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Health Care Eligibility Benefit Inquiry (X279A1)
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X12 270 Health Care Eligibility Benefit Inquiry (X279A1)

X12 Release 5010

This X12 Transaction Set contains the format and establishes the data contents of the Eligibility, Coverage or Benefit Inquiry Transaction Set (270) for use within the context of an Electronic Data Interchange (EDI) environment. This transaction set can be used to inquire about the eligibility, coverages or benefits associated with a benefit plan, employer, plan sponsor, subscriber or a dependent under the subscriber's policy. The transaction set is intended to be used by all lines of insurance such as Health, Life, and Property and Casualty.

Delimiters
  • ~ Segment
  • * Element
  • > Component
  • ^ Repetition
EDI samples
  • Example 1: Generic Request By a Clinic for the Patient’s (Subscriber) Eligibility
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https://www.stedi.com/app/guides/view/united-healthcare/health-care-eligibility-benefit-inquiry-x279a1/01H00H99R0BA0N23EJY2HFMC3T
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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
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 2
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
PRV
0900
Provider Information
Max use 1
Optional
DMG
1000
Subscriber Demographic Information
Max use 1
Optional
INS
1100
Multiple Birth Sequence Number
Max use 1
Optional
HI
1150
Subscriber Health Care Diagnosis Code
Max use 1
Optional
DTP
1200
Subscriber Date
Max use 2
Optional
Subscriber Eligibility or Benefit Inquiry Loop
SE
2100
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

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

HS
Eligibility, Coverage or Benefit Inquiry (270)
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.
270
Eligibility, Coverage or Benefit Inquiry
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 the number, for example "0001", and increment from there. This number must be unique within a specific group and interchange, but can repeat in other groups and interchanges.
  • Use the corresponding value in SE02 for this transaction set.
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 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

01
Cancellation

Use this code to cancel a previously submitted 270 transaction that used a BHT06 code of "RT". Only 270 transactions that used a BHT06 code of "RT" can be canceled. The cancellation 270 transaction must also contain a BHT06 of "RT".

13
Request
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
  • Due to the nature of batch transaction processing, the receiver of the 270 transaction (whether it is a clearinghouse or information source) may or may not be able to return the 270 BHT03 value in the 271 BHT03. See Section 1.4.6 Information Linkage for additional information and requirements.
  • This element is to be used to trace the transaction from one point to the next point, such as when the transaction is passed from one clearinghouse to another clearinghouse. This identifier is to be returned in the corresponding 271 transaction's BHT03. This identifier will only be returned by the last entity to handle the 270. This identifier will not be passed through the complete life of the transaction.
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.
BHT-06
640
Transaction Type Code
Optional
Identifier (ID)

Code specifying the type of transaction

Usage notes
  • Certain Medicaid programs support additional functionality for Spend Down. Use this code when necessary to further specify the type of transaction to a Medicaid program that supports this functionality.
RT
Spend Down

"Spend Down" is a term used by certain Medicaid programs when a recipient must pay a predetermined amount out of his or her own pocket before full coverage benefits are applied. In order to decrement the amount the recipient must pay out of pocket, a 270 transaction must be sent in with this code.

In the event that the service is not rendered and the Spend Down amount is returned to the recipient, an additional 270 must be sent in with a BHT02 with a code "01" to cancel the Spend Down.

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.
1
Additional Subordinate HL Data Segment in This Hierarchical Structure.
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 NM1 loop to identify an entity by name and/or identification number. This NM1 loop is used to identify the eligibility or benefit information source, (e.g., insurance company, HMO, IPA, employer).
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

Use this code only if the information source is a Gateway Provider and an individual.

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

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 code value "XX" if the information source is a provider and the CMS National Provider Identifier is mandated for use.

Use "XV" when reporting Health Plan ID (HPID) or Other Entity Identifier (OEID).

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

2100A Information Source Name Loop end
2000B Information Receiver Level Loop
RequiredMax >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.
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, employer, 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
Required
String (AN)
Min 1Max 60

Individual last name or organizational name

NM1-04
1036
Information Receiver First Name
Optional
String (AN)
Min 1Max 35

Individual first name

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

Individual middle name or initial

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

Suffix to individual name

Usage notes
  • Use this only if NM102 is "1".
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 270/271 transaction sets are used between two payers.

PP
Pharmacy Processor Number
SV
Service Provider Number

Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.

XV
Centers for Medicare and Medicaid Services PlanID
XX
Centers for Medicare and Medicaid Services National Provider Identifier
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 the information in 2100B NM1 is not sufficient to identify the information receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
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.
  • 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 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 ID 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 the information receiver is a provider who has multiple locations and it is needed to identify the location relative to the request. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
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 the information receiver is a provider who has multiple locations and it is needed to identify the location relative to the request. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
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.
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
  • Required when the Information Receiver believes Provider Information is relevant to the request and is necessary to convey the provider's role in or taxonomy code related to the eligibility/benefit being inquired about and the provider is also the Information Receiver. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
  • For example, if the Information Receiver is also the Referring Provider, this PRV segment would be used to identify the provider's role.
  • PRV02 qualifies PRV03.
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

2100B Information Receiver Name Loop end
2000C Subscriber Level Loop
RequiredMax >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 2

To uniquely identify a transaction to an application

Usage notes
  • The information receiver may assign one TRN segment in this loop if the subscriber is the patient. A clearinghouse may assign one TRN segment in this loop if the subscriber is the patient. See Section 1.4.6 Information Linkage.
  • This segment must not be used if the subscriber is not the patient. See section 1.4.2. Basic Concepts.
  • Required when information receiver or clearinghouse intends to use the TRN segment as a tracing mechanism for the eligibility transaction and the subscriber is the patient. If not required by this implementation guide, do not send.
  • Trace numbers assigned at the subscriber level are intended to allow tracing of an eligibility/benefit transaction when the subscriber is the patient.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers
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
  • Use this number for the trace or reference number assigned by the information receiver or clearinghouse.
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
  • Use this number for the identification number of the company that assigned the trace or reference number specified in the previous data element (TRN02).
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
  • This information allows the originating company to further identify a specific division or group within that organization that was responsible for assigning the trace or reference number.
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. Use this NM1 loop to identify the insured or subscriber.
  • Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
  • In worker's compensation or other property and casualty transactions, the "subscriber" may be a non-person entity (for example, the employer). However, this varies by state.
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.
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
Subscriber Last Name
Optional
String (AN)
Min 1Max 60

Individual last name or organizational name

Usage notes
  • Use this name for the subscriber's last name.
  • Information sources cannot require subscriber's name suffix be sent as a part of the subscriber's last name.
NM1-04
1036
Subscriber First Name
Optional
String (AN)
Min 1Max 35

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.
II
Standard Unique Health Identifier for each Individual in the United States

Under the Health Insurance Portability and Accountability Act of 1996, the Secretary of the Department of Health and Human Services may adopt a standard individual identifier for use in this transaction.

MI
Member Identification Number

This code may only be used prior to the mandated use of code "II". This is the unique number the payer or information source uses to identify the insured (e.g., Health Insurance Claim Number, Medicaid Recipient ID Number, HMO Member ID, etc.).

NM1-09
67
Subscriber Primary Identifier
Optional
String (AN)
Min 2Max 80

Code identifying a party or other code

Usage notes
  • Use this reference number as qualified by the preceding data element (NM108).
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
  • Use this segment when needed to convey identification numbers other than or in addition to the Member Identification Number. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100C loop.
  • Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Numbers are to be provided in the NM1 segment as a Member Identification Number when it is the primary number an information source knows a member by (such as for Medicare or Medicaid). Do not use this segment for the Health Insurance Claim (HIC) Number or Medicaid Recipient Identification Number unless they are different from the Member Identification Number provided in the NM1 segment.
  • Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
  • Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
    OR
    Required when this segment is used to transmit the Patient Account Number when REF01 = EJ (see Section 1.4.6).
    OR
    Required when this segment is used to transmit the Provider's Contract Number when REF01 = CT.
    If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
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.
  • 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 after the Unique Patient Identifier is available and has been provided in the NM109, but use of the UPI has not been mandated.

3H
Case Number

Uses this code to identify the Case Number assigned to the subscriber by the information source.

6P
Group Number
18
Plan Number
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 2.

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.

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

See segment note 2.

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 only to be used when submitting an eligibility request to 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 reference number as qualified by the preceding data element (REF01).;
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 information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
    If not required by this implementation guide, do not send.
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 information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
    If not required by this implementation guide, do not send.
Example
Only one of Subscriber 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
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
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.
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
  • This segment must not be used to identify the information receiver or the information receiver's specialty type, unless the information is different from that sent in the 2100B loop.
  • If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about when the provider is not the information receiver. For example, if the information receiver is a hospital and a referring provider must be identified, this is the segment where the referring provider would be identified.
  • Required when the information source is known to process this information in creating a 271 response and the information receiver feels it is necessary to identify a specific provider or to associate a specialty type related to the service identified in the 2110C loop. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
  • If identifying a specific provider, this segment contains reference identification numbers, all of which may be used up until the time the National Provider Identifier (NPI) is mandated for use. After the NPI is mandated, only the code for National Provider Identifier may be used.
  • If identifying a type of specialty associated with the services identified in loop 2110C, use code PXC in PRV02 and the appropriate code in PRV03.
  • PRV02 qualifies PRV03.
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 specific provider and the National Provider ID is mandated for use, code value "HPI" must be used, otherwise one of the other code values may be used.
  • If this segment is used to identify a type of specialty associated with the services identified in loop 2110C, use code PXC.
9K
Servicer

Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.

D3
National Council for Prescription Drug Programs Pharmacy Number
EI
Employer's Identification Number
HPI
Centers for Medicare and Medicaid Services National Provider Identifier

Required value when identifying a specific provider when the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.

PXC
Health Care Provider Taxonomy Code
SY
Social Security Number

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

TJ
Federal Taxpayer's Identification Number
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 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 when needed to convey birth date or gender demographic information for the subscriber.
  • Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
  • Required when the subscriber is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).
    OR
    Required when the subscriber is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).
    OR
    Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
    If not required by this implementation guide, do not send.
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

Usage notes
  • Use this code to indicate the subscriber's gender.
F
Female
M
Male
INS
1100
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > INS

Multiple Birth Sequence Number

OptionalMax use 1

To provide benefit information on insured entities

Usage notes
  • Required when the information receiver believes it is necessary to identify the birth sequence of the subscriber in the case of multiple births with the same birth date for an Alternate Search Option supported by the Information Source (See Section 1.4.8). If not required by this implementation guide, do not send.
  • This segment must not be used if the subscriber is not part of a multiple birth.
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.
Usage notes
  • The value Y is used to satisfy X12 syntax.
Y
Yes

The value Y is used to satisfy X12 syntax. This data has no business purpose and must not be used to indicate if the insured is a subscriber.

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

Code indicating the relationship between two individuals or entities

Usage notes
  • The value 18 is used only to satisfy X12 syntax.
18
Self

The value 18 is used to satisfy X12 syntax. This data has no business purpose and must not be used to indicate the Individual's relationship to the insured.

INS-17
1470
Birth Sequence Number
Required
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 > Subscriber Name Loop > HI

Subscriber Health Care Diagnosis Code

OptionalMax use 1

To supply information related to the delivery of health care

Usage notes
  • Use the HI segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the subscriber if that information cannot be returned in the 271 response.
  • Use this segment to identify Diagnosis codes as they relate to the information provided in the EQ segments.
  • Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
  • Required when the information receiver believes the Diagnosis information is relevant to the inquiry, the information is available and if the information source supports or is believed to support this level of functionality. If not required by this implementation guide, do not send.
Example
HI-01
C022
Health Care Code Information
Required
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
Optional
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
Optional
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
Optional
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
Optional
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
Optional
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
Optional
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
Optional
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 2

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

Usage notes
  • Absence of a Plan date indicates the request is for the date the transaction is processed and the information source is to process the transaction in the same manner as if the processing date was sent.
  • Use this segment to convey the plan date(s) for the subscriber or for the issue date of the subscriber's identification card for the information source.
  • When using code "291" (Plan) at this level, it is implied that these dates apply to all of the Eligibility or Benefit Inquiry (EQ) loops that follow. If there is a need to supply a different Plan date for a specific EQ loop, it must be provided in the DTP segment within the EQ loop and it will only apply to that EQ loop.
  • Required when the information receiver wishes to convey the plan date(s) for the subscriber in relation to the eligibility/benefit inquiry. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
    OR
    Required when utilizing a search option other than either the Primary Search Option or a Required Alternate Search Option identified in section 1.4.8 which requires the ID Card Issue Date. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

102
Issue

Used for the ID Card Issue Date if utilizing a search option other than the Primary or one of the Required Alternate Search Options identified in section 1.4.8 and the Card Issue Date is present on the identification card and is available.

291
Plan
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.
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.
2110C Subscriber Eligibility or Benefit Inquiry Loop
OptionalMax 10
EQ
1300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > EQ

Subscriber Eligibility or Benefit Inquiry

RequiredMax use 1

To specify inquired eligibility or benefit information

Usage notes
  • When the subscriber is not the patient, the 2110C EQ segment must not be used. When the transaction is used in a batch environment, it is possible to have both 2110C and 2110D EQ segments when the subscriber and dependent(s) are patients whose eligibility or benefits are being verified. See Section 1.4.3 Batch and Real Time for additional information.
  • The 2110C EQ segment begins the 2110C loop.
  • Required when the subscriber is the patient whose eligibility or benefits are being verified. If not required by this implementation guide, do not send.
  • If the EQ segment is used, either EQ01 - Service Type Code or EQ02 - Composite Medical Procedure Identifier must be used. Only EQ01 or EQ02 is to be sent, not both.
    An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01. An information source may support the use of Service Type Codes other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion.
    An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes can be supplied in the 2100C HI segment and place of service in the 2110C III segment.
  • If an information source receives a Service Type Code "30" submitted in the 270 EQ01 or a Service Type Code that they do not support, the 2110C EB03 values identified in Section 1.4.7.1 Item #8 must also be returned if they are a covered benefit category at a plan level. Refer to Section 1.4.7 for additional information.
  • EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
Example
At least one of Service Type Code (EQ-01) or Composite Medical Procedure Identifier (EQ-02) is required
EQ-01
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
  • An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01.
  • An information source may support the use of Service Type Codes from the list other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion. If an information source supports codes in addition to "30", the information source may provide a list of the supported codes from the list below to the information receiver. If no list is provided, an information receiver may transmit the most appropriate code.
  • If an inquiry is submitted with a Service Type Code from the list other than "30" and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of "30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.
  • EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110C loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
  • Not used if EQ02 is used.
1
Medical Care
2
Surgical
3
Consultation
4
Diagnostic X-Ray
5
Diagnostic Lab
6
Radiation Therapy
7
Anesthesia
8
Surgical Assistance
9
Other Medical
10
Blood Charges
11
Used Durable Medical Equipment
12
Durable Medical Equipment Purchase
13
Ambulatory Service Center Facility
14
Renal Supplies in the Home
15
Alternate Method Dialysis
16
Chronic Renal Disease (CRD) Equipment
17
Pre-Admission Testing
18
Durable Medical Equipment Rental
19
Pneumonia Vaccine
20
Second Surgical Opinion
21
Third Surgical Opinion
22
Social Work
23
Diagnostic Dental
24
Periodontics
25
Restorative
26
Endodontics
27
Maxillofacial Prosthetics
28
Adjunctive Dental Services
30
Health Benefit Plan Coverage

If only a single category of inquiry can be supported, use this code.

32
Plan Waiting Period
33
Chiropractic
34
Chiropractic Office Visits
35
Dental Care
36
Dental Crowns
37
Dental Accident
38
Orthodontics
39
Prosthodontics
40
Oral Surgery
41
Routine (Preventive) Dental
42
Home Health Care
43
Home Health Prescriptions
44
Home Health Visits
45
Hospice
46
Respite Care
47
Hospital
48
Hospital - Inpatient
49
Hospital - Room and Board
50
Hospital - Outpatient
51
Hospital - Emergency Accident
52
Hospital - Emergency Medical
53
Hospital - Ambulatory Surgical
54
Long Term Care
55
Major Medical
56
Medically Related Transportation
57
Air Transportation
58
Cabulance
59
Licensed Ambulance
60
General Benefits
61
In-vitro Fertilization
62
MRI/CAT Scan
63
Donor Procedures
64
Acupuncture
65
Newborn Care
66
Pathology
67
Smoking Cessation
68
Well Baby Care
69
Maternity
70
Transplants
71
Audiology Exam
72
Inhalation Therapy
73
Diagnostic Medical
74
Private Duty Nursing
75
Prosthetic Device
76
Dialysis
77
Otological Exam
78
Chemotherapy
79
Allergy Testing
80
Immunizations
81
Routine Physical
82
Family Planning
83
Infertility
84
Abortion
85
AIDS
86
Emergency Services
87
Cancer
88
Pharmacy
89
Free Standing Prescription Drug
90
Mail Order Prescription Drug
91
Brand Name Prescription Drug
92
Generic Prescription Drug
93
Podiatry
94
Podiatry - Office Visits
95
Podiatry - Nursing Home Visits
96
Professional (Physician)
97
Anesthesiologist
98
Professional (Physician) Visit - Office
99
Professional (Physician) Visit - Inpatient
A0
Professional (Physician) Visit - Outpatient
A1
Professional (Physician) Visit - Nursing Home
A2
Professional (Physician) Visit - Skilled Nursing Facility
A3
Professional (Physician) Visit - Home
A4
Psychiatric
A5
Psychiatric - Room and Board
A6
Psychotherapy
A7
Psychiatric - Inpatient
A8
Psychiatric - Outpatient
A9
Rehabilitation
AA
Rehabilitation - Room and Board
AB
Rehabilitation - Inpatient
AC
Rehabilitation - Outpatient
AD
Occupational Therapy
AE
Physical Medicine
AF
Speech Therapy
AG
Skilled Nursing Care
AH
Skilled Nursing Care - Room and Board
AI
Substance Abuse
AJ
Alcoholism
AK
Drug Addiction
AL
Vision (Optometry)
AM
Frames
AN
Routine Exam

Use for Routine Vision Exam only.

AO
Lenses
AQ
Nonmedically Necessary Physical
AR
Experimental Drug Therapy
B1
Burn Care
B2
Brand Name Prescription Drug - Formulary
B3
Brand Name Prescription Drug - Non-Formulary
BA
Independent Medical Evaluation
BB
Partial Hospitalization (Psychiatric)
BC
Day Care (Psychiatric)
BD
Cognitive Therapy
BE
Massage Therapy
BF
Pulmonary Rehabilitation
BG
Cardiac Rehabilitation
BH
Pediatric
BI
Nursery
BJ
Skin
BK
Orthopedic
BL
Cardiac
BM
Lymphatic
BN
Gastrointestinal
BP
Endocrine
BQ
Neurology
BR
Eye
BS
Invasive Procedures
BT
Gynecological
BU
Obstetrical
BV
Obstetrical/Gynecological
BW
Mail Order Prescription Drug: Brand Name
BX
Mail Order Prescription Drug: Generic
BY
Physician Visit - Office: Sick
BZ
Physician Visit - Office: Well
C1
Coronary Care
CA
Private Duty Nursing - Inpatient
CB
Private Duty Nursing - Home
CC
Surgical Benefits - Professional (Physician)
CD
Surgical Benefits - Facility
CE
Mental Health Provider - Inpatient
CF
Mental Health Provider - Outpatient
CG
Mental Health Facility - Inpatient
CH
Mental Health Facility - Outpatient
CI
Substance Abuse Facility - Inpatient
CJ
Substance Abuse Facility - Outpatient
CK
Screening X-ray
CL
Screening laboratory
CM
Mammogram, High Risk Patient
CN
Mammogram, Low Risk Patient
CO
Flu Vaccination
CP
Eyewear and Eyewear Accessories
CQ
Case Management
DG
Dermatology
DM
Durable Medical Equipment
DS
Diabetic Supplies
GF
Generic Prescription Drug - Formulary
GN
Generic Prescription Drug - Non-Formulary
GY
Allergy
IC
Intensive Care
MH
Mental Health
NI
Neonatal Intensive Care
ON
Oncology
PT
Physical Therapy
PU
Pulmonary
RN
Renal
RT
Residential Psychiatric Treatment
TC
Transitional Care
TN
Transitional Nursery Care
UC
Urgent Care
EQ-02
C003
Composite Medical Procedure Identifier
Optional
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes

Required if utilizing a Medical Procedure Code inquiry when the information receiver believes that the information source supports this high level of functionality and EQ01 is not used. If not required by this implementation guide, do not send.

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 qualify the type of specific Product/Service ID that will be used in EQ02-2.
AD
American Dental Association Codes
CJ
Current Procedural Terminology (CPT) Codes
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
ID
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code
N4
National Drug Code in 5-4-2 Format
ZZ
Mutually Defined

Use this code only for International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS).

CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

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 number for the product/service ID as identified by the preceding data element (EQ02-1).
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
  • Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
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
  • Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
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
  • Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
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
  • Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
EQ-03
1207
Coverage Level Code
Optional
Identifier (ID)

Code indicating the level of coverage being provided for this insured

Usage notes
  • It is at the sole discretion of the information source whether to support this functionality or not. If not supported, information source will process without this data element.
FAM
Family
EQ-05
C004
Composite Diagnosis Code Pointer
Optional
To identify one or more diagnosis code pointers
Usage notes

Required when a 2100C HI segment is used. If not required by this implementation guide, 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 EQ segment. Remaining diagnosis pointers indicate declining level of importance to the EQ segment. Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100C.
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.
AMT
1350
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > AMT

Subscriber Spend Down Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Use this segment only if it is necessary to report a Spend Down amount. Under certain Medicaid programs, individuals must indicate the dollar amount that they wish to apply towards their deductible. These programs require individuals to pay a certain amount towards their health care cost before Medicaid coverage starts.
  • Required if Spend Down amount is being reported. If not required by this implementation guide, do not send.
Example
Variants (all may be used)
AMTSubscriber Spend Down Total Billed Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

R
Spend Down
AMT-02
782
Spend Down Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

Usage notes
  • Use this monetary amount to specify the dollar amount associated with this inquiry.
AMT
1350
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > AMT

Subscriber Spend Down Total Billed Amount

OptionalMax use 1

To indicate the total monetary amount

Usage notes
  • Required if Spend Down amount is being reported in a separate 2110C AMT segment and the information source also requires the Spend Down Total Billed Amount. If not required by this implementation guide, do not send.
  • Use this segment only if it is necessary to report the Spend Down Total Billed Amount in addition to the Spend Down Amount. See 2110C Subscriber Spend Down Amount segment for more information about Spend Down.
Example
Variants (all may be used)
AMTSubscriber Spend Down Amount
AMT-01
522
Amount Qualifier Code
Required
Identifier (ID)

Code to qualify amount

PB
Billed Amount
AMT-02
782
Spend Down Total Billed Amount
Required
Decimal number (R)
Min 1Max 15

Monetary amount

Usage notes
  • Use this monetary amount to specify the dollar amount associated with this inquiry.
III
1700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > III

Subscriber Eligibility or Benefit Additional Inquiry Information

OptionalMax use 1

To report information

Usage notes
  • Use the III segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment.
  • Required when the information receiver believes the Facility Type information is relevant to the inquiry and the information is available. If not required by this implementation guide, do not send.
Example
III-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

Usage notes
  • Use this code to specify the code that is following in the III02 is a Facility Type Code.
ZZ
Mutually Defined

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

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

Code indicating a code from a specific industry code list

Usage notes
  • Use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below; however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.
    01 Pharmacy
    03 School
    04 Homeless Shelter
    05 Indian Health Service Free-standing Facility
    06 Indian Health Service Provider-based Facility
    07 Tribal 638 Free-standing Facility
    08 Tribal 638 Provider-based Facility
    11 Office
    12 Home
    13 Assisted Living Facility
    14 Group Home
    15 Mobile Unit
    20 Urgent Care Facility
    21 Inpatient Hospital
    22 Outpatient Hospital
    23 Emergency Room - Hospital
    24 Ambulatory Surgical Center
    25 Birthing Center
    26 Military Treatment Facility
    31 Skilled Nursing Facility
    32 Nursing Facility
    33 Custodial Care Facility
    34 Hospice
    41 Ambulance - Land
    42 Ambulance - Air or Water
    49 Independent Clinic
    50 Federally Qualified Health Center
    51 Inpatient Psychiatric Facility
    52 Psychiatric Facility - Partial Hospitalization
    53 Community Mental Health Center
    54 Intermediate Care Facility/Mentally Retarded
    55 Residential Substance Abuse Treatment Facility
    56 Psychiatric Residential Treatment Center
    57 Non-residential Substance Abuse Treatment Facility
    60 Mass Immunization Center
    61 Comprehensive Inpatient Rehabilitation Facility
    62 Comprehensive Outpatient Rehabilitation Facility
    65 End-Stage Renal Disease Treatment Facility
    71 Public Health Clinic
    72 Rural Health Clinic
    81 Independent Laboratory
    99 Other Place of Service
REF
1900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > REF

Subscriber Additional Information

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the subscriber has received a referral or prior authorization number and the information receiver believes the information is relevant to the inquiry (such as for a benefit or procedure that requires a referral or prior authorization) and the information is available. If not required by this implementation guide do not send.
  • Use this segment when it is necessary to provide a referral or prior authorization number for the benefit being inquired about.
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.
9F
Referral Number
G1
Prior Authorization Number
REF-02
127
Prior Authorization or Referral Number
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 reference number as qualified by the preceding data element (REF01).;
DTP
2000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Subscriber Name Loop > Subscriber Eligibility or Benefit Inquiry Loop > DTP

Subscriber Eligibility/Benefit Date

OptionalMax use 1

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

Usage notes
  • Use this segment to convey plan dates associated with the information contained in the corresponding EQ segment.
  • This segment is only to be used to override dates provided in Loop 2100C when the date differs from the date provided in the DTP segment in Loop 2100C. Dates that apply to the entire request must be placed in the DTP segment in Loop 2100C. In order for a date to appear here, there must be a date or a date range in the corresponding 2100C loop.
  • Required when the plan date(s) are different from the date(s) provided in the 2100C loop. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

291
Plan
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) or time(s) that follow in the next data element.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
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.
2110C Subscriber Eligibility or Benefit Inquiry 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 2

To uniquely identify a transaction to an application

Usage notes
  • Trace numbers assigned at the dependent level are intended to allow tracing of an eligibility/benefit transaction when the dependent is the patient.
  • The information receiver may assign one TRN segment in this loop if the dependent is the patient. A clearinghouse may assign one TRN segment in this loop if the dependent is the patient. See Section 1.4.6 Information Linkage.
  • Required when information receiver or clearinghouse intends to use the TRN segment as a tracing mechanism for the eligibility transaction and the dependent is the patient. If not required by this implementation guide, do not send.
Example
TRN-01
481
Trace Type Code
Required
Identifier (ID)

Code identifying which transaction is being referenced

1
Current Transaction Trace Numbers
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
  • Use this number for the trace or reference number assigned by the information receiver or clearinghouse.
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
  • Use this number for the identification number of the company that assigned the trace or reference number specified in the previous data element (TRN02).
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
  • This information allows the originating company to further identify a specific division or group within that organization that was responsible for assigning the trace or reference number.
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.
  • Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
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.
Usage notes
  • Use this code to indicate whether the entity is an individual person or an organization.
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.
  • Information sources cannot require dependent's name suffix be sent as a part of 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
  • Use this segment when needed to convey identification numbers for the dependent. The type of reference number is determined by the qualifier in REF01. Only one occurrence of each REF01 code value may be used in the 2100D loop.
  • Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
  • Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
    OR
    Required when this segment is used to transmit the Patient Account Number when REF01 = EJ (see Section 1.4.6).
    OR
    Required when this segment is used to transmit the Provider's Contract Number when REF01 = CT.
    If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
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.
  • 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

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

6P
Group Number
18
Plan Number
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 2100D. 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
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
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 be used when submitting an eligibility request to 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 reference number as qualified by the preceding data element (REF01).;
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 receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
    If not required by this implementation guide, do not send.
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 receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
    If not required by this implementation guide, do not send.
Example
Only one of Dependent 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
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
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.
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
  • This segment must not be used to identify the information receiver or the information receiver's specialty type, unless the information is different from that sent in the 2100B loop.
  • Required when the information source is known to process this information in creating a 271 response and the information receiver feels it is necessary to identify a specific provider or to associate a specialty type related to the service identified in the 2110D loop. If not required by this implementation guide, may be provided at sender's discretion, but cannot be required by the receiver.
  • If identifying a specific provider, use this segment to convey specific information about a provider's role in the eligibility/benefit being inquired about when the provider is not the information receiver. For example, if the information receiver is a hospital and a referring provider must be identified, this is the segment where the referring provider would be identified.
  • If identifying a specific provider, this segment contains reference;identification numbers, all of which may be used up until the time the;National Provider Identifier (NPI) is mandated for use. After the NPI is mandated, only the code for National Provider Identifier may be used.
  • If identifying a type of specialty associated with the services identified in loop 2110D, use code PXC in PRV02 and the appropriate code in PRV03.
  • PRV02 qualifies PRV03.
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 specific provider and the National Provider ID is mandated for use, code value "HPI" must be used, otherwise one of the other code values may be used.
  • If this segment is used to identify a type of specialty associated with the services identified in loop 2110D, use code PXC.
9K
Servicer

Use this code for the identification number assigned by the information source to be used by the information receiver in health care transactions.

D3
National Council for Prescription Drug Programs Pharmacy Number
EI
Employer's Identification Number
HPI
Centers for Medicare and Medicaid Services National Provider Identifier

Required value when identifying a specific provider when the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used.

PXC
Health Care Provider Taxonomy Code
SY
Social Security Number

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

TJ
Federal Taxpayer's Identification Number
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 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 when needed to convey the birth date or gender demographic information for the dependent.
  • Please refer to Section 1.4.8 Search Options for specific information about how to identify an individual to an Information Source.
  • Required when the dependent is the patient and the information receiver is utilizing the Primary Search Option (See Section 1.4.8).
    OR
    Required when the dependent is the patient and the information receiver is utilizing one of the Required Alternate Search Options that require the Patient's Date of Birth (See Section 1.4.8).
    OR
    Required when the information receiver believes this is needed for an Alternate Search Option supported by the Information Source (See Section 1.4.8).
    If not required by this implementation guide, do not send.
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 individual.;
DMG-03
1068
Dependent Gender Code
Optional
Identifier (ID)

Code indicating the sex of the individual

Usage notes
  • Use this code to indicate the dependent's gender.
F
Female
M
Male
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
  • Different types of health plans identify patients in different manners;depending upon how their eligibility is structured. However, two;approaches predominate.

The first approach is to assign each member of the family (and plan) a;unique ID number. This number can be used to identify and access;that individual's information independent of whether he or she is a;child, spouse, or the actual subscriber to the plan. The relationship of this individual to the actual subscriber or contract holder would be;one of spouse, child, self, etc.

The second approach is to assign the actual subscriber or contract;holder a unique ID number that is entered into the eligibility system.;Any related spouse, children, or dependents are identified through the;subscriber's ID and have no unique identification number of their;own. In this approach, the subscriber would be identified at the Loop;2100C subscriber or insured level and the actual patient (spouse,;child, etc.) would be identified at the Loop 2100D dependent level;under the subscriber.

  • Required when the information receiver believes it is necessary to identify for an Alternate Search Option supported by the Information Source (See Section 1.4.8) the dependent's relationship to the insured and/or the birth sequence of the dependent in the case of multiple births with the same birth date. If not required by this implementation guide, do not send.
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
34
Other Adult
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.).
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
  • Use the HI segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment. The information source must not use information in an HI segment of the 270 transaction in the determination of eligibility or benefits for the dependent if that information cannot be returned in the 271 response.
  • Required when the information receiver believes the Diagnosis information is relevant to the inquiry, the information is available and if the information source supports or is believed to support this level of functionality. If not required by this implementation guide, do not send.
  • Use this segment to identify Diagnosis codes as they relate to the information provided in the EQ segments.
  • Do not transmit the decimal points in the diagnosis codes. The decimal point is assumed.
Example
HI-01
C022
Health Care Code Information
Required
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
Optional
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
Optional
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
Optional
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
Optional
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
Optional
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
Optional
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
Optional
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 2

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

Usage notes
  • Absence of a Plan date indicates the request is for the date the transaction is processed and the information source is to process the transaction in the same manner as if the processing date was sent.
  • Use this segment to convey the plan date(s) for the dependent or for the issue date of the dependent's identification card for the information source.
  • When using code "291" (Plan) at this level, it is implied that these dates apply to all of the Eligibility or Benefit Inquiry (EQ) loops that follow. If there is a need to supply a different Plan date for a specific EQ loop, it must be provided in the DTP segment within the EQ loop and it will only apply to that EQ loop.
  • Required when the information receiver wishes to convey the plan date(s) for the dependent in relation to the eligibility/benefit inquiry. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
    OR
    Required when utilizing a search option other than either the Primary Search Option or a Required Alternate Search Option identified in section 1.4.8 which requires the ID Card Issue Date. If not required by this implementation guide, may be sent at the sender's discretion but cannot be required by the information source.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

102
Issue

Used for the ID Card Issue Date if utilizing a search option other than the Primary or one of the Required Alternate Search Options identified in section 1.4.8 and the Card Issue Date is present on the identification card and is available.

291
Plan
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) or time(s) that follow in the next data element.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
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.
2110D Dependent Eligibility or Benefit Inquiry Loop
RequiredMax 10
EQ
1300
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Inquiry Loop > EQ

Dependent Eligibility or Benefit Inquiry

RequiredMax use 1

To specify inquired eligibility or benefit information

Usage notes
  • Use this segment to begin the eligibility/benefit inquiry looping structure.
  • If the EQ segment is used, either EQ01 - Service Type Code or EQ02 - Composite Medical Procedure Identifier must be used. Only EQ01 or EQ02 is to be sent, not both.

An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01. An information source may support the use of Service Type Codes other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion.

An information source may support the use of EQ02 - Composite Medical Procedure Identifier at their discretion. The EQ02 allows for a very specific inquiry, such as one based on a procedure code. Additional information such as diagnosis codes can be supplied in the 2100D HI segment and place of service in the 2110D III segment.

  • If an information source receives a Service Type Code "30" submitted in the 270 EQ01 or a Service Type Code that they do not support, the 2110D EB03 values identified in Section 1.4.7.1 Item #8 must also be returned if they are a covered benefit category at a plan level. Refer to Section 1.4.7 for additional information.
  • EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
Example
At least one of Service Type Code (EQ-01) or Composite Medical Procedure Identifier (EQ-02) is required
EQ-01
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
  • An information source must support a generic request for Eligibility. This is accomplished by submitting a Service Type Code of "30" (Health Benefit Plan Coverage) in EQ01.
  • An information source may support the use of Service Type Codes from the list other than "30" (Health Benefit Plan Coverage) in EQ01 at their discretion. If an information source supports codes in addition to "30", the information source may provide a list of the supported codes from the list below to the information receiver. If no list is provided, an information receiver may transmit the most appropriate code.
  • If an inquiry is submitted with a Service Type Code from the list other than "30" and the information source does not support this level of functionality, a generic response will be returned. The generic response will be the same response as if a Service Type Code of "30" (Health Benefit Plan Coverage) was received by the information source. Refer to Section 1.4.7 for additional information.
  • EQ01 is a repeating data element that may be repeated up to 99 times. If all of the information that will be used in the 2110D loop is the same with the exception of the Service Type Code used in EQ01, it is more efficient to use the repetition function of EQ01 to send each of the Service Type Codes needed. If an Information Source supports more than Service Type Code "30", and can support requests for multiple Service Type Codes, the repetition use of EQ01 must be supported.
  • Not used if EQ02 is used.
1
Medical Care
2
Surgical
3
Consultation
4
Diagnostic X-Ray
5
Diagnostic Lab
6
Radiation Therapy
7
Anesthesia
8
Surgical Assistance
9
Other Medical
10
Blood Charges
11
Used Durable Medical Equipment
12
Durable Medical Equipment Purchase
13
Ambulatory Service Center Facility
14
Renal Supplies in the Home
15
Alternate Method Dialysis
16
Chronic Renal Disease (CRD) Equipment
17
Pre-Admission Testing
18
Durable Medical Equipment Rental
19
Pneumonia Vaccine
20
Second Surgical Opinion
21
Third Surgical Opinion
22
Social Work
23
Diagnostic Dental
24
Periodontics
25
Restorative
26
Endodontics
27
Maxillofacial Prosthetics
28
Adjunctive Dental Services
30
Health Benefit Plan Coverage

If only a single category of inquiry can be supported, use this code.

32
Plan Waiting Period
33
Chiropractic
34
Chiropractic Office Visits
35
Dental Care
36
Dental Crowns
37
Dental Accident
38
Orthodontics
39
Prosthodontics
40
Oral Surgery
41
Routine (Preventive) Dental
42
Home Health Care
43
Home Health Prescriptions
44
Home Health Visits
45
Hospice
46
Respite Care
47
Hospital
48
Hospital - Inpatient
49
Hospital - Room and Board
50
Hospital - Outpatient
51
Hospital - Emergency Accident
52
Hospital - Emergency Medical
53
Hospital - Ambulatory Surgical
54
Long Term Care
55
Major Medical
56
Medically Related Transportation
57
Air Transportation
58
Cabulance
59
Licensed Ambulance
60
General Benefits
61
In-vitro Fertilization
62
MRI/CAT Scan
63
Donor Procedures
64
Acupuncture
65
Newborn Care
66
Pathology
67
Smoking Cessation
68
Well Baby Care
69
Maternity
70
Transplants
71
Audiology Exam
72
Inhalation Therapy
73
Diagnostic Medical
74
Private Duty Nursing
75
Prosthetic Device
76
Dialysis
77
Otological Exam
78
Chemotherapy
79
Allergy Testing
80
Immunizations
81
Routine Physical
82
Family Planning
83
Infertility
84
Abortion
85
AIDS
86
Emergency Services
87
Cancer
88
Pharmacy
89
Free Standing Prescription Drug
90
Mail Order Prescription Drug
91
Brand Name Prescription Drug
92
Generic Prescription Drug
93
Podiatry
94
Podiatry - Office Visits
95
Podiatry - Nursing Home Visits
96
Professional (Physician)
97
Anesthesiologist
98
Professional (Physician) Visit - Office
99
Professional (Physician) Visit - Inpatient
A0
Professional (Physician) Visit - Outpatient
A1
Professional (Physician) Visit - Nursing Home
A2
Professional (Physician) Visit - Skilled Nursing Facility
A3
Professional (Physician) Visit - Home
A4
Psychiatric
A5
Psychiatric - Room and Board
A6
Psychotherapy
A7
Psychiatric - Inpatient
A8
Psychiatric - Outpatient
A9
Rehabilitation
AA
Rehabilitation - Room and Board
AB
Rehabilitation - Inpatient
AC
Rehabilitation - Outpatient
AD
Occupational Therapy
AE
Physical Medicine
AF
Speech Therapy
AG
Skilled Nursing Care
AH
Skilled Nursing Care - Room and Board
AI
Substance Abuse
AJ
Alcoholism
AK
Drug Addiction
AL
Vision (Optometry)
AM
Frames
AN
Routine Exam

Use for Routine Vision Exam only.

AO
Lenses
AQ
Nonmedically Necessary Physical
AR
Experimental Drug Therapy
B1
Burn Care
B2
Brand Name Prescription Drug - Formulary
B3
Brand Name Prescription Drug - Non-Formulary
BA
Independent Medical Evaluation
BB
Partial Hospitalization (Psychiatric)
BC
Day Care (Psychiatric)
BD
Cognitive Therapy
BE
Massage Therapy
BF
Pulmonary Rehabilitation
BG
Cardiac Rehabilitation
BH
Pediatric
BI
Nursery
BJ
Skin
BK
Orthopedic
BL
Cardiac
BM
Lymphatic
BN
Gastrointestinal
BP
Endocrine
BQ
Neurology
BR
Eye
BS
Invasive Procedures
BT
Gynecological
BU
Obstetrical
BV
Obstetrical/Gynecological
BW
Mail Order Prescription Drug: Brand Name
BX
Mail Order Prescription Drug: Generic
BY
Physician Visit - Office: Sick
BZ
Physician Visit - Office: Well
C1
Coronary Care
CA
Private Duty Nursing - Inpatient
CB
Private Duty Nursing - Home
CC
Surgical Benefits - Professional (Physician)
CD
Surgical Benefits - Facility
CE
Mental Health Provider - Inpatient
CF
Mental Health Provider - Outpatient
CG
Mental Health Facility - Inpatient
CH
Mental Health Facility - Outpatient
CI
Substance Abuse Facility - Inpatient
CJ
Substance Abuse Facility - Outpatient
CK
Screening X-ray
CL
Screening laboratory
CM
Mammogram, High Risk Patient
CN
Mammogram, Low Risk Patient
CO
Flu Vaccination
CP
Eyewear and Eyewear Accessories
CQ
Case Management
DG
Dermatology
DM
Durable Medical Equipment
DS
Diabetic Supplies
GF
Generic Prescription Drug - Formulary
GN
Generic Prescription Drug - Non-Formulary
GY
Allergy
IC
Intensive Care
MH
Mental Health
NI
Neonatal Intensive Care
ON
Oncology
PT
Physical Therapy
PU
Pulmonary
RN
Renal
RT
Residential Psychiatric Treatment
TC
Transitional Care
TN
Transitional Nursery Care
UC
Urgent Care
EQ-02
C003
Composite Medical Procedure Identifier
Optional
To identify a medical procedure by its standardized codes and applicable modifiers
Usage notes

Required if utilizing a Medical Procedure Code inquiry when the information receiver believes that the information source supports this high level of functionality and EQ01 is not used. If not required by this implementation guide, do not send.

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 qualify the type of specific Product/Service ID that will be used in EQ02-2.
AD
American Dental Association Codes
CJ
Current Procedural Terminology (CPT) Codes
HC
Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes
ID
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) - Procedure
IV
Home Infusion EDI Coalition (HIEC) Product/Service Code
N4
National Drug Code in 5-4-2 Format
ZZ
Mutually Defined

Use this code only for International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS).

CODE SOURCE 896: International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

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 number for the product/service ID as identified by the preceding data element (EQ02-1).
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
  • Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
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
  • Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
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
  • Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
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
  • Used when an information source supports or may be thought to support this high level of functionality if modifiers are required to further specify the service. If not supported, information source will process without this data element.
EQ-05
C004
Composite Diagnosis Code Pointer
Optional
To identify one or more diagnosis code pointers
Usage notes

Required when a 2100D HI segment is used. If not required by this implementation guide, 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 EQ segment. Remaining diagnosis pointers indicate declining level of importance to the EQ segment. Acceptable values are 1 through 8, and correspond to Composite Data Elements 01 through 08 in the Health Care Diagnosis Code HI segment in loop 2100D.
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 2100D.
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 2100D.
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 2100D.
III
1700
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Inquiry Loop > III

Dependent Eligibility or Benefit Additional Inquiry Information

OptionalMax use 1

To report information

Usage notes
  • Use the III segment when an information source supports or may be thought to support this level of functionality. If not supported, the information source will process without this segment.
  • Required when the information receiver believes the Facility Type information is relevant to the inquiry and the information is available. If not required by this implementation guide, do not send.
Example
III-01
1270
Code List Qualifier Code
Required
Identifier (ID)

Code identifying a specific industry code list

Usage notes
  • Use this code to specify the code that is following in the III02 is a Facility Type Code.
ZZ
Mutually Defined

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

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

Code indicating a code from a specific industry code list

Usage notes
  • Use this element for codes identifying a place of service from code source 237. As a courtesy, the codes are listed below; however, the code list is thought to be complete at the time of publication of this implementation guideline. Since this list is subject to change, only codes contained in the document available from code source 237 are to be supported in this transaction and take precedence over any and all codes listed here.
    01 Pharmacy
    03 School
    04 Homeless Shelter
    05 Indian Health Service Free-standing Facility
    06 Indian Health Service Provider-based Facility
    07 Tribal 638 Free-standing Facility
    08 Tribal 638 Provider-based Facility
    11 Office
    12 Home
    13 Assisted Living Facility
    14 Group Home
    15 Mobile Unit
    20 Urgent Care Facility
    21 Inpatient Hospital
    22 Outpatient Hospital
    23 Emergency Room - Hospital
    24 Ambulatory Surgical Center
    25 Birthing Center
    26 Military Treatment Facility
    31 Skilled Nursing Facility
    32 Nursing Facility
    33 Custodial Care Facility
    34 Hospice
    41 Ambulance - Land
    42 Ambulance - Air or Water
    49 Independent Clinic
    50 Federally Qualified Health Center
    51 Inpatient Psychiatric Facility
    52 Psychiatric Facility - Partial Hospitalization
    53 Community Mental Health Center
    54 Intermediate Care Facility/Mentally Retarded
    55 Residential Substance Abuse Treatment Facility
    56 Psychiatric Residential Treatment Center
    57 Non-residential Substance Abuse Treatment Facility
    60 Mass Immunization Center
    61 Comprehensive Inpatient Rehabilitation Facility
    62 Comprehensive Outpatient Rehabilitation Facility
    65 End-Stage Renal Disease Treatment Facility
    71 Public Health Clinic
    72 Rural Health Clinic
    81 Independent Laboratory
    99 Other Place of Service
REF
1900
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Inquiry Loop > REF

Dependent Additional Information

OptionalMax use 1

To specify identifying information

Usage notes
  • Required when the dependent has received a referral or prior authorization number and the information receiver believes the information is relevant to the inquiry (such as for a benefit or procedure that requires a referral or prior authorization) and the information is available. If not required by this implementation guide do not send.
  • Use this segment when it is necessary to provide a referral or prior authorization number for the benefit being inquired about.
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.
9F
Referral Number
G1
Prior Authorization Number
REF-02
127
Prior Authorization or Referral Number
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 reference number as qualified by the preceding data element (REF01).;
DTP
2000
Detail > Information Source Level Loop > Information Receiver Level Loop > Subscriber Level Loop > Dependent Level Loop > Dependent Name Loop > Dependent Eligibility or Benefit Inquiry Loop > DTP

Dependent Eligibility/Benefit Date

OptionalMax use 1

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

Usage notes
  • Use this segment to convey plan dates associated with the information contained in the corresponding EQ segment.
  • This segment is only to be used to override dates provided in Loop 2100D when the date differs from the date provided in the DTP segment in Loop 2100D. Dates that apply to the entire request must be placed in the DTP segment in Loop 2100D. In order for a date to appear here, there must be a date or a date range in the corresponding 2100D loop.
  • Required when the plan date(s) are different from the date(s) provided in the 2100C loop. If not required by this implementation guide, do not send.
Example
DTP-01
374
Date Time Qualifier
Required
Identifier (ID)

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

291
Plan
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) or time(s) that follow in the next data element.
D8
Date Expressed in Format CCYYMMDD
RD8
Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD
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.
2110D Dependent Eligibility or Benefit Inquiry Loop end
2100D Dependent Name Loop end
2000D Dependent Level Loop end
2000C Subscriber Level Loop end
2000B Information Receiver Level Loop end
2000A Information Source Level Loop end
SE
2100
Detail > SE

Transaction Set Trailer

RequiredMax use 1

To indicate the end of the transaction set and provide the count of the transmitted segments (including the beginning (ST) and ending (SE) segments)

Usage notes
  • Use this segment to mark the end of a transaction set and provide control information on the total number of segments included in the transaction set.
Example
SE-01
96
Transaction Segment Count
Required
Numeric (N0)
Min 1Max 10

Total number of segments included in a transaction set including ST and SE segments

Usage notes
  • Use this number to indicate the total number of segments included in the transaction set inclusive of the ST and SE segments.
SE-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. This number must be unique within a specific functional group (segments GS through GE) and interchange, but can repeat in other groups and interchanges.
Detail end

Functional Group Trailer

RequiredMax use 1

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

Example
GE-01
97
Number of Transaction Sets Included
Required
Numeric (N0)
Min 1Max 6

Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element

GE-02
28
Group Control Number
Required
Numeric (N0)
Min 1Max 9

Assigned number originated and maintained by the sender

Interchange Control Trailer

RequiredMax use 1

To define the end of an interchange of zero or more functional groups and interchange-related control segments

Example
IEA-01
I16
Number of Included Functional Groups
Required
Numeric (N0)
Min 1Max 5

A count of the number of functional groups included in an interchange

IEA-02
I12
Interchange Control Number
Required
Numeric (N0)
Min 9Max 9

A control number assigned by the interchange sender

EDI Samples

Example 1: Generic Request By a Clinic for the Patient’s (Subscriber) Eligibility

ST*270*1234*005010X279A1~
BHT*0022*13*10001234*20060501*1319~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*2*BONE AND JOINT CLINIC*****SV*2000035~
HL*3*2*22*0~
TRN*1*93175-012547*9877281234~
NM1*IL*1*SMITH*ROBERT****MI*11122333301~
DMG*D8*19430519~
DTP*291*D8*20060501~
EQ*30~
SE*13*1234~

Example 2: Generic Request by a Physician for the Patient’s (Dependent) Eligibility

ST*270*1235*005010X279A1~
BHT*0022*13*10001235*20060501*1320~
HL*1**20*1~
NM1*PR*2*ABC COMPANY*****PI*842610001~
HL*2*1*21*1~
NM1*1P*1*JONES*MARCUS****SV*0202034~
HL*3*2*22*1~
NM1*IL*1******MI*11122333301~
HL*4*3*23*0~
TRN*1*93175-012547*9877281234~
NM1*03*1*SMITH*MARY~
DMG*D8*19781014~
DTP*291*D8*20060501~
EQ*30~
SE*15*1235~

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