amount of time it takes to format the response and the amount of time it will take to transmit that response. Since these limitations will vary by information source, it would be completely arbitrary for the developers to set a limit. It is not the intent of the developers to limit the amount of information that is returned in a response, rather to alert information sources to consider the potential delays if the response contains too much information to be formatted and transmitted in real time.
  • Use this segment to begin the eligibility/benefit information looping structure. The EB segment is used to convey the specific eligibility or benefit information for the entity identified.
Example
If either Quantity Qualifier (EB-09) or Benefit Quantity (EB-10) is present, then the other is required
EB-01
1390
Eligibility or Benefit Information
Required
Identifier (ID)

Code identifying eligibility or benefit information

  • EB01 qualifies EB06 through EB10.
Usage notes
  • Use this code to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category that is being further described in the following data elements. This data element also qualifies the data in elements EB06 through EB10.
  • If codes A, B, C, G, J or Y are used, it is required that the patient's portion of responsibility is reflected in either EB07 or EB08. See Section 1.4.9 Patient Responsibility for detailed information and definitions.
1
Active Coverage
6
Inactive
A
Co-Insurance

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

B
Co-Payment

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

C
Deductible

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

EB-02
1207
Benefit Coverage Level Code
Optional
Identifier (ID)

Code indicating the level of coverage being provided for this insured

Usage notes
  • This element is used in conjunction with EB01 codes (e.g. Active Family Coverage, Deductible Individual, etc.). This element can be used to identify types of individual's within the Subscriber's family that eligibility or benefits extends to (unless EB01 = E - Exclusions).
CHD
Children Only
DEP
Dependents Only
ECH
Employee and Children
EMP
Employee Only
ESP
Employee and Spouse
FAM
Family
IND
Individual
SPC
Spouse and Children
SPO
Spouse Only
EB-03
1365
Service Type Code
Optional
Identifier (ID)
Max use 99

Code identifying the classification of service

  • Position of data in the repeating data element conveys no significance.
Usage notes
  • See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what service type codes must be returned.
  • EB03 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 EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110C loop are identical.
  • Not used if EB13 is present.
30
Health Benefit Plan Coverage

See Section 1.4.7.1

EB-04
1336
Insurance Type Code
Optional
Identifier (ID)

Code identifying the type of insurance policy within a specific insurance program

12
Medicare Secondary Working Aged Beneficiary or Spouse with Employer Group Health Plan
13
Medicare Secondary End-Stage Renal Disease Beneficiary in the Mandated Coordination Period with an Employer's Group Health Plan
14
Medicare Secondary, No-fault Insurance including Auto is Primary
15
Medicare Secondary Worker's Compensation
16
Medicare Secondary Public Health Service (PHS)or Other Federal Agency
41
Medicare Secondary Black Lung
42
Medicare Secondary Veteran's Administration
43
Medicare Secondary Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP)
47
Medicare Secondary, Other Liability Insurance is Primary
AP
Auto Insurance Policy
C1
Commercial
CO
Consolidated Omnibus Budget Reconciliation Act (COBRA)
CP
Medicare Conditionally Primary
D
Disability
DB
Disability Benefits
EP
Exclusive Provider Organization
FF
Family or Friends
GP
Group Policy
HM
Health Maintenance Organization (HMO)
HN
Health Maintenance Organization (HMO) - Medicare Risk
HS
Special Low Income Medicare Beneficiary
IN
Indemnity
IP
Individual Policy
LC
Long Term Care
LD
Long Term Policy
LI
Life Insurance
LT
Litigation
MA
Medicare Part A
MB
Medicare Part B
MC
Medicaid
MH
Medigap Part A
MI
Medigap Part B
MP
Medicare Primary
OT
Other

When this code is returned by Medicare or a Medicare Part D administrator, this code indicates a type of insurance of Medicare Part D.

PE
Property Insurance - Personal
PL
Personal
PP
Personal Payment (Cash - No Insurance)
PR
Preferred Provider Organization (PPO)
PS
Point of Service (POS)
QM
Qualified Medicare Beneficiary
RP
Property Insurance - Real
SP
Supplemental Policy
TF
Tax Equity Fiscal Responsibility Act (TEFRA)
WC
Workers Compensation
WU
Wrap Up Policy
EB-05
1204
Plan Coverage Description
Optional
String (AN)
Min 1Max 50

A description or number that identifies the plan or coverage

Usage notes
  • This element is to be used only to convey the specific product name or special program name for an insurance plan. For example, if a plan has a brand name, such as "Gold 1-2-3", the name may be placed in this element. This element must not be used to give benefit details of a plan.
EB-06
615
Time Period Qualifier
Optional
Identifier (ID)

Code defining periods

6
Hour
7
Day
13
24 Hours
21
Years
22
Service Year
23
Calendar Year
24
Year to Date
25
Contract
26
Episode
27
Visit
28
Outlier
29
Remaining
30
Exceeded
31
Not Exceeded
32
Lifetime
33
Lifetime Remaining
34
Month
35
Week
36
Admission
EB-07
782
Benefit Amount
Optional
Decimal number (R)
Min 1Max 15

Monetary amount

Usage notes
  • Use this monetary amount as qualified by EB01.
  • When EB01 = B, C, G, J or Y, the amount represents the Patient's portion of responsibility. See Section 1.4.9 Patient Responsibility.
  • Use if eligibility or benefit must be qualified by a monetary amount; e.g., deductible, co-payment.
EB-08
954
Benefit Percent
Optional
Decimal number (R)
Min 1Max 10

Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through 100%)

Usage notes
  • Use this percentage rate as qualified by EB01.
  • When EB01 = A, the amount represents the Patient's portion of responsibility. See Section 1.4.9 Patient Responsibility.
  • Use if eligibility or benefit must be qualified by a percentage; e.g., co-insurance.
EB-09
673
Quantity Qualifier
Optional
Identifier (ID)

Code specifying the type of quantity

Usage notes
  • Use this code to identify the type of units that are being conveyed in the following data element (EB10).
8H
Minimum
99
Quantity Used
CA
Covered - Actual
CE
Covered - Estimated
D3
Number of Co-insurance Days
DB
Deductible Blood Units
DY
Days
HS
Hours
LA
Life-time Reserve - Actual
LE
Life-time Reserve - Estimated
M2
Maximum
MN
Month
P6
Number of Services or Procedures
QA
Quantity Approved
S7
Age, High Value

Use this code when a benefit is based on a maximum age for the patient.

S8
Age, Low Value

Use this code when a benefit is based on a minimum age for the patient.

VS
Visits
YY
Years
EB-10
380
Benefit Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

Usage notes
  • Use this number for the quantity value as qualified by the preceding data element (EB09).
EB-11
1073
Authorization or Certification Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • EB11 is the authorization or certification indicator. A "Y" value indicates that an authorization or certification is required per plan provisions. An "N" value indicates that an authorization or certification is not required per plan provisions. A "U" value indicates it is unknown whether the plan provisions require an authorization or certification.
Usage notes
  • Use code "U" - Unknown, In the event that a payer typically responds Yes or No for some benefits, but the inquired benefit requirements are not accessible or the rules are more complex than can be determined using the data sent in the 270.
N
No
U
Unknown
Y
Yes
EB-12
1073
In Plan Network Indicator
Optional
Identifier (ID)

Code indicating a Yes or No condition or response

  • EB12 is the plan network indicator. A "Y" value indicates the benefits identified are considered In-Plan-Network. An "N" value indicates that the benefits identified are considered Out-Of-Plan-Network. A "U" value indicates it is unknown whether the benefits identified are part of the Plan Network.
Usage notes
  • Use code "U" - Unknown, In the event that a payer typically responds Yes or No for some benefits, but the inquired benefit requirements are not accessible or the rules are more complex than can be determined using the data sent in the 270.
N
No
U
Unknown
W
Not Applicable

Use code "W" - Not Applicable when benefits are the same regardless of whether they are In Plan-Network or Out of Plan-Network or a Plan-Network does not apply to the benefit.

Y
Yes
EB-13
C003
Composite Medical Procedure Identifier
OptionalMax use 1
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes

Required when a Medical Procedure Code was used from the 270 to determine the response being identified in the 2110C loop;
OR
Required when the Information Source supports Medical Procedure Code based 271 transactions and a Medical Procedure Code is available and appropriate for the eligibility or benefits being identified in the 2110C loop.
If not required by this implementation guide or if EB03 is used, do not send.

C003-01
235
Product or Service ID Qualifier
Required
Identifier (ID)

Code identifying the type/source of the descriptive number used in Product/Service ID (234)

  • C003-01 qualifies C003-02 and C003-08.
Usage notes
  • Use this code to identify the external code list of the following procedure/service code.
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

This code set is not allowed for use under HIPAA at the time of this writing. The qualifier can only be used 1) If a new rule names HIEC as an allowable code set under HIPAA. 2) For Property & Casualty claims/encounters that are not covered under HIPAA.

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)

C003-02
234
Procedure Code
Required
String (AN)
Min 1Max 48

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.
Usage notes
  • Use this ID number for the product/service code as qualified by the preceding data element.
C003-03
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
C003-04
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
C003-05
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
C003-06
1339
Procedure Modifier
Optional
String (AN)
Min 2Max 2

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.
Usage notes
  • Use this modifier for the procedure code identified in EB13-2 if modifiers are needed to further specify the service.
C003-08
234
Product or Service ID
Optional
String (AN)
Min 1Max 48

Identifying number for a product or service

  • C003-08 represents the ending value in the range in which the code occurs.
Usage notes
  • EB13-2 indicates the beginning of value of the range of procedure codes and EB13-8 represents the end of the range of procedure codes. All procedure codes in the range will apply.
EB-14
C004
Composite Diagnosis Code Pointer
OptionalMax use 1
To identify one or more diagnosis code pointers
Usage notes

Required when a 2100C HI segment is used and the information in this 2110C EB loop is related to a diagnosis code. If 2100C HI segment is not used or if the information in this 2110C EB loop is not related to a diagnosis code, do not send.

C004-01
1328
Diagnosis Code Pointer
Required
Numeric (N0)
Min 1Max 2

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.
Usage notes
  • This first pointer designates the primary diagnosis for this EB segment. Remaining diagnosis pointers indicate declining level of importance to the EB 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.
C004-02
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

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.
Usage notes
  • 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.
C004-03
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

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.
Usage notes
  • 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.
C004-04
1328
Diagnosis Code Pointer
Optional
Numeric (N0)
Min 1Max 2

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.
Usage notes
  • 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.
HSD
1350
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > HSD

Health Care Services Delivery

OptionalMax use 9

To specify the delivery pattern of health care services

Usage notes
  • Required when needed to identify a specific delivery or usage pattern associated with the benefits identified in either EB03 or EB13. If not required by this implementation guide, do not send.
Example
If either Quantity Qualifier (HSD-01) or Benefit Quantity (HSD-02) is present, then the other is required
If Period Count (HSD-06) is present, then Time Period Qualifier (HSD-05) is required
HSD-01
673
Quantity Qualifier
Optional
Identifier (ID)

Code specifying the type of quantity

Usage notes
  • Required if HSD02 is used.
DY
Days
FL
Units
HS
Hours
MN
Month
VS
Visits
HSD-02
380
Benefit Quantity
Optional
Decimal number (R)
Min 1Max 15

Numeric value of quantity

Usage notes
  • Required if HSD01 is used.
HSD-03
355
Unit or Basis for Measurement Code
Optional
Identifier (ID)

Code specifying the units in which a value is being expressed, or manner in which a measurement has been taken

DA
Days
MO
Months
VS
Visit
WK
Week
YR
Years
HSD-04
1167
Sample Selection Modulus
Optional
Decimal number (R)
Min 1Max 6

To specify the sampling frequency in terms of a modulus of the Unit of Measure, e.g., every fifth bag, every 1.5 minutes

HSD-05
615
Time Period Qualifier
Optional
Identifier (ID)

Code defining periods

6
Hour
7
Day
21
Years
22
Service Year
23
Calendar Year
24
Year to Date
25
Contract
26
Episode
27
Visit
28
Outlier
29
Remaining
30
Exceeded
31
Not Exceeded
32
Lifetime
33
Lifetime Remaining
34
Month
35
Week
HSD-06
616
Period Count
Optional
Numeric (N0)
Min 1Max 3

Total number of periods

HSD-07
678
Delivery Frequency Code
Optional
Identifier (ID)

Code which specifies the routine shipments, deliveries, or calendar pattern

1
1st Week of the Month
2
2nd Week of the Month
3
3rd Week of the Month
4
4th Week of the Month
5
5th Week of the Month
6
1st & 3rd Weeks of the Month
7
2nd & 4th Weeks of the Month
8
1st Working Day of Period
9
Last Working Day of Period
A
Monday through Friday
B
Monday through Saturday
C
Monday through Sunday
D
Monday
E
Tuesday
F
Wednesday
G
Thursday
H
Friday
J
Saturday
K
Sunday
L
Monday through Thursday
M
Immediately
N
As Directed
O
Daily Mon. through Fri.
P
1/2 Mon. & 1/2 Thurs.
Q
1/2 Tues. & 1/2 Thurs.
R
1/2 Wed. & 1/2 Fri.
S
Once Anytime Mon. through Fri.
SG
Tuesday through Friday
SL
Monday, Tuesday and Thursday
SP
Monday, Tuesday and Friday
SX
Wednesday and Thursday
SY
Monday, Wednesday and Thursday
SZ
Tuesday, Thursday and Friday
T
1/2 Tue. & 1/2 Fri.
U
1/2 Mon. & 1/2 Wed.
V
1/3 Mon., 1/3 Wed., 1/3 Fri.
W
Whenever Necessary
X
1/2 By Wed., Bal. By Fri.
Y
None (Also Used to Cancel or Override a Previous Pattern)
HSD-08
679
Delivery Pattern Time Code
Optional
Identifier (ID)

Code which specifies the time for routine shipments or deliveries

A
1st Shift (Normal Working Hours)
B
2nd Shift
C
3rd Shift
D
A.M.
E
P.M.
F
As Directed
G
Any Shift
Y
None (Also Used to Cancel or Override a Previous Pattern)
REF
1400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > REF

Subscriber Additional Identification

OptionalMax use 9

To specify identifying information

Usage notes
  • Use this segment for reference identifiers related only to the 2110C loop that it is contained in (e.g. Other or Additional Payer's identifiers).
  • Required when the Information Source requires one or more of these additional identifiers for subsequent EDI transactions (see Section 1.4.7);
    OR
    Required when an additional identifier is associated with the eligibility or benefits being identified in the 2110C loop. If not required by this implementation guide, do not send.
  • Use this segment to identify other or additional reference numbers for the entity identified. 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 2110C loop.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes
  • Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
  • Use "1W", "49", "F6", and "NQ" only in a 2110C loop with EB01 = "R".
  • Only one occurrence of each REF01 code value may be used in the 2110C loop.
1L
Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes "IG" or "6P" when they can be determined.

1W
Member Identification Number
6P
Group Number
9F
Referral Number
18
Plan Number
49
Family Unit Number

Required when the Information Source is a Pharmacy Benefit Manager (PBM) and the individual has a suffix to their member ID number that is required for use in the NCPDP Telecom Standard in the Insurance Segment in field 303-C3 Person Code. If not required by this implementation Guide, do not send.

NOTE: For all other uses, the Family Unit Number (suffix) is considered a part of the Member ID number and is used to uniquely identify the individual and must be returned at the end of the Member ID number in 2110C REF02 if REF01 is "1W".

ALS
Alternative List ID

Allows the source to identify the list identifier of a list of drugs and its alternative drugs with the associated formulary status for the patient.

CLI
Coverage List ID

Allows the source to identify the list identifier of a list of drugs that have coverage limitations for the associated patient.

F6
Health Insurance Claim (HIC) Number
FO
Drug Formulary Number
G1
Prior Authorization Number
IG
Insurance Policy Number
M7
Medical Assistance Category
N6
Plan Network Identification Number
NQ
Medicaid Recipient Identification Number
REF-02
127
Subscriber Eligibility or Benefit Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Use this information for the reference number as qualified by the preceding data element (REF01).;
REF-03
352
Plan, Group or Plan Network Name
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

DTP
1500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > DTP

Subscriber Eligibility/Benefit Date

OptionalMax use 20

To specify any or all of a date, a time, or a time period

Usage notes
  • Required when the individual has active coverage with multiple plans or multiple plan periods apply (See 2100C DTP segment);
    OR
    Required when needed to convey dates associated with the eligibility or benefits being identified in the 2110C loop.
    If not required by this implementation guide, do not send.
  • When using the DTP segment in the 2110C loop this date applies only to the 2110C Eligibility or Benefit Information (EB) loop in which it is located.

If a DTP segment with the same DTP01 value is present in the 2100C loop, the date is overridden for only this 2110C Eligibility or Benefit Information (EB) loop.

Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

356
Eligibility Begin
357
Eligibility End
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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.
Usage notes
  • Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
D8
Date Expressed in Format CCYYMMDD
DTP-03
1251
Eligibility or Benefit Date Time Period
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

Usage notes
  • Use this date for the date(s) as qualified by the preceding data elements.

Eligibility Date (Effective or Termination Date).

AAA
1600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > AAA

Subscriber Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request could not be processed at a system or application level when specifically related to specific eligibility/benefit inquiry data contained in the original 270 transaction's subscriber eligibility/benefit inquiry information loop (Loop 2110C) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.
  • Use this segment to indicate problems in processing the transaction;specifically related to specific eligibility/benefit inquiry data contained in the original 270 transaction's subscriber eligibility/benefit inquiry information loop (Loop 2110C).
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No

Use this code to indicate that the request or an element in the request is not valid. The transaction has been rejected as identified by the code in AAA03.

Y
Yes

Use this code to indicate that the request is valid, however the transaction has been rejected as identified by the code in AAA03.

AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

Usage notes
  • Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.
15
Required application data missing
33
Input Errors

Use this code only when data is present in this transaction and no other Reject Reason Code is valid for describing the error. Detail of the error must be supplied in the MSG segment of the 2110C loop containing this Reject Reason Code.

52
Service Dates Not Within Provider Plan Enrollment
53
Inquired Benefit Inconsistent with Provider Type
54
Inappropriate Product/Service ID Qualifier
55
Inappropriate Product/Service ID
56
Inappropriate Date
57
Invalid/Missing Date(s) of Service
60
Date of Birth Follows Date(s) of Service
61
Date of Death Precedes Date(s) of Service
62
Date of Service Not Within Allowable Inquiry Period
63
Date of Service in Future
69
Inconsistent with Patient's Age
70
Inconsistent with Patient's Gender
98
Experimental Service or Procedure
AA
Authorization Number Not Found

Use this code only when the Referral Number or Prior Authorization Number in 2110C REF02 is not found.

AE
Requires Primary Care Physician Authorization
AF
Invalid/Missing Diagnosis Code(s)
AG
Invalid/Missing Procedure Code(s)

Use this code for errors with Procedure Codes in EQ02-2 or Procedure Code Modifiers in EQ02-3 through EQ02-6.

AO
Additional Patient Condition Information Required

Use this code only if the Information Source supports responding to a detailed eligibility request and the information can be processed from a 270 transaction received by the Information Source but was not received and is needed to respond appropriately.

CI
Certification Information Does Not Match Patient

Use this code only when the Referral Number or Prior Authorization Number in 2110C REF02 is found but is not associated with the subscriber.

E8
Requires Medical Review
IA
Invalid Authorization Number Format

Use this code only when the Referral Number or Prior Authorization Number in 2110C REF02 is not formatted properly.

MA
Missing Authorization Number

Use this code only when the Referral Number or Prior Authorization Number has been issued and is missing in 2110C REF02 but is needed to respond appropriately.

AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

Usage notes
  • Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).
C
Please Correct and Resubmit
N
Resubmission Not Allowed
R
Resubmission Allowed
W
Please Wait 30 Days and Resubmit
X
Please Wait 10 Days and Resubmit
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly
MSG
2500
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > MSG

Message Text

OptionalMax use 10

To provide a free-form format that allows the transmission of text information

Usage notes
  • Free form text or description fields are not recommended because they require human interpretation.
  • Under no circumstances can an information source use the MSG segment to relay information that can be sent using codified information in existing data elements (including combinations of multiple data elements and segments). Information that has been provided in codified form in other segments or elements elsewhere in the 271 for the individual must not be repeated in the MSG segment. If the information cannot be codified, then cautionary use of the MSG segment is allowed as a short term solution. It is highly recommended that the entity needing to use the MSG segment approach X12N with data maintenance to solve the long term business need, so the use of the MSG segment can be avoided for that issue.
  • Required when the eligibility or benefit information cannot be codified in existing data elements (including combinations of multiple data elements and segments);
    AND
    Required when this information is pertinent to the eligibility or benefit response.
    If not required by this implementation guide, do not send.
  • Benefit Disclaimers are strongly discouraged. See section 1.4.11 Disclaimers Within the Transaction. Under no circumstances are more than one MSG segment to be used for a Benefit Disclaimer per individual response.
Example
MSG-01
933
Free Form Message Text
Required
String (AN)
Min 1Max 264

Free-form message text

2115C Subscriber Eligibility or Benefit Additional Information Loop
OptionalMax 10
III
2600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Eligibility or Benefit Additional Information Loop > III

Subscriber Eligibility or Benefit Additional Information

RequiredMax use 1

To report information

Usage notes
  • Required when III segments in Loop 2110C of the 270 Inquiry were used in the determination of the eligibility or benefit response;
    OR
    Required when needed to identify limitations in the benefits explained in the corresponding Loop 2110C (such as if benefits are limited to a type of facility).
    If not required by this implementation guide, do not send.
  • This segment has two purposes. Information that was received in III segments in Loop 2110C of the 270 Inquiry and was used in the determination of the eligibility or benefit response must be returned. If information was provided in III segments of Loop 2110C but was not used in the determination of the eligibility or benefits it must not be returned. This segment can also be used to identify limitations in the benefits explained in the corresponding Loop 2110C, such as if benefits are limited to a type of facility.
  • Use this segment to identify Nature of Injury Codes and/or Facility Type as they relate to the information provided in the EB segment.
  • Use the III segment only if an information source can support this high level functionality.
  • Use this segment only one time for the Facility Type Code.
Example
If either Code List Qualifier Code (III-01) or Industry Code (III-02) is present, then the other is required
If Code Category (III-03) is present, then Injured Body Part Name (III-04) is required
III-01
1270
Code List Qualifier Code
Optional
Identifier (ID)

Code identifying a specific industry code list

Usage notes
  • Use this code to specify if the code that is following in the III02 is a Nature of Injury Code or a Facility Type Code.
GR
National Council on Compensation Insurance (NCCI) Nature of Injury Code
NI
Nature of Injury Code

Other code source as specified by the jurisdiction.

ZZ
Mutually Defined

Use this code for Facility Type Code.
See Appendix A for Code Source 237, Place of Service Codes for Professional Claims.

III-02
1271
Industry Code
Optional
String (AN)
Min 1Max 30

Code indicating a code from a specific industry code list

Usage notes
  • If III01 is GR, use this element for NCCI Nature of Injury code from code source 284.

  • If III01 is NI, use this element for Nature of Injury code from code source 407.

  • If III01 is ZZ, 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 State or Local Public Health Clinic
    72 Rural Health Clinic
    81 Independent Laboratory
    99 Other Place of Service

III-03
1136
Code Category
Optional
Identifier (ID)

Specifies the situation or category to which the code applies

  • III03 is used to categorize III04.
44
Nature of Injury
III-04
933
Injured Body Part Name
Optional
String (AN)
Min 1Max 264

Free-form message text

Usage notes
  • Use this element to describe the injured body part or parts.
2115C Subscriber Eligibility or Benefit Additional Information Loop end
LS
3300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > LS

Loop Header

OptionalMax use 1

To indicate that the next segment begins a loop

Example
LS-01
447
Loop Identifier Code
Required
String (AN)
Min 1Max 6

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

2120C Subscriber Benefit Related Entity Name Loop
OptionalMax 23
NM1
3400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > NM1

Subscriber Benefit Related Entity Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Required when provider was identified in 2100C PRV02 and PRV03 by Identification Number (not Taxonomy Code) in the 270 Inquiry and was used in the determination of the eligibility or benefit response;
    OR
    Required when needed to identify an entity associated with the eligibility or benefits being identified in the 2110C loop such as a provider (e.g. primary care provider), an individual, an organization, another payer, or another information source;
    If not required by this implementation guide, do not send.
Example
If either Identification Code Qualifier (NM1-08) or Benefit Related Entity Identifier (NM1-09) is present, then the other is required
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

73
Other Physician
P3
Primary Care Provider
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
Usage notes
  • Use this code to indicate whether the entity is an individual person or an organization.
1
Person
2
Non-Person Entity
NM1-03
1035
Benefit Related Entity Last or Organization Name
Optional
String (AN)
Min 1Max 35

Individual last name or organizational name

Usage notes
  • Use this name for the organization name if the entity type qualifier is a non-person entity. Otherwise, this will be the individual's last name.
NM1-04
1036
Benefit Related Entity First Name
Optional
String (AN)
Min 1Max 25

Individual first name

NM1-05
1037
Benefit Related Entity Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

NM1-07
1039
Benefit Related Entity Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

Usage notes
  • Use for name suffix only (e.g. Sr, Jr, II, III, etc.).
NM1-08
66
Identification Code Qualifier
Optional
Identifier (ID)

Code designating the system/method of code structure used for Identification Code (67)

Usage notes
  • Use code value "XX" if the entity is a provider and the National Provider ID is mandated for use.
    Use code value "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).
    If the entity being identified is an individual, the "HIPAA Individual Identifier" must be used once this identifier has been adopted.
    Otherwise use appropriate code value for the entity.
XX
Centers for Medicare and Medicaid Services National Provider Identifier
NM1-09
67
Benefit Related Entity Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • Use this code for the reference number as qualified by the preceding data element (NM108).

Use appropriate NPI.

NM1-10
706
Benefit Related Entity Relationship Code
Optional
Identifier (ID)

Code describing entity relationship

  • NM110 and NM111 further define the type of entity in NM101.
01
Parent
02
Child
27
Domestic Partner
41
Spouse
48
Employee
65
Other
72
Unknown
N3
3600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > N3

Subscriber Benefit Related Entity Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Use this segment to identify address information for an entity.
  • Required when needed to further identify the entity or individual in loop 2120C NM1 and the information is available. If not required by this implementation guide, do not send.
Example
N3-01
166
Benefit Related Entity Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this information for the first line of the address information.
N3-02
166
Benefit Related Entity Address Line
Optional
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this information for the second line of the address information.
N4
3700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > N4

Subscriber Benefit Related Entity City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when needed to further identify the entity or individual in loop 2120C NM1 and the information is available. If not required by this implementation guide, do not send.
  • Use this segment to identify address information for an entity.
Example
Only one of Benefit Related Entity State Code (N4-02) or Benefit Related Entity Country Subdivision Code (N4-07) may be present
If Benefit Related Entity DOD Health Service Region (N4-06) is present, then Benefit Related Entity Location Qualifier (N4-05) is required
If Benefit Related Entity Country Subdivision Code (N4-07) is present, then Benefit Related Entity Country Code (N4-04) is required
N4-01
19
Benefit Related Entity City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Benefit Related Entity State Code
Optional
Identifier (ID)
Min 2Max 2

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.
N4-03
116
Benefit Related Entity Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Benefit Related Entity Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-05
309
Benefit Related Entity Location Qualifier
Optional
Identifier (ID)

Code identifying type of location

Usage notes
  • Use this element only to communicate the Department of Defense Health Service Region.
RJ
Region

Use this code only to communicate the Department of Defense Health Service Region in N406.

N4-06
310
Benefit Related Entity DOD Health Service Region
Optional
String (AN)
Min 1Max 30

Code which identifies a specific location

Usage notes
  • Use this element only to communicate the Department of Defense Health Service Region.
  • CODE SOURCE DOD1: Military Health Systems Functional Area Manual - Data.
N4-07
1715
Benefit Related Entity Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
PER
3800
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > PER

Subscriber Benefit Related Entity Contact Information

OptionalMax use 3

To identify a person or office to whom administrative communications should be directed

Usage notes
  • Use this segment when needed to identify a contact name and/or communications number for the entity identified. This segment allows for three contact numbers to be listed. This segment is used when the information source wishes to provide a contact for the entity identified in loop 2120C NM1.

If telephone extension is sent, it should always be in the occurrence of the communications number following the actual phone number. See the example for an illustration.

  • If this segment is used, at a minimum either PER02 must be used or PER03 and PER04 must be used. It is recommended that at least PER02, PER03 and PER04 are sent if this segment is used.
  • When the communication number represents a telephone number in the United States and other countries using the North American Dialing Plan (for voice, data, fax, etc.), the communication number should always include the area code and phone number using the format AAABBBCCCC. Where AAA is the area code, BBB is the telephone number prefix, and CCCC is the telephone number (e.g. (534)224-2525 would be represented as 5342242525). The extension, when applicable, should be included in the communication number immediately after the telephone number.
  • Required when Contact Information exists and is available. If not required by this implementation guide, do not send.
Example
If either Communication Number Qualifier (PER-03) or Benefit Related Entity Communication Number (PER-04) is present, then the other is required
If either Communication Number Qualifier (PER-05) or Benefit Related Entity Communication Number (PER-06) is present, then the other is required
If either Communication Number Qualifier (PER-07) or Benefit Related Entity Communication Number (PER-08) is present, then the other is required
PER-01
366
Contact Function Code
Required
Identifier (ID)

Code identifying the major duty or responsibility of the person or group named

Usage notes
  • Use this code to specify the type of person or group to which the contact number applies.
IC
Information Contact
PER-02
93
Benefit Related Entity Contact Name
Optional
String (AN)
Min 1Max 60

Free-form name

Usage notes
  • Use this name for the individual's name or group's name to use when contacting the individual or organization.
PER-03
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

Usage notes
  • Use this code to specify what type of communication number is following.
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
WP
Work Phone Number
PER-04
364
Benefit Related Entity Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

Usage notes
  • The format for US domestic phone numbers is:
    AAABBBCCCC
    AAA = Area Code
    BBBCCCC = Local Number
  • Use this for the communication number or URL as qualified by the preceding data element.
PER-05
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

Usage notes
  • Use this code to specify what type of communication number is following.
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
WP
Work Phone Number
PER-06
364
Benefit Related Entity Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

Usage notes
  • The format for US domestic phone numbers is:
    AAABBBCCCC
    AAA = Area Code
    BBBCCCC = Local Number
  • Use this for the communication number or URL as qualified by the preceding data element.
PER-07
365
Communication Number Qualifier
Optional
Identifier (ID)

Code identifying the type of communication number

Usage notes
  • Use this code to specify what type of communication number is following.
ED
Electronic Data Interchange Access Number
EM
Electronic Mail
EX
Telephone Extension
FX
Facsimile
TE
Telephone
UR
Uniform Resource Locator (URL)
WP
Work Phone Number
PER-08
364
Benefit Related Entity Communication Number
Optional
String (AN)
Min 1Max 256

Complete communications number including country or area code when applicable

Usage notes
  • The format for US domestic phone numbers is:
    AAABBBCCCC
    AAA = Area Code
    BBBCCCC = Local Number
  • Use this for the communication number or URL as qualified by the preceding data element.
PRV
3900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > Subscriber Benefit Related Entity Name Loop > PRV

Subscriber Benefit Related Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when needed either to identify a provider's role or associate a specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, do not send.
  • 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.
  • If there is a PRV segment in 2100B or 2100C, this PRV overrides it for this occurrence of the 2110C loop.
Example
If either Reference Identification Qualifier (PRV-02) or Benefit Related Entity Provider Taxonomy Code (PRV-03) is present, then the other is required
PRV-01
1221
Provider Code
Required
Identifier (ID)

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
PRV-02
128
Reference Identification Qualifier
Optional
Identifier (ID)

Code qualifying the Reference Identification

PXC
Health Care Provider Taxonomy Code
PRV-03
127
Benefit Related Entity Provider Taxonomy Code
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Use this reference number as qualified by the preceding data element (PRV02).
2120C Subscriber Benefit Related Entity Name Loop end
LE
4000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Information Loop > LE

Loop Trailer

OptionalMax use 1

To indicate that the loop immediately preceding this segment is complete

Example
LE-01
447
Loop Identifier Code
Required
String (AN)
Min 1Max 6

The loop ID number given on the transaction set diagram is the value for this data element in segments LS and LE

2110C Subscriber Eligibility or Benefit Information Loop end
2100C Subscriber Name Loop end
2000D Dependent Level Loop
OptionalMax >1
HL
0100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > HL

Hierarchical Level

RequiredMax use 1

To identify dependencies among and the content of hierarchically related groups of data segments

Example
HL-01
628
Hierarchical ID Number
Required
String (AN)
Min 1Max 12

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.
HL-02
734
Hierarchical Parent ID Number
Required
String (AN)
Min 1Max 12

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.
HL-03
735
Hierarchical Level Code
Required
Identifier (ID)

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
HL-04
736
Hierarchical Child Code
Optional
Identifier (ID)

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.
TRN
0200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > TRN

Dependent Trace Number

OptionalMax use 3

To uniquely identify a transaction to an application

Usage notes
  • An information source may receive up to two TRN segments in each loop;2000D of a 270 transaction and must return each of them in loop 2000D;of the 271 transaction unless the person submitted in loop 2000D is determined to be a subscriber, then the TRN segments must be returned in loop 2000C (See Section 1.4.2). The returned TRN segments will have a value of "2" in TRN01. See Section 1.4.6 Information Linkage for additional information.
  • An information source may add one TRN segment to loop 2000D with a;value of "1" in TRN01 and must identify themselves in TRN03.
  • Required when the 270 request contained one or two TRN segments and the dependent is the patient (See Section 1.4.2.). One TRN segment for each TRN submitted in the 270 must be returned.;
    OR
    Required when the Information Source needs to return a unique trace number for the current transaction.
    If not required by this implementation guide, do not send.
  • If this transaction passes through a clearinghouse, the clearinghouse will receive from the information source the information receiver's TRN segment and the clearinghouse's TRN segment with a value of "2" in TRN01. Since the ultimate destination of the transaction is the information receiver, if the clearinghouse intends on passing their TRN segment to the information receiver, the clearinghouse must change the value in TRN01 to "1" of their TRN segment. This must be done since the trace number in the clearinghouse's TRN segment is not actually a referenced transaction trace number to the information receiver.
  • The trace number in the 271 transaction TRN02 must be returned exactly as submitted in the 270 transaction. For example, if the 270 transaction TRN02 was 012345678 it must be returned as 012345678 and not as 12345678.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers

The term "Current Transaction Trace Numbers" refers to trace or reference numbers assigned by the creator of the 271 transaction (the information source).

If a clearinghouse has assigned a TRN segment and intends on returning their TRN segment in the 271 response to the information receiver, they must convert the value in TRN01 to "1" (since it will be returned by the information source as a "2").

2
Referenced Transaction Trace Numbers

The term "Referenced Transaction Trace Numbers" refers to trace or reference numbers originally sent in the 270 transaction and now returned in the 271.

TRN-02
127
Trace Number
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

  • TRN02 provides unique identification for the transaction.
Usage notes
  • This element must contain the trace number submitted in TRN02 from the 270 transaction and must be returned exactly as submitted.
TRN-03
509
Trace Assigning Entity Identifier
Required
String (AN)
Min 10Max 10

A unique identifier designating the company initiating the funds transfer instructions, business transaction or assigning tracking reference identification.

  • TRN03 identifies an organization.
Usage notes
  • If TRN01 is "1", use this information to identify the organization that assigned this trace number.
  • If TRN01 is "2", this is the value received in the original 270 transaction.
  • The first position must be either a "1" if an EIN is used, a "3" if a DUNS is used or a "9" if a user assigned identifier is used.
TRN-04
127
Trace Assigning Entity Additional Identifier
Optional
String (AN)
Min 1Max 50

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.
Usage notes
  • If TRN01 is "1", use this information if necessary to further identify a specific component, such as a specific division or group of the entity identified in the previous data element (TRN03).
  • If TRN01 is "2", this is the value received in the original 270 transaction.
2100D Dependent Name Loop
RequiredMax 1
NM1
0300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > NM1

Dependent Name

RequiredMax use 1

To supply the full name of an individual or organizational entity

Usage notes
  • Use this segment to identify an entity by name. This NM1 loop is used to identify the dependent of an insured or subscriber.
Example
NM1-01
98
Entity Identifier Code
Required
Identifier (ID)

Code identifying an organizational entity, a physical location, property or an individual

03
Dependent
NM1-02
1065
Entity Type Qualifier
Required
Identifier (ID)

Code qualifying the type of entity

  • NM102 qualifies NM103.
1
Person
NM1-03
1035
Dependent Last Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

Usage notes
  • Use this name for the dependent's last name.
NM1-04
1036
Dependent First Name
Optional
String (AN)
Min 1Max 35

Individual first name

Usage notes
  • Use this name for the dependent's first name.
NM1-05
1037
Dependent Middle Name
Optional
String (AN)
Min 1Max 25

Individual middle name or initial

Usage notes
  • Use this name for the dependent's middle name or initial.
NM1-07
1039
Dependent Name Suffix
Optional
String (AN)
Min 1Max 10

Suffix to individual name

Usage notes
  • Use this for the suffix to an individual's name; e.g., Sr., Jr., or III.
REF
0400
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > REF

Dependent Additional Identification

OptionalMax use 9

To specify identifying information

Usage notes
  • If the 270 request contained a REF segment with a Patient Account Number in Loop 2100D/REF02 with REF01 equal EJ, then it must be returned in the 271 transaction using this segment if the patient is the Dependent. The Patient Account Number in the 271 transaction must be returned exactly as submitted in the 270 transaction.
  • Required when the Information Source requires additional identifiers necessary to identify the Dependent for subsequent EDI transactions (see Section 1.4.7);
    OR
    Required when the 270 request contained a REF segment with a Patient Account Number in Loop 2100D/REF02 with REF01 equal EJ;
    OR
    Required when the 270 request contained a REF segment and the information provided in that REF segment was used to locate the individual in the information source's system (See Section 1.4.7).
    If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
  • Use this segment to supply an identification number 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 2100D 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.
Example
REF-01
128
Reference Identification Qualifier
Required
Identifier (ID)

Code qualifying the Reference Identification

Usage notes
  • Use this code to specify or qualify the type of reference number that is following in REF02, REF03, or both.
  • Only one occurrence of each REF01 code value may be used in the 2100D loop.
1L
Group or Policy Number

Use this code only if it cannot be determined if the number is a Group Number or a Policy number. Use codes "IG" or "6P" when they can be determined.

1W
Member Identification Number

Required only for Property and Casualty use when the Property and Casualty Patient Identifier is a Member ID and needed for 837 claims in 2010CA REF. This code must not be used for any other purposes.

6P
Group Number
18
Plan Number
49
Family Unit Number

Required when the Information Source is a Pharmacy Benefit Manager (PBM) and the individual has a suffix to their member ID number that is required for use in the NCPDP Telecom Standard in the Insurance Segment in field 303-C3 Person Code. If not required by this implementation Guide, do not send.

NOTE: For all other uses, the Family Unit Number (suffix) is considered a part of the Member ID number and is used to uniquely identify the individual and must be returned at the end of the Member ID number in 2100C NM109 or in 2100C REF02 if REF01 is "1W".

CE
Class of Contract Code

This code is used in the 835 and may be returned if there is sufficient information contained in the 270 transaction to determine the applicable Class of Contract for claims processing.

CT
Contract Number

This code is to be used only to identify the provider's contract number of the provider identified in the PRV segment of Loop 2100C. This code is only to be used once the CMS National Provider Identifier has been mandated for use, and must be sent if required in the contract between the Information Receiver identified in Loop 2100B and the Information Source identified in Loop 2100A.

EA
Medical Record Identification Number
EJ
Patient Account Number
F6
Health Insurance Claim (HIC) Number

See segment note 3.

GH
Identification Card Serial Number

Use this code when the Identification Card has a number in addition to the Member Identification Number or Identity Card Number. The Identification Card Serial Number uniquely identifies the card when multiple cards have been or will be issued to a member (e.g., on a monthly basis, replacement cards). This is particularly prevalent in the Medicaid environment.

HJ
Identity Card Number

Use this code when the Identity Card Number is different than the Member Identification Number. This is particularly prevalent in the Medicaid environment.

IF
Issue Number
IG
Insurance Policy Number
MRC
Eligibility Category
N6
Plan Network Identification Number
NQ
Medicaid Recipient Identification Number

See segment note 3.

Q4
Prior Identifier Number

This code is to be used when a corrected or new identification number is returned in NM109, the originally submitted identification number is to be returned in REF02. To be used in conjunction with code "001" in INS03 and code "25" in INS04.

SY
Social Security Number

The social security number may not be used for any Federally administered programs such as Medicare.

Y4
Agency Claim Number

This code is to only to be used when the information source is a Property and Casualty payer. Use this code to identify the Property and Casualty Claim Number associated with the dependent. This code is not a HIPAA requirement as of this writing.

REF-02
127
Dependent Supplemental Identifier
Required
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Use this information for the reference number as qualified by the preceding data element (REF01).;
  • If REF01 is "EJ", the Patient Account Number from the 270 transaction must be returned exactly as submitted.
REF-03
352
Plan, Group or Plan Network Name
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

N3
0600
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N3

Dependent Address

OptionalMax use 1

To specify the location of the named party

Usage notes
  • Required when the Information Source requires this information to identify the Dependent for subsequent EDI transactions (see Section 1.4.7),
    OR
    Required if a rejection response is generated and this segment was present in the 270 and is the cause of the rejection.
    If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
  • Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
  • Use this segment to identify address information for a dependent.
Example
N3-01
166
Dependent Address Line
Required
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this information for the first line of the address information.
N3-02
166
Dependent Address Line
Optional
String (AN)
Min 1Max 55

Address information

Usage notes
  • Use this information for the second line of the address information.
N4
0700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > N4

Dependent City, State, ZIP Code

OptionalMax use 1

To specify the geographic place of the named party

Usage notes
  • Required when the Information Source requires this information to identify the Dependent for subsequent EDI transactions (see Section 1.4.7),
    OR
    Required if a rejection response is generated and this segment was present in the 270 and is the cause of the rejection.
    If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
  • Do not return address information from the 270 request unless the transaction is rejected and the rejection was caused by the address and this segment was present in the 270. See Section 1.4.7.1 271 item 7 for additional information.
  • Use this segment to identify address information for a dependent.
Example
Only one of Dependent State Code (N4-02) or Dependent Country Subdivision Code (N4-07) may be present
If Dependent Country Subdivision Code (N4-07) is present, then Dependent Country Code (N4-04) is required
N4-01
19
Dependent City Name
Required
String (AN)
Min 2Max 30

Free-form text for city name

  • A combination of either N401 through N404, or N405 and N406 may be adequate to specify a location.
N4-02
156
Dependent State Code
Optional
Identifier (ID)
Min 2Max 2

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.
N4-03
116
Dependent Postal Zone or ZIP Code
Optional
Identifier (ID)
Min 3Max 15

Code defining international postal zone code excluding punctuation and blanks (zip code for United States)

N4-04
26
Dependent Country Code
Optional
Identifier (ID)
Min 2Max 3

Code identifying the country

Usage notes
  • Use the alpha-2 country codes from Part 1 of ISO 3166.
N4-07
1715
Dependent Country Subdivision Code
Optional
Identifier (ID)
Min 1Max 3

Code identifying the country subdivision

Usage notes
  • Use the country subdivision codes from Part 2 of ISO 3166.
AAA
0850
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > AAA

Dependent Request Validation

OptionalMax use 9

To specify the validity of the request and indicate follow-up action authorized

Usage notes
  • Required when the request could not be processed at a system or application level when specifically related to the data contained in the original 270 transaction's dependent name loop (Loop 2100D) and to indicate what action the originator of the request transaction should take. If not required by this implementation guide, do not send.
  • Use this segment to indicate problems in processing the transaction;specifically related to the data contained in the original 270;transaction's dependent name loop (Loop 2100D).
Example
AAA-01
1073
Valid Request Indicator
Required
Identifier (ID)

Code indicating a Yes or No condition or response

  • AAA01 designates whether the request is valid or invalid. Code "Y" indicates that the code is valid; code "N" indicates that the code is invalid.
N
No
Y
Yes
AAA-03
901
Reject Reason Code
Required
Identifier (ID)

Code assigned by issuer to identify reason for rejection

Usage notes
  • Use this code for the reason why the transaction was unable to be processed successfully. This may indicate problems with the system, the application, or the data content.
  • Use codes "43", "45", "47", "48", or "51" only in response to information that is in or should be in the PRV segment in the Dependent Name loop (2100D).
  • See section 1.4.8 Search Options for data content criteria for the dependent.
15
Required application data missing
35
Out of Network

Use this code to indicate that the dependent is not in the Network of the provider identified in the 2100B NM1 segment, or the 2100B/2100D PRV segment if present, in the 270 transaction.

42
Unable to Respond at Current Time

Use this code in a batch environment where an information source returns all requests from the 270 in the 271 and identifies "Unable to Respond at Current Time" for each individual request (subscriber or dependent) within the transaction that they were unable to process for reasons other than data content (such as their system is down or timed out in generating a response). Use only codes "R", "S", or "Y" for AAA04.

43
Invalid/Missing Provider Identification
45
Invalid/Missing Provider Specialty
47
Invalid/Missing Provider State
48
Invalid/Missing Referring Provider Identification Number
49
Provider is Not Primary Care Physician
51
Provider Not on File
52
Service Dates Not Within Provider Plan Enrollment
56
Inappropriate Date
57
Invalid/Missing Date(s) of Service
58
Invalid/Missing Date-of-Birth

Code 58 may not be returned if the information source has located an individual and the Birth Date does not match; use code 71 instead.

60
Date of Birth Follows Date(s) of Service
61
Date of Death Precedes Date(s) of Service
62
Date of Service Not Within Allowable Inquiry Period
63
Date of Service in Future
64
Invalid/Missing Patient ID
65
Invalid/Missing Patient Name

Required when the transaction was rejected when the information source cannot find a match for the Patient Name submitted or if the Patient Name was missing.

66
Invalid/Missing Patient Gender Code
67
Patient Not Found

Code 67 may not be returned if the information receiver submitted all four pieces of the mandated search option.

68
Duplicate Patient ID Number
71
Patient Birth Date Does Not Match That for the Patient on the Database

Code 71 must be returned when the transaction was rejected when the information source located an individual based other information submitted, but the Birth Date does not match.

77
Subscriber Found, Patient Not Found
AAA-04
889
Follow-up Action Code
Required
Identifier (ID)

Code identifying follow-up actions allowed

Usage notes
  • Use this code to instruct the recipient of the 271 about what action needs to be taken, if any, based on the validity code and the reject reason code (if applicable).
C
Please Correct and Resubmit
N
Resubmission Not Allowed
R
Resubmission Allowed

Use only when AAA03 is "42".

S
Do Not Resubmit; Inquiry Initiated to a Third Party
W
Please Wait 30 Days and Resubmit
X
Please Wait 10 Days and Resubmit
Y
Do Not Resubmit; We Will Hold Your Request and Respond Again Shortly

Use only when AAA03 is "42".

PRV
0900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > PRV

Provider Information

OptionalMax use 1

To specify the identifying characteristics of a provider

Usage notes
  • Required when the 270 request contained a 2100D PRV segment and the information contained in the PRV segment was used to determine the 271 response.;
    OR
    Required when needed either to identify a provider's role or to associate a specialty type related to the service identified in the 2110D loop. This PRV segment applies to all benefits in this 2100D loop unless overridden by a PRV segment in the 2120D loop.
    If not required by this implementation guide, do not send.
  • If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about or to convey the provider's Taxonomy Code 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 type of specialty associated with the services identified in loop 2110D, use code PXC in PRV02 and the appropriate code in PRV03.
  • If there is a PRV segment in 2100B, this PRV overrides it for this occurrence of the 2100D loop.
Example
If either Reference Identification Qualifier (PRV-02) or Provider Identifier (PRV-03) is present, then the other is required
PRV-01
1221
Provider Code
Required
Identifier (ID)

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
PRV-02
128
Reference Identification Qualifier
Optional
Identifier (ID)

Code qualifying the Reference Identification

Usage notes
  • If this segment is used to identify a type of specialty associated with the services identified in loop 2110D, use code PXC.
PXC
Health Care Provider Taxonomy Code
PRV-03
127
Provider Identifier
Optional
String (AN)
Min 1Max 50

Reference information as defined for a particular Transaction Set or as specified by the Reference Identification Qualifier

Usage notes
  • Use this number for the reference number as qualified by the preceding data element (PRV02).
DMG
1000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DMG

Dependent Demographic Information

OptionalMax use 1

To supply demographic information

Usage notes
  • Use this segment to convey the birth date or gender demographic information for the dependent.
  • Required when the Dependent is the patient unless a rejection response is generated with a 2100D or 2110D AAA segment and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
Example
If either Date Time Period Format Qualifier (DMG-01) or Dependent Birth Date (DMG-02) is present, then the other is required
DMG-01
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

Code indicating the date format, time format, or date and time format

Usage notes
  • Use this code to indicate the format of the date of birth that follows in DMG02.
D8
Date Expressed in Format CCYYMMDD
DMG-02
1251
Dependent Birth Date
Optional
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • DMG02 is the date of birth.
Usage notes
  • Use this date for the date of birth of the dependent.
DMG-03
1068
Dependent Gender Code
Optional
Identifier (ID)

Code indicating the sex of the individual

F
Female
M
Male
U
Unknown
INS
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > INS

Dependent Relationship

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • This segment may also be used to identify that the information source has changed some of the identifying elements for the dependent that the information receiver submitted in the original 270 transaction.
  • Required when the Dependent is the patient unless a rejection response is generated with a 2100D or 2110D AAA segment and this segment was not sent in the request. If not required by this implementation guide, may be provided at sender's discretion but cannot be required by the receiver.
Example
INS-01
1073
Insured Indicator
Required
Identifier (ID)

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
INS-02
1069
Individual Relationship Code
Required
Identifier (ID)

Code indicating the relationship between two individuals or entities

01
Spouse
19
Child
20
Employee
21
Unknown

Use this code if the relationship code of Unknown is valid for this person when received in the 837 2000C PAT01
OR
Use this code if relationship information is not available and there is a need to use data elements INS03, INS04, or INS17.

39
Organ Donor
40
Cadaver Donor
53
Life Partner
G8
Other Relationship
INS-03
875
Maintenance Type Code
Optional
Identifier (ID)

Code identifying the specific type of item maintenance

Usage notes
  • Use this element (and code "25" in INS04) if any of the identifying elements for the dependent have been changed from those submitted in the 270.
001
Change
INS-04
1203
Maintenance Reason Code
Optional
Identifier (ID)

Code identifying the reason for the maintenance change

Usage notes
  • Use this element (and code "001" in INS03) if any of the identifying elements for the dependent have been changed from those submitted in the 270.
25
Change in Identifying Data Elements

Use this code to indicate that a change has been made to the primary elements that identify a specific person. Such elements are first name, last name, date of birth, and identification numbers.

INS-17
1470
Birth Sequence Number
Optional
Numeric (N0)
Min 1Max 9

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.).
Usage notes
  • Use to indicate the birth order in the event of multiple births in association with the birth date supplied in DMG02.
HI
1150
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > HI

Dependent Health Care Diagnosis Code

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Required when an HI segment was received in the 270 and if the information source uses the information in the determination of the eligibility or benefit response for the dependent. All information used from the HI segment of the 270 used in the determination of the eligibility or benefit response for the dependent must be returned. If information was provided in an HI segment of 270 but was not used in the determination of the eligibility or benefits for the dependent it must not be returned. 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.
    OR
    Required when needed to identify limitations in the benefits identified in the 2110D loops, such as if benefits are limited for a specific diagnosis code if the information source can support this high level functionality. If the information source cannot support this high level functionality, do not send.
  • Use the Diagnosis code pointers in 2110D EB14 to identify which diagnosis code or codes in this HI segment relates to the information provided in the EB segment.
  • Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
Example
HI-01
C022
Health Care Code Information
RequiredMax use 1
To send health care codes and their associated dates, amounts and quantities
C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-02
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-03
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-04
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-05
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-06
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-07
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
HI-08
C022
Health Care Code Information
OptionalMax use 1
To send health care codes and their associated dates, amounts and quantities
Usage notes

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.

C022-01
1270
Diagnosis Type Code
Required
Identifier (ID)

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
C022-02
1271
Diagnosis Code
Required
String (AN)
Min 1Max 30

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.
DTP
1200
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > DTP

Dependent Date

OptionalMax use 9

To specify any or all of a date, a time, or a time period

Usage notes
  • The dates represented may be in the past, the current date, or a future date. The dates may also be a single date or a span of dates. Which date(s) to use is determined by the format qualifier in DTP02.
  • Required to identify the Plan (DTP01 = 291) or Plan Begin (DTP01 = 346) date when the individual has active coverage unless multiple plans apply to the individual or multiple plan periods apply, which must then be returned in the 2110D DTP (See Section 1.4.7);
    OR
    Required when needed to identify other relevant dates that apply to the Dependent.
    If not required by this implementation guide, do not send.
  • Dates supplied in the 2100D DTP apply to the Dependent and all 2110D loops unless overridden by an occurrence of a 2110D DTP with the same value in DTP01.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

Code specifying type of date or time, or both date and time

096
Discharge
102
Issue
152
Effective Date of Change
291
Plan
307
Eligibility
318
Added

Information Sources are encouraged to return Added date in the case of retroactive eligibility.

340
Consolidated Omnibus Budget Reconciliation Act (COBRA) Begin
341
Consolidated Omnibus Budget Reconciliation Act (COBRA) End
342
Premium Paid to Date Begin
343
Premium Paid to Date End
346
Plan Begin
347
Plan End
356
Eligibility Begin
357
Eligibility End
382
Enrollment
435
Admission
442
Date of Death
458
Certification
472
Service
539
Policy Effective
540
Policy Expiration
636
Date of Last Update
771
Status
DTP-02
1250
Date Time Period Format Qualifier
Required
Identifier (ID)

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.
Usage notes
  • Use this code to specify the format of the date(s)/time(s) that follow in the next data element.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
DTP-03
1251
Date Time Period
Required
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

Usage notes
  • Use this date for the date(s) as qualified by the preceding data elements.
MPI
1275
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > MPI

Dependent Military Personnel Information

OptionalMax use 1

To report military service data

Usage notes
  • Required when this transaction is processed by DOD or CHAMPUS/TRICARE and when necessary to convey the Dependent's military service data If not required by this implementation guide, do not send.
Example
If either Date Time Period Format Qualifier (MPI-06) or Date Time Period (MPI-07) is present, then the other is required
MPI-01
1201
Information Status Code
Required
Identifier (ID)

A code to indicate the status of information

A
Partial
C
Current
L
Latest
O
Oldest
P
Prior
S
Second Most Current
T
Third Most Current
MPI-02
584
Employment Status Code
Required
Identifier (ID)

Code showing the general employment status of an employee/claimant

AE
Active Reserve
AO
Active Military - Overseas
AS
Academy Student
AT
Presidential Appointee
AU
Active Military - USA
CC
Contractor
DD
Dishonorably Discharged
HD
Honorably Discharged
IR
Inactive Reserves
LX
Leave of Absence: Military
PE
Plan to Enlist
RE
Recommissioned
RM
Retired Military - Overseas
RR
Retired Without Recall
RU
Retired Military - USA
MPI-03
1595
Government Service Affiliation Code
Required
Identifier (ID)

Code specifying the government service affiliation

A
Air Force
B
Air Force Reserves
C
Army
D
Army Reserves
E
Coast Guard
F
Marine Corps
G
Marine Corps Reserves
H
National Guard
I
Navy
J
Navy Reserves
K
Other
L
Peace Corp
M
Regular Armed Forces
N
Reserves
O
U.S. Public Health Service
Q
Foreign Military
R
American Red Cross
S
Department of Defense
U
United Services Organization
W
Military Sealift Command
MPI-04
352
Description
Optional
String (AN)
Min 1Max 80

A free-form description to clarify the related data elements and their content

  • MPI04 is the actual response to further identify the exact military unit.
MPI-05
1596
Military Service Rank Code
Optional
Identifier (ID)

Code specifying the military service rank

A1
Admiral
A2
Airman
A3
Airman First Class
B1
Basic Airman
B2
Brigadier General
C1
Captain
C2
Chief Master Sergeant
C3
Chief Petty Officer
C4
Chief Warrant
C5
Colonel
C6
Commander
C7
Commodore
C8
Corporal
C9
Corporal Specialist 4
E1
Ensign
F1
First Lieutenant
F2
First Sergeant
F3
First Sergeant-Master Sergeant
F4
Fleet Admiral
G1
General
G4
Gunnery Sergeant
L1
Lance Corporal
L2
Lieutenant
L3
Lieutenant Colonel
L4
Lieutenant Commander
L5
Lieutenant General
L6
Lieutenant Junior Grade
M1
Major
M2
Major General
M3
Master Chief Petty Officer
M4
Master Gunnery Sergeant Major
M5
Master Sergeant
M6
Master Sergeant Specialist 8
P1
Petty Officer First Class
P2
Petty Officer Second Class
P3
Petty Officer Third Class
P4
Private
P5
Private First Class
R1
Rear Admiral
R2
Recruit
S1
Seaman
S2
Seaman Apprentice
S3
Seaman Recruit
S4
Second Lieutenant
S5
Senior Chief Petty Officer
S6
Senior Master Sergeant
S7
Sergeant
S8
Sergeant First Class Specialist 7
S9
Sergeant Major Specialist 9
SA
Sergeant Specialist 5
SB
Staff Sergeant
SC
Staff Sergeant Specialist 6
T1
Technical Sergeant
V1
Vice Admiral
W1
Warrant Officer
MPI-06
1250
Date Time Period Format Qualifier
Optional
Identifier (ID)

Code indicating the date format, time format, or date and time format

D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
MPI-07
1251
Date Time Period
Optional
String (AN)
Min 1Max 35

Expression of a date, a time, or range of dates, times or dates and times

  • MPI07 indicates the date span of military service.
2110D Dependent Eligibility or Benefit Information Loop
OptionalMax >1
EB
1300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Information Loop > EB

Dependent Eligibility or Benefit Information

RequiredMax use 1

To supply eligibility or benefit information

Usage notes
  • See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what information must be returned if the subscriber is the person whose eligibility or benefits are being sent.
  • Either EB03 or EB13 may be used in the same EB segment, not both.
  • Required when the dependent is the person whose eligibility or benefits are being described and the transaction is not rejected (see Section 1.4.10) or if the transaction needs to be rejected in this loop. If not required by this implementation guide, do not send.
  • EB03 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 EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110D loop are identical.
  • A limit to the number of repeats of EB loops has not been established. In a batch environment there is no practical reason to limit the number of EB loop repeats. In a real time environment, consideration should be given to how many EB loops are generated given the amount of time it takes to format the response and the amount of time it will take to transmit that response. Since these limitations will vary by information source, it would be completely arbitrary for the developers to set a limit. It is not the intent of the developers to limit the amount of information that is returned in a response, rather to alert information sources to consider the potential delays if the response contains too much information to be formatted and transmitted in real time.
  • Use this segment to begin the eligibility/benefit information looping structure. The EB segment is used to convey the specific eligibility or benefit information for the entity identified.
Example
If either Quantity Qualifier (EB-09) or Benefit Quantity (EB-10) is present, then the other is required
EB-01
1390
Eligibility or Benefit Information
Required
Identifier (ID)

Code identifying eligibility or benefit information

  • EB01 qualifies EB06 through EB10.
Usage notes
  • Use this code to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category that is being further described in the following data elements. This data element also qualifies the data in elements EB06 through EB10.
  • If codes A, B, C, G, J or Y are used, it is required that the patient's portion of responsibility is reflected in either EB07 or EB08. See Section 1.4.9 Patient Responsibility for detailed information and definitions.
1
Active Coverage
2
Active - Full Risk Capitation
3
Active - Services Capitated
4
Active - Services Capitated to Primary Care Physician
5
Active - Pending Investigation
6
Inactive
7
Inactive - Pending Eligibility Update
8
Inactive - Pending Investigation
A
Co-Insurance

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

B
Co-Payment

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

C
Deductible

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

CB
Coverage Basis
D
Benefit Description
E
Exclusions
F
Limitations
G
Out of Pocket (Stop Loss)

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

H
Unlimited
I
Non-Covered
J
Cost Containment

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

K
Reserve
L
Primary Care Provider
M
Pre-existing Condition
MC
Managed Care Coordinator
N
Services Restricted to Following Provider
O
Not Deemed a Medical Necessity
P
Benefit Disclaimer

Not recommended. See section 1.4.11 Disclaimers Within the Transaction.

Q
Second Surgical Opinion Required
R
Other or Additional Payor
S
Prior Year(s) History
T
Card(s) Reported Lost/Stolen

Code "T" is typically used by Medicaids to indicate to a provider that the person who has presented the ID card is using a stolen ID card.

U
Contact Following Entity for Eligibility or Benefit Information
V
Cannot Process
W
Other Source of Data
X
Health Care Facility
Y
Spend Down

See Section 1.4.9 Patient Responsibility for detailed information and definitions.

EB-02
1207
Benefit Coverage Level Code
Optional
Identifier (ID)

Code indicating the level of coverage being provided for this insured

Usage notes
  • This element is used in conjunction with EB01 codes (e.g. Active Family Coverage, Deductible Individual, etc.). This element can be used to identify types of individual's within the Subscriber's family that eligibility or benefits extends to (unless EB01 = E - Exclusions).
CHD
Children Only
DEP
Dependents Only
ECH
Employee and Children
ESP
Employee and Spouse
FAM
Family
IND
Individual
SPC
Spouse and Children
SPO
Spouse Only
EB-03
1365
Service Type Code
Optional
Identifier (ID)
Max use 99

Code identifying the classification of service

  • Position of data in the repeating data element conveys no significance.
Usage notes
  • See Section 1.4.7 Implementation-Compliant Use of the 270/271 Transaction Set for information about what service type codes must be returned.
  • EB03 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 EB03, it is more efficient to use the repetition function of EB03 to send each of the Service Type Codes needed. If an Information Source supports responses with multiple Service Type Codes, the repetition use of EB03 must be supported if all other elements in the 2110D loop are identical.
  • Not used if EB13 is present.
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

See Section 1.4.7.1

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
EB-04
1336
Insurance Type Code
Optional
Identifier (ID)

Code identifying the type of insurance policy within a specific insurance program

12
Medicare Secondary Working Aged Beneficiary or Spouse with E